Grief after a death: when does it become depression that needs treatment?

Grief after a death: is what you are going through normal?

Grief after a death is a natural human reaction to loss, not an illness. It can hurt terribly, but for most people it eases gradually over time and usually does not need treatment, as the American Psychiatric Association (APA) explains. Grief has no fixed timetable and no single "right" way to do it: everyone grieves in their own way.

For some people, though, the pain does not settle. It grows heavier until it becomes depression that needs treatment, or what doctors call prolonged grief disorder (often known as complicated grief). This article explains the difference and when to get help.

What does normal grief look like, and how long does grief last?

The UK's National Health Service (NHS) and MedlinePlus, the medical encyclopedia of the US National Library of Medicine, describe feelings that are common after a loss, including:

• Shock and numbness in the first days, as if what happened is not real.
• Deep sadness, frequent crying and longing for the person who died.
• Anger at the circumstances or at other people, and guilt over something that was said or left unsaid.
• Tiredness, disturbed sleep and appetite, and a harder time working and concentrating.

Grief often comes in waves: it quietens for a few days, then suddenly returns. The US National Cancer Institute (NCI) notes that these bursts of grief can be set off by holidays, the anniversary of the death or giving away the person's belongings, and that they sometimes come with no clear reason. In Egypt and the Arab world, the first Ramadan or the first Eid without them can be among the hardest times. As for the famous five "stages of grief", the NHS points out that people do not necessarily go through all of them, or in the same order.

How long does grief last?

There is no length of time that fits everyone. MedlinePlus says the acute phase may last up to about two months and that milder symptoms may continue for a year or longer, while the NCI says that for most people symptoms ease between six months and two years after the loss. These are general figures, not deadlines you have to meet, and a sudden or violent death may take longer to come to terms with. What matters is the direction of the pain: is it slowly easing as you return to your life, or is it growing heavier and holding you back?

Grief or depression: when does grief turn into depression?

Grief and depression share crying, sleeplessness and loss of appetite. The APA and the NCI describe differences that can help you tell them apart:

• In grief, the pain comes in waves and is often mixed with warm memories of the person who died. In depression, low mood or loss of pleasure is more constant, most of the day and nearly every day.
• In grief, the way you see yourself usually stays intact. In depression, feelings of worthlessness or self-loathing are common.

So if you notice a lasting sense of being worthless, hopelessness that anything will ever get better, loss of interest in everything you used to enjoy, and being unable to get through your day for a long time, grief may have turned into depression. The APA also points out that when grief and depression occur together, the grief is more severe and lasts longer, so do not just wait for time to pass. Read more about the symptoms of depression and how it is diagnosed.

What is prolonged grief disorder (complicated grief)?

Prolonged grief disorder is a recent diagnosis. It was added to the World Health Organization's International Classification of Diseases, 11th revision (ICD-11), and to the revised diagnostic manual the APA published in 2022 (DSM-5-TR). It is intense, persistent grief that disrupts daily life, and its signs include:

• Intense, persistent longing for the person who died, or constant preoccupation with them.
• Sharp emotional pain: sorrow, bitterness, anger or guilt.
• Great difficulty believing the death has happened, and avoiding anything that is a reminder of it.
• Feeling that part of you died with them, or that life has become meaningless.
• Emotional numbness, intense loneliness, and difficulty getting back to people and interests.

But these feelings also appear in normal grief. That is why the disorder is diagnosed only when intense grief lasts a long time, clearly goes beyond what is expected in the person's culture and religion, and disrupts their life at home or at work. A published paper on the WHO criteria explains that grief which lasts a long time but stays within what is usual in the person's culture and religion counts as normal grief. Some researchers believe the line between this disorder and normal grief still needs more research, and they warn against treating ordinary grief as an illness.

According to a meta-analysis of fourteen studies published in 2017 in the Journal of Affective Disorders, about 9.8% of adults who lost someone to a non-violent death have this disorder, although the researchers advise reading the figure with caution. The APA lists factors that raise the risk, including a sudden or violent death, losing a child or a spouse or partner, a past history of depression and little social support.

Faith, mourning customs and family support: real sources of strength

In Egypt and the Arab world, people rarely grieve alone. There are the condolence gatherings (the 'aza), visits from relatives and neighbors, prayers and supplication (du'a) for the person who died, the fortieth-day remembrance (al-arba'in) and the yearly anniversary. The NCI notes that little social support makes it more likely that a person will struggle to adjust to a loss, so the support of family and friends makes a real difference. Studies on the role of religion do not all agree, but some have linked regular worship and the support of a religious community with coping better with a loss and understanding it more deeply.

Faith does not mean you must not grieve. Crying over someone you love is not an objection to God's decree, and patience (sabr) does not mean hiding your pain. If grief turns into depression or prolonged grief, seeking treatment is taking the means to recovery, just as you would for any other illness. It is not a sign of weak faith.

How can you support someone who has lost a loved one?

• Listen more than you advise, and let them talk about the person who died.
• Avoid phrases like "enough grieving now" or "you have to forget".
• The days of condolences end quickly, and loneliness begins after them: call and visit in the months that follow and on difficult occasions.

Men who hide their grief, and teenagers after a loss

Many men take charge of the funeral, the condolences and the family, then go back to work quickly without ever crying in front of anyone. The NCI notes that men who lose a wife tend to face more difficulties than women, including worse depression, and that this may be linked to the lower support they receive. The NHS points out that grief can change how you behave in ways you may not link to the loss, and it advises against turning to alcohol or drugs to cope. Read about depression in men and its hidden signs.

Teenagers aged 15 and over may not put their grief into words. Reactions the NCI describes in children aged 9 and older, teenagers included, are guilt and anger, mood swings, changes in sleep and eating, losing interest in activities outside the home, and not wanting to seem different from their peers. Ask them gently how they feel, and if they withdraw for a long time or show signs of depression in teenagers, get help. Oxygen Center sees teenagers from the age of 15, with a guardian's consent for those under 18.

When should you get help, and what if you wish you could join the person who died?

Book an appointment with a psychiatrist if you notice any of these signs in yourself or in someone you love, as the NHS and MedlinePlus advise:

• Intense sadness or guilt that does not ease as the months pass.
• Constant thoughts about the person who died, or ongoing difficulty accepting the death.
• Being unable to return to your work, studies or responsibilities.
• Depression or anxiety that is getting worse instead of better.
• Drinking more alcohol or using drugs to bear the pain.
• Thoughts about death or about ending your life.

When longing becomes a wish to die

Someone who has lost a loved one may say, "I wish I had gone with them." The APA notes that thoughts of "joining" the person who died can come up during grief. Even if they seem fleeting, talk about them with someone you trust or with a doctor. If they turn into a real wish to die or thoughts of ending your life, this is a warning sign that should not be left to time. Other warning signs listed by the US National Institute of Mental Health (NIMH) include talking about wanting to die or about being a burden, hopelessness, withdrawing from people, and saying goodbye to them or giving away important belongings.

If you notice this in someone you love, ask them directly and calmly: "Are you thinking about ending your life?" NIMH explains that asking about these thoughts does not plant them or make them worse. Listen without judging, do not promise to keep it secret, and do not leave them alone if they are in danger.

How are prolonged grief and depression after a loss treated?

Normal grief needs time and support. Prolonged grief, or depression that comes with a loss, has effective treatment. It starts with an appointment with a psychiatrist, who listens to the story of the loss, assesses grief, depression, sleep and any thoughts of death, and then agrees a plan with you that suits you:

• Grief-focused psychotherapy: the APA says treatments based on cognitive behavioral therapy reduce symptoms, including one that focuses on accepting the reality of the loss and on rebuilding your goals and your satisfaction with life. It is offered in regular therapy sessions.
• Treating depression if it is present: in a clinical trial of 395 people published in JAMA Psychiatry in 2016, therapy designed specifically for grief helped the most. Adding an antidepressant did not improve the grief itself any further, but it eased the accompanying symptoms of depression more. Only a doctor decides whether medication is needed.
• There is no medicine for grief itself so far, as the APA notes. Do not take sleeping pills or sedatives on your own, and do not start or stop any medicine unless your doctor decides so.

Oxygen Center offers doctor appointments and therapy sessions for men and women aged 15 and over. For severe cases that need round-the-clock care, inpatient psychiatric treatment is available for males, and the family can come alone first. Recovery does not mean forgetting the person who died. It means carrying their memory while being able to live again.