Complicated Grief: Depression after a Loved One’s Death

Introduction: Complicated Grief (or Prolonged Grief)

Losing a loved one can be one of the most painful experiences we ever endure, and sadly, one that most of us will encounter. Whether saying goodbye to a friend, spouse, family member, cherished pet, or anyone significant in your life, oftentimes there’s no way to prepare for the emotional hardship that can follow. This part of the human experience can be hard to navigate but with the help of friends, family, and other support networks, symptoms will typically begin to subside. 

But when the natural grieving doesn’t improve over time, when most can enter a state of acceptance and move forward with their life, prolonged grief (formerly known as complicated grief) can make it difficult to do so. 

Symptoms of prolonged grief disorder can prevent someone from resuming their life after a loved one’s passing, oftentimes causing someone to feel engulfed by tragedy.

While we all grieve differently, most of us will move through similar stages of grieving until we can make peace with our loss. But when we find ourselves stuck somewhere along this trajectory, unable to recover more than a year after our loss, we may require additional support.

Seeking treatment for prolonged grief can help someone heal from their loss and return to their prior level of functioning. The aim is not to leave behind the memory of a loved one, but rather to honor their memory in a way that’s conducive to one’s healing and overall well-being. 

Here, we talk more about how prolonged grief differs from the typical grieving process, the signs, and symptoms, and when to seek treatment.

If you or someone you know is grieving the loss of a loved one, know you’re not alone and there is support available.

Understanding Grief

The Mayo Clinic (2016) explains grief as a personal and universal experience—one that is perceived differently from one person to the next due to our brain and nervous system anatomy along with environmental factors and personal experiences. 

An individual’s encounter with grief may have several layers and embody a range of emotions. Grief can also be experienced when a loss is anticipated but has not yet occurred.  

Common grief responses include feeling numb and removed from daily life, anxiety, anger, sadness, being unable to carry on with regular duties while saddened, and disrupted sleep and appetite. 

If you are wondering how long the grieving period can last, there is no definite answer. Typically, symptoms will lessen over time, and after one year, should be much improved. 

Seven Stages of Grief

The seven-stage grieving process is used as a guided reference when discussing loss, with the stages as follows: shock, denial, anger, bargaining, depression, testing, and acceptance. 

First developed as a 5-stage model by Psychiatrist Elisabeth Kubler-Ross, the stages were originally used to help individuals with terminal illnesses explore their thoughts and feelings when nearing the end of life. After being revised to a comprehensive 7-stage grieving process, it continues to serve as a framework for understanding grief (Waichler, 2023).

Still, it’s important to remember that the grieving process is not always a linear journey. The seven stages of grief serve as a tool to enhance understanding of the multi-dimensional grieving process, not to necessarily pre-determine how someone should or shouldn’t be affected by a loss. In referring to this framework, knowing others hold similar experiences to our own can help us to feel less alone.

The seven stages of grief include:

Shock 

When met with the news of someone’s passing, particularly when that person is close to us, feelings of shock are probable. Even if we’ve had a chance to prepare for the loss of a loved one, the realization of it transpiring can feel physically and emotionally distressing—so much so that the body will put up defenses to protect us from the impact. 

Denial

After the initial shock has passed, many will experience some level of denial following their loss. Denial could imply not believing that the loss has truly occurred as well as having trouble picturing life without the person. 

Anger

Feeling angry following a loved one’s passing is quite common. Anger is an emotion that often gets minimized and criticized. Many try to conceal this emotion, thus can make healing more difficult. By embracing strong reactions, and not denying them or displacing them, we allow ourselves the freedom to better feel and connect with our pain.

Bargaining

The bargaining stage entails seeking an explanation for this person’s passing, even asking the universe for a chance to start over, to have them here again. Bargaining may occur as a result of one’s distress surrounding the loss but may also be associated with shame or guilt. That maybe there was something that could have changed the outcome. Bargaining might sound like, “If only I did this—“then they would still be here. 

Depression

The whirlwind of emotions that arise after a loved one’s passing may lead to feelings of depression, isolation, and anxiety. When bargaining has failed to provide any sort of relief, some yearn to be reunited with the deceased and are unsure of where to turn. Suffering in silence is never the answer and it’s critical to seek support from friends, family, and a mental health professional if these feelings continue. 

Testing

In the testing stage, people experiment with ways to manage and cope with loss. Testing may look like joining a support group, reconciling with an old friend, or changing one’s location. But where bargaining is about escaping reality, testing entails trying out sustainable strategies to better cope with loss.

Acceptance  

In the acceptance stage, a person understands the magnitude of their loss but can move forward. How well a person moves forward after their loss is often dependent on several factors, including the nature of the loss, personal psychosomatic factors, motivations for the future, and whether or not someone has a support network. 

What is Complicated Grief/Prolonged Grief?

After experiencing loss, if symptoms don’t subside and are severe enough to disrupt an individual’s life, they may be experiencing prolonged grief. 

For an estimated 7%-10% of adults, feelings of severe grief persist and cause significant disruption in their life bereavement (Szuhany, Malgaroli, Miron, & Simon, 2021, as cited in APA, 2022). 

Among children and adolescents, approximately 5%-10% will experience depression, post-traumatic stress disorder (PTSD), and/or prolonged grief disorder following a loss (Melhem, Porta, Walker Payne, & Brent, 2013, as cited in APA, 2022). 

To be diagnosed with prolonged grief disorder, the loss of a loved one would have to occur at least a year prior for adults, and at least 6 months prior for children and adolescents. Individuals must also have experienced at least three of the symptoms below, nearly every day, for at least the last month (APA, 2022).

Symptoms of prolonged grief disorder include the below (APA, 2022).

• Having a marked sense of disbelief regarding the death
• Disruption of one’s identity
• Avoidance of reminders that the person is dead
• Intense emotional pain (such as anger, bitterness, and sorrow) related to the death
• Difficulty returning to a previous state of functioning before the death (such as problems engaging with friends, pursuing interests, and planning for the future)
• Emotional numbness (absence or marked reduction of emotional experience)
• A feeling of hopelessness or that life is meaningless
• Feeling alone or detached from others and experiences 

What are the Complications?

Adding prolonged grief disorder to the DSM-5-TR gives clinicians the ability to differentiate between the normal grief cycle and that which is persistent, unrelenting, and disrupts one’s daily functioning. Accurately diagnosing and providing treatment for prolonged grief is critical as symptoms can affect people physically, mentally, and socially. 

Without appropriate treatment, complications of complicated grief can include the below (Mayo Clinic, 2022):

• Depression
• Suicidal thoughts or behaviors
• Anxiety 
• PTSD
• Sleep disturbances
• Increased risk for health problems, such as heart disease, cancer, or high blood pressure
• Long-term difficulty with work, maintaining relationships, and everyday functioning
• Substance misuse 

Risk Factors 

Like with other mental health disorders, the causes of prolonged grief are not certain but there are many factors involving one’s environment, personality, inherited traits, anatomy, and physiological responses that can increase the risk. 

Being of the female gender at birth, along with an older adult, caregiver, or someone with a history of depression or bipolar disorder, can also increase the risk. In situations where the loss occurs suddenly or under traumatic circumstances, there is also an increased risk for prolonged grief (Szuhany et al., 2021, as cited in APA, 2022).

Prolonged grief disorder can also co-occur with other mental health conditions such as PTSD, anxiety, or depression. An estimated 80% of people also report sleep difficulties with this diagnosis (Szuhany et al., 2021, as cited in APA, 2022).

Prevention 

Receiving counseling after a loss can help someone better manage their symptoms, especially for those who are at increased risk for prolonged grief. 

For caregivers providing end-of-life care, seeking counseling and additional support to help prepare for death and its emotional aftermath can have a significant impact on the grieving process (Mayo Clinic, 2022).

There are many means of support available after the loss of a loved one, including bereavement counseling, in-person and online support groups, as well as self-help books, articles, and videos that are accessible on the internet, through your doctor’s office, local library, and community outreach programs.   

Allowing yourself the time and space to grieve while focusing on self-care will encourage movement towards a stage of acceptance, of no longer living in the past but finding peace in the present, and where memories bring a sense of comfort rather than pain. While it may be difficult to open up during a time of incredible vulnerability, talking about your feelings and leaning on your support network can be helpful outlets. 

Ways to Cope 

Even briefly, it’s necessary to allow yourself a time and place to breathe. Try out a few coping techniques to see what feels most natural. Most importantly, be gentle with your mind and body, focusing on self-care can be one of the best ways to stay in tune with your thoughts, feelings, and emotions. 

Other helpful coping techniques include:

• Taking time to process your grief and express it in a safe place
• Talking with others who can relate to your experience
• Journaling 
• Spending quality time with family and friends, doing activities you enjoy
• Maintaining healthy habits (receiving adequate nutrition, sleep, exercise, and time outdoors) and keeping up with a routine
• Honoring your loved ones’ memory in a way that’s best for you 
• Engaging in small acts of kindness or volunteering for a cause that’s important to you
• Contacting your PCP or insurance company to discuss bereavement resources or referrals for counseling

Treatment is Available 

There is a wide range of treatment modalities effective in treating prolonged grief disorder. Most commonly used are Prolonged Grief Disorder Therapy (PGDT), previously known as complicated grief therapy (CGT), and cognitive-behavioral therapy (CBT). Currently, no medications are approved to treat specific symptoms of grief. Bereavement groups can also provide a strong source of support and social connection. 

Still, despite the availability of effective treatments, people experiencing persistent, intense grief may not always seek help which can exaggerate symptoms, delaying both the acceptance of the loss and the return to one’s previous state of functioning. 

Reaching Out

Contact your doctor or a mental health professional if you have intense, persistent grief and difficulties functioning that don’t improve at least one year after the passing of your loved one. 

If you have thoughts of self-harm or suicide, talk to someone you trust or contact a suicide hotline right away. In the U.S., call or text 988 for the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Services are free and confidential. If you think you may act on suicidal feelings, always call 911 or your emergency services number. 

Navigating the loss of a loved one is complex. One day you may feel gratitude; other days, you may feel anger, guilt, depression, or uncertainty about how to process your pain. This fluctuation in emotions is normal and will typically stabilize over time. Letting go of guilt and shame, finding a way to honor your loved one’s memory, and focusing on memories that bring joy, can be an uplifting way to keep their eternal spirit with you. 

For individuals experiencing prolonged grief, it’s helpful to seek support from a professional who can better help process your thoughts, feelings, and experiences related to your grief and loss. No matter how you find comfort and healing, talking to close friends, family, counselors, or those who can relate to your experience, can be a healthy outlet for our emotions. And if at any time the grief experienced from losing a loved one becomes too overwhelming, always reach out for help.

References

1. American Psychiatric Association. (2022, May). Prolonged grief disorder. Psychiatry.org – Prolonged Grief Disorder. Retrieved February 9, 2023, from https://www.psychiatry.org/patients-families/prolonged-grief-disorder# 
2. American Psychological Association. (2023, January 6). How to cope with traumatic stress. American Psychological Association. Retrieved February 9, 2023, from https://www.apa.org/topics/trauma/stress 
3. BetterHelp. (2023, February 3). The 7 stages of grief and how death affects you. BetterHelp. Retrieved February 9, 2023, from https://www.betterhelp.com/advice/grief/the-7-stages-of-grief-and-how-they-affect-you/ 
4. The Columbia Center for Complicated Grief. The Center for Prolonged Grief. (2022, November 15). Retrieved February 9, 2023, from https://prolongedgrief.columbia.edu/professionals/complicated-grief-professionals/overview/ 
5. Holland, K. (2022, June 27). The stages of grief: How to understand your feelings. Healthline. Retrieved February 9, 2023, from https://www.healthline.com/health/stages-of-grief#5-stages 
6. Mayo Foundation for Medical Education and Research. (2016, October 19). What is grief? Mayo Clinic. Retrieved February 9, 2023, from https://www.mayoclinic.org/patient-visitor-guide/support-groups/what-is-grief
7. Mayo Foundation for Medical Education and Research. (2022, December 13). Complicated grief. Mayo Clinic. Retrieved February 9, 2023, from https://www.mayoclinic.org/diseases-conditions/complicated-grief/symptoms-causes/syc-20360374
8. Waichler, I. (2023, January 27). 7 stages of grief: Examples & what to expect. Choosing Therapy. Retrieved February 9, 2023, from https://www.choosingtherapy.com/7-stages-of-grief