The bereavement rule in mhGAP-IG
This man has felt sad most of the day for 5 weeks, has lost interest in fishing with his friends, and has stopped working, 4 months after his wife's death. These symptoms could reflect grief or depression. The WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) gives a specific rule for this situation: when there has been a major loss such as bereavement within the last 6 months, depression is considered likely only if certain features are present. Beliefs of worthlessness, such as saying he has become a worthless burden to his children, are one of those features, so this finding makes depression likely.
The features that decide the question
After a recent major loss, mhGAP-IG considers depression likely if any of the following is present: suicidal ideation, beliefs of worthlessness, psychotic symptoms, slowed speech or movement, or a previous history of depression. If none is present, the person is managed under other significant mental health complaints, with support for the grieving process, rather than treated for depression. This rule helps health workers avoid labeling normal grief as illness while still detecting depression that needs treatment.
| Finding | Common in grief? | Decides depression after recent loss? |
|---|
| Weight loss from skipped meals | Yes | No |
| Early morning waking | Yes | No |
| Crying at her photograph | Yes, expected | No |
| Believes he is a worthless burden | Not typical | Yes |
Why the other findings do not decide it
Weight loss and early waking are depressive symptoms, but they also occur commonly in grief, so they do not by themselves override the bereavement rule. Crying when he looks at his wife's photograph is an expected part of mourning. In grief, painful feelings tend to come in waves linked to reminders of the person who died, and self-esteem is usually preserved. In depression, the person's view of himself is damaged, and feelings of worthlessness or guilt not related to the loss suggest that more than grief is present.
Watch out! Always ask about suicidal thoughts in a bereaved person with depressive symptoms. If suicidal ideation is present, depression is likely under the same rule, and safety assessment becomes urgent.
Exam takeaway
Key point! Within 6 months of a major loss, mhGAP-IG considers depression likely only with suicidal ideation, worthlessness, psychotic symptoms, slowed speech or movement, or past depression. Without these, support the grief and follow up.