Grief is not an illness, but psychiatric illness can occur with bereavement.
Bereavement is one of life’s most disruptive and distressing experiences. The grief that ensues is not an illness but, rather, the manifestation of the adjustment process. This fact does not preclude the occurrence of psychiatric illness in the wake of bereavement. Clinicians need to recognize and support adaptive grief as well as diagnose and treat bereavement-related psychiatric conditions. The year 2008 saw publication of several studies that clarified how best to understand bereaved people.
Several studies in different populations indicate that most bereaved people never meet criteria for major depression, and that those who do should be treated like anyone else with a major depressive episode. In a study of 306 individuals with major depression related to recent bereavement or to other adverse life events, researchers documented that depression is not a manifestation of normal grief. Similarly, in a reanalysis of epidemiologic data collected in war-torn Lebanon that included 193 depressed participants (J Affect Disord 2009 Jan; 112:102), bereavement-related and bereavement-unrelated depression showed no differences in prevalence, symptom profile, impairment, treatment seeking, or recurrence; average episode duration, however, was longer in the bereaved group. In an open, uncontrolled, 12-week, pilot study of escitalopram for 30 bereaved and depressed individuals, researchers found a clinically and statistically significant reduction in depression and somewhat weaker, although still significant, benefits for grief symptoms (J Affect Disord Jul 2; e-pub ahead of print).
Then again, not all bereavement-related illness is depression. Although complicated grief is not included in DSM-IV, recent research has now identified this condition as distinct from normal grief and from bereavement-related depression. For people with complicated grief, symptoms acquire a life of their own and hinder, rather than help, adjustment. Complicated grief is characterized by pronounced and prolonged yearning for the deceased; difficulty in accepting the death; preoccupation with thoughts and memories of the person who died; bitterness, guilt, and anger; and avoidance of reminders that the person is gone.
A growing body of research is beginning to identify neurobiologic characteristics of complicated grief. In a functional MRI study of 23 bereaved women (NeuroImage Aug 15; 42:969), reminders of the death triggered activation in the nucleus accumbens in the group of 11 women who met criteria for complicated grief, but not in the group of 12 bereaved women without complicated grief. The degree of activation correlated with intensity of yearning for the deceased. The nucleus accumbens is part of the reward pathway, and its activation in complicated grief is different from neurobiological changes in depression. Other researchers studied variation in the monoamine oxidase A (MAO-A) promoter gene in 66 bereaved depressed patients, with and without complicated grief (Neuropsychobiology 2007; 56:191). In women only, the long allele (associated with greater MAO-A activity) was strongly associated with symptoms of complicated grief, but not with depression severity, post-traumatic stress symptoms, or other anxiety symptoms. People with complicated grief were more likely than the others to have lost a close family member.
Knowledge of risk and protective factors can inform early interventions to reduce mental health problems after bereavement. Sandler and colleagues recently reviewed their body of research in this area (Death Stud Jan; 32:59), including their intervention program for parentally bereaved children, which used strategies that increased protective parental behaviors by positive parenting, encouraged children’s emotional expression and positive coping skills, and reduced threat appraisals.
In summary, bereavement is a clinically meaningful life event that can trigger prolonged impairing symptoms. Although most people adjust to an important loss, major depression or complicated grief occurs in a minority; these conditions are distinct from each other and require targeted treatment. Clinicians need to be aware of risk and protective factors in order to facilitate positive outcomes from the grieving process.
Published in Journal Watch Psychiatry December 29, 2008
