Is it Depression or Grief?

Sherry Dale, MSW, RSW
Winter 2010

Marilyn and her husband Gordon sat in my office during a counselling session. Marilyn was in tears; Gordon held her hand, a very worried look on his face. Marilyn told me, “In the three years we’ve been trying to get pregnant, I’ve gotten more and more depressed. We’ve done three rounds of IVF now. The first two didn’t work – with each of those calls, I spiralled deeper. On the third try, we actually, finally got pregnant… only to miscarry a week later. I honestly didn’t think I could feel worse than I already did, but losing that baby dropped me into a chasm I’m not sure I’ll ever get out of. I’m so depressed that I can’t even picture what’s next. I used to think my life was so wonderful; now I can’t even remember what it feels like to be happy.”

We tend to use the word “depression” to describe feelings of sadness. However, not all sadness is necessarily “depression.” One author says the word “depression” has come to have two meanings in our everyday language. One is the clinical meaning, the description of a psychological condition. The other is a non-clinical meaning, where the word “depression” is commonly used to describe an emotional state of feeling sad or low. ^[i] Since the symptoms of depression and grief are much the same, it can be very difficult to differentiate.

Depression may be diagnosed in several ways. The Beck Depression Inventory is a commonly used tool to assess depressive symptoms. The most recent version, the BDI-II, separates the questions into areas related to eight emotional factors and thirteen physical ones. People rank from zero to three statements reflecting these factors. The emotional items are pessimism, past failures, guilt, punishment, self-dislike, self-criticalness, suicidal thoughts or wishes, and worthlessness. The physical factors include sadness, loss of pleasure, crying, agitation, loss of interest, indecisiveness, loss of energy, change in sleep patterns, irritability, change in appetite, concentration difficulties, tiredness and/or fatigue, and loss of interest in sex. This example refers to the “past failure” item:

I do not feel like a failure.
I have failed more than I should have
As I look back, I see a lot of failures.
I feel I am a total failure as a person

An overall score of 0–13 indicates minimal depression; 14–19 mild depression; 20–28 moderate depression; and 29–63 severe depression.

The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) includes the listing “major depressive episode.” In order to receive this diagnosis, in a two-week period, you would have experienced a depressed mood most of the day, nearly every day, and a markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day. You also would have experienced at least three of the following:

    * significant weight loss or weight gain, or decrease or increase in appetite
    * inability to sleep or sleeping too much
    * physical agitation or sluggishness
    * fatigue or loss of energy
    * feelings of worthlessness or excessive or inappropriate guilt
    * diminished ability to think or concentrate, or indecisiveness
    * recurrent thoughts of suicide

These symptoms must cause clinically significant distress or impairment in socially, at work, or in other important areas of functioning.

Many infertility patients would identify with enough of these requirements to warrant a diagnosis of depression. And because some couples go through fertility testing and treatments for years, the emotions that go with infertility will always last longer than two weeks.

Causes of depression and grief

The National Institute of Mental Health states there is no single cause of depression. Factors that can lead to depression can include genetics (some types of depression appear to run in families), brain chemistry and structure (some people’s neurotransmitters don’t function properly), and environmental and psychological factors (trauma, loss, and other stressors). People respond differently to these factors, and recover at different rates. Researchers continue to search for the causes of depression.^[ii]

We know that grief is caused by loss.

Grief or depression?

Some people are comfortable thinking in terms of depression and receiving a diagnosis of it. In fact, some seek this diagnosis, since they wish for a prescription for antidepressants that they hope will take away their emotional pain. They may take comfort in having a clinical name for what they feel.

Other people are frightened of being labelled with depression. Perhaps they have had previous experience with it or someone close to them has had depression, or they might feel that there is a stigma associated with depression. It is not uncommon for people to become “depressed about being depressed!”

A great many of my clients find it comforting to frame their emotional distress as grief rather than depression. One author states, “All major losses are painful beyond words and require a lengthy adjustment period. The appropriate response in every case is grief.” ^[iii] When we accept that the inevitable human response to loss is grief, we can begin the process of grieving.

At first, the concept of grieving in relation to infertility may seem strange. If we think about grieving, it may seem we have given up. This is absolutely not the case – embracing the idea of grief simply means that you acknowledge that even if you eventually conceive or adopt a child, you have already experienced a profound set of losses.

Infertility and loss

Thinking about the painful emotions arising from your infertility as “grief” starts with understanding the connection between loss and grief. We tend to think of grieving as something we do when someone we love dies. Of course, death is a common and significant loss, but there are so many other significant losses we experience in our lives. We lose jobs, relationships, money, our health. We lose confidence, faith, hope, and love.

Greg Harvey says that “loss” refers to “a breaking of a bond you’ve formed with a significant person, place, thing, or idea (including beliefs) in your life.” In the case of infertility, the bond is no less strong simply because the person has not yet been conceived or born.

The most commonly and deeply felt loss in infertility involves the anticipation of the loss of the child you yearn for – to your heart, this potential loss can feel the same as if a child had been born and then died. Harvey continues, “The loss of a child of any age is a parent’s worst nightmare. No other profound loss seems quite as difficult to integrate into one’s life because the loss of a child represents both a cosmic injustice and a forfeiture of a potential and anticipated future. When a child dies the parents must mourn not only his passing but also the demise of all the hopes, dreams, and plans that they had for the child… parents also may mourn their legacy to a future generation.” Harvey points out that the average time for grieving a profound loss is five years, but grieving the loss of a child may take even longer.

However, it’s not just the loss or potential loss of the child you experience as you go through infertility. There are many, many other losses, both concrete and abstract. You may find it helpful to make a list of the losses you have already incurred throughout your infertility. The purpose of this list is not to make you feel worse – it’s to give you some context for the grief you already feel. Whether or not you conceive or adopt a child, you have already experienced this significant set of losses, each of which will produce a grief response.

Patricia Johnston lists the most significant potential losses of infertility:

    * Control over many aspects of life
    * Individual genetic continuity linking past and future
    * The joint conception of a child with one’s life partner
    * The physical satisfactions of pregnancy and birth
    * The emotional gratifications of pregnancy and birth
    * The opportunity to parent^[iv]

Patricia Mahlstedt points out that there are specific losses that can lead to depression: loss of a relationship; of health; of status or prestige; of self-esteem; of security; of hope of fulfilling an important fantasy; of someone of great symbolic value. ^[v] Infertility involves all of these losses.

Distinguishing between sudden or prolonged loss, Deits says, “While you may feel deep shock when the illness or situation is first disclosed, that feeling is eventually buried under the incredible burden of coping with prolonged loss. Emotions soar and fall with every hopeful or discouraging development. When all is said and done, prolonged loss involves just as much grieving and feelings of emptiness as sudden loss.” Most infertility patients will identify strongly with the concept of prolonged loss.

How to grieve your losses

The task of grieving is to examine, acknowledge, feel, honour, and learn from your painful emotions rather than fighting and avoiding them. “Death, divorce, infertility, adoption – the losses involved in each plunge adults and children alike into grief. This grief cannot be denied, refused, overlooked, minimized, or belittled. It must be named and faced head on. If the family born of the loss is to thrive, the passages of grief need to be honored, not rushed or cast aside.” ^[vi]

Grief is normal. I have this quote framed on my wall: “Grief is not a disorder, a disease or a sign of weakness. It is an emotional, physical, and spiritual necessity, the price you pay for love. The only cure for grief is to grieve.” ^[vii]

You are not helpless in your grief. You can help move grief along its path. The first step is to make the decision to acknowledge and engage with your grief. When you feel the painful emotions, locate them in your body, and name them (“Oh, yeah – that’s sorrow…that’s fear…”).

Feel the feelings – breathe into them. You may be afraid that you’ll drown in the emotions, but you won’t. When emotions are fully acknowledged, they tend to move and run their course, rather than remaining stuck.

You can journal, writing out your loss and grief. In her book Healing Through the Dark Emotions: The Wisdom of Grief, Fear, and Despair, Miriam Greenspan includes 33 “emotional exercises” that can provide structure to your grieving. You may decide to see an infertility counsellor who can guide you through your grieving and bear witness to it.

My clients often ask me when the pain will go away – how long will they feel so badly? I always respond, “Longer than you want.” Harvey says, “Grieving is a nonlinear process and will take however long it takes. The grief is going to shift and get easier, even though right now that seems impossible.” He adds, “Grieving is a basic part of being human, and like it or not, you need to engage in the process for as long as it takes.”

The decision to actively grieve your infertility losses is a courageous one. It can have wonderful effects as you stop seeing your painful emotions as enemies, and instead, as natural responses to loss. Your emotions become less frightening, less powerful. And you can use the energy you have previously spent fighting and avoiding these emotions toward your main priority: building your family.

[i] Harvey, G. (2007). Grieving for Dummies. Indianapolis: Wiley Publishing

[ii] National Institute of Mental Health (2007). Depression. Available online: http://www.nimh.nih.gov/health/publications/depression-easy-to-read/depression-easy-to-read.pdf

[iii] Deits, B. (2009). Life After Loss: A Practical Guide to Renewing Your Life After Experiencing Major Loss. Cambridge: Lifelong Books.

[iv] Johnston, P.I. (1992). Adopting After Infertility. Indianapolis: Perspectives Press.

[v] Mahlstedt, P. (1985). The psychological component of infertility. Fertility and Sterility, 43, 335-346.

[vi] Coloroso, B. (2004). Parenting Through Crisis. New York: HarperCollins Publishers

[vii] Grollman, E.A. (1993). Straight Talk About Death with Teenagers: How to Cope with Losing Someone You Love. Boston: Beacon Press.

8Greenspan, M. (2003). Healing Through the Dark Emotions: The Wisdom of Grief, Fear, and Despair. Boston: Shambhala Publications.

Sherry Dale specializes in counseling for infertility and pregnancy loss. She works full time at LifeQuest Centre for Reproductive Medecine. Clients can see her at LifeQuest even if they are not patients there (e-mail sdale@lifequestivf.com or call 416-506-0804). Sherry also has a private counseling practice, where she can be reached at sherry.dale@pathcom.com or 416-410-8904. Sherry lives in Toronto with her two sons, both conceived through assisted reproductive technologies.