Journal of Affective Disorders 92 (2006) 117–124www.elsevier.com/locate/jad

Review

Treatment of bereavement-related depression and traumatic grief

Paula L. Hensley⁎

Department of Psychiatry, Health Sciences Center, University of New Mexico School of Medicine, 2400 Tucker NE, 4th Floor, Albuquerque,NM 87131, USA

Available online 3 February 2006

Abstract

In the bereaved, approximately 40% meet criteria for major depression within a month of the death. At a year, approximately15% of the bereaved are depressed and at 2 years, the figure is approximately 7%. Open-label trials of medication for bereavement-related depression have shown promising results for desipramine, nortriptyline, and bupropion SR. One double-blind controlledtrial supports the use of nortriptyline, but interpersonal psychotherapy did no better than placebo. In all these trials, depressivesymptoms improve more than bereavement symptoms. Effective open-label treatments for traumatic grief include paroxetine,nortriptyline, and a form of psychotherapy called traumatic grief treatment.© 2005 Elsevier B.V. All rights reserved.

Keywords: Bereavement; Bereavement-related depression; Traumatic grief

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1172. Treatment of bereavement-related depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1193. Traumatic grief and its treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1224. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

1. Introduction

Bereavement is listed in the Diagnostic and StatisticalManual of Mental Disorders, 4th edition-TR (DSM-IV-TR, 2000) as a V code for additional conditions that maybe a focus of clinical attention. The criteria recommendnot diagnosing depression related to bereavement until 2months have passed from the loss but recognize certain

⁎ Tel.: +1 505 272 3871; fax: +1 505 272 5572.E-mail address: phensley@salud.unm.edu.

0165-0327/$ - see front matter © 2005 Elsevier B.V. All rights reserved.doi:10.1016/j.jad.2005.12.041

symptoms which are not characteristic of a normal griefreaction (including guilt, suicidality, worthlessness, psy-chomotor retardation, continued severe functional im-pairment, and persistent hallucinations).

Studies have repeatedly shown that the experience ofbereavement leads to chronic depression in approximately10–15% of people. Annually in the US approximately800,000 people are newly widowed; by age 65, over 50%of all women and over 10%of all men have beenwidowedat least one time (Zisook et al., 1994a). For clarification,the term bereavement refers to a person's reaction to a loss

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by death. Grief is the emotional and/or psychologicalreaction to a significant loss, not necessarily limited to lossby death (for example the loss of use of a limb).Mourningis the social expression of grief or bereavement and isoften influenced by religious beliefs and cultural custom.Traumatic grief, with symptoms such as preoccupationwith the deceased, searching, and yearning, is a potentialcomplication of bereavement related to trauma andseparation distress.

Most descriptions of bereavement have delineatedthree stages. Clayton titled these numbness, depression,and recovery (Clayton, 1982). She describes numbnessas lasting a few hours to a few weeks. The bereavedperson typically functions somewhat automatically, ac-complishing necessary things but often rememberingevents and conversations poorly. In the second stage,depression, irritability and restlessness occur frequently,although all depressive symptoms are present. This stagelasts from a few weeks to a year after the death; somesymptoms often recur around significant anniversariesand holidays. By 6 months, many bereaved persons areon their way to recovery, meaning acceptance of thedeath accompanied by a return to the level of functioningthat preceded the death. Although most people movethrough the stages of bereavement without significantmorbidity and mortality, some develop chronic majordepressive disorder.

Clayton's work with the bereaved has yielded impor-tant data on what to expect in the bereaved period; herwork encompasses three samples. The first was a groupof forty bereaved Caucasian relatives of people who haddied at a general hospital (Clayton et al., 1968) inter-viewed soon after the death (within 16 days) and againwithin four months. At the first interview, only threesymptoms were endorsed by more than 50% of the sam-ple-depressedmood (87%), sleep disturbance (85%), andcrying (79%). Difficulty concentrating, loss of interest intelevision and the news, and anorexia/weight loss oc-curred in 47%, 42%, and 49% of the sample, respec-tively. At the follow-up evaluation, 81% of the samplewas improved and 4% was worse; those who improvedreported that their improvement occurred 6 to 10 weeksafter the death.

The second sample was a group of 109 Caucasianwidows and widowers identified from obituaries anddeath certificates (Clayton et al., 1971). In the first month,the majority of subjects reported depressed mood, sleepdisturbance, crying, anorexia/weight loss, difficulty con-centrating/poor memory, and use of medication to treatsleep disturbance or nervousness. The symptom patternsin the widows and widowers from both samples are quitesimilar. In fact, when the second sample is compared to

the widows and widowers from the first sample, only therate of anxiety attacks differs significantly between thetwo groups (39% in the widowed subgroup of the firstsample vs. 10% in the second sample).

The third sample was a group of younger (under age45 years, average 36 years) widowed persons (N=62) in-terviewed within a month of the death of a spouse (ClaytonandDarvish, 1979). The second and third samples were re-interviewed at one year. The last two samples (N=171)were matched with married, age-matched nonbereavedpeople and followed prospectively in order to assessmorbidity and mortality. By the end of the first year,somatic symptoms tended to improve, although insomnia,restlessness, and periodic low mood tended to persist.Overall, somatic symptoms improved to a greater degreethan did the psychological symptoms.

Clayton and Darvish (1979) reported that a full syn-drome of depression was present in approximately 42%of the bereaved at 1 month, decreasing to 16% at 1 year.Comparing the bereaved to matched controls, the 1 yearincidence of a full depressive syndrome was 47% in thebereaved vs. 8% in the controls (Clayton, 1990). Overall,Clayton's work with these three sample yielded minimalsignificant differences symptomatically betweenmen andwomen, between those affected by a sudden death vs.those bereaved from a lingering death, between thosewho defined their marriages as good vs. bad, and betweenpeople who considered themselves religious and thosewho did not (Clayton et al., 1968, 1971; Clayton andDarvish, 1979). In addition, there were no differences inphysical symptoms or hospitalizations when comparingthe bereaved to control subjects. However, the rate ofuse of alcohol, tranquilizers, hypnotics, and smokingincreased following bereavement.

Zisook and Shuchter (1991) reported similar rates ofbereavement-related depression—24% of their sampleof widows and widowers met criteria for a major depres-sive episode (DSM-III-R) at 2 months, 23% were de-pressed at 7 months, and 16% met criteria at 13 months.Their comparison group of married nonbereaved personshad a rate of depression of 4%. Risk factors for de-pression at 13 months in their bereaved sample includeyounger age, past history of major depressive disorder,continued grief at 2 months following the loss, meetingcriteria for depression at 2 and/or 7 months after the loss,and self-perception of poor physical health. A later reportby Zisook et al. (1994b) estimates that at 25 months,approximately 7% of the sample has symptomatic majordepression.

In summary, disregarding the DSM convention of notdiagnosing major depressive disorder within 2months ofa loss, approximately 40% of the bereaved meet criteria

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for major depression within a month of the death, ap-proximately 15% are depressed at 1 year, and approx-imately 7% are depressed at 2 years. Once identified,debate exists about how best to treat these patients.This paper will review the treatment of bereavement-related depression, focusing on psychopharmacologictreatments, and discuss the diagnosis and treatment oftraumatic grief.

2. Treatment of bereavement-related depression

Three open-label antidepressant trials for the treat-ment of bereavement depression have been published.See Table 1 for demographic variables. Jacobs and col-leagues published the first of these (Jacobs et al., 1987).Ten subjects were treated with desipramine, starting at75mg at bedtime for 1 week and increasing to 150mg bythe end of the second week. Dose adjustments were al-lowed when side effects occurred. After 4 weeks, if thepatient had a good response to the treatment and wishedto continue with it, treatment was transferred to the pri-mary care doctor, although follow-up of patients is notreported.

At the end of 4weeks, four of the ten subjects achieveda rating of “very much improved” on the Clinical GlobalImpression (CGI) scale. Hamilton Depression RatingScale (HDRS, 21 items) scores for these four participantsdeclined by 60%, 90%, 90%, and 100%. Three subjectswere rated as “much improved” on the CGI scale; thesesubjects' HDRS scores fell 43%, 60%, and 88%. Twosubjects were rated “minimally improved” on the CGI;their HDRS scores decreased by 44% and 39%. Citingside effects (dry mouth and a macular rash), one patientdropped out in the middle of the second week of treat-ment, thus preventing ratings at 4 weeks. In summary,70% of the subjects achieved ratings of “much im-proved” or “very much improved” on the CGI scale. Ofeight subjects in whom grief intensity was measuredusing a 14-item assessment of separation distress, theintensity of grief declined in seven; however, the authorsfelt that only three of these seven experienced a reduction

Table 1Open-label treatments of bereavement depression

Author/year Subjects Race Age

Jacobs et al., 1987 8 Women Not reported Mean not re2 Men Range, 26–6

Pasternak et al., 1991 8 Women Not reported Mean, 71.15 Men Range, 61–7

Zisook et al., 2001 17 Women 19 Caucasian Mean, 63.55 Men 2 Hispanic Range, 45–8

1 African-American

“of major proportion.” Though limited by smallnumbers, this study shows promising results of pharma-cologic intervention for depression in the bereaved.

In the second open trial, Pasternak and colleaguestreated thirteen widows and widowers with nortriptyline(Pasternak et al., 1991). The subjects started antidepres-sant therapy at a mean of 11.9 months (range, 2–25months) following the death of their spouse. All met cri-teria for major depression using the Research DiagnosticCriteria (RDC) and had a minimal score of 15 on theHDRS (17-items). The authors defined criteria for re-sponse as a HDRS score of less than or equal to 10 for 3or more weeks after a therapeutic blood level of nortrip-tyline had been obtained. Following acute treatment, thesubjects continued the medication treatment for an addi-tional 16 weeks.

The median response time was 6.4 weeks (mean was9.6±8.2); the mean dose at time of response was 49.2±13.5 mg/day, yielding a mean steady-state level of 68.1±19.37 ng/mL. The medication was well tolerated, and nopatients discontinued treatment. Depression was mea-sured using the HDRS, Beck Depression Inventory(BDI), and Brief Symptom Inventory (BSI). All thir-teen subjects improved compared to baseline depressionratings. On the HDRS, ratings went from a pretreatmentmean score of 22.1±3.6 to a posttreatment mean score of7.2±2.8, p=0.001—an improvement of 67.9%. On theBDI, themean fell from 20.6±11.7 to 6.5±2.6, p= 0.002,yielding an improvement of 68.4%. Finally, on the BSI,mean scores went from 1.1±0.6 to 0.5±0.4, p=0.005, a54.5% improvement. All subjects reported improvementof sleep during use of nortriptyline. Ratings on thePittsburgh Sleep Quality Index (PSQI) went from a meanscore of 12.7±4.0 pretreatment to 7.5±2.9 posttreatment,p=0.001.Nortriptyline treatmentwas also associatedwithimprovement in the Global Assessment Scale (GAS)scores, from a pretreatment mean of 54.5±7.2 to aposttreatment mean of 80.2±6.5, p=0.001. The TexasRevised Inventory of Grief (TRIG; Faschingbauer, 1981)was used to measure grief intensity and showedstatistically significant improvement with a pretreatment

Treatment Type of loss

p. Desipramine, 4 weeks Spouse5

Nortriptyline, time varied according to response Spouse8

Bupropion SR, 8 weeks Spouse3

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mean score of 51.4±7.3 and a posttreatment mean of46.6±6.9, p=0.005. Grief intensity decreased in elevenof the thirteen subjects; none of the participants showedan increase in rating of grief. The authors question theclinical significance of the improvement, however, as ityielded an overall improvement rate of only 9.3%. So,similar to the findings of Jacobs et al. (1987), Pasternaket al. (1991) found that grief intensity seemed to de-crease less than depression severity with antidepressanttreatment.

Zisook et al. (2001) report the third and last open-label treatment of bereavement depression. They treatedtwenty-two depressed (DSM-IV criteria) widows andwidowers within 8 weeks of bereavement with bupro-pion SR. Subjects were started with 150 mg/day for thefirst week, and depending on both efficacy and sideeffects, the dose could be increased to 300 mg/day by thesecond week of treatment. Treatment lasted 8 weeks; noformal psychotherapy was provided, but the authors notethat during every session there was time to listen to thepatient's concerns and reminiscences, to encourage andsupport, and (if appropriate) to assure the patients thattheir grief reactions were normal. The participants hadbeen married a mean of 35.18±15.56 years (range 5 to59 years). For the majority of subjects, this was the firstepisode of major depression; four of the 22 (18.2%) hadhad a previous major depressive episode.

Fourteen of the 22 subjects completed the 8 weeks oftreatment and results were reported for both the “com-pleter sample” and the “intent-to-treat sample.” Reasonsfor premature discontinuation were side effects (N=4),intercurrent medical illness (N=1), transportation diffi-culties (N=1), “feeling better” (N=1), and lack of effi-cacy (N=1). Overall, 20 of the 22 subjects reported atleast one side effect, the most common being dry mouth(N=9), headaches (N=9), and insomnia (N=5). The sideeffects leading to premature discontinuation in four pa-tients were (1) insomnia plus flashbacks, (2) tinnitus plusheadaches, (3) restlessness, and (4) dizziness.

In rating depression, both the completer sample andthe intent-to-treat sample showed statistically significantimprovement on both the HDRS (16-items consisting ofthe traditional 17-item scale minus the item rating sexualinterest) and the CGI severity of illness scale. For thecompleter sample (N=14), mean HDRS scores fell from16.51±4.15 to 4.50±3.28, pb0.001, a mean improve-ment of 73%. Twelve (86%) of the 14 completers had atleast a 50% improvement in HDRS score. For the intent-to-treat sample (N=22), mean HDRS scores fell from16.77±3.36 to 7.73±5.69, pb0.001, a mean improve-ment of 54%. Thirteen (59%) of the 22 members ofthe intent-to-treat sample had at least a 50% improve-

ment on the HDRS. On the CGI severity scale, meanscores for the completer sample went from 3.29±0.73to 1.57±0.65, pb0.001, a mean improvement of 52%.Mean scores for the intent-to-treat sample fell from 3.32±0.85 to 2.09±1.06, pb0.001, a mean improvement of37%. Eleven of the 14 completers (79%) achieved a scoreof 1 or 2 (very much improved or much improved, re-spectively) on the CGI improvement scale; 12 of theentire sample of 22 (55%) achieved the same level ofimprovement.

Grief was measured using the TRIG and the In-ventory of Complicated Grief (ICG; Prigerson, 1996).The completer sample showed a trend toward improvedTRIG score and a statistically significant improvementin ICG. The intent-to-treat sample showed statisticallysignificant improvement in both the TRIG and the ICG,although the mean improvement was rather small −5%and 18%, respectively. Correlations between changesin HDRS scores and grief scale scores are in a positivedirection. The improvement in grief ratings is relativelymodest compared to the improvement in depressionratings; however, the authors make the point that theresults suggest that treatment with antidepressants doesnot interfere with the grieving process, as some mightfear. They also take note of the fact that this inter-vention was started earlier than that of previous anti-depressant trials and that end ratings were doneapproximately 4 months after the death of a spouse, atime when most people would be continuing to grieve.Some patients in this study explicitly stated that theyfelt that the treatment allowed them to start grieving orto grieve more intensely since their depression wasreduced. The authors suggest that targeted psychother-apy (such as cognitive–behavioral therapy or interper-sonal psychotherapy) might have helped to lessen thegrief intensity.

In summary, the Zisook et al. (2001) study supportsthe use of bupropion SR for the treatment of bereavementdepression; again, depression ratings fell more than didthose for bereavement. See Table 2 for a summary ofthese results.

In addition to impairment in mood, it appears that thebereaved depressed show signs of impairment in ac-tivities of daily living (ADL). Oakley et al. (2002) reporton ten individuals grieving the loss of a spouse; theauthors measured the ADL function of elderly bereavedsubjects to determine whether ADL are impaired in thebereaved and whether psychopharmacologic interven-tion improves ADL. Ten subjects (five men and fivewomen) who met DSM-IV criteria for major depressionwere entered into a double-blind parallel trial of sertra-line and nortriptyline. Grief ratings were not reported,

Table 2Summary of results for the open-label trials

Author/year Results

Jacobs et al., 1987 70% were much improved or very muchimproved on the CGI a

Pasternak et al., 1991 Mean HDRSb scores decreased by 67.9%Mean BDI c scores fell by 68.4%Mean TRIGd scores fell by 9.3%

Zisook et al., 2001 ITTe sample: mean HDRS scores fell 54%59% responded to treatment (50% orgreater decrease in HDRS)55% were much improved or very muchimproved on the CGIMean TRIG scores decreased by 5%;mean ICG f scores fell by 18%

a CGI: Clinical Global Impression Scale.b HDRS: Hamilton Depression Rating Scale.c BDI: Beck Depression Inventory.d TRIG: Texas Revised Inventory of Grief.e ITT: Intent-to-treat.f ICG: Inventory of Complicated Grief.

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and the results of all subjects were pooled for this paper,so that the medication effects are not reported separately.Before treatment, depressed bereaved subjects proved tohave difficulties with ADL motor and ADL processskills compared to a well comparison group. From thepretreatment to posttreatment response phase, subjectsshowed a significant improvement in ADL motor andADL process abilities so that the treated group was com-parable to the well comparison group. In the treatmentgroup, Hamilton depression rating scale scores fell froma mean of 20.6 (SD=3.9) to 8.8 (SD=1.7) overall,pb0.001. So, in addition to improvement in depressionratings, it appears that ADL improve with treatment ofbereavement depression.

To date, the only double-blind trial in bereavementdepression that reports the treatment groups separately waspublished by Reynolds et al. (1999). In this study, 80subjects aged 50 and over, bereaved following the loss of aspouse, child, parent, or siblingwere randomly assigned to16 weeks of treatment in one of four treatment conditions:nortriptyline plus interpersonal psychotherapy (N=16),nortriptyline alone in a medication clinic (N=25), placeboplus interpersonal psychotherapy (N=17), or placeboalone in a medication clinic (N=22). Most subjects res-ponded to print advertisements or to letters sent to surviv-ing spouses identified through obituaries; few werereferred clinically. Entry criteria included meeting majordepressive episode criteria on both the Schedule forAffective Disorders and Schizophrenia-Lifetime Version(SADS-L) or the Structured Clinical Interview for DSM-IV (SCID) and the Research Diagnostic Criteria (RDC).Onset of depression was required to occur between 6

months before the death and 12 months after the death; inaddition, a bereavement intensity score of 45 or higher onthe TRIG was required—this was a proxy for active griev-ing. The typical subject was a Caucasian woman in her 60swith mild to moderate major depression, having experi-enced a loss seven to nine months previously (meanwas 32 weeks). Approximately a third of the subjectsreported prior depressive episodes. Of the demographicvariables, only age was significantly different among thegroups; the group assigned to the placebo in medicationclinic condition was younger than the other groups.Measures of bereavement intensity, depression severity,cognitive impairment, and anxiety did not differ amongthe groups.

Two years into subject recruitment, the study waschanged from a two-cell design (nortriptyline vs. placebo)to a four-cell design as described above because thegroup's open-label pilot data (Pasternak et al., 1991,cited above) suggested that antidepressant medicationdid not lessen the severity of bereavement symptoms.Therefore, the numbers of subjects in the four treatmentconditions are not equal. Nortriptyline was chosen as theantidepressant treatment because of the strong supportfor its efficacy in the literature, the group's previous pilotdata supporting its efficacy and safety in bereavement-related depression, and the medication's side effectprofile. The authors chose interpersonal psychotherapy(IPT) due to its inclusion of a module for grief and thegroup's perceptions of it being easily combined with atablet (either placebo or active medication), “user-friendly” for elderly depressed patients, and clinicallyrelevant to spousal bereavement. This group previouslyreported successful IPT treatment of elderly, depressed,spousally bereaved subjects; preliminary treatment out-comes in six subjects showed a mean change in the 17-item HDRS from 18.5±2.3 to 7.2±4.6 SD after anaverage of 17 weekly IPT sessions (Miller et al., 1994).

In the Reynolds et al. (1999) study, IPTwas deliveredin weekly 50 min session by experienced clinicianstrained and maintained at proficiency by two of the co-investigators. Medication clinic visits occurred weeklyduring the acute phase; those not assigned to IPTreceived no specific psychotherapy. Nortriptyline ormatching placebo was initiated at 25 mg per night for thefirst week then increased in 25 mg increments each weekusing clinical and blood level data. A non-blinded mon-itoring committee oversaw the nortriptyline dosing usingweekly plasma nortriptyline levels to obtain a steady-state plasma level of between 50 and 120 ng/ml.

Remission of symptoms was defined as a HDRS 17-item score of 7 or less for three consecutive weeks; thosesubjects achieving remission during acute treatment

122 P.L. Hensley / Journal of Affective Disorders 92 (2006) 117–124

entered double-blind continuation treatment for 16more weeks. Participants not achieving at least a 50%reduction in HDRS score by the end of 8 weeks wereconsidered non-responders and switched to opentreatment. Subjects completing continuation treatmentwere withdrawn from treatment over 6 weeks andfollowed for 2 years.

Remission rates for the four treatment conditionswere:(1) nortriptyline+IPT, 69% (11 of 16 patients), (2) me-dication clinic, nortriptyline, 56% (14 of 25 patients),(3) placebo+IPT, 29% (5 of 17 patients), and (4) med-ication clinic, placebo, 45% (10 of 22 patients). Com-pletion rates were greatest in the combined treatmentgroup of nortriptyline plus IPT compared to the othergroups. Relapse rates during the 16 week continuationperiod were low in all conditions. Decline in bereave-ment intensity as measured by the TRIG and ICG wasnot different across the four conditions. Overall, TRIGscores decreased from a mean of 50.1 to 38.4 over 16weeks of treatment.

The authors found a statistically significant drug effectbut no main effect for IPT and no nortriptyline-by-IPTinteraction when testing remission vs. no remissionwith a linear model using age as a covariate. In a directpairwise comparison of the nortiptyline+ IPT and theplacebo+ IPT conditions, response rates were signif-icantly different. Whether this is support for the authors'hypothesis that IPT interacts differently with activemedication than with placebo or is reflective of drug-placebo difference is a potential matter of debate. Theauthors suggest that the presence of an active antidepres-sant served to reduce depressive symptoms more than inthe placebo condition, potentially allowing greatergains in IPT and treatment retention.

In summary, the Reynolds et al. (1999) study is thefirst double-blind placebo-controlled study of bereave-ment depression and supports the use of nortriptyline.The results for IPT failed to show any difference fromplacebo. Similar to previous open-label work, improve-ment in depressive symptoms was greater than that forbereavement.

3. Traumatic grief and its treatment

The term complicated grief was at one time used torefer to bereavement-related depression with psychosis,but later was adopted by a group of researchers who usedit to refer to a group of bereavement-related symptoms,distinguishable from depression, which predicted con-tinuing functional impairment (Frank et al., 1997). Thename was changed to ‘traumatic grief’ to better capturethe underlying components of trauma and separation

distress (Prigerson et al., 1997). Horowitz et al. (1997)proposed criteria for complicated grief; these requiredthat at least fourteen months had passed from the loss inorder to make the diagnosis.

Later, Prigerson et al. (1999) published consensuscriteria for traumatic grief. The diagnosis requires at leastthree of the following four symptoms: “(a) Intrusivethoughts about the deceased, (b) Yearning for the de-ceased, (c) Searching for the deceased, (d) Loneliness asresult of the death” (Prigerson et al., 1999). In addition,the diagnosis requires four of the following eight symp-toms: purposelessness, numbness, disbelief about thedeath, emptiness, feeling loss of a part of the self, lost senseof security, assumption of symptoms of the deceased, andexcessive anger or irritability (Prigerson et al., 1999).While acknowledging the need for further empiricalvalidation, the authors require duration of symptoms forat least 2 months and clinically significant impairmentin social, occupational, or another important area offunctioning.

Data on medication treatments for traumatic grief areless available than for bereavement depression. Zygmontand colleagues conducted a post-hoc comparison ofparoxetine and nortriptyline for the treatment of trau-matic grief (Zygmont et al., 1998). In their study, twenty-one patients with traumatic grief (minimal score of 20 onthe ICG) were treated with open-label paroxetine. Sixsubjects dropped out prematurely, five due to side effectsand one who refused further treatment. Fifteen subjects(eleven women and four men) completed the 16 weektrial. The mean age of completers was 56.9±10.1 years(range 40 to 79 years); fourteen subjects were Caucasianand one was African American. The mean time from theloss was 16.6 months (range 6.1 to 138.6 months); eightsubjects had lost a spouse, five had lost a child, one hadlost a grandchild, and one had lost a parent. Using theSCID for DSM-IV, ten participants had a current di-agnosis of a major depressive episode and two others hada history of major depression. A variety of other psy-chiatric diagnoses were present in the sample, includingdepressive disorder not otherwise specified, posttrau-matic stress disorder, minor depressive disorder, gener-alized anxiety disorder, adjustment disorder, and panicdisorder.

Paroxetine was started at 10 mg/day and increasedweekly in 10 mg increments to a maximum dose of30 mg/day. If no improvement (defined as a re-duction of the baseline ICG by 25% or greater) wasapparent at 6 weeks, the dose was increased to 50mg/day. The median dose at the end of the study was 30mg/day (range 20 to 50 mg). In addition, the subjects alsohad “traumatic grief psychotherapy,” which the authors

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describe as a new psychotherapeutic intervention toaddress the symptoms of traumatic grief.

For the fifteen study completers, the authors reportedthat traumatic grief as measured by the ICG decreased by53% and that depression as measured by the HDRS 17-item scale decreased by 54%. In addition, general levelof functioning as measured by the Global AssessmentScale (GAS) improved, going from a baseline mean of56.3±6.6 to 76.2±9.1, p=0.0002. Overall, statisticallysignificant differences were seen in mean scores at base-line compared to time 2 (16 weeks) in the HDRS, GAS,ICG, Pittsburgh Sleep Quality Index (PSQI), and theImpact of Event Scale-Revised: Avoidance, Intrusion,Hyperarousal (RIES-A, -I, -H). The improvement seen insymptoms of traumatic grief is positively correlated withimprovement in depression symptoms.

These patients treated with paroxetine were thencompared to twenty-two nortriptyline-treated patients ina trial of bereavement depression, the Reynolds et al.(1999) trial discussed previously. Both medications ap-peared to improve the symptoms of depression morethan those of traumatic grief, and the improvement intraumatic grief was comparable with the two agents. Inspite of comparable results, the authors point out otherfacts that may make the SSRIs as a class preferable toTCAs, with their greater side effect burden, lethality inoverdose, and, in the case of nortriptyline, need tomonitor blood levels to maintain a therapeutic windowfor efficacy. These authors reiterate the call for double-blind, placebo-controlled trials in the treatment oftraumatic grief.

Two reports of a psychotherapeutic technique cal-led “Traumatic Grief Treatment,” employing imaginaland in vivo exposure techniques show promisingresults (Shear et al., 2001 and Harkness et al., 2002).The treatment utilizes IPT techniques to encouragerelationship reengagement and cognitive behavioraltechniques (CBT) for PTSD symptoms. A manualguides the treatment and is available from Dr. Shear;the treatment is ideally delivered n approximately 16sessions over 4 months (Shear et al., 2001). Exposurestrategies (both imaginal in which the death scene isreexperienced and in vivo in which avoided situationsare targeted) are the primary means for grief reduction(Shear et al., 2001).

In the Shear et al. (2001) report, 21 subjects with amean age of 51.4 years (SD=15.8 years) were treated amean time frombereavement of 2.9 years (range 3monthsto 9 years). The ICG at intake was required to be greaterthan 25; the mean ICG in the 21 subjects was 40.33.Although grief symptoms were the primary clinical pro-blem, nine subjects met criteria for major depression and

seven had PTSD. Eight subjects dropped out after one ormore sessions (mean number of sessions was 5.75,SD=3.37, range was 1 to 10). Dropouts tended to beyounger than completers and were more likely to begrieving violent deaths. Thirteen subjects (nine womenand four men) completed a full 4 month treatmentcourse. Scores on the ICG fell a significant amount frompretreatment to posttreatment in both the completer group(N=13, mean change 22.79, SD=13.14, z=−3.11,p= 0.002) and the intent-to-treat group (N= 21,mean=16.91, SD=14.99, z=−3.51, pb0.001). Theeffect sizes were large at 2.19 and 1.45, respectively.

Depression and anxiety as measured by the BeckAnxiety Inventory and the Beck Depression Inventoryshowed significant reductions in both the completer andITT groups (anxiety in completers: z=−3.06, p=0.002;anxiety in ITT group: z=−3.92, pb0.001; depression incompleters: z=−2.98, p=0.003; depression in ITTgroup: z=−3.44, p=0.001). Effect sizes were 2.04 and1.08, respectively, for the Beck Anxiety Inventory and1.80 and 1.16, respectively, for the Beck DepressionInventory. So, this report shows promising results for theuse of Traumatic Grief Treatment in reducing symptomsof traumatic grief, depression, and anxiety.

In the Harkness et al. (2002) report, case histories offour patients treated with Traumatic Grief Treatment areexplored. All met DSM-IV criteria for a current majordepressive episode, and one also met criteria for BipolarAffective Disorder type II. All scored at least 25 on theICG. All four subjects were already in psychotherapy andwere referred to the pilot treatment due to persistingsymptoms of grief, 18 months to 2 years following thedeath of a family member.None of the patients took me-dication during the treatment. All the patients werewomen; two had been widowed, one had lost an adultson, and one had lost an adult brother. The authorsdescribe the four cases in detail. All four experienceddecreases in traumatic grief as measured by the ICG. Bythe end of treatment, three of the four no longer metcriteria for traumatic grief (as determined by a cutoffscore of 25 on the ICG). For all four patients, thetreatment decreased the emotional intensity associatedwith imaginal revisiting of the death, increased theability to remember positive things about the deceased,and increased the ability to engage in positive activities.In addition, all the subjects reported marked decreasesin their rating of depression on the Beck DepressionInventory (BDI) and anxiety on the Beck AnxietyInventory (BAI) by the end of treatment. Traumaticgrief therapy seems quite promising, and these authorsstate that it is currently being tested in a randomizedcontrolled trial.

124 P.L. Hensley / Journal of Affective Disorders 92 (2006) 117–124

4. Conclusions

Bereavement-related depression may be diagnosed inapproximately 15% of people 1 year after the death of aloved one. Although most data about treatment hasfocused on widows and widowers, we also have infor-mation about treatment of bereaved subjects who havelost parents, children, and siblings. Data from thesestudies suggests that antidepressants are well toleratedand tend to improve the symptoms of depression morethan those of grief. Interpersonal psychotherapy, thoughseeming to have good face validity for treating bereave-ment depression, was no better than placebo in the onlydouble-blind, placebo-controlled trial that has beendone. Traumatic grief may require specific psychoth-erapeutic techniques addressing the trauma and separa-tion distress central to this disorder.

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