Is it sadness, depression, grief or something more complicated?

Because the term "depressed" has been misappropriated in popular vernacular by its use in contexts that depict sadness, there is much confusion around what constitutes symptoms of a depressive disorder as opposed to normal undulations (shifts) in mood. Distinguishing between major depressive disorder and aversive mood-states that result from difficult life-events may help people get the help that they need when they need it most.

Major depressive disorder is a clinical syndrome with very serious, potentially life-threatening symptoms (APA, 2013). Specifically, major depressive disorder includes at least 2 weeks of heightened sadness, hopelessness, or irritability, loss of pleasure, motivation, or energy, sleeping or eating too much or too little, difficulty concentrating, paying attention or making decisions, and either slowed down or full of restless energy (APA, 2013). In addition, major depressive disorder often presents with thoughts of death or suicide, potentially manifesting as passive wishes for death in an effort to reduce their pain (APA, 2013). On a physiological level, major depressive disorder is associated with low levels of serotonin, high levels of cortisol, depleted glutathione, oxidative damage to cells, and in cases of suicidal depression, very low cholesterol levels (Du et al., 2016).

Grief is the process of integrating the conditions posed by a loss into one’s life. Grief results from bereavement, a state of significant loss, and is often accompanied by mourning, a state of sorrow that may encompass behavioral and emotional reactions. A state of bereavement does not always necessitate grief or mourning, however. Grief can occur with the loss of loved ones, physical capacities (e.g., injured athletes often grieve the loss of their athletic careers), relationships, and identities (e.g., role confusion after retirement or unplanned severance from one’s career). Disruption to sleep, work, and social interactions may be quite severe, but are time-limited when typical grief is the source of dysphoric emotions (Zisook & Shear, 2009).

In order to understand the difference between major depression and grief, it is important to understand a mental health condition that can arise from grief. Persistent complex bereavement disorder (aka complicated grief) is a mental health condition marked by an unusual or unexpected grieving process (APA, 2013). Persistent complex bereavement disorder is marked by symptoms of intense dysphoric mood, including anger or sadness, experiencing frequent, repetitive thoughts and images related to the death of a loved one, obsession with death in general, experiencing self-blame for the death, avoidance of reminders of the loss, inability to accept the loss, desire to die in order to be with the deceased, major disruptions to identity and social networks (e.g., losses in identity, friends, and valued activities, and feelings of detachment; APA, 2013). Complicated grief is out of context for one’s culture or religion and interferes with the bereaved person’s ability to function in their work, school, family, or social roles (APA, 2013). Complicated grief is not treated well with medication, but with a psychotherapy that combines Cognitive Behavior Therapy and Motivational Interviewing (Zisook & Shear, 2009).

While bereavement can trigger major depressive disorder and persistent complex bereavement disorder (aka complicated grief), typical grief shares some similarities and differences with diagnosable syndromes (APA, 2013). Typical grief does not constitute a mental health condition, as it tends to recede after a reasonable period of time and its emotional impact becomes muted over time. Suicidal ideation or desire to die is notably absent from typical grief, though such thoughts are the most severe manifestation of major depressive disorder and complicated grief (Zisook & Shear, 2009).

Another notable difference involves the duration and intensity of symptoms. While intense sadness, anger, or other dysphoric emotions can accompany typical grief, the duration of such intense emotions is limited and even transient, as the emotions dull over time and/ or present at random intervals (Zisook & Shear, 2009). Persistent complex bereavement disorder is marked by dysphoric emotions, changes in thinking, and focus on death that are present without remission over at least a period of 1 year (APA, 2013). With major depression, symptoms are intense and pervasive over a period of at least 2 weeks and do not have a known precipitating factor (APA, 2013).

Finally, the impact of symptoms upon important aspects of a person’s life differs between typical grief, major depression, and complicated grief. Complicated grief and major depressive disorder are both associated with increased health problems and difficulty with occupational functioning (Zisook & Shear, 2009). In fact, due to lost wages and the cost of disability, depression has a greater economic impact than either type II diabetes or cancer, costing over $180 billion (Li et al., 2020). Typical grief may interfere with occupational, social, or other valued activities in the short-term, but not to the degree or duration of major depression or complicated grief.

Counseling or therapy can be sought with typical grief, major depression, and persistent complicated bereavement disorder. Should a person’s grief persist long enough and severe enough to represent complicated grief, psychotherapy has been found to be more effective than medication (Zisook & Shear, 2009). Cognitive Behavioral Therapy and Mindfulness approaches represent some of the most effective treatments for Major Depressive Disorder, particularly in combination with medication (Zisook & Shear, 2009). The treatment for uncomplicated grief is more supportive than curative and rarely involves coordinated care with a psychiatrist (Zisook & Shear, 2009). In fact, grief counseling represents one of the ways that mental health providers seek to optimize functioning in their clients, a common function of such providers that is often misunderstood by those unfamiliar with the field.

If you're not sure whether your mood is due to depression, grief, or something else, it may help to talk with a trained and licensed provider. Whether it's a diagnosable condition or not, many people find psychotherapy (aka talk therapy) a helpful place to learn skills to manage difficult thoughts, emotions, and behavior.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Du, J., Zhu, M., Bao, H., Li, B., Dong, Y., Xiao, C., Zhang, G. Y., Henter, I., Rudorfer, M., & Vitiello, B. (2016). The Role of Nutrients in Protecting Mitochondrial Function and Neurotransmitter Signaling: Implications for the Treatment of Depression, PTSD, and Suicidal Behaviors. Critical reviews in food science and nutrition, 56(15), 2560–2578. https://doi.org/10.1080/10408398.2013.876960

Li, G., Zhang, L., DiBernardo, A., Wang, G., Sheehan, J. J., Lee, K., Reutfors, J., & Zhang, Q. (2020). A retrospective analysis to estimate the healthcare resource utilization and cost associated with treatment-resistant depression in commercially insured US patients. PloS one, 15(9), e0238843. https://doi.org/10.1371/journal.pone.0238843

Zisook, S., & Shear, K. (2009). Grief and bereavement: what psychiatrists need to know. World psychiatry : official journal of the World Psychiatric Association (WPA), 8(2), 67–74. https://doi.org/10.1002/j.2051-5545.2009.tb00217.x