Grief, unresolved grief, and depression

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  • SIDNEY ZISOOK, M.D.

    RICHARD A. DeVAUL, M.D.

    Grief, unresolved grief:and depression

    Dr. Zisook is associate prOfessor ofpsychiatry at the University of California, SanDiego, School of Medicine and Dr. De Vaul is associate professor ofpsychiatry andbehavioral sciences at The University of Texas Medical School at Houston. Reprintrequests to Dr. Zisook, Department of Psychiatry, University of California, SanDiego, School ofMedicine, Gifford Mental Health Clinic, 3427 Fourth A venue, SanDiego, CA 92103.

    ABSTRACT: For examination of relationships between grief,unresolved grief, and depression, 211 subjects completedquestionnaires designed to measure grief, identify unresolvedgrief, and measure depression. Fourteen percent of the studypopulation showed evidence of unresolved grief. This group wasyounger, less likely to have attended the funeral, and moredepressed than the resolved-grief group. Depression is likely tobe more severe with unresolved grief, which tends to persist oncepresent. The results are discussed in relation to the relevantliterature.

    Grief, the constellation ofsigns andsymptoms following a personallysignificant loss, is generally con-ceptualized as a dysphoric but self-limited process. As experienced byan adult, it ordinarily follows anoverlapping sequence of phasesbeginning with a brief period ofshock and denial, merging into aphase of acute dysphoria, and end-ing with a period of resolution. l .s

    Occasionally this process becomes

    deviant, and one or more of thephases of grief is absent, delayed,intensified, or prolonged. This oc-currence has been variously de-scribed as morbid,2 atypical,4pathologic,6 or neurotic' grief.Symptoms of deviant grief seem todiffer in degree rather than in kindfrom ordinary grief.8 We have pre-viously conceptualized these syn-dromes as effects of nonresolutionof the usual stages of the grief

    process and therefore prefer theterm "unresolved grief."9 Whileunresolved grief may present clini-cally in various forms, such as psy-chotic denial, pathologic identifica-tion with the deceased, or chronicdepression, this report explores therelationships between grief, unre-solved grief, and depression.

    The relationship between lossand depression is well established.As recently reviewed by Lloyd,1Ochildhood bereavement and a vari-ety of adult losses, including be-reavement, increase the risk for de-pression. In a series of studies byClayton and associates,II-16 depres-sion was found to be a commonaccompaniment of widowhood.This depression could not be dis-tinguished from the depression ofthe nonbereaved control groups onthe basis of symptoms. However,depression following death of aspouse was not more common inwomen than in men, not associatedwith a family history of depressionor with previous depressive epi-sodes, not likely to be treated bypsychiatrists, nor associated with asubjective sense of being ill.

    MARCH 1983 VOL 24 NO 3 147

  • Grief and depression

    -

    Table 1-Past Behaviors Endorsed as Mostly orCompletely True by over 50% of Respondents

    Table 2-Present Feelings Endorsed as Mostly orCompletely True by over 50% of Respondents

    Depression Scale.'~

    7977737265

    5351

    89878478676460

    % ofrespondents

    %ofrespondents

    Results

    Two hundred and eleven complet-ed questionnaires were receivedfrom all areas of the United States.Most of the respondents were fe-male (62%). well educated (13.7years), middle class (mean familyincome of $15,000), white (65%white, 17% black. 11% Mexican-American, 7% other), middle-aged(mean of 36.5 years with a range of19 to 74), and Protestant (47%Protestant, 26% Catholic, 13% Jew-ish. 13% other or none). The de-ceased had expired at a mean age

    I am now functioning about as well as beforeI feel I have adjusted well to the lossI very much miss the personNo one will ever take his/her place in my lifeNow I can talk about the person without discomfort

    I grieved for the person who diedI attended the funeralI criedI kept thinking about him/herI was depressedIt was hard to believe the person had diedI was shocked to learn he/she had diedII took me a long time to really acceptthe person's death

    I felt empty inside

    most closely approximated thosecharacteristics used clinically by usto help identify unresolved griefwere chosen to comprise an Unre-solved Grief Index: (I) "I feel 1have grieved for the person whodied"; (2) "Now I can talk aboutthe person without discomfort";and (3) "I feel I have adjusted wellto the loss." This somewhat arbi-trary, but clinically based, indexwill be examined further in theDiscussion.

    In addition to the Grief Invento-ry and Unresolved Grief Index,each respondent was asked to care-fully complete a Zung Self-Rating

    Depression, like unresolvedgrief, is a relatively common con-sequence of bereavement. The na-ture of the relationship betweendepression and unresolved grief,however, remains unclear. We havepreviously postulated that severedepression would be seen more fre-quently in unresolved grief. Thusfar we are unaware of any empiri-cal evidence that confirms the rela-tionship. This study attempts to ex-amine the relationship based on theresults of a questionnaire survey ofa nonclinical population.

    The surveyIn an effort to develop a reliableand valid instrument to better de-scribe and measure grief. the au-thors developed the Texas Invento-ry of Grief, a 14-item self-reportscale. 17 Based on the literature ofnormative and atypical grief reac-tions, as well as the clinical experi-ence of the authors, the original14-item inventory was expanded to58 items. ls To obtain normativedata, the instrument was sent tofriends and colleagues around thecountry so that they could ask oneor two friends or neighbors whohad lost a relative or close friend tocomplete the questionnaire.

    The respondents were asked togive their age, sex, race, religion,educational level, relationship tothe deceased, length of time sincethe death, and the age of the de-ceased. They were asked to checkone of the five responses on each of24 items relating to their feelingswhen the person died (the Past Be-haviors list) and 34 items pertain-ing to present feelings (the PresentFeelings list). The possible re-sponses for each item were: com-pletely true, mostly true, partly trueand partly false, mostly false, andcompletely false. Three items that

    248 PSYCHOSOMATICS

  • Table 4-Zung Items Significantly Relatedto Unresolved Grief I

    ings list that the majorIty of re-spondents felt were mostly or com-pletely true about them. Grief-related present feelings peaked be-tween one and two years followingthe loss (P< .05), but continued tobe substantial even ten or moreyears later. Table 3 shows the per-cent of respondents endorsing eachof the three items comprising theUnresolved Grief Index. Unlike thetotal Present Feelings score, theUnresolved Grief Index score didnot change as a function of time-when present, it tended to remain.

    .. 0' respondentsby category

    0' respons.t0 1 2 3 4

    I grieved for the person who died 86 1 1 1 11I feel I have adjusted well to the loss 58 19 8 3 11Now 1can talk about the personwithout discomfort 43 22 16 5 14

    Table 3-Unresolved Grief IndexOn the Unresolved Grief Index,

    with a score of 0 to I denotingresolved grief, and 6 or more asdefinitely unresolved grief, 14%(30) of our population showed evi-dence of unresolved grief. Thisgroup was no different from itscounterparts with resolved grief(37% or 78 persons) in terms ofeducational level, income, sex, timesince death, age of the deceased, orrelationship to the deceased. Onthe other hand, the unresolved griefgroup was younger (39 years vs 31years, P

  • SINEQUAN Cdoxepin Hel)Re ereflCe 1 Barranco 5F. Thrash ML. Hac ell E Frey J. el al (Pllzer f'harmaceullCaJs. PhzerInc ow 'brl
  • chiatric disorders, an increased riskfor the onset of medical illness, andprolonged social incapacitation areall associated with grief. Clinicalevidence suggests that unresolvedgrief may account for all or most ofthis medical risk. For example,Schmale,24 in a study of the fre-quency of loss antedating medicalhospitalization, found the effects ofhopelessness and helplessness(unresolved griet). rather than thefact of the loss itself. to be thecrucial factor. Both an increase25

    and a decrease21 of acute responsesto bereavement have been relatedto later complications. Jacobs1b

    suggests that the process of griefacts as a bridge between loss andillness or death, and David22 statesthat unresolved grief (not just loss)in childhood or adolescence leadsto later problems.22 Zisook27 foundunresolved grief a major charac-teristic of grief-related facsimile ill-ness, namely, the phenomenon inwhich pathologic identificationwith the deceased presented in theform of the terminal illness. At theminimum, resolution of the griefprocess appears related to healthand adjustment.

    Our findings suggest a relation-ship between unresolved grief andother complications, especially de-pression. By our index, individualswith unresolved grief were signifi-cantly more depressed as measuredby total Zung scores and numerousitems on the Zung scale. Althoughno cause and effect relationship canbe defined, it does appear that per-sons who report that they havegrieved, adjusted to the loss, andcan talk about the deceased with-out difficulty are less likely to bedepressed than those who indicatethat they have not grieved.

    Our results support previous re-ports that a significant proportion

    MARCH 1983 ' VOL 24 ' NO 3

    of bereaved individuals go througha somewhat typical grief process inthe sequence previously men-tioned. Sixty-four percent of ourpopulation acknowledged a stageof shock and disbelief. In the nextstage of acute dysphoria, 80% feltthat they had grieved for the personwho died, 84% cried, 78% keptthinking about him or her, and 67%felt they were depressed. A majori-ty of the respondents showed evi-dence of reaching the third stage ofresolution. Although 73% stillmissed the deceased and 72% feltthat no one would ever take his orher place, 79% believed that they

    Once present, unresolvedgrief tended to remain,suggesting the need foractive inten'ention whenidentified.

    were functioning as well as theyhad previously, 77% felt that theyhad adjusted to the loss, and 65%stated that they were able to discussthe deceased without difficulty.Present grief-related feelings andbehaviors peaked in intensity be-tween the first and second years,and gradually diminished thereaf-ter.

    Unresolved grief, on the otherhand, did not significantly changeover time. Once present, it tendedto remain, suggesting the need foractive intervention when identified.Factors found in the literature3.5.2oto impede the resolution of griefinclude lack of social supports, thebereaved's psychological makeup,substance abuse, age, multipleprior losses, ambivalent or over-in-vested relationships to the de-ceased, and fortuitous factors. In a

    large epidemiologic study ofwidows and widowers, Parkes25

    found four major factors that pre-dicted poor outcome: low socioeco-nomic status; a short terminal ill-ness with little warning of impend-ing death; multiple life crises; andreactions to bereavement that in-clude severe distress, yearning,anger, or self-reproach. His studydid not find demographic factorsimportant, nor did he confirmMaddison's finding2M that supportfrom family relationships or closefriends was especially significant.

    We found demographic factorsnot particularly related to outcome,the one exception being the age ofthe bereaved. Younger individualstended to have more unresolvedgrief. This is consistent with Parkes'and Maddison's finding thatyounger widows had more illnessesthan older widows, and with Clay-ton's finding29 that younger widowshad more physical and depressivesymptoms and hospitalizations.

    In addition, our respondentsidentified as having unresolvedgrief were less likely to have at-tended the deceased's funeral. Thisis consistent with Volkan's concIu-sion30 that persons exhibitingpathologic grief often fail to par-ticipate fully in funeral rites. Ourunresolved grief group also hadoverall present and past grief scoresmore consistent with Parkes'4.25finding that, instead of delayed orinhibited grief leading to latercomplication, the most disturbedindividuals after one year werethose most disturbed three to sixweeks after bereavement.

    ConclusionIn our study a significant percent-age of bereaved individuals did notcom pletely resolve their grief.These persons tended to be

    (continued)

  • Refamca: 1. laoob!on A et aI: Psychophysi%sY7:345. Sep 1970.2. LynchT. Creme Vf: IfrColJPhys Surs 4:87-90. Ian 1975. J. lames NM. MontasueAf:NZ Med 181 :246-248. Mar 12. 1975. 4. TawsER. Brunning ,. A!enmas L: Ifni Med Res 3:417-422.lun 1975. 5. Broadhurst AD. A!enOIas L: GUT Med ResOpin 3:413-416. lui 1975.6. Data on file. HoIImann-La Roche Inc.. Nutley. NI. 7. KaJes A et a/: I Clin Phar-macoII7:207-213. Apr 1977. 8. GreenblaU 01. AllenMD. Shader R/: Clin Pharmacol Ther 21:355-361. Mar1977. 9. Monti 1M: Methods Find up Clin Pharmacol3:303-326. May 1981.

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