Measuring Grief and Depression in Seriously Ill Outpatients Using the Palliative Grief Depression Scale

Abstract

Almost all persons experience grief when faced with a serious illness.1,2 The grief experienced by seriously ill patients often manifests as physical symptoms (insomnia, loss of appetite, etc.) and emotional, social, spiritual, cognitive, and behavioral changes through which a person attempts to resolve or adjust to the losses imposed by the serious illness. Depression, while common in seriously ill patients, is neither a normal nor a universal phenomenon.3 Depression is underdiagnosed in seriously ill patients, though the prevalence is high. In a recent meta-analysis4 which reviewed 70 studies with 10,071 individuals across 14 countries in oncological, hematological, and palliative care settings, the prevalence of Diagnostic and Statistical Manual of Mental Disorders (DSM)-defined major depression was 14.9% (range: 12/2%–17.7%); for DSM-defined minor depression, 19.2% (9.1%–31.9%); and for all types of depression, 20.7% (12.9%–29.8%). Persistent dysphoria, anhedonia, a sense of hopelessness, helplessness, worthlessness, and an active and persistent desire for an early death could be manifestations of depression2,3 in seriously ill patients. Depression, when present, significantly diminishes the quality of life of these patients and likely complicates the presentation and optimal palliation of other distressing symptoms such as pain and fatigue. Distinguishing between grief and depression in seriously ill patients is vitally important, as the treatments differ.3 Normal grief, an adaptive process, often responds well to counseling and ongoing support. In contrast, depression is a pathological state causing significant distress and needs to be treated with a combination of nonpharmacological and pharmacological modalities. If diagnosed and treated appropriately, depression can be palliated effectively in seriously ill patients.5 Differentiating grief from depression in seriously ill patients Differentiating between grief and depression2,3 is especially challenging in a seriously ill patient population due to the following reasons: (1) grief and depression share common symptoms and may coexist; (2) many of the somatic symptoms traditionally used to diagnose depression (appetite, weight and libido changes, loss of energy, insomnia) may be present as a part of the serious illness process or due to grief; (3) the affective changes used to identify depression (sadness, crying) are also seen in grief; (4) there is a common misperception that depression is a universal and normal phenomenon in a seriously ill population. Thus clinicians may fail to routinely screen these patients for clinical depression. Therefore there is a great need for a robust instrument that will aid in measuring grief and distinguish it from depression in a seriously ill population.