August 1, 2011

The death of a loved one, especially a child, spouse, or someone of similar closeness, is one of the most significant and traumatic events a person is likely to experience. Despite this, the majority of people handle the loss with minimum morbidity. For a small minority, the loss may lead to increased doctor visits for new or worsening medical conditions, increased use of substances (such as alcohol, benzodiazepines, and hypnotics), the development of chronic depression or a posttraumatic stress disorder (PTSD)-like syndrome termed “complicated grief,” and even increased mortality. In order to understand the more pathologic outcomes, one must be familiar with the more expected reaction in the immediate post-bereavement period and in the year following.

Before proceeding with the normal reaction, it is necessary to clarify terms. Bereavement is the reaction to a loss by death. Grief is the emotional and/or psychological reaction to any loss, but not limited to death. Mourning is the social expression of bereavement or grief, sometimes defined by culture, custom, and religion. Complicated or traumatic grief is the disordered psyche and behavioral state present beyond 6 months following a loss; the term implies unresolved loss and impaired performance. With these definitions in mind, we will discuss bereavement and complicated or traumatic grief.

Most studies of the recently bereaved have delineated three stages. The first stage is termed numbness, since this is the term that the recently widowed used to describe themselves. It lasts from a few hours to a few days, perhaps a few weeks. Things that need to be done get done, but most of what is said and done is poorly remembered. Anxiety symptoms may appear. The second stage is depression. While symptoms of irritability and restlessness are prominent, all depressive symptoms are common. Many people are on their way to recovery by 6 months, although others continue to have symptoms through the first year and even into the second year. The survivor’s mood is almost always disturbed on holidays, anniversaries, the birthday of the deceased, the anniversary of the death, and other personal or meaningful events and may partially be the cause of the much-discussed “Christmas depression.”

In the recently bereaved, prominent symptoms of the second stage are crying, sleep disturbance, sadness, depression, loneliness, restlessness, poor appetite, feeling tired, poor memory, loss of interest in some things (but not necessarily neighbors and friends), difficulty concentrating, and weight loss. The weight loss can be profound. The sleep disturbance often remains entrenched, whereas the weight loss usually ends after the second month. From the third month on there is more likely to be weight gain. By one year, the most prominent symptoms are sleep disturbance and loneliness. The third stage, recovery, is acceptance of the death and a return to some level of functioning that was established before the death.

Since depressive symptoms are common, the question is how many of the recently bereaved experience the full depressive syndrome that we know as major depressive disorder. In studies of widowed persons, about 50% meet criteria for major depression at some time during the first year. About 10% of the recently widowed experience a chronic depression. There are very few predictors of this chronic depression. Those that have been verified across several studies include poor physical health prior to the loss, poor mental health prior to the loss (particularly a previous depressive episode or prior substance abuse), and depression at 1-2 months postloss. An unknown percentage of those with chronic depression develop complicated grief. These people experience preoccupation with the deceased, crying, searching, and yearning for the deceased, feeling stunned, disbelief, nonacceptance, anger, distress, detachment, avoidance, some replication of symptoms that the deceased experienced, loneliness, bitterness, and guilt. This syndrome demands an intervention.

There is still a good deal of controversy over the physical morbidity and mortality of bereavement. The bereaved do not have more physical symptoms than matched controls; and there is no increase in hospitalization, either psychiatric or general, after a loss. The most important outcome in the immediate bereavement period is that those who use substances, use more; those who drink, drink more; those who smoke, smoke more. This may explain some of the morbidity and mortality associated with bereavement. There have been numerous studies on mortality following the death of someone close. Men under the age of 75 (the “young-old”) have an increased mortality in the first 6 months after a loss. Women do not clearly have this increased mortality.

The vast majority of people who experience a loss will recover gradually without any interventions. Those who become chronically depressed or develop complicated grief need psychiatric intervention. Although the treatment could be simple, such as education and selfhelp groups, a more logical treatment is psychotherapy (such as interpersonal therapy, IPT) or pharmacotherapy (such as antidepressant therapy). It is unclear how best to treat complicated bereavement. For postbereavement depression, open-label studies of antidepressants have demonstrated remission rates at or above 50% in the first 2-3 months of treatment; low relapse rates occurred following medication discontinuation. The field awaits a definitive study involving placebo controls.

SEE ALSO: Depression, Mood disorders, Posttraumatic stress disorder


Category: B