WARNING: This post might be triggering for some individuals.

I was covering the psychiatry consultation service at a county medical center when I was asked to evaluate a patient on the labor and delivery floor. The consultation request was for “odd behaviors” and “depression.” When I asked for more information I was told the patient had been crying inconsolably with intermittent episodes of screaming and yelling for the past 24 hours. When I asked for more information, I was shocked by what I heard…

The patient was a young woman in her mid twenties without any past psychiatric history. She was approximately 37 weeks pregnant and in a normal state of health when suddenly she felt painful contractions with significant bleeding while in the shower. She told her young children to call 911. When paramedics arrived they immediately recognized the problem: The patient’s baby was in the breech position (i.e. the baby’s feet were positioned to be delivered first). Normally, babies will move positions a few weeks prior to delivery such that the head moves closer to the birth canal to be delivered first.

 

Sadly, on the way to the hospital (and still in labor), this young woman lost her baby. To make matters worse, she saw the whole thing transpire and could not get the imagery out of her mind. I remember sitting with her for many minutes in silence as she cried. She started to explain the reason for her “odd behaviors” and I immediately told her she didn’t need to explain herself…only if she wanted to and/or needed to. Words do not adequately describe the sadness I felt for her and I wasn’t the one who had just experienced one of the most traumatic events a new mother (or anyone for that matter) could experience. 

When I left the patient’s room, I was asked three questions: 1) “Do you think she has depression?” 2) “Do you think we should start an antidepressant?” and 3) “Should we be concerned?” The short answer was “No” to all three questions, but it is much more complicated than that. I remember immediately thinking “if I was called and told this story and the patient wasn’t distressed, then I would be worried.”

The questions asked of me are the reason I decided to post on this topic because I get asked about it frequently. That is, “when does normal sadness become depression?” So here is my attempt at answering this very difficult question without writing a novel…

“Normal” is a relative term (just like everything in life). Everyone reacts differently to stressful situations or significant losses. As a psychiatrist, my role is not to tell my patients how they should or shouldn’t react or feel. Instead, my role is to listen and explore (with the patient) how their feelings and/or “symptoms” are affecting their quality of life and to provide recommendations about the various options (medications, therapy, self-help activities, etc) that may help relieve suffering. From an “academic” standpoint, the teaching is that grief and depression are differentiated primarily by the predominant symptoms, the time course of those symptoms, the severity of impairment in functioning, and most importantly, whether those symptoms meet “diagnostic criteria” for a depressive episode, which I will explain below. (Note: I realize the word “symptoms” seems very clinical and sterile but it is the word physicians use).

Briefly, depression is diagnosed when an individual experiences five or more symptoms (from a list of 9 possible symptoms) persistently for at least a period of two weeks and causes significant distress or impairment in social, occupational, or other areas of functioning. One of the symptoms must be EITHER depressed mood most of the day, nearly everyday, OR diminished interest or pleasure in most activities nearly everyday (anhedonia)

The predominant features of grief are feelings of loss, emptiness, and intense sadness that come and go and usually are triggered by reminders (both internal or external). The feelings experienced when grieving usually (but not always) become less severe or intense as time passes. Individuals who are grieving still have an ability to feel joy even if it is short lived. It is not uncommon to see humor and positive emotions in people who are grieving, which is not typical of the persistent unhappiness and anhedonia associated with a depressed episode. The predominant features of depression are low mood and inability to anticipate happiness or pleasure which is persistent and does not “come and go” with reminders or triggers of the deceased (or other significant loss such as person, pet, personal item, house, etc).

Depression Grief
  • Persistent Low Mood
  • Persistent Anhedonia (lack of joy or pleasure)
  • Symptom severity usually does not decrease over time
  • Predominant feelings of loss, emptiness, sadness
  • Symptoms come and go
  • Symptoms are triggered by reminders
  • Individuals still have an ability to feel joy even if short lived
  • Symptoms usually become less severe as time passes

To make things more complicated, an individual can be grieving but also depressed. This is when a professional’s “clinical judgement” becomes important. The important thing to remember is that significant distress can occur with both depression and grief. Extreme emotional outbursts involving anger, irritability, crying, tearfulness, weeping, intense sadness, gut-wrenching ruminations, and/or hearing/seeing the deceased may occur in “normal” grief. 

If you are currently experiencing depression or grief, I encourage you to reach out to a mental health professional…no one should go through emotional pain alone. And to finish the story of the patient described above, she ultimately received outpatient psychotherapy and attended grief-centered groups for many weeks. Although she will always carry an emotional scar and will continue to have her “moments,” I am happy to report that she recently gave birth to a beautiful young girl and they both are doing very well.

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