Review
Treatment of bereavement-related depression and traumatic grief

https://doi.org/10.1016/j.jad.2005.12.041Get rights and content

Abstract

In the bereaved, approximately 40% meet criteria for major depression within a month of the death. At a year, approximately 15% of the bereaved are depressed and at 2 years, the figure is approximately 7%. Open-label trials of medication for bereavement-related depression have shown promising results for desipramine, nortriptyline, and bupropion SR. One double-blind controlled trial supports the use of nortriptyline, but interpersonal psychotherapy did no better than placebo. In all these trials, depressive symptoms improve more than bereavement symptoms. Effective open-label treatments for traumatic grief include paroxetine, nortriptyline, and a form of psychotherapy called traumatic grief treatment.

Introduction

Bereavement is listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition-TR (DSM-IV-TR, 2000) as a V code for additional conditions that may be a focus of clinical attention. The criteria recommend not diagnosing depression related to bereavement until 2 months have passed from the loss but recognize certain symptoms which are not characteristic of a normal grief reaction (including guilt, suicidality, worthlessness, psychomotor retardation, continued severe functional impairment, and persistent hallucinations).

Studies have repeatedly shown that the experience of bereavement leads to chronic depression in approximately 10–15% of people. Annually in the US approximately 800,000 people are newly widowed; by age 65, over 50% of all women and over 10% of all men have been widowed at least one time (Zisook et al., 1994a). For clarification, the term bereavement refers to a person's reaction to a loss by death. Grief is the emotional and/or psychological reaction to a significant loss, not necessarily limited to loss by death (for example the loss of use of a limb). Mourning is the social expression of grief or bereavement and is often influenced by religious beliefs and cultural custom. Traumatic grief, with symptoms such as preoccupation with the deceased, searching, and yearning, is a potential complication of bereavement related to trauma and separation distress.

Most descriptions of bereavement have delineated three stages. Clayton titled these numbness, depression, and recovery (Clayton, 1982). She describes numbness as lasting a few hours to a few weeks. The bereaved person typically functions somewhat automatically, accomplishing necessary things but often remembering events and conversations poorly. In the second stage, depression, irritability and restlessness occur frequently, although all depressive symptoms are present. This stage lasts from a few weeks to a year after the death; some symptoms often recur around significant anniversaries and holidays. By 6 months, many bereaved persons are on their way to recovery, meaning acceptance of the death accompanied by a return to the level of functioning that preceded the death. Although most people move through the stages of bereavement without significant morbidity and mortality, some develop chronic major depressive disorder.

Clayton's work with the bereaved has yielded important data on what to expect in the bereaved period; her work encompasses three samples. The first was a group of forty bereaved Caucasian relatives of people who had died at a general hospital (Clayton et al., 1968) interviewed soon after the death (within 16 days) and again within four months. At the first interview, only three symptoms were endorsed by more than 50% of the sample-depressed mood (87%), sleep disturbance (85%), and crying (79%). Difficulty concentrating, loss of interest in television and the news, and anorexia/weight loss occurred in 47%, 42%, and 49% of the sample, respectively. At the follow-up evaluation, 81% of the sample was improved and 4% was worse; those who improved reported that their improvement occurred 6 to 10 weeks after the death.

The second sample was a group of 109 Caucasian widows and widowers identified from obituaries and death certificates (Clayton et al., 1971). In the first month, the majority of subjects reported depressed mood, sleep disturbance, crying, anorexia/weight loss, difficulty concentrating/poor memory, and use of medication to treat sleep disturbance or nervousness. The symptom patterns in the widows and widowers from both samples are quite similar. In fact, when the second sample is compared to the widows and widowers from the first sample, only the rate of anxiety attacks differs significantly between the two groups (39% in the widowed subgroup of the first sample vs. 10% in the second sample).

The third sample was a group of younger (under age 45 years, average 36 years) widowed persons (N = 62) interviewed within a month of the death of a spouse (Clayton and Darvish, 1979). The second and third samples were re-interviewed at one year. The last two samples (N = 171) were matched with married, age-matched nonbereaved people and followed prospectively in order to assess morbidity and mortality. By the end of the first year, somatic symptoms tended to improve, although insomnia, restlessness, and periodic low mood tended to persist. Overall, somatic symptoms improved to a greater degree than did the psychological symptoms.

Clayton and Darvish (1979) reported that a full syndrome of depression was present in approximately 42% of the bereaved at 1 month, decreasing to 16% at 1 year. Comparing the bereaved to matched controls, the 1 year incidence of a full depressive syndrome was 47% in the bereaved vs. 8% in the controls (Clayton, 1990). Overall, Clayton's work with these three sample yielded minimal significant differences symptomatically between men and women, between those affected by a sudden death vs. those bereaved from a lingering death, between those who defined their marriages as good vs. bad, and between people who considered themselves religious and those who did not (Clayton et al., 1968, Clayton et al., 1971, Clayton and Darvish, 1979). In addition, there were no differences in physical symptoms or hospitalizations when comparing the bereaved to control subjects. However, the rate of use of alcohol, tranquilizers, hypnotics, and smoking increased following bereavement.

Zisook and Shuchter (1991) reported similar rates of bereavement-related depression—24% of their sample of widows and widowers met criteria for a major depressive episode (DSM-III-R) at 2 months, 23% were depressed at 7 months, and 16% met criteria at 13 months. Their comparison group of married nonbereaved persons had a rate of depression of 4%. Risk factors for depression at 13 months in their bereaved sample include younger age, past history of major depressive disorder, continued grief at 2 months following the loss, meeting criteria for depression at 2 and/or 7 months after the loss, and self-perception of poor physical health. A later report by Zisook et al. (1994b) estimates that at 25 months, approximately 7% of the sample has symptomatic major depression.

In summary, disregarding the DSM convention of not diagnosing major depressive disorder within 2 months of a loss, approximately 40% of the bereaved meet criteria for major depression within a month of the death, approximately 15% are depressed at 1 year, and approximately 7% are depressed at 2 years. Once identified, debate exists about how best to treat these patients. This paper will review the treatment of bereavement-related depression, focusing on psychopharmacologic treatments, and discuss the diagnosis and treatment of traumatic grief.

Section snippets

Treatment of bereavement-related depression

Three open-label antidepressant trials for the treatment of bereavement depression have been published. See Table 1 for demographic variables. Jacobs and colleagues published the first of these (Jacobs et al., 1987). Ten subjects were treated with desipramine, starting at 75 mg at bedtime for 1 week and increasing to 150 mg by the end of the second week. Dose adjustments were allowed when side effects occurred. After 4 weeks, if the patient had a good response to the treatment and wished to

Traumatic grief and its treatment

The term complicated grief was at one time used to refer to bereavement-related depression with psychosis, but later was adopted by a group of researchers who used it to refer to a group of bereavement-related symptoms, distinguishable from depression, which predicted continuing functional impairment (Frank et al., 1997). The name was changed to ‘traumatic grief’ to better capture the underlying components of trauma and separation distress (Prigerson et al., 1997). Horowitz et al. (1997)

Conclusions

Bereavement-related depression may be diagnosed in approximately 15% of people 1 year after the death of a loved one. Although most data about treatment has focused on widows and widowers, we also have information about treatment of bereaved subjects who have lost parents, children, and siblings. Data from these studies suggests that antidepressants are well tolerated and tend to improve the symptoms of depression more than those of grief. Interpersonal psychotherapy, though seeming to have

References (24)

  • S.C. Jacobs et al.

    Treating depressions of bereavement with antidepressants: a pilot study

    Psychiatr. Clin. North Am.

    (1987)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (2000)
  • P.J. Clayton

    Bereavement

  • P.J. Clayton

    Bereavement and depression

    J. Clin. Psychiatry

    (1990)
  • P.J. Clayton et al.

    Course of depressive symptoms following the stress of bereavement

  • P.J. Clayton et al.

    A study of normal bereavement

    Am. J. Psychiatry

    (1968)
  • P.J. Clayton et al.

    The bereavement of the widowed

    Dis. Nerv. Syst.

    (1971)
  • J.R. Faschingbauer

    Texas Revised Inventory of Grief Manual

    (1981)
  • E. Frank et al.

    Phenomenology and treatment of bereavement-related distress in the elderly

    Int. Clin. Psychopharmacol.

    (1997)
  • K.L. Harkness et al.

    Traumatic grief treatment: case histories of 4 patients

    J. Clin. Psychiatry

    (2002)
  • M.J. Horowitz et al.

    Diagnostic criteria for complicated grief disorder

    Am. J. Psychiatry

    (1997)
  • M.D. Miller et al.

    Applying interpersonal psychotherapy to bereavement-related depression following loss of a spouse in late life

    J. Psychother. Pract. Res.

    (1994)
  • Cited by (50)

    • Bereavement and grief

      2020, Handbook of Mental Health and Aging
    • Impaired mental health and low-grade inflammation among fatigued bereaved individuals

      2018, Journal of Psychosomatic Research
      Citation Excerpt :

      The management of bereavement-related fatigue is important to reduce symptom burden and the risk for comorbidities. Today, several approaches have been implemented to help improve bereavement-related fatigue, including pharmacotherapy [71] and/or psychotherapy [72] psychoeducation [73], mindfulness-based stress interventions, including yoga and Qigong [23], as well as exercise [74]. Interestingly, exercise and mindfulness-based interventions have been associated with reductions in inflammatory markers, including CRP [16, 75].

    • Bereavement-related depression in the older adult population: A distinct disorder?

      2013, Journal of Affective Disorders
      Citation Excerpt :

      In this community sample of older adults with depression, the prevalence of bereavement-related depression reached 39%. This estimate concords with other findings reporting prevalence rates of bereavement-related depression ranging between 8% and 40% (Zisook and Kendler, 2007; Newson et al., 2010; Lamb et al., 2010; Shah and Meeks, 2012; Hensley, 2006). Looking at symptom differences, the exploratory latent class analysis we carried out showed that individuals with bereavement-related depression were as likely to report all the different symptoms of depression, but in lower probabilities.

    View all citing articles on Scopus
    View full text