Understanding the Depression Stage of Grief

Depression is one of the five stages of grief. The five stages of grief is a model also known as the Kübler-Ross model after Swiss-American psychiatrist Elisabeth Kübler-Ross, who coined the phrase in her 1969 book, On Death and Dying^[1].

Although the Kübler-Ross model was developed as a way to support terminally ill people in facing their imminent death, other types of mental health practitioners found it so helpful the model was adapted as a way of thinking about grief in general.

The five stages of grief, as outlined by Kübler-Ross, are:

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

This article focuses on the depression stage of grief – what it is, why it happens, and how to manage it. You can find articles on the other four stages of grief elsewhere on the site.

What is depression?

According to the National Institute of Mental Health, an estimated 21 million adults in the United States have at least one major depressive episode each year. This number represented 8.4% of all U.S. adults.

Depression is a severe medical condition that requires treatment. While sadness can be one of its symptoms, depression is much more severe than typical sadness and can significantly disrupt people’s lives if left untreated. The World Health Organization lists depression as a leading cause of medical disability worldwide.

Culturally, the word ‘depression’ is often used to describe sadness, which isn’t the same as the clinical depression described above. However, depression as a stage of grief doesn’t quite fit into either category.

What is the depression stage of grief?

Depression is the fourth of the five stages of grief, as described by Elisabeth Kübler-Ross. According to the American Psychological Association, the depression stage of grief is ‘characterized by feelings of sadness, loss, regret, or uncertainty that typically represent, consciously or unconsciously, some level of acceptance in facing one’s own or another’s impending or actual death or some other great loss or trauma.’

What does depression have to do with grief?

The bereaved may encounter feelings of sorrow and other signs of depression at any phase of the grieving journey, or they may not encounter them at all. The length, frequency, and intensity of their emotions and symptoms can also differ. Every person uniquely responds to grief.

However, understanding the features and signs of the depression stage of mourning as described by the Kubler-Ross model can be helpful as it can enable you to identify some of your responses after suffering a loss.

Many symptoms of clinical depression are also common reactions among grievers, such as difficulty concentrating, disrupted sleeping and eating patterns, fluctuating emotions, and decreased energy. However, it is essential to note that grief is a normal reaction to loss, while clinical depression is not and requires different treatment.

Unfortunately, the line between grief-related depression and clinical depression has become blurred, in part due to the adoption of non-existent stages of grief by medical and mental health professionals.

This confusion can lead to harm in two ways.

Firstly, those experiencing grief may believe depression is a stage that will eventually pass and, therefore, delay seeking help or taking action to improve their well-being.

Secondly, medical or psychological professionals may confirm a self-diagnosis of depression made by someone in the throes of grief and prescribe medication. While there is nothing wrong with medication to treat clinical depression, for those experiencing deep sadness at the loss of their loved one, it may be more helpful to remain open to the possibility of these feelings lifting in their own time.

This approach was confirmed in research conducted by the National Comorbidity Survey^[1] that revealed up to 25% of grieving individuals diagnosed as depressed and prescribed antidepressant medication are not clinically depressed. Instead, they may benefit more from supportive therapies that could prevent them from developing full-blown depression. Therefore, it is crucial to understand the distinction between grief-related depression and clinical depression and to approach treatment accordingly.

What does the depression stage of grief look and feel like?

According to the University of Washington, the depression stage of grief can look like:

• Sleep and appetite changes
• Reduced energy
• Reduced social interest
• Reduced motivation
• Crying
• Increased alcohol or drug use

It can feel like:

• Sadness
• Despair
• Helplessness
• Hopelessness
• Overwhelmed
• Disappointment

In this fourth stage of grief, the person experiencing loss comes to the realization and acceptance of death. The individual may feel stuck and unable to move forward. Previously, the grieving individual may have experienced denial, anger, or bargaining, but, in this stage, they may feel powerless to change the inevitable outcome. This is a natural response to circumstances beyond control, and it does not indicate a mental illness.

During the depression stage, grief permeates every aspect of life, leaving the person feeling empty and consumed with sadness. They may spend hours reflecting and crying, becoming silent and isolated. The grieving person may withdraw from social contact and refuse visitors, while the dying person may become bitter or harsh towards loved ones. These reactions allow the person to detach emotionally from those closest to them.

It is important to understand depression as a natural part of the grieving process, and it is not something that can be ‘fixed’ by loved ones. The duration of the depression stage varies from person to person. It can be influenced by factors such as the closeness of the relationship with the deceased, the circumstances surrounding the death, and the individual’s personality.

How to cope with the depression stage of grief

Several strategies can help manage the depression stage of grief:

• Accept support: It is important to accept help from friends, family, colleagues, and spiritual leaders who have been supportive in the past. Isolating oneself can exacerbate feelings of depression.
• Acknowledge your emotions: Try to accept and acknowledge all the emotions that arise without judgment. No feeling is wrong or right. Avoid self-criticism such as “I shouldn’t be feeling this way now,” which can intensify feelings of depression.
• Engage in meaningful rituals: Participating in rituals and routines can aid in processing and understanding the loss. For example, writing letters to someone who has passed away or following the traditions of one’s faith can help honor their life.
• Seek professional help if needed: If grief consumes your life and affects daily functioning, seeking professional support can be beneficial. It may be time to seek help if reminders of the loss are avoided, trouble accepting the loss persists after six months, or suicidal thoughts arise.

What is complicated grief?

Complicated grief, also known as ‘persistent complex bereavement disorder,’ is a condition that is triggered by the death of a loved one and can last for months, years, or even longer. Unlike normal grief, complicated grief can result in feelings of worthlessness and suicidal thoughts, similar to depression. While the exact number of people with complicated grief is unknown, it is estimated that approximately 10 million people in the United States experience symptoms severe enough to be considered as having Complicated Grief.

Complicated grief is distinct from depression, which is a clinical disorder that affects brain function and can manifest in various forms, such as major depressive disorder, postpartum depression, and psychotic depression. Although depression can be triggered by a traumatic event, such as the death of a loved one, it is treated differently than complicated grief.

What causes complicated grief?

Complicated grief is most commonly caused by the sudden death of a loved one, and while it does not have any identified biological causes, genetics, body chemistry, personality, and environment can play a role in its development.

What are the symptoms of complicated grief?

Symptoms of complicated grief include intense sadness, numbness, loss of purpose, and loss of trust in others. These symptoms can overlap with depression, which can also cause constant sadness, guilt, loss of interest in hobbies, and suicidal thoughts.

Complicated grief can be triggered by a history of trauma or abuse, a dependent relationship with the deceased, or violent deaths, such as those resulting from car accidents or natural disasters, which may also lead to post-traumatic stress disorder (PTSD). If you or someone you know is experiencing symptoms of complicated grief or depression, it is essential to seek help from a doctor or mental health professional.

What is the impact of complicated grief on the brain?

Studies have shown that complicated grief can activate areas of the brain associated with reward, such as the nucleus accumbens, which creates an intense longing for the lost loved one that is never fully satisfied 3. This may explain why complicated grief can persist for an extended period, resembling an addiction. Furthermore, complicated grief can stimulate the amygdala, resulting in avoidance behaviors that can exacerbate the addictive tendencies associated with this condition.

What are the treatment options for complicated grief?

If you are experiencing complicated grief, seeking professional help is recommended. Complicated Grief Therapy (CGT), which includes techniques such as retelling the story of your loved one’s death, can help you confront and accept your loss. CGT may also help you focus on building personal relationships and achieving personal goals.

Antidepressants may also be recommended, especially if you are experiencing depression symptoms that worsen your grief or if you have pre-existing depression. Antidepressants can help restore brain imbalances that cause depression and provide support while you work through your grief.

If you are struggling to cope with the loss of a loved one and feel your grief is overwhelming and prolonged, it is essential to speak to your doctor. They can assess your symptoms and determine whether you are experiencing complicated grief or depression. Your doctor can also help you decide on the best course of action, which may include therapy, medication, or both, to help you confront and accept your loss.

Does everyone go through all five stages of grief?

No. Some people go through some but not all five stages. Some never get to a place of acceptance. Grief is a complex, challenging, and unique experience, with everyone reacting to it in their own way.

People find other models of grief helpful – these are mentioned in the ‘What are the five stages of grief after a significant loss’ article.

What should I do if I cannot cope with grief?

If you or someone you know is experiencing suicidal thoughts, contact the National Suicide Prevention Lifeline at 988 for immediate support and assistance from a trained counselor. In cases of immediate danger, call 911.

For additional mental health resources, consult the National Helpline Database.

Help is out there for you if you feel you cannot cope with your grief or the ways in which you are managing are harmful. Equally, for some, grief can trigger a deep depression that can become entrenched.

Bereavement or grief counseling is available for those who need help in processing their loss. This type of therapy allows you to talk your feelings through with a professional experienced in this field, who can allow you the time and space to talk about your loved one and the emotions you’re experiencing. Don’t suffer alone.

The Center • A Place for HOPE is an award-winning treatment facility with over 37 years of mental and behavioral health leadership. We are a top ten facility for depression treatment, meaning that our caring and experienced staff are well-placed to provide you with professional excellence in various treatment options.

1 – Kübler-Ross, E. (2002) On death and dying; questions and answers on death and dying; on Life after death. New York: Quality Paperback Book Club.
2 – Greenberg, P.E., Kessler, R.C., Birnbaum, H.G., Leong, S.A., Lowe, S.W., Berglund, P.A., Corey-Lisle, P.K. (2003). The economic burden of depression in the United States: How did it change between 1990-2000? The Journal of Clinical Psychiatry, 64(12), 1465-1475
3 – https://www.apa.org/monitor/2018/11/ce-corner#:~:text=Mary%2DFrances%20O’Connor%2C,with%20reward%20(%20Neuroimage%20%2C%20Vol.