Anticipatory Grief vs. Depression: How to Tell What You’re Actually Carrying

SANDWICH GENERATION • July 27, 2026

The Velcro Was Fraying

Monday, 11:08 a.m. Randee sat back in the exam chair at her primary care provider’s office, the vinyl cool beneath her. The small room smelled faintly of antiseptic and the dregs of a coffee maker two rooms away. Her eyes drifted to the blood-pressure cuff hanging on the wall, its velcro fraying at the edge. A detail her mind fixated on, because it was easier than the words she had just heard: “Your PHQ-9 is a 14. That’s in the moderate range. I’d like to talk about options.”

Randee’s gaze shifted to the glass-fronted cabinet behind the provider, the reflection showing her own chart on the computer screen in blurred, indecipherable shapes. The clipboard from the waiting room, where she had answered nine questions about her sleep and her appetite and her interest in things she used to enjoy, felt less like a tool and more like a verdict. She thought: My mother is dying. My PHQ-9 is a 14. I don’t know which of those is causing the other. I don’t know if a medication will help me grieve, or if it’ll make me less of a daughter.

In that moment, the fraying velcro became a quiet metaphor. Worn, strained, still holding the fabric together, just barely. Randee’s tangled feelings mirrored that fraying exactly: the pull between grief and depression, between hope and surrender, between a diagnosis and an identity.

For many women in the sandwich generation, the ones balancing the care of aging parents with the demands of their own households and careers, this exact moment of not knowing is common. The weight is real. It’s also, so often, invisible, carried underneath a calendar that has no line item for it.

What Randee didn’t have language for yet, sitting in that chair, was that her body had been keeping a kind of ledger long before her mind caught up. Bessel van der Kolk, MD, psychiatrist and trauma researcher, has spent decades documenting how loss and unresolved threat register in the nervous system, not only in conscious thought. I think about his work often when a caregiving client tells me she “doesn’t feel like herself” and can’t say more than that. The fraying velcro was more than a metaphor for Randee’s emotional state. It was a somatic signal of the strain her body had been carrying for months.

Why Anticipatory Grief and Major Depression Look Identical on a Clipboard

The PHQ-9, a nine-item questionnaire used across primary care, was built to screen for major depressive disorder. For caregivers like Randee, who are grieving a loss that hasn’t happened yet while also living through it in real time, the overlap between that screening tool and her actual emotional experience gets confusing fast.

Anticipatory grief is a complex, often intense response to an expected death or significant loss. It can involve sadness, anxiety, disrupted sleep, and changes in appetite. Symptoms that mirror major depressive disorder closely enough that a PHQ-9 score alone can’t tell the two apart.

Therese Rando, PhD, a psychologist and one of the earliest researchers to formally study anticipatory grief in caregiving families, describes it as activating many of the same emotional and physiological pathways as depression, while remaining fundamentally different in both intent and course. It’s a natural, adaptive response to a loss that’s coming. Major depressive disorder is a diagnosable condition with a different trajectory and a different treatment protocol.

Without careful clinical inquiry, this distinction gets lost in the rush of a fifteen-minute appointment. That loss of nuance lands hardest on women in the sandwich generation, who are already doing the emotional labor of caregiving while holding down professional and relational roles that don’t pause for grief.

Anticipatory grief also involves an ongoing adjustment to a shifting reality: new roles, altered relationships, a slow emotional bracing for what’s coming. That process moves. Moments of deep sorrow sit next to moments of hope, or even joy, in a shared memory. Depression, by contrast, tends to settle in as a more persistent, unrelenting weight that doesn’t lift with good news or a good day.

What I keep coming back to in cases like Randee’s is a 2009 paper by Marylene Cloitre, PhD, and colleagues, including Judith Herman, MD, the psychiatrist whose work on trauma and recovery shaped a generation of clinicians. Their research on cumulative developmental trauma found that complex emotional experiences routinely resist neat diagnostic categories. A caregiver’s anticipatory grief can be compounded by earlier, unresolved losses, and the clinical picture that results rarely fits cleanly into a single box on an intake form.

Here’s the three-layer version of what’s happening for a reader like Randee. Clinically, anticipatory grief and major depressive disorder share a symptom cluster: low mood, fatigue, sleep disruption, appetite change. Think of it like two different weather systems that can both produce rain. One is a storm passing through a specific, known valley (the decline of a specific parent, on a specific timeline). The other can form anywhere, for no clear reason, and doesn’t necessarily clear when the weather in that valley changes. What this looks like in Randee’s actual week: she can be in tears folding her mother’s laundry on a Tuesday, and by Thursday, laughing at something her daughter said at dinner. That range, that capacity to still feel joy even inside grief, is itself a clinical clue, and it’s one a rushed appointment rarely has time to ask about.

The Six Clinical Tells That Distinguish Them (And Why the Distinction Matters)

Clinicians rely on several nuanced signs to tell anticipatory grief and major depressive disorder apart. Recognizing these clinical tells can shape treatment decisions and prevent medication that isn’t actually needed yet, or, just as important, prevent depression from going untreated because it got waved off as “just grief.”

1. Emotional context: Grief is tied to a known loss or an impending one. Depression may arise with no specific external trigger. Randee’s sadness is anchored in her mother’s decline. If her mood starts shifting independently of caregiving stressors, depression becomes the more likely explanation.
2. Self-esteem: In grief, self-worth generally stays intact. In depression, pervasive worthlessness is common. Randee might feel sad but still know her own value, where depression tends to erode that sense of self entirely.
3. Guilt: Grief-related guilt tends to center on the relationship or the care given. Depression-related guilt tends to be more global and self-critical. Randee might regret not visiting more often, but depression’s guilt can widen into feeling like a failure across every part of her life.
4. Temporal pattern: Anticipatory grief fluctuates with moments of connection or crisis. Depression tends to be more persistent and pervasive. Randee may have days that feel connected and even hopeful, set against days of real sorrow, unlike the flatter, steadier low mood of depression.
5. Suicidal ideation: Grief can involve thoughts about death, but they’re usually thoughts about the person dying, not a wish to die oneself. Depression carries a substantially higher risk of suicidal intent. This distinction is clinically important and should always be assessed directly rather than assumed.
6. Functional impairment: Grief may temporarily strain functioning but tends to leave essential caregiving roles intact. Depression more often disrupts functioning across every domain. Randee might struggle with sleep or low energy but keep managing caregiving tasks, where depression can produce a wider withdrawal from responsibilities altogether.

Holly Prigerson, PhD, a psychiatric epidemiologist at Weill Cornell Medicine who has spent more than three decades researching pathological grief responses, led the research that became the basis for prolonged grief disorder, the diagnosis the DSM-5-TR formally added in 2022 to replace the older, provisional “persistent complex bereavement disorder” category. I find her framing clarifying: misdiagnosing grief as depression risks pathologizing a natural process, and it can cause clinicians to overlook grief-specific interventions that would actually help.

Clinicians and patients alike benefit when a treatment plan honors the emotional reality underneath the symptoms. The stakes are real for driven women balancing caregiving, careers, and whatever is left of their own care, because an accurate read can be the difference between a plan that helps and one that adds a new problem on top of an old one.

What an SSRI Will and Will Not Do for Anticipatory Grief

When Randee’s PCP raised medication, the implicit suggestion was an SSRI, a common class of antidepressant. It matters to understand exactly what these medications can and can’t do in the context of grief.

SSRIs work by changing serotonin availability in the brain, which can ease symptoms of clinical depression such as persistent sadness, low energy, and impaired concentration. Anticipatory grief, though, isn’t primarily a serotonin problem. It’s an emotional and relational response to a loss that’s unfolding in real time.

SSRIs may ease some of the somatic symptoms that ride alongside grief, like sleep disturbance or anxiety. What they don’t address is the core experience of mourning, or the relational weight of caregiving and impending loss. In some cases, they can blunt emotional responsiveness in a way that feels like the grief process itself getting muffled rather than metabolized.

Clinicians who specialize in grief tend to emphasize that feeling the full range of grief is part of what allows eventual healing. Medication, used carefully and alongside psychotherapy, can support that process. It shouldn’t replace grief-specific care altogether.

For Randee, an SSRI might actually help reduce panic or insomnia, freeing up some capacity to be present with her mother. But the sorrow, the waves of loss, the bittersweet memory, those need a different kind of care. Often that means psychotherapeutic work that holds and validates grief instead of trying to manage it into silence.

Tara Brach, PhD, psychologist and meditation teacher, has written about the pause between stimulus and response as a doorway into working with difficult emotion rather than around it. I think of her work often with caregiving clients: mindfulness and self-compassion practices, alongside traditional therapy, can help someone stay with grief long enough to actually move through it, instead of reaching for medication as the only lever available.

The Risk of Medicating Grief Away Versus Letting Grief Become Depression

There’s a real balance to strike in deciding whether to medicate symptoms that show up during anticipatory grief. Overmedicating grief risks suppressing the emotional processing that adaptive coping actually depends on.

Conversely, untreated grief can evolve into major depression, especially when it’s compounded by relational trauma, ambiguous loss, and the chronic stress of caregiving. That risk is real, not theoretical.

M. Katherine Shear, MD, psychiatrist and director of the Center for Complicated Grief at Columbia University, has argued for decades that caregiving women need assessment that holds the full context: the pain of an impending loss, the exhaustion of caregiving itself, and the presence of depressive symptoms that clearly exceed what grief alone would produce.

Clinicians need to stay alert for signs of prolonged grief disorder or major depressive disorder emerging out of ordinary anticipatory grief. The goal is to neither pathologize grief nor let depression take hold unaddressed.

For Randee, her initial sadness deepening into pervasive hopelessness, or a real withdrawal from caregiving itself, would be the signal that something has shifted from grief into depression. Catching that shift early can prevent a much longer decline.

Pauline Boss, PhD, whose theory of ambiguous loss describes the particular pain of losses without closure, dementia caregiving being one of the clearest examples, has written that unresolved grief can become chronic and disabling when it isn’t tended to with care. That’s not a reason to medicate preemptively. It’s a reason to keep watching, together, with someone qualified to help tell the difference.

Both/And: Your Suffering Is Real AND Your Suffering Has a Name That Is Not “Depressed”

Randee’s experience, like so many women caring for aging parents while running their own households, holds a both/and truth. The ache she carries is fully real, whether or not it ends up wearing the label of anticipatory grief or depression.

Her suffering is legitimate without needing premature pathologizing, and without needing dismissal either. A grief-informed approach can hold the full complexity of what she’s feeling: the loss, the hope, the anxiety, and the exhaustion, all at once, without forcing any of it to resolve into a single tidy diagnosis before it’s ready to.

Ericka, Randee’s closest friend and a fellow caregiver two states away with her own father, put it to her over the phone one night: “Sometimes I feel like I’m drowning in feelings I don’t have words for. And then I feel guilty for not having the words, on top of everything else.” That sentence captures the clinical challenge exactly: real suffering that resists the neat boxes a fifteen-minute visit is built to check.

Both states, grief and depression, ask for compassionate care. Naming that duality out loud lets women look for support that actually matches their real experience, instead of the closest available label.

Rather than treating grief and depression as mutually exclusive, a both/and lens holds the fluidity of what’s actually happening. As Randee learns to tolerate the discomfort of grief itself, she can also stay alert for the signs that something more than grief has entered the picture.

Grief-informed psychiatry, a framework gaining traction in clinical circles, takes this nuanced stance seriously. It builds an understanding of grief’s natural course into psychiatric evaluation, avoiding medication that isn’t needed yet while staying open to treating a co-occurring disorder when one is actually present.

The Systemic Lens: Why a Fifteen-Minute Visit Can’t Hold This

Here’s the structural piece underneath Randee’s story, and it has nothing to do with her individual coping. The average US primary care visit runs somewhere between fifteen and twenty minutes, and that window has to cover blood pressure, medication refills, a depression screener, and whatever else came up since the last visit, before there’s any time left for a nuanced conversation about grief versus depression.

That structural squeeze lands hardest on women, and it lands hardest of all on driven women who have built their adult lives around being the reliable one. The sandwich generation, disproportionately women in their late thirties through fifties, absorbs caregiving labor that the broader health system still hasn’t built adequate infrastructure to support. There’s no billing code that reimburses a physician for the extra ten minutes it takes to ask the six clinical tells outlined above.

Which means, in practice, that the burden of getting an accurate read falls back onto the exhausted person in the exam chair. Randee has to be the one who notices the PHQ-9 doesn’t capture her context, who brings her own language for what’s happening, who advocates for a slower conversation inside a system built for speed. That’s not a personal failing of primary care doctors, many of whom would love more time with every patient. It’s a structural reality of how US primary care is currently resourced and reimbursed.

Naming that system pressure doesn’t remove it. It does mean Randee’s confusion in that exam room was never a sign that something was wrong with her capacity to understand her own feelings. It was a predictable result of asking a fifteen-minute, single-tool screening process to do a job it was never built to do alone.

The Clinical Conversation to Have With Your PCP (And the Questions to Bring)

When Randee’s PCP raised medication, an important conversation opened up. It’s one many women avoid out of uncertainty, or out of a quiet fear of being dismissed. That clinical dialogue can become truly useful when it’s guided by specific questions and some clarity about what you’re actually experiencing.

Questions worth bringing to your PCP include:

• “Can we talk through whether my symptoms are more connected to grief than depression?”
• “What are the real benefits and limitations of medication in my specific situation?”
• “Are there grief-specific therapies or supports you’d recommend alongside, or instead of, medication?”
• “How will we track whether my symptoms shift over time, so we can adjust the plan?”
• “Can you refer me to a grief counselor or therapist who works with caregiving families?”

Open communication like this supports shared decision-making, respects your lived experience, and makes room for more careful care. Randee’s willingness to say what she actually needed became a real turning point.

In the exam room, Randee found her voice. She said, “I want to understand what I’m feeling instead of only labeling it. I want to be there for my mom, but I also need to take care of myself.” That single sentence opened the door to collaborative care: some combination of medication, therapy, and support from people who actually understood what she was carrying.

Giving patients real information about grief and depression helps take down stigma and makes honesty easier. A primary care provider’s role here matters enormously, guiding this process with both empathy and clinical precision.

If what you’re carrying includes thoughts of ending your own life, rather than only thoughts about the person you’re losing, please treat that as urgent. In the United States, you can call or text 988 to reach the Suicide & Crisis Lifeline, available 24 hours a day. If you’re outside the US, please contact your local emergency services or a crisis line in your country. This applies regardless of whether your experience turns out to be grief, depression, or both. Suicidal ideation always calls for a direct, immediate conversation with a qualified professional, not a wait-and-see approach.

The Caregivers Who Got the Diagnosis Right, and How It Changed Their Recovery

Among the women who have come through the sandwich generation crucible, the ones who received a precise diagnosis, whether that was anticipatory grief, depression, or both together, describe a real shift in how their recovery went. Getting it right meant they could access the actual supports they needed: grief therapy, medication, or some combination of the two.

One caregiver told me that understanding her experience as anticipatory grief, not depression, freed her from a layer of self-judgment she hadn’t realized she was carrying. It let her grieve honestly while still staying present for caregiving. Another described how recognizing an emerging depression early led to timely intervention that likely prevented a much harder crisis down the line.

Holding clinical precision alongside the lived reality of caregiving builds a foundation for healing that honors both the difficulty and the resilience of women like Randee and Ericka.

Women who get this right often describe a renewed sense of agency. They find room to feel sorrow without shame, and to ask for practical help without guilt attached to the asking.

For more on this, visit our Sandwich Generation Resource Hub, and explore our guides on anticipatory grief in the sandwich generation, ambiguous loss in dementia caregiving, and caregiver burnout versus grief.

For further reading on grief and caregiving, our guides on relational and betrayal trauma, grief arriving alongside a teenager’s mental health crisis, and perimenopause in the sandwich generation offer more clinically grounded context.

References

Peer-Reviewed Research (Vancouver)

1. Cloitre M, Stolbach BC, Herman JL, van der Kolk B, Pynoos R, Wang J, et al. A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. J Trauma Stress. 2009;22(5):399-408. doi:10.1002/jts.20444. PMID: 19795402.
2. Prigerson HG, Shear MK, Reynolds CF 3rd. Prolonged Grief Disorder Diagnostic Criteria, Helping Those With Maladaptive Grief Responses. JAMA Psychiatry. 2022;79(4):277-278. doi:10.1001/jamapsychiatry.2021.4201. PMID: 35107569.

Books & Cultural Sources (Chicago Author-Date)

• Brach, Tara. Radical acceptance. Bantam Books, 2003.
• Dickinson, Emily. The complete poems of Emily Dickinson. Little, Brown, 1960.

Warmly, Annie

Medical Disclaimer

Medical Disclaimer