Dear Dr. Neimeyer,
Is the best and probably only way to get through complicated grief through the use of antidepressants?
Both clinical experience and clinical research suggest that antidepressant medication is a mixed blessing in the context of bereavement, for several reasons. In fact, for many years psychiatrists agreed that depression could not be diagnosed in the early months following the death of a loved one, because profound sadness and its disruptive effects on the survivor’s life could be understood as essentially normal, rather than a “mental disorder” that required medical intervention. However, this has recently changed, as bereavement is no longer excluded from the diagnosis of a depressive disorder, opening the door to more widespread use of drugs as a treatment option from the early weeks following loss. However, evidence suggests caution in following this path.
One reason for caution is that reaching for a solution to a profound and very real existential challenge in the form of medication could lead professionals, potential social support figures and the bereaved themselves to neglect other forms of support and coping that have been shown to be at least as effective as medication in addressing depression. For example, closely retelling and reviewing the circumstances of the loss, processing the meaning of the loss for our lives via journaling, prompting ourselves to actively re-engage the world and circumstances we have avoided since the loss, and seeking the practical and emotional support of others in our lives have all been found to improve adjustment to bereavement in general, and depressive reactions in particular. Sometimes medication can help people find the energy to engage in these other forms of self-help, but it does not in itself accomplish the many psychological, social and family changes that bereavement requires.
A related reason that antidepressants rarely “fill the bill” as an adequate treatment for bereavement is that grief and depression are substantially different things. Granted, sadness, lack of energy and withdrawal may be common to both, but the key symptoms of complicated grief (profound separation distress, preoccupation with the death, feeling that our future is without meaning in the absence of the loved one) cannot be found in any list of symptoms of depression, and in fact have more in common with anxiety states than with depression, per se. Accordingly, multiple studies have shown that these core features of separation distress simply are not helped greatly by antidepressants, even if medication does improve symptoms of depression (inability to experience pleasure, loss of energy, disrupted sleep, etc.) more narrowly defined.
So, what might be the appropriate role for antidepressants be in treating complicated grief? Perhaps the most enlightened view would be that they can play a useful role in addressing depression triggered by the loss, though not separation distress, when both conditions co-occur for several months following a loved one’s death (as one study suggests might be the case for approximately 25% of survivors of a loved one’s violent death, for example). In other words, antidepressant medication is rarely if ever a sufficient treatment for bereavement distress, though it can contribute to survivors’ adaptation when depressive symptoms compound complicated grief. Used alongside social support, personal efforts to process the loss and re-engage life, and professional counseling or psychotherapy, it can sometimes provide a partial answer to the many biopsychosocial challenges of loss, though not a comprehensive one.