GRIEF, BEREAVEMENT, AND DEPRESSION
| GRIEF, BEREAVEMENT, AND MOURNING —Sidney Zisook, MD, Professor and Residency Training Director,
Department of Psychiatry, University of California, San Diego, School of Medicine, and Director of San
Diego Regional Site for STAR*D and National Institute of Mental Health Depression Network.
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| Terminology: grief—overall psychosocial reaction to any loss; may include separation distress, sadness, anxiety,
helplessness, anger, shame, disbelief, intrusive memories, survival guilt, remorse, and/or social withdrawal;
may also include positive emotions; bereavement—term used specifically to refer to loss of loved one
through death; mourning—behavioral and social manifestations of grief, such as funerals and/or other rituals
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| Normal grieving: 2-yr study of widows and widowers to determine some components of normal grieving;
findings—88% reported they were still grieving 2 mo after death of spouse; however, 12% who were not still
grieving “did fine” and were less likely to be depressed at 2 yr; 75% reported yearning for spouse at 2 mo, 45% at 2
yr; 70% cried fairly regularly at 2 mo, 30% at 2 yr; loneliness did not decrease at all (even those who remarried continued
to be lonely for deceased spouse); positive emotions common, even within 2 mo of death; 61% had sense of
continuing contact with deceased at 2 mo, 50% at 2 yr; >33% had regular conversations with deceased spouse
at 2 mo, 25% at 2 yr; conclusions—grief necessary; intense grief healthy, but minimal or absent grief not unhealthy;
work of grief is not of letting go, but finding new ways to maintain relationship with deceased; grief
does not disappear by 2 yr after death; symptoms of major depression associated with grief tend to be as
chronic and recurring as those of major depression not associated with grief; treating symptoms of major depression
does not interfere with work of grief, but rather facilitates it; general observations—medical morbidity
increases in time of bereavement; nobody in above study started using drugs or alcohol after spouse died,
but those who had problem before spouse’s death found it worsening after; anxiety and mood disorders can
occur during bereavement period
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| Acute grief reaction: by 2 yr after death of spouse, 75% of individuals in above study felt they had made
good overall adjustment to bereavement, but 25% struggled with continued acute grief reaction; acute grief
reaction can include traumatic distress, separation distress, guilt or remorse, social withdrawal, and preoccupation
with images and memories of deceased; interest in world around griever regained as preoccupation
lessens; acute grief is transient; over ≈6 mo (this time frame controversial), people begin to accept
loss, positive emotions become more frequent, and painful negative emotions begin to lessen in intensity;
as people forgive themselves, their anger dissipates and their compassion increases; people often develop
or renew meaning in life
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| Integrated grief: “grief doesn’t just end”; grief is lifelong process, and after period of acute grief, integrated
grief begins to develop as background state
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| Prolonged acute grief reaction: also called complicated grief or traumatic grief; instead of acceptance and
compassion, fear predominates; belief that deceased still alive persists, often accompanied by excess of guilt
and anger and sense of moral indignation; symptoms overlap with those of major depression and posttraumatic
stress disorder (PTSD), but prolonged acute grief reaction seems to be separate entity
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| Bereavement and depression: Kraepelin noted that death of loved one can precipitate major depression, but
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) says depression associated
with bereavement is not depression but bereavement; speaker thinks this “kind of funny” and advocates for
change in DSM-V; study showed that bereaved people in general have many depressive symptoms at 1 mo,
and, in fact, 42% met criteria for major depression; however, by 1 yr, only 16% met criteria for major depression;
differences between depressive symptoms associated with bereavement and symptoms of major depression—
depression after loss of loved one occurs equally in men and women (whereas, major depression more common
in women); depression after loss of loved one not associated with family history of dysphoria (although
more recent studies have found such association); depression after loss of loved one not more common in
those previously treated for depression; both patients and clinicians felt that depressive symptoms after loss of
loved one normal; conclusion from all studies is that depressive symptoms associated with bereavement and
major depression not same thing
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| Predicting depression after bereavement: nonpredictors—quality and duration of relationship; minimal or absent
grief in first 2 mo after death; sudden unanticipated death (except in cases involving homicide or suicide); risk
factors for developing depression after bereavement—personal or family history of depression; depression at time
of loved one’s death; death due to suicide or homicide; younger age of survivor; poor general medical health; meeting
criteria for major depression 2 mo after loss of loved one; speaker concludes that bereavement-related major depression
no different from any other major depression
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| Treatment issues: acceptable for therapist to cry when patient discussing loss (“crying can be very supportive;
shedding tears in appropriate context with a patient can let [him or her] know you care”); send condolence
card; attending funeral or memorial service not inappropriate boundary violation (“there are times when our
humanness is important”); “give sorrow words; the grief that does not speak/Whispers the o’er-fraught
heart and bids it break” (Macbeth, Act 4, scene III, line 243)
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 | Psychotherapy: no randomized controlled studies in literature
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| Antidepressants: several studies show antidepressants may help relieve depression so work of grief can progress;
only randomized controlled study done with nortriptyline in widows and widowers whose depression began at
least 6 mo before or within first year after spouse’s death; patients randomized to placebo alone, placebo plus
interpersonal psychotherapy (IPT), nortriptyline alone, or nortriptyline plus IPT; best outcomes obtained with
nortriptyline plus IPT; in speaker’s study of administering antidepressants early in people who met criteria for
depression, medication did not interfere with grief, but relieving depression allowed work of grief to progress
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| Treatment guidelines: patient with personal or family history of depression at high risk for bereavement-related
depression; consider starting treatment before spouse’s death; do not let time of death dictate treatment
decisions (start treatment when symptoms appear, no matter how long since death); psychotherapy plus antidepressant
seems to give best outcomes; help patient to understand normal grief process; encourage patient to
explore relationship with deceased; select medication as for any other form of depression
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| COMPLICATED GRIEF —M. Katherine Shear, MD, Marion E. Kenworthy Professor of Psychiatry, and Director,
Bereavement Research and Training Program, Columbia University School of Social Work, New York,
NY
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| Introduction: grief one of most severe stressors humans can experience; universal; risk factor for functional
impairment and health problems; literature shows that in general, intervention not needed
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| Bereavement and trauma: speaker’s group considers bereavement form of trauma (defined as intensely disruptive
and threatening event); trauma entails mismatch between mental representation of world in general
and reality of traumatic event; people who have experienced trauma often have lasting psychologic and socia
l changes; speaker proposes theory of traumatic loss, which is not exposure to negative event, but removal
of positive situation (eg, loss of important significant other person)
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| Attachment representations: humans have mental representations of important people in their lives, called attachment
representations, object representations, or working models, that develop in relation to actual experience
with attachment figures; serve critical role in mental functioning, especially during times of stress; they
comprise kind of digital summary, weighted toward consistent experiences; they are constantly matched to
ongoing experience and change gradually in response to consistent change in relationship; they do not change
quickly in response to death
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| Attachment system: functioning affects other social motivational systems, such as fear modulation and exploratory
behaviors, and in adults, caregiving and sexuality; when attachment figure dies, death consciously perceived
before internalized representation of that figure adjusted to match reality; irreconcilability of reality and
its mental representation renders working model useless; stress of death leads to attachment-seeking behavior
and strongly activates working model; result—intense yearning and searching for and preoccupation with deceased;
disturbing feelings of continued presence of deceased; confusion, disorientation, and dysphoria; temporary
immobilization of attachment and caregiving systems; secondary inhibitory effects on competence,
motivation, sexuality, and psychobiologic regulatory systems; adjustment to loss requires realignment of attachment
and caregiving and reactivation of secondary systems
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| Grief due to traumatic loss: ≈80% of people who experience bereavement make transition from acute grief to integrated
grief; acute grief—lasts most of day every day for up to 6 mo (controversial), then recurs transiently;
characteristics include sense of disbelief, difficulty accepting death, mix of emotions (with painful emotions usually
dominant), predominant and preoccupying thoughts and memories of deceased, attenuation of interest and
engagement in ongoing life; integrated grief—primarily background state in which grief occurs intermittently
and changes over time; develops by 6 mo after loss; characterized by comprehension of death, mix of emotions
(with positive emotions usually dominant), accessibility of but not preoccupation with thoughts and
memories of deceased, and reestablishment of interest and engagement in life
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| Complicated grief: also called traumatic grief and prolonged acute grief reaction; bereaved person does not
make transition from acute grief to integrated grief; occurs comorbidly with major depression and PTSD,
but also occurs separately; diagnosed using Inventory of Complicated Grief; score >25 at 13 mo and/or 25
mo after loss increases risk of developing negative mental and physical health problems
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| Treatment goals: help patient understand natural grief and complicated grief; decrease traumatic aspects of
loss; decrease excessive guilt; get patient back on track with relationships and daily activities; help patient
maintain sense of connectedness to deceased
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| Complicated grief therapy (CGT): components—introductory sessions; personal goal setting; meeting with
significant other; revisiting activities; imaginal revisiting; memories and pictures; imaginal conversation
with deceased; IPT; strategy—each session has dual focus of emotional processing of loss and restoration
of satisfying life; in trial that compared CGT and IPT, CGT outcomes statistically significantly better; IPT
alone had same effect as escitalopram alone; best outcomes obtained with CGT and escitalopram
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| Summary: complicated grief is debilitating condition of prolonged acute grief is characterized by symptoms of
persistent difficulty in accepting death, recurrent pangs of intense grief, preoccupation with thoughts and images
of deceased, and avoidance of reminders of loss; therapist must recognize problem, provide information
about grief and complicated grief, and administer targeted psychotherapy and selective serotonin reuptake inhibitor
(SSRI)
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Educational Objectives
| The goal of this program is to educate the listener about grief, bereavement, and depression. After hearing and
assimilating this program, the clinician will be better able to:
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| 1. Describe the normal processes of grief and mourning after the death of a loved one.
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| 2. Discuss the similarities and differences between grief and depression.
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| 3. Diagnose and treat bereavement-related depression.
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| 4. Describe complicated grief, also called traumatic grief and prolonged acute grief reaction.
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| 5. Develop a treatment plan for helping the patient make the transition from prolonged acute grief reaction
to integrated grief.
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Suggested Reading
Bonanno GA, Kaltman S: The varieties of grief experience. Clin Psychol Rev 21:705, 2001; Bonanno GA,
Kaltman S: Toward an integrative perspective on bereavement. Psychol Bull 125:760, 1999; Chentsova Dutton
Y, Zisook S: Adaptation to bereavement. Death Stud 29:877, 2005; Glass RM: Is grief a disease? Sometimes.
JAMA 293:2658, 2005; Horowitz MJ et al: Diagnostic criteria for complicated grief disorder. Am J
Psychiatry 154:904, 1997; Lewis, CS: A Grief Observed. San Francisco: HarperSanFrancisco, 2001; Monk TH,
Houck PR, Shear MK: The daily life of complicated grief patients—what gets missed, what gets added?
Death Stud 30:77, 2006; Pasternak RE et al: Acute open-trial nortriptyline therapy of bereavement-related depression
in late life. J Clin Psychiatry 52:307, 1991; Prigerson HG et al: Complicated grief as a disorder distinct
from bereavement-related depression and anxiety: a replication study. Am J Psychiatry 153:1484, 1996;
Prigerson HG et al: Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss. Psychiatry
Res 59:65, 1995; Prigerson HG et al: Traumatic grief as a risk factor for mental and physical morbidity.
Am J Psychiatry 154:616, 1997; Prigerson HG, Shear MK, Zisook S et al: Consensus criteria for traumatic
grief. A preliminary empirical test. Br J Psychiatry 174:67, 1999; Reynolds CF 3rd et al: Sleep after spousal
bereavement: a study of recovery from stress. Biol Psychiatry 34:791, 1993; Shear K et al: Treatment of complicated
grief: a randomized controlled trial. JAMA 293:2601, 2005; Shear K, Shair H: Attachment, loss, and
complicated grief. Dev Psychobiol 47:253, 2005; Shear MK, Zuckoff A, Frank E: The syndrome of traumatic
grief. CNS Spectr 6:339, 2001; Silverman GK et al: Quality-of-life impairments associated with diagnostic criteria
for traumatic grief. Psychol Med 30:857, 2000; Stroebe M, Schut H: The dual-process model of coping
with bereavement: rationale and description. Death Stud 23:197, 1999; Stroebe M, Schut H: To continue or relinquish
bonds: a review of consequences for the bereaved. Death Stud 29:477, 2005; Zisook S, Shuchter SR et
al: Bupropion sustained release for bereavement: results of an open trial. J Clin Psychiatry 62:227, 2001.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant
financial relationship with the manufacturer or provider of any commercial product or service discussed.
For this issue, Dr. Zisook disclosed that he is on the Speakers’ Bureau of, is a consultant to, or has received
grants from Cyberonics, GlaxoSmithKline, Forest, National Institutes of Mental Health, and Aspect Medical
Systems. Dr. Shear disclosed that she is a consultant for Pfizer and has received grants from Forest.
Dr. Zisook was recorded at Treatment Resistant Disorders, held March 31 to April 2, 2006, in San Francisco,
CA, and sponsored by the University of Iowa Roy J. and Lucille A. Carver College of Medicine and the American
Academy of Clinical Psychiatrists. Dr. Shear was recorded at Inspirational Insights from Incandescent Illuminati,
held March 10-11, 2006, in Madison, WI, and sponsored by the University of Wisconsin School of
Medicine and Public Health and the Madison Institute of Medicine, Inc. The Audio-Digest Foundation thanks
the speakers and the sponsors for their cooperation in the production of this program.
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