Felicia Keeling grieved so deeply over the death of her fiancé that she couldn't get out of bed or eat, even though she was six months pregnant and had a young son who needed her. She was sinking into depression when her mother told her — with love — that it was time to get some help.

"She said, 'You have to live. You have to live for your baby and for your son,'" recalled Keeling. During the final months of her pregnancy and in the year and a half since, she reached out to get the help she needed to cope with the overwhelming grief she was experiencing. She has been on antidepressants and in therapy, and sought support from military widows — her fiancé was a member of the National Guard — and from Al-Anon, which has helped her understand the drug addiction that contributed to his death.

One thing she learned from therapy and reaching out to other widows and survivors is that she wasn't alone. "You feel so isolated, like you are the only person in the world who ever went through something like this," she said. "It's very overwhelming, and it always means a hole in your heart that you can't fill, but not facing it is the worst thing you can do to yourself."

When Grieving Becomes Complicated Grief

Approximately 2.5 million people die each year, leaving even more millions struggling with grief. Many people experience symptoms similar to depression, such as persistent sadness, but aren't actually depressed. However, for 7 percent and 20 percent of people who are coping with loss, grief can trigger depression or turn into complicated grief, a condition of prolonged grieving somewhere close to clinical depression with some similarities to post-traumatic stress disorder, though it is neither one of those. In fact, the psychiatric field considered including complicated grief in the DSM-V, the manual that guides mental health diagnoses.

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According to many practitioners, complicated grief is a delicate and controversial subject because grief itself should not be viewed as a mental health problem. 

"The vast majority of people will work through their loss with their own resources, religious resources, social support, and without coming into care with a clinician," said Naomi Simon, MD, associate professor at Harvard Medical School and director of the Center for Anxiety and Traumatic Stress Disorders in Boston.

People experience acute grief in the months immediately following a death and then transition into integrated grief — feelings of yearning, sorrow, and loss continue to come and go, but people are also able to move forward with their lives.

The Grieving Continuum

Everyone grieves in their own way, said Dr. Simon. The depth of a person's grief often relates to how close he or she was to the person who died as well as factors such as the circumstances of the death — suicide, for example, is much more likely to cause depression or complicated grief. Somewhere between six months and a year after the death, the grieving person is usually able to adapt to life without their loved one, even if he or she still feels sad at times.

However, during this process, grief can trigger depression, particularly among people who have a history of depression. If the natural flow from acute to integrated grief is interrupted in some way, the grieving person might end up with complicated grief, which has a few defining characteristics, said Simon, including:

  • Focusing on the person's death or one's own perceived contributions to that death, such as not calling a doctor soon enough in the course of an illness or failing to see how unhappy a person was before suicide.
  • Difficulty remembering the good things about the person who died or their time together.
  • A sense of the death as being recent, even if many months and even years have passed.
  • The inability to plan a future without the person who has died.
  • Avoiding everything that reminds them of their loved one, and when this includes everyday activities or places, living can be difficult.

People with complicated grief often don't want to get help because they are afraid a therapist or psychiatrist will take away the memories they are holding onto and tell them not to grieve. Contrary to this belief, Simon said that the process of grief therapy should help you gain access to some of the good memories and feelings about your loved one that complicated grief has kept you from recalling.

When to Seek Help

While Simon said people in general shouldn't feel that grief requires a mental health expert, she pointed out these signs that suggest it's time to get help, some more urgently than others:

  • Hopelessness. You can't see a future without the person who died and you don't even want a future without him or her.
  • Thoughts of suicide. You are contemplating any such ideas, especially those that involve planning a suicide attempt.
  • Inability to move on. A year has passed and your friends and family are starting to tell you that they worry about your ability to move forward with your life, or you have a sense that others who were grieving with you are moving forward but you aren't. Therapy can help you figure out where your healing process got stuck.
  • Sleep problems. You've tried but can't improve your sleep. Difficulty sleeping well is part of depression and also part of complicated grief.
  • Inability to live life. During acute grief, people around you may be understanding when you don't want to eat, can't sleep, and need a break from work or other demands. Over time, though, you're finding that you still can't do these basic things or you are avoiding them because of your memories.

Helping Yourself Move Forward

In addition to seeking support from a grief counselor or therapist, these steps can help you heal:

  • Remember the good times. Don't be distressed if it seems impossible. A grief counselor can help.
  • Forgive yourself. People may believe they could have done something to prevent their loved one's death. Letting go of guilt or self-blame can help you move on.
  • Create new patterns. If avoiding certain places, people, or activities has you stuck at home, it's time to find new ways to live. This is not about letting go of your memories, but about moving forward.
  • Look to the future. Think about where you might want to be in your life a week, a month, a year from now.
  • Seek support. Keeling found the support of people who were also grieving to be invaluable. If you haven't reached out to a grief support group, try it. You'll feel less alone.