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Depression Differences: A Q&A with Psychiatrist Sidney Zisook, MD


By Gabrielle Johnston, MPH   |   May 04, 2018

​May is Mental Health Awareness Month, and depression is one the primary mental health problems faced by approximately 3.3 million Americans. But what is depression? Is it feeling blue for a few days, is it a consistent feeling of melancholy or is it sadness experienced after the loss of a loved one? Sidney Zisook, MD, psychiatrist at UC San Diego Health and professor of psychiatry at UC San Diego School of Medicine, talks about different types of depression as well as available treatment options.

Is there a difference between situational and clinical depression?

Sidney Zisook

Most psychiatrists no longer differentiate between situational and clinical depression. Part of the confusion stems from the wide use of the word depression. Depression commonly describes everything from the everyday blues, frustration, sadness and demoralization we all feel from time to time to a morbid clinical condition that can be life-threatening. I like to think of the first use of the term as depression with a small “d” and the second as depression with a big “D”. Small “d” depression does not require formal treatment, but rather responds to some combination of distraction, time, encouragement and support.

Big “D” depression has specific criteria psychiatrists use for diagnosis and is clinically known as Major Depressive Disorder (MDD). This form of depression is a serious disturbance in mood that is marked by persistent sadness and misery over weeks, months or even years. It usually consists of pervasive disturbances in the way we feel about ourselves and others, think, act, relate and function. In its more severe forms, MDD can be associated with feelings of worthlessness and self-loathing, and believing that life is no longer worth living because of feeling worthless, undeserving or an inability to cope with the unrelenting pain and mental agony that someone can feel. MDD often occurs in discrete episodes; each episode may or may not be triggered by environmental events, stresses or losses. Whether brought on by a stressful life event, or if the disturbance of mood is intense and persistent, treatment is usually indicated and may be life-saving.

What is “uncomplicated” grief?

The emotional response to the death of a loved one is called grief and is a universal, instinctual and adaptive part of the human experience. Grief touches us not only emotionally, but also physically, socially, cognitively and spiritually. It is not a clinical condition, and although often exquisitely painful and disruptive, it is not the same as big “D” depression. There are no prescribed ways of getting through grief, and each individual gets through it on their own terms, with uniquely individualized experiences, symptoms and time courses. Emotional expressions of grief, often occurring in waves, usually peak within days to weeks to months. Painful as it can be, grief is the way bereaved individuals come to grips with their loss and ultimately transition to a life where deceased loved ones are not forgotten, but rather find a comfortable place in the bereaved individual’s hearts and memories.

What is complicated grief?

For a small percentage of bereaved individuals, the smooth passage described above is blocked and successful adaptation to a loss does not occur. Instead, a condition we call “complicated grief” may ensue. Complicated grief is marked by its unusual intensity, lasting well beyond the period expected by social and cultural norms and is accompanied by impairments in daily functioning. Symptoms include persistent, intense yearning, longing and sadness. These symptoms are often accompanied by an inability to accept the painful reality of the person’s death, insistent thoughts or images of the deceased, rumination focused on angry or guilty recrimination related to circumstances of the death and avoidance of reminders or attempts to “hold onto” the deceased person by remaining tethered to any and all reminders.

How is complicated grief different than depression?

Complicated grief can be differentiated from MDD in that loss and loneliness, rather than persistent and pervasive unhappiness, are the predominant preoccupations. Yearning and longing for the deceased person are common; bursts of painful emotions, thoughts and bodily sensations occur in waves that diminish in intensity and frequency over time; guilt tends to center on deeds done or not done in relationship to the deceased; all-consuming thoughts of worthlessness are not common; and suicidal feelings are more about joining the deceased than of being undeserving to live. It is important to recognize that sometimes bereavement may trigger both complicated grief and MDD in the same individual. Individuals with a history of MDD may be more likely than others to experience complicated grief after the death of a loved one, and individuals experiencing complicated grief may be especially vulnerable to MDD.

Are there treatments for MDD and complicated grief?

There are excellent treatments for both MDD and complicated grief. For MDD, a variety of antidepressant medications and evidence-based psychotherapies have been demonstrated to be effective. Often a combination of both medication and psychotherapy are better than either alone. For complicated grief, grief-targeted psychotherapy has been demonstrated to be a very effective treatment, helping bereaved people find ways to ease their pain and restore meaningful connections to others, a sense of purpose and the possibility for happiness.

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