Considering Bereavement Anew (Part 2 of 2): Clinical Assessment of Grief

by Sandra Haas Binford, MAEd

Introduction

Grief can affect a person's life to the point where it changes from normal feelings of loss of a loved one to a serious clinical entity. For some, grief can lead to pathological grief, serious dysfunction, and even dangerous psychiatric symptoms. Though it may be obvious to some, any symptoms that include suicidal ideations, homicidal ideations, or psychosis constitutes a psychiatric emergency in the realm of major depressive disorder (MDD).

Part 1 in this series, Considering Bereavement Anew: Definition and Assessment Approach, outlined distinctions among bereavement, normal grief, and prolonged (complicated) grief, calling upon clinicians to consider whether their bereaved patients are moving through the grief process or have become mired down to the point where functional performance is affected.

The focus of this article, Clinical Assessment of Grief, is the differential diagnosis of bereavement and major depressive episode (MDE). Please note, as one episode of MDE can constitute MDD,(1) these terms are used interchangeably.

Review of Grief Symptoms

The DSM-IV-TR states: "After the loss of a loved one, even if depressive symptoms are of sufficient duration and number to meet criteria for a Major Depressive Episode, they should be attributed to Bereavement rather than to a Major Depressive Episode, unless they persist for more than 2 months or include marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation." DSM-IV-TR lists bereavement in the V Code section, placing it among conditions that may be the focus of attention or treatment but that are not directly attributable to a psychiatric disorder.(1)

Therefore, once it is known that a patient has experienced a meaningful loss, the clinician's challenge and opportunity is to identify those patients exhibiting symptoms that may require explanation or intervention given current psychiatric guidelines. Table I highlights the diagnostic differences between MDD and bereavement.

* Excerpt and adaptation from Auster T, Moutier C, Lanouette N, Zisook S. Bereavement and Depression: Implications for Diagnosis and Treatment. Psychiatric Annals 2008;38(10):655-661.

As noted, Table I does not specifically name prolonged grief. However, as mentioned in Part 1 of this series, members of the psychiatry community have proposed a category for prolonged (complicated) grief in DSM-V.(3) There are diagnostic criteria for symptoms of grief that exceed the norm but differ from or do not meet the criteria for a major depressive episode (MDE) that can be assessed using the Inventory for Complicated Grief—Revised.(4,5) More information about this assessment tool will follow under Prolonged (Complicated) Grief Screening, below.

The DSM-IV-TR identification of several atypical symptoms that are not associated with a normal course of bereavement are worth mentioning: "1) guilt about things other than actions taken or not taken by the survivor at the time of the death; 2) thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person; 3) morbid preoccupation with worthlessness; 4) marked psychomotor retardation; 5) prolonged and marked functional impairment; and 6) hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person."(1)

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Screening Approach

It is important to evaluate the impact of grief using careful psychiatric interview questions or validated screening tools. However, little evidence recommends one screening method over another; therefore, clinicians may choose the method that is most consistent with their personal preferences, the patient population being served, and the practice setting.(6)

All positive screening tests should trigger full diagnostic interviews that use standard diagnostic criteria from the DSM-IV-TR to determine the presence or absence of specific depressive disorders, such as MDD or dysthymia. The severity of depression and comorbid psychological problems (for example, anxiety, panic attacks, or substance abuse) should be addressed.(6)

Clinicians may choose to pursue one of these two assessment approaches:

1. A detailed psychiatric, diagnostic interview that should be more in-depth than usual because patients are not always forthcoming with grief information.
2. Office screening tools that may guide the interview process and expedite the evaluation. Depression screening tools can focus the psychiatric interview, so their use may be a particularly useful approach for clinicians who take a psychometric point of view or who work in primary care and need to consider a great variety of presenting problems.

The Psychiatric Interview for Grief Symptoms

Listening for Grief

Although accepting the death of a loved one is a fact of life that all of us must face, there are some individuals who become "stuck" in the grief process and progress onto a clinical diagnosis. These are the individuals on whom we will focus.

A key component of the interview process for any clinician is to think beyond simple or superficial questions and to see information that someone may not readily come forward with. Clinicians need to listen with the "third ear," their clinician's ear. Asking questions and really listening to a patient's answers is a well-honed skill that is developed over time. (This is a feat that is not always easy for busy primary care clinicians who are focused on listening for a "chief complaint" phrase from an interview so they can expedite a rapid diagnosis and move toward a treatment solution.)

Listening between the lines is not an easy step for some clinicians and requires the art of paying attention. If asked quickly, most people will respond to the question, "How are you feeling?" with "fine" or "I am doing okay." But if this question is put in the context of a person's day or life, perhaps the question will produce different responses. For example, if the clinician says in response to 'fine,' "Is this the case all of the time, or are there times when you don't feel so fine?" This question moves beyond a superficial "How are you?" to a more in-depth query.

A patient can experience bereavement many years after a loss occurred. This may cause patients to underestimate the effects of loss in their personal lives or may lead to long-term guilt over not "getting over it." In either case, they could ignore or fail to mention grief as a meaningful part of psychiatric history. Further, it is possible even among clinicians who know individual patients well to assume that a long-past death no longer bears discussion.

Patient Care Time and Format

Some clinicians who work often with bereavement suggest that having 90-minute initial evaluations can make a difference in the information obtained. Such long evaluations are not typical because many clinicians may not have the opportunity to devote such significant amount of time and attention to each patient. Psychiatrists and psychologists may have 50-minute initial evaluation appointments; sometimes such time is also scheduled for follow-up appointments in these practices. The common perception is that primary and other specialty care clinic visits are short, but how much time does it take to evaluate grief symptoms?

Appointment format is also relevant. Short, focused, interview questions are useful in a practice that does not routinely use psychiatric assessment tools. A question that identifies that additional screening might be necessary is, "Has there ever been a death of a significant person in your life where the loss of that person changed you?"(7)

The U.S. Preventive Services Task Force reviewed evidence about the accuracy of screening instruments in identifying depressed adults. Findings point out that "many formal screening tools are available, including instruments designed specifically for older adults. Asking 2 simple questions about mood and anhedonia ('Over the past 2 weeks, have you felt down, depressed, or hopeless?' and 'Over the past 2 weeks, have you felt little interest or pleasure in doing things?') may be as effective as using more formal instruments."(6) These questions are nearly identical to questions on the 2-item Patient Health Questionnaire (PHQ-2), discussed below.(8,9)

Mental Status Exam

Elements of the mental status exam(10) can provide insights into grief symptoms with or without major depressive disorder. Some points to cover are:

• Cognitive deficit: Rule out dementia.
• Mood: Focus in on the major elements relevant to mood and depression. Note affect and appearance.
• Psychopathology: In particular, make sure that there is no evidence of psychosis or major psychopathology. Assess for morbid thoughts and anger at self or others (suicidality or homicidality). For instance, ask, "Do you think you'd be better off dead?"
• Sleep: Do they have difficulty sleeping? Falling asleep, staying asleep, early-morning awakening? Do they lie in bed in the day? Do they have disturbing dreams? What time do they get up?
• Social activity: Do they get out with others? Are they interacting with others and family members? How would others describe their mood and interactions with others right now?
• Appetite: Has their appetite changed? Are they interested in food?
• Activities: Are there any changes in their daily routine? Do they have any interests such as reading the newspaper or doing hobbies? Are they working inside or outside the home?

Monitoring Progress

Clues to diagnosis may be found in the assessment of daily functioning and thought. If a clinician is searching for clues, not only validated instruments may reveal progress of symptoms from bereavement and grief to depression. A clinician who is pressed for time can suggest that a patient should keep a written or spoken journal about answers to certain questions each day, for instance:

1. How do you feel?
2. What is your predominant thought about yourself today?
3. When did you sleep over the last 24 hours?
4. What were your activities today?
5. Describe your work and life today.

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Assessment Tools and Questionnaires

One reason for screening is that patients may not be forthcoming with bereavement-related information. They may answer questions in a simplistic fashion and not understand the clinician's direction with questioning (or be too depressed to care). Standardized, validated tools for depression screening can help define where a person's progress through the grief process stands, supplementing in-depth or regular patient interviews to discern whether a patient continues to move through the process of bereavement or is lost in the search for a different identity.

Akizuki and colleagues reported that major depression and adjustment disorders were common among patients with cancer and caused serious effects on quality of life. They studied depression and anxiety in terminally ill patients. Terminally ill patients and their bereaved relatives both experience the continuum of anticipatory grief that extends, in the case of the bereaved, to grief after a loved one's death.(3) The authors suggest consistent use of screening tools among the bereaved.(12)

Screening for grief symptoms is appropriate in any patient who volunteers information that a loved one has died. Validated, reliable assessment tools help the clinician ascertain the levels of cognitive and functional distress that a grieving person experiences. They can be of value to assist in an accurate diagnosis because bereavement is a highly varied process. Using screening tools also helps save time and avoid the need for repeated follow-ups by providing a tool that asks the most pertinent questions at once, helping the clinician.

Longer Questionnaires and Tools

Anxiety and Mood Screening
While the anxiety-oriented symptoms of bereavement are not discussed here, if the clinician is concerned that a patient's symptoms are more closely aligned with those of adjustment disorder with or without depressed mood, then use of an anxiety assessment tool may also be useful. The Structured Clinical Interview for DSM-IV (SCID Non-Patient Version) screens for both anxiety and mood disorders.(13) The SCID is a reliable and valid tool for assessing criteria for DSM-IV mood disorders (including MDD) and anxiety disorders including generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and panic disorder (PD).(14) This is a longer tool that is often used in research.

Mood Screening
The 9-question Patient Health Questionnaire (PHQ-9) is usually self-administered and clinician-scored. It (1) assesses symptoms and functional impairment using the diagnostic criteria for major depressive disorder in the DSM-IV to make a tentative diagnosis of depression, and (2) derives a severity score that translates to advice on monitoring and treatment.(15) It has become the recommended depression measure in primary care settings(16) and would be useful in assessing progression of grief symptoms into MDD. Compared with the SCID mood disorders module, the PHQ-9 results showed a sensitivity of 77% and a specificity of 100%.(16)

An online version of the PHQ-9 is available through the MacArthur Initiative on Depression and Primary Care and may be found with scoring information. The design measures the two components of symptomatology and functional impairment, which the Initiative recommends. It also recommends regular use of a chronicity question to aid consideration of mild chronic depression (dysthymic disorder). Because several steps are required to score the PHQ-9, some have suggested using a simpler scoring proxy system to estimate diagnostic categories.(17) However, average time to administer the tool was 5 minutes(8) and scoring time was seconds.(16) (See sample scoring at www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/questionnaire_sample/ and retrieve the free toolkit for primary care at www.depression-primarycare.org/clinicians/toolkits/.)(9)

The Hamilton Depression Rating Scale (HAM-D)(18) has been a standard for the assessment of depression for more than 40 years. The ten-item Montgomery-Åsberg Depression Rating Scale (MADRS)(19) is also used to measure the severity of depressive episodes in patients with mood disorders. Each scale assesses a constellation of symptoms. In the case of the HAM-D, the original scale proposed by Hamilton contained 17 items that were considered most consistent in detecting change. Other HAM-D items were developed and added over time by Hamilton and other researchers. In general, the most commonly used forms of theHAM-D are the original 17-item version and the later 24-item version. In the case of the MADRS, a smaller symptom set of only 10 items is used. There is overlap in the phenomenology of the symptom survey conducted by the HAM-D and MADRS, but there are also some differences. For instance, the HAM-D gives more representation to the areas of anxiety and physical symptom distress than the MADRS does. The HAM-D also surveys a wider range of purely psychiatric symptoms than is seen in the MADRS. Nevertheless, it is generally accepted that the HAM-D and the MADRS are well correlated with each other.(20)

The Brief Symptom Inventory (BSI) includes measures on depression, obsessive/compulsiveness, anxiety, phobic anxiety, hostility, psychoticism, paranoia, and somaticism. The BSI administration time is 8 – 12 minutes.(21) This self-report scale was developed over 25 years ago from its parent instrument, the 90-item Symptom Checklist—Revised (SCL-90-R) by Leonard Derogatis, PhD, and has good convergent and construct validity results from psychometric evaluation.(22)

Prolonged (Complicated) Grief Screening
Prigerson and colleagues (2009) have proposed and tested criteria for a new diagnosis involving cases of complicated grief, prolonged grief disorder. While the psychiatry community has not adopted these criteria, they "appear able to identify bereaved persons at heightened risk for enduring distress and dysfunction"(4) and so may be useful to the practicing clinician who is working to discern grief from major depression in a given patient.

The Inventory of Complicated Grief—Revised (ICG–R), a 19-item measure, can be used to assess a single underlying construct of complicated (prolonged) grief. This tool assesses a distinct cluster of symptoms that have been found to predict long-term dysfunction and is based on previous empirical literature that confirms the distinction between complicated grief, anxiety and depression. Validity testing by Prigerson and colleagues showed high internal consistency, high test-retest reliability estimates, good convergent and criterion validity, and good correlation of the ICG total score with measures of depressive symptoms and a general measure of grief. Scores above 25 indicated significantly greater impairment in social, general, mental, and physical health functioning and in bodily pain. It appears to be an easily administered tool to assess for complicated grief. However, the researchers call for longitudinal research to determine the extent to which the ICG–R is able to predict individuals at risk for complicated grief responses over time.(5)

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In Search of Very Short Questionnaires

A short questionnaire that can be accurately and orally administered would be useful.(23) For instance, use of the simple, mnemonic, 4-question CAGE interview was developed to help screen for alcoholism. However, in one study, about half of physicians polled said that they have heard of the CAGE questionnaire, but just 14% could recall all 4 questions.(24)

The 2-Item Patient Health Questionnaire (PHQ-2)
Phelan and colleagues (2010) also suggested that brief screening tools are preferable for use in primary care settings; therefore, the authors also examined the PHQ-2 in identifying patients with major and minor depression.(8) The PHQ-2 is an abbreviated version of the PHQ-9 and consists of the first two symptomatology questions about depressed mood and anhedonia;(8) please note that it does not include the functional impairment question. As with the PHQ-9, Phelan and colleagues documented better sensitivity and specificity of the PHQ-2 than of the 15-item Geriatric Depression Scales (GDS) at the standard minimum scores for major depression; but like the PHQ-9, it also risked missing cases because of its lower sensitivity at those scores.

The PHQ-2 items are:(8,9)
Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?

0. Not at all
1. Several days
2. More than half the days
3. Nearly every day

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

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Bereavement Assessment in Older Populations

Bereavement is a concern in individuals of all ages. However, older persons are more likely to lose spouses, siblings, and other loved ones, even grown children, to illness or "old age." In fact, in the United States, the mean age of widowhood or widowerhood is 69 years for men and 66 years for women. Forty-five percent of women and 15% of men over the age of 65 have lost a spouse. Widowers are more likely to remarry after losing their wives, so women more commonly remain widows, however, older men are at higher risk for mortality than are women after the loss of a spouse.(30) Therefore, it makes sense to evaluate grief and depression in this population and to consider specific measures of depression that are validated for use in older populations.

Phelan and colleagues' 2010 study of PHQ-9 and PHQ-2 tested sensitivity and specificity in a population of older persons. As in other studies, they state, the low score that indicated major depression required modification to achieve the best balance between sensitivity and specificity for elderly populations. Even with modification of the scoring level, they found that the PHQ-2 performs less well for detection of major depression among older persons in primary care than in younger adults, where sensitivity and specificity have been reported to be 83% and 92% respectively. Their finding was consistent with the one other study of the PHQ-2 for detecting major depression in older primary care patients, which found a sensitivity of only 79% and specificity of 58% with a score of 1 or greater.(8) If you find that the PHQ-9, PHQ-2, or GDS is appropriate for use in your clinical population, you may need to consider Phelan and colleagues' modified minimum scores, which offered the best combination of sensitivity and specificity: a PHQ-9 score ≥ 9, a PHQ-2 score ≥ 2, and a GDS score ≥ 7. Broadening the definition of depression to include depression of lesser severity and dysthymia did not improve the sensitivity of depression screening instruments as it did in other studies.(8)

In the assessment of cognitive function, it is important to consider the effects of comorbid medical illness or dementia. Assess appropriate appearance, determining whether any poor appearance may be attributable to age-related, functional difficulty with bathing, dressing, or activities of daily living. Differential diagnosis of grief may require analysis of signs and symptoms of all present illness.

Finally, consider symptom-tracking measures that may be comfortable for different populations of bereaved individuals. For instance, older persons with arthritis in the hands may prefer to speak aloud into a recorder. Those with a lifelong history of writing letters may prefer to journal every day. Those who enjoy charts for the efficiency that they bring might appreciate a list of questions with days of the week or month ready for scoring by symptom.

"To Treat or Not to Treat" the Depression Diagnosis

Some consternation has developed about the removal of the bereavement exclusion for depression in the draft DSM-5.(31) The concern is that the change may cause individuals who are grieving to automatically receive diagnoses of major depressive disorder.(32) However, Kenneth Kendler, MD, states that "there are little to no systematic differences between individuals who develop a major depression in response to bereavement and in response to other severe stressors," and further that "the vast majority of individuals exposed to grief and to … other terrible misfortunes do not develop major depression as described in the diagnostic criteria."(32)

One question is whether one treats the pain of grief just as one would treat the pain of a broken leg.(31) Little or no clinical evidence exists showing that the grieving process affects outcomes.(31) Holly Prigerson, PhD, a well-known bereavement researcher, says that "it is not yet known whether the pain of normal grief actually helps people to process their loss."(31) Should a grieving person receive any form of therapy if the pain of grief does not meet MDD criteria? Should a person, conversely, not receive any form of therapy if the pain of grief does not meet MDD criteria? If a diagnosis of "prolonged grief" is added to the DSM-5, will treatment be encouraged beyond the point at which it occurs today? Will clinicians monitor symptoms of regular grief, prolonged grief, and MDD before initiating treatment?

If a valid depression or anxiety diagnosis is given, clinicians should develop an individualized monitoring or treatment plan for each patient. For those who are not helped by mutual-support groups, psychotherapy is known to help patients in bereavement; this is particularly true for those at high risk for grief-process difficulties: people who have a history of mental illness; who have experienced multiple adverse life events or losses; have poor health, lack of social support, or life stresses; or who are bereaved as the result of an accident in which the survivor may have been at fault.(33) Expansive discussion of the various therapies used to address bereavement is beyond the scope of this article, however psychotherapy and/or pharmacotherapy may be indicated in patients who have been identified through the use of reliable, valid diagnostic tools and whose symptoms have progressed to indicate a major depressive episode. If symptoms have progressed at any time, whether before or after 2 months of loss, to dangerous symptoms, treatment intervention is warranted: suicidal ideations, homicidal ideations, or psychosis. Treatment may also be warranted if symptoms match the DSM-IV-TR identification of atypical symptoms that are not associated with a normal course of bereavement, listed under Review of Grief Symptoms, above.

Dr. Kendler reminds us that "diagnosis in psychiatry, as in the rest of medicine, provides the possibility but by no means the requirement that treatment be initiated. Watchful waiting is important tool for all skilled clinicians."(32)

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Summary

Differentiating between normal and complicated bereavement has not always been easy.(26) The DSM-IV-TR identifies several atypical symptoms that are not associated with a normal course of bereavement, and clinicians have distinguished both "bereavement-related major depressive syndrome"(2) and "prolonged (complicated) grief."(4)

In grief, there is no such thing as an "expiration date." Clinicians should ask about bereavement and the grieving process. Especially if affect and demeanor suggest sadness of unknown etiology, gently pursue gaining more information. Being prepared with short, psychiatric screening questions about mood and mental status can accommodate even a limited appointment time. One question is insufficient to screen for depression, yet oral administration of the PHQ-2 can reliably indicate that one should assess depression and grief symptoms further. The U. S. Preventive Services Task Force independently validated the items in the PHQ-2 as questions to ask patients, stating that these questions may be as effective as an initial depression screen as the use of more formal instruments.

Using well-established psychiatric interview questions and clinically validated assessment tools can help diagnose and monitor grief-associated depression. Although there can be a time factor in administering standardized, validated screening tools, they can nevertheless yield valuable information to assist in making a diagnosis of MDD. The MacArthur Initiative provides a free, comprehensive, clinical toolkit to support its provision of the PHQ-9.

A comprehensive psychiatric interview with mental status exam that focuses on mood components and psychopathology can help discern whether grief symptoms have meaningfully interfered with functioning and activities of daily living enough to warrant a diagnosis of major depressive disorder that is consistent with DSM-IV-TR criteria and recognizes Criterion E, the bereavement exclusion of the major depressive episode. In the absence of a formal assessment for "bereavement," the interviewing and other assessment techniques given here for MDE are meant to help rule out those cases, not to rule in "bereavement" or the proposed "prolonged grief" as appropriate diagnoses.

Consider psychological and/or pharmacological treatment, if watchful waiting proves that this is necessary, if major depressive disorder is diagnosed, or if symptoms indicate a psychiatric emergency.

The bottom line is that assessing grief is important, and adding its assessment to the clinical routine can often be overlooked. Screening tools can be an aid to diagnosis and a careful interview can be valuable in assessing grief. They can also save clinical time and improve a bereaved person's quality of life by identifying the degree of grief being experienced.

Clinical Connections

• The DSM-IV-TR has identified atypical symptoms that are not associated with a normal course of bereavement. Primary care clinicians should be familiar with symptoms of guilt; thoughts of death or worthlessness; psychomotor retardation or functional impairment; or hallucinations. Clinicians who are evaluating patients who may be grieving should also be ready to distinguish normal bereavement from grief-precipitated MDD.
• One question is not sufficient to screen for grief-related depression. The PHQ-2 may be administered very quickly; a minimum score of 2 (geriatrics) or 3 (general medical population) may indicate that in-depth assessment for depression is necessary.
• Consider administering a validated tool such as the PHQ-9 or the HAM-D-17 (or 15-item GDS in older persons) before making a diagnosis of MDD in bereaved patients.
• If symptoms have meaningfully interfered with cognition, overall functioning, and activities of daily living, consider MDD diagnosis using DSM-IV-TR criteria that recognizes Criterion E, the bereavement exclusion for MDD. Rule out or consider comorbid illness.
• Consider therapy if MDD is diagnosed or if symptoms indicate a psychiatric emergency.

Community of Practice Tools

Depression screening tools for cases of bereavement or grief: Link to the PHQ-9 at the MacArthur Foundation Initiative for Depression and Primary Care, http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/questionnaire_sample

Acknowledgment

The author gratefully acknowledges the contributions and wisdom of Ms. Becky Dunn, who volunteered her clinical experiences and practice needs in response to the CME Outfitters Clinical Points™ article on Bereavement, Part I, published September 7, 2010.

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