A Systematic Review of Grief and Depression in Adults

Moreira, D., Azeredo, A., Moreira, D. S., Fávero, M., & Sousa-Gomes, V. (2022). Why Does Grief Hurt?. European Psychologist, 28(1), 35–52. https://doi.org/10.1027/1016-9040/a000490

Although grief is a normal response to loss, it is a complex and multidimensional process that can involve a wide range of distressing symptoms and significantly affect an individual’s functioning. People respond to death in diverse ways, both adaptively and maladaptively, and these reactions are highly personalized.

During this time, bereaved individuals engage in tasks such as accepting the reality of the loss, managing emotional distress, adjusting to life without the deceased, and eventually letting go of the emotional attachment to the person who has died.

Key Points

• This systematic review synthesized findings on depression and grief in adults, aiming to identify specificities of depression in grief and whether grief varies based on the type of loss.
• Factors like gender, education level, socioeconomic status, age of the deceased, cause of death, and time since loss significantly affect grief outcomes and the development of depression.
• The research, while enlightening, has limitations, such as the inability to isolate depression from other grief symptoms in some studies and variation in the types of losses examined.
• Understanding the relationship between grief and depression is universally relevant, as most people will experience the loss of a loved one and may be at risk for negative mental health outcomes.

Rationale

Grief is a profound life experience that can lead to complications like depression for bereaved individuals. Depressive symptoms place a heavy burden on societal resources (Moreira et al., 2023).

Previous research has shown significant overlap between grief and depression in terms of symptoms, characteristics, family history, and response to medication (Kendler et al., 2008; Lamb et al., 2010; Zisook & Kendler, 2007; Zisook et al., 2001, 2007).

Increasing evidence indicates losing a loved one can lead to prolonged grief disorder and depressive symptoms/syndromes (Bonanno et al., 2007; Prigerson et al., 2009; Shear et al., 2011).

This systematic review aimed to synthesize findings on depression and grief to identify specificities of depression in grief and factors influencing grief outcomes.

Understanding the distinctions between grief and depression has important implications for the mental and physical health of bereaved individuals.

Method

This systematic review followed PRISMA guidelines. Studies were identified through searching EBSCO, PubMed, and Web of Science databases.

• Search terms included variations of “depression,” “grief,” “bereavement,” and “mourning.”
• Inclusion criteria were having a grief sample and depression measures.
• Exclusion criteria included case studies, theoretical essays, reviews, instrument validations, not examining grief and depression, non-bereaved samples, and low study quality.

41 studies published between 1939-2021 were included. Two independent reviewers selected studies with almost perfect agreement (Cohen’s κ = .86). Study quality was assessed with the Quantitative Research Assessment Tool.

The search equation used variations of the key terms in the databases:

• EBSCO: TI (depress* OR mood disorder) AND TI (mourn* OR grief OR bereave* OR death OR loss)
• PubMed: (depress[Title] OR mood disorder[Title]) AND (mourn[Title] OR grief[Title] OR bereave* OR death[Title] OR loss)
• Web of Science: TI=(depress* OR mood disorder) AND TI=(mourn* OR grief OR bereave* OR death OR loss)

Results

Studies can be grouped into two categories based on time of loss, namely grief during pregnancy or grief of a close relative

Prenatal

• After spontaneous abortion, women experienced more grief and depressive symptoms than their male partners. Childless women and those with infertility had higher grief.
• After miscarriage, 26.6% of women who met grief criteria also had depressive episodes.
• Grief symptoms decreased over a year after pregnancy loss, but depressive symptoms increased around 6 months for women who experienced sudden losses.
• Negative cognitions predicted grief 16-19 months after a perinatal death. Having more children was associated with less depression.

Early Childhood

• Infant death was associated with increased depression and psychosis-like experiences in mothers.
• 34% of caregivers had clinically significant depressive symptoms 3 months after losing a loved one.

Childhood/Adolescence

• 30% of bereaved parents had depression 5 years after a child’s cancer death vs. 14% of parents whose child survived. Mothers had more depression than fathers.
• Parental grief was predicted more by couple-level factors while depression was predicted more by individual factors. Traumatic child deaths led to more parental grief.

Adults/Elderly

• In gay men who lost a friend to AIDS, grief and depression were distinct. Depression was predicted by negative affect, health concerns, and loneliness. Grief was predicted by number of AIDS losses.
• 16% met criteria for complicated grief (CG) 1-2 years after losing a friend/relative. Relationship depth predicted CG while dependence predicted depression.
• Pre-loss grief, being a partner, and low education predicted post-loss CG and depression in caregivers.
• Violent deaths led to more depression, especially in females. CG and depression decreased over time after loss. More years since loss was associated with less depression in elders.

Insight

This review provides insights into the complex relationship between grief and depression after different types of losses.

While there is overlap, they emerge as distinct responses – certain factors uniquely predict grief (e.g., relationship depth, couple-level factors), while others uniquely predict depression (e.g., personal vulnerabilities, less time since loss).

Gender, education level, socioeconomic status, age of the deceased, cause of death, and time since loss are significant factors that influence grief outcomes and the development of depression following bereavement.

Research has shown that women often experience more intense grief and depressive symptoms compared to men, particularly in cases of miscarriage or child loss. Lower levels of education and socioeconomic status have been associated with a higher risk of complicated grief and difficulty coping with loss.

The age of the deceased also plays a role, with the loss of a child or younger individual often leading to more severe grief reactions compared to the loss of an older person.

Sudden, traumatic, or violent causes of death, such as accidents, homicide, or suicide, can result in more complicated grief and depression compared to losses due to natural causes or prolonged illness.

Finally, the time elapsed since the loss is a significant factor, as grief and depressive symptoms tend to decrease over time as individuals adjust to their new reality.

However, for some, grief may remain intense and prolonged, leading to complicated grief or persistent depression. Understanding these factors can help identify individuals at higher risk for adverse grief outcomes and inform targeted interventions.

Future research could further examine how the predictors of grief and depression vary depending on kinship to the deceased and expand to include more diverse causes of death.

Strengths

• Followed PRISMA guidelines for systematic reviews
• Broad search of multiple databases
• Rigorous inclusion/exclusion criteria
• Independent reviewer selection of studies with high inter-rater reliability
• Assessed study quality with a standardized tool
• Examined grief and depression in response to various types of losses across the lifespan

Limitations

• Some included studies could not statistically isolate depression from other grief symptoms
• High variability in the types of losses and kinship of bereaved individuals across studies
• Conclusions may be limited by the demographics of study samples and countries where research was conducted
• Cross-sectional and retrospective designs of some studies prevent causal conclusions

Clinical Implications

The results have significant real-world implications, especially for clinical practice.

Understanding risk factors for intense, prolonged grief and depression can help practitioners identify bereaved clients who may need more support.

For example, those with prior depression/mental health issues, traumatic losses, or fewer coping resources may be more vulnerable.

Screening for complicated grief (CG) is important since it is underpinned more by interpersonal factors and may not respond to depression treatments.

Distinguishing between grief and depression is important for intervention and treatment, as grief is a normal response while depression may be more likely in individuals with certain vulnerabilities. However, some individuals with vulnerabilities may have a decreased ability to grieve.

The findings also suggest value in dyadic and family interventions since couple/family dynamics can influence grief. Gender differences imply the potential benefits of tailoring treatments.

Broadly, the review underscores the need to recognize the long-term impacts of bereavement, as grief and depressive symptoms can persist for years. Societal resources should be allocated to make bereavement support accessible.

More public education on the range of normal grief responses may help destigmatize the grief experience.

References

Primary reference

Moreira, D., Azeredo, A., Moreira, D. S., Fávero, M., & Sousa-Gomes, V. (2022). Why Does Grief Hurt?. European Psychologist, 28(1), 35–52. https://doi.org/10.1027/1016-9040/a000490

Other references

Bonanno, G. A., Neria, Y., Mancini, A., Coifman, K. G., Litz, B., & Insel, B. (2007). Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity. Journal of Abnormal Psychology, 116(2), 342–351. https://doi.org/10.1037/0021-843x.116.2.342

Kendler, K. S., Myers, J., & Zisook, S. (2008). Does bereavement-related major depression differ from major depression associated with other stressful life events? American Journal of Psychiatry, 165(11), 1449-1455. https://doi.org/10.1176/appi.ajp.2008.07111757

Lamb, K., Pies, R., & Zisook, S. (2010). The bereavement exclusion for the diagnosis of major depression: To be or not to be. Psychiatry, 7(7), 19-25.

Moreira, D., Azeredo, A., Moreira, D.S., Fávero, M., & Sousa-Gomes, V. (2023). Why does grief hurt? A systematic review of grief and depression in adults. European Psychologist, 28(1), 35-52. https://doi.org/10.1027/1016-9040/a000490

Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., Raphael, B., Marwit, S. J., Wortman, C., Neimeyer, R. A., Bonanno, G. A., Block, S. D., Kissane, D., Boelen, P., Maercker, A., Litz, B. T., Johnson, J. G., First, M. B., & Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), Article e1000121. https://doi.org/10.1371/journal.pmed.1000121

Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., Reynolds, C., Lebowitz, B., Sung, S., Ghesquiere, A., Gorscak, B., Clayton, P., Ito, M., Nakajima, S., Konishi, T., Melhem, N., Meert, K., Schiff, M., O’Connor, M., … Keshaviah, A. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28(2), 103–117. https://doi.org/10.1002/da.20780

Zisook, S., & Kendler, K. S. (2007). Is bereavement-related depression different than non-bereavement-related depression?. Psychological Medicine, 37(6), 779-794. https://doi.org/10.1017/S0033291707009865

Zisook, S., Shuchter, S. R., Pedrelli, P., Sable, J., & Deaciuc, S. C. (2001). Bupropion sustained release for bereavement: Results of an open trial. Journal of Clinical Psychiatry, 62(4), 227-230. https://doi.org/10.4088/jcp.v62n0403

Zisook, S., Shear, K., & Kendler, K. S. (2007). Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode. World Psychiatry, 6(2), 102-107.

Keep Learning

• What factors do you think might influence how an individual responds to and copes with the death of a loved one? How could cultural background play a role?
• This review found some gender differences in grief and depression. Why do you think men and women may respond differently to loss? What are the implications for providing support?
• Imagine someone close to you experienced a significant loss one year ago. Based on the findings, what signs might indicate they are struggling with complicated grief and could benefit from professional help?
• The results suggest grief and depression are distinct but overlapping responses. How would you explain the difference between grief and depression to a friend who recently lost a loved one?
• Many of the studies used self-report measures of grief and depression symptoms. What are the strengths and limitations of this type of data? What other methods could provide useful insights?
• No single theory can fully explain the range of grief responses. What are some different theoretical perspectives on the grieving process? How could integrating them help us better understand the complexity of coping with loss?