1. Describe the normal process of grieving after the death of a loved one.

2. Distinguish between normal grieving, prolonged acute grief, and bereavement-related depression.

3. Discuss the elements of combined grief therapy.

4. Express sympathy for a bereaved patient in a professionally appropriate way.

5. Treat prolonged acute grief and bereavement-related depression.

Sidney Zisook, MD
Professor of Psychiatry, University of California, San Diego, School of Medicine, and Director, Residency Training, San Diego Veterans Affairs Medical Center, La Jolla, CA

Introduction: grief—defined as biopsychosocial reaction to loss (any loss); common components include separation distress (eg, sadness, anxiety, helplessness, anger, shame, pain), traumatic distress (eg, disbelief, intrusive memories, avoidance of memories), survivor guilt or remorse, and social withdrawal; bereavement—grief specific to loss of loved one; in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), defined as depressive syndrome within 2 mo of death of loved one; bereavement reaction—grief related to bereavement; mourning—behavioral and social manifestations of bereavement; prolonged acute grief—long-lasting intense grief that requires intervention; also called unresolved, complicated, or traumatic grief

Bereavement: loss of loved one through death; “grief is the price we pay for love”; San Diego Widowhood Study helped to establish understanding of normal bereavement; 350 men and women evaluated within 2 mo of death of spouse, then followed with questionnaires at 6 mo, 1 yr, 1.5 yr, and 2 yr; ≈14% had history of major depression; in 63% of cases, death was expected; at 6 to 8 wk, 88% still grieving, but 12% either had not grieved or had finished grieving; however, this 12% “did fine”; 1 yr after loss, they were less likely to be depressed, less likely to be still grieving, and less likely to be physically ill; worst outcomes seen in people most intensely grieving with most pain early on

Multidimensional assessment of spousal bereavement: emotional response—yearning for dead spouse common initially and at all follow-up reviews, but decreased in intensity and frequency over time; positive emotions also common, and included enjoying talking about deceased spouse, recollections, telling funny anecdotes, taking pride in honoring deceased, warmth in recollecting closeness of relationship, and relief from burden of caring for deceased; some felt guilty about positive feelings and found that talking about it helped to relieve that guilt; people with more positive feelings immediately after loss tended to do better over time; positive emotions related to pre-loss resilience and associated with post-loss life satisfaction, tranquility, and optimism

Maintaining relationship with dead spouse: fundamental part of grief; involves reformulating, not severing, attachment bonds to maintain deceased in survivor’s life psychologically and emotionally over time; initially, ≈66% of survivors felt that dead spouse was watching over them in some way, and >50% still felt same at 2 yr; at 2 mo, 39% were talking regularly with dead spouse, and 23% at 2 yr; seeing dead spouse in dreams increased over time as survivor found ways during awake hours to accept loss; symbolic representation (eg, keeping deceased’s belongings) 48% at 2 mo, 36% at 2 yr

George Burns and Gracie Allen: show business couple who were married for 38 yr; Allen died in 1964; Burns, who never remarried, died in 1996 near his 100th birthday; Burns visited Allen’s grave weekly, left flowers, and talked to her, maintaining their relationship

Hearing voice of deceased: not pathologic hallucination, but part of maintaining relationship

New relationships: men—immediately after loss, most men thought they would never be interested in another woman, but 61% were in new relationship or remarried by 2 yr; predictors for developing new relationship or remarriage included having money and higher education; women—less likely to enter new intimate relationship or to remarry because they were less interested, were more loyal to deceased spouse, and because of shortage of men in older age groups; only predictor for developing new relationship or for remarriage was woman’s youth; depression—when present, in either sex, person less likely to develop new relationship or to remarry; when to start dating or to remarry—highly individual; encourage children to “let their [bereaved] parents alone, support them and encourage them,” because “people who do get into new relationships do better, are less depressed, and almost invariably the new relationships work out”

More dimensions of bereavement: changes in functioning (functioning may be impaired immediately after loss, but usually improves over time); changes in identity (people often feel that experience of having been married and having dealt with grief and survived it makes them stronger, more sensitive to others, and more self-confident)

Overall adjustment: by 2 mo after loss, 62% feel they are adjusting well, 70% at 1 yr, 75% at 2 yr

Complications of grief: time of loss is time of vulnerability to medical and psychiatric conditions; study showed increase in general medical morbidity after loss of loved one; in speaker’s study, no widow or widower started using drugs or alcohol who had not used them before, but individuals with history of drug or alcohol abuse were at higher risk for recurrence or exacerbation

Prolonged grief: also called complicated grief; for purposes of research, acute grief considered prolonged when it endures 6 mo after loss; model of normal biobehavioral process—acute grief reaction immediately after death of loved one; usually within ≈6 mo, acute grief reaction lessened as survivor experiences some degree of acceptance, feels more positive emotions, forgives self, develops compassion, and ascribes meaning to the loss; acute grief evolves into integrated grief (also called abiding grief), which is background state that can be brought into awareness by, eg, anniversaries, reminiscences, or happy occasions that survivor would have liked to share with deceased; memories may be bittersweet; grief does not disappear, but is accessible, changing, and lessens over time; prolonged grief reaction—acute grief that persists after 6 mo; usual instinctive pathway blocked; instead of acceptance, meaning-making, and development of new relationships, predominant affect is fear; survivor fears pain, loss of control, being thought disloyal, and loses self-identity; disbelief persists; anger and guilt are excessive (anger can be directed at self, deceased, God, caregivers, or “everybody”); survivor experiences indignation, rumination, and excessive avoidance, and does not progress to integrated grief; prolonged grief reaction may last for years, is painful and disabling, and interferes with development of new relationships and maintenance of existing relationships; in addition, prolonged grief associated with poor health and multiple comorbidities; some data even suggest increased suicide rates

Case examples: woman lost mother to natural causes, grieved for ≈10 yr before getting treatment; man lost daughter to car accident, grieved for ≈3 yr before seeking treatment; another woman lost husband to cancer, grieved for ≈20 yr before treatment; in each case, prolonged grief debilitating; each survivor described “a big hole that couldn’t be filled”; cases demonstrate that prolonged grief can occur whether death sudden or expected after chronic illness

Combined grief therapy (CGT): literature search found no treatments successful (whether support groups, psychotherapy, or medication), so CGT developed by group at University of Pittsburgh School of Medicine; integrative therapy that combines interpersonal psychotherapy (IPT), prolonged exposure, and cognitive behavioral treatment strategies; based on model of coping with grief that posits contemporaneous oscillating attention to loss-focused work and life-focused work (ie, in addition to dealing with loss and grieving, patient must also deal with continuing to live); treatment strategy—each session has dual focus of emotional processing of the loss (accomplished through imaginal revisiting of the death, imaginal conversation with deceased, revisiting painful activities and places, and working with memories) and restoration of satisfying life (addressed through setting personal goals, working on interpersonal problems, and revisiting satisfying activities and places); in study, CGT produced better results than standard IPT; best results occurred in patients already taking antidepressant medication when they started CGT (those taking medication had better adherence rates); unfortunately, very few therapists currently trained in CGT

Bereavement and depression: bereavement often associated with onset of major depression; in US epidemiologic study, 10% of people with major depression had lost loved one to death within past year, and often ascribed their depression to that death; in sample from Lebanon (during war), 26% of those who met criteria for major depression had lost someone to death within previous 2 mo; in 1971 study of bereaved people, 42% met criteria for major depression within 3 mo after loss; in speaker’s 1993 study of bereavement, 24% had major depression at 2 mo, 16% at 2 yr; in study of risk factors for depression among elderly community subjects, biggest risk factor was recent bereavement (odds ratio 3.3); crying every day most common depressive symptom at 1 mo (89%); although decreased at 13 mo (33%), still higher than in general population

Summary of 24 longitudinal studies: bereavement-related major depressive disorder (MDD) approximately equally prevalent in children, adults, and older adults; in controlled studies, rates of MDD consistently higher in recently bereaved than in nonbereaved controls; bereavement-related MDD persists over time; in studies that began before bereavement, rates of major depressive episode (MDE) and dysphoria already higher in soon-to-be-widowed than in those who would remain married; prebereavement MDE and dysphoria predict bereavement- related depression after loss; MDE and dysphoria highest in months after death, and decrease over time, but remain elevated, compared to nonbereaved, for 1 to 3 yr

Treatment

Do: express sympathy; acknowledge that you as clinician do not know “exactly what [the bereaved person is] going through”; talk about the deceased, saying his or her name; inquire about circumstances of death; encourage expression of feelings; observe “3 Hs” (hush [do not say too much], hug, hang out [be around])

Do not: be casual or passive (eg, instead of saying, “call me when you want to talk,” say, “I’ll call you [at specific time on specific day]”); imply death was “for the best” or acceptable; suggest bereaved person “is strong and will or should get over it”; avoid discussion of death or person who died

Acceptable for therapist to: cry (better to allow oneself to cry than try to repress it for duration of session); send condolence card (such cards can be very comforting to bereaved); attend funeral or memorial service (ask bereaved person’s permission when possible)

Medication: study of medication alone, psychotherapy alone, and combination found medication better than placebo, but best results occurred with combination; another study found escitalopram remission and response rates “very similar to what you would expect in nonbereaved populations”; third study found bupropion effective; speaker concludes that treating depression did not interfere with grief (“depression interfered with grief”), and treating the depression helped both depression and grief

Guidelines: “think preventive”; if person with current or past depression is losing somebody, that person at risk for recurrence or exacerbation of depression and should be offered treatment for depression; multidimensional approach, using psychotherapy plus medication, best treatment

Summary: acute grief painful and disruptive, but usually evolves into less painful, integrated grief; prolonged grief can precipitate depression; grief not medical condition and does not require treatment; however, complications (eg, prolonged acute grief, bereavement-related major depression) can be identified and should be treated

Questions and answers: if antidepressant started for bereavement-related depression, dose and duration same as for depression from any other cause; no studies examining ability of religious values to protect individual against developing prolonged acute grief reaction; however, several studies show religious values do not protect against depression; antidepressant medication allows grieving individual with depression to do grief work; speaker recognizes association between grief and posttraumatic stress disorder (PTSD), even when death of loved one expected; many normal symptoms of grief overlap with symptoms of PTSD