grief, unresolved grief, and depression

6
SIDNEY ZISOOK, M.D. RICHARD A. DeVAUL, M.D. Grief, unresolved grief: and depression Dr. Zisook is associate prOfessor of psychiatry at the University of California, San Diego, School of Medicine and Dr. De Vaul is associate professor of psychiatry and behavioral sciences at The University of Texas Medical School at Houston. Reprint requests to Dr. Zisook, Department of Psychiatry, University of California, San Diego, School of Medicine, Gifford Mental Health Clinic, 3427 Fourth A venue, San Diego, CA 92103. ABSTRACT: For examination of relationships between grief, unresolved grief, and depression, 211 subjects completed questionnaires designed to measure grief, identify unresolved grief, and measure depression. Fourteen percent of the study population showed evidence of unresolved grief. This group was younger, less likely to have attended the funeral, and more depressed than the resolved-grief group. Depression is likely to be more severe with unresolved grief, which tends to persist once present. The results are discussed in relation to the relevant literature. Grief, the constellation of signs and symptoms following a personally significant loss, is generally con- ceptualized as a dysphoric but self- limited process. As experienced by an adult, it ordinarily follows an overlapping sequence of phases beginning with a brief period of shock and denial, merging into a phase of acute dysphoria, and end- ing with a period of resolution. l . s Occasionally this process becomes deviant, and one or more of the phases of grief is absent, delayed, intensified, or prolonged. This oc- currence has been variously de- scribed as morbid,2 atypical,4 pathologic,6 or neurotic' grief. Symptoms of deviant grief seem to differ in degree rather than in kind from ordinary grief. 8 We have pre- viously conceptualized these syn- dromes as effects of non resolution of the usual stages of the grief process and therefore prefer the term "unresolved grief."9 While unresolved grief may present clini- cally in various forms, such as psy- chotic denial, pathologic identifica- tion with the deceased, or chronic depression, this report explores the relationships between grief, unre- solved grief, and depression. The relationship between loss and depression is well established. As recently reviewed by Lloyd,1O childhood bereavement and a vari- ety of adult losses, including be- reavement, increase the risk for de- pression. In a series of studies by Clayton and associates,II-16 depres- sion was found to be a common accompaniment of widowhood. This depression could not be dis- tinguished from the depression of the nonbereaved control groups on the basis of symptoms. However, depression following death of a spouse was not more common in women than in men, not associated with a family history of depression or with previous depressive epi- sodes, not likely to be treated by psychiatrists, nor associated with a subjective sense of being ill. MARCH 1983 • VOL 24 NO 3 147

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Page 1: Grief, unresolved grief, and depression

SIDNEY ZISOOK, M.D.

RICHARD A. DeVAUL, M.D.

Grief, unresolved grief:and depression

Dr. Zisook is associate prOfessor ofpsychiatry at the University of California, SanDiego, School of Medicine and Dr. De Vaul is associate professor ofpsychiatry andbehavioral sciences at The University of Texas Medical School at Houston. Reprintrequests to Dr. Zisook, Department of Psychiatry, University of California, SanDiego, School ofMedicine, Gifford Mental Health Clinic, 3427 Fourth A venue, SanDiego, CA 92103.

ABSTRACT: For examination of relationships between grief,unresolved grief, and depression, 211 subjects completedquestionnaires designed to measure grief, identify unresolvedgrief, and measure depression. Fourteen percent of the studypopulation showed evidence of unresolved grief. This group wasyounger, less likely to have attended the funeral, and moredepressed than the resolved-grief group. Depression is likely tobe more severe with unresolved grief, which tends to persist oncepresent. The results are discussed in relation to the relevantliterature.

Grief, the constellation ofsigns andsymptoms following a personallysignificant loss, is generally con­ceptualized as a dysphoric but self­limited process. As experienced byan adult, it ordinarily follows anoverlapping sequence of phasesbeginning with a brief period ofshock and denial, merging into aphase of acute dysphoria, and end­ing with a period of resolution. l .s

Occasionally this process becomes

deviant, and one or more of thephases of grief is absent, delayed,intensified, or prolonged. This oc­currence has been variously de­scribed as morbid,2 atypical,4pathologic,6 or neurotic' grief.Symptoms of deviant grief seem todiffer in degree rather than in kindfrom ordinary grief.8 We have pre­viously conceptualized these syn­dromes as effects of nonresolutionof the usual stages of the grief

process and therefore prefer theterm "unresolved grief."9 Whileunresolved grief may present clini­cally in various forms, such as psy­chotic denial, pathologic identifica­tion with the deceased, or chronicdepression, this report explores therelationships between grief, unre­solved grief, and depression.

The relationship between lossand depression is well established.As recently reviewed by Lloyd,1Ochildhood bereavement and a vari­ety of adult losses, including be­reavement, increase the risk for de­pression. In a series of studies byClayton and associates,II-16 depres­sion was found to be a commonaccompaniment of widowhood.This depression could not be dis­tinguished from the depression ofthe nonbereaved control groups onthe basis of symptoms. However,depression following death of aspouse was not more common inwomen than in men, not associatedwith a family history of depressionor with previous depressive epi­sodes, not likely to be treated bypsychiatrists, nor associated with asubjective sense of being ill.

MARCH 1983 • VOL 24 • NO 3 147

Page 2: Grief, unresolved grief, and depression

Grief and depression

-

Table 1-Past Behaviors Endorsed as Mostly orCompletely True by over 50% of Respondents

Table 2-Present Feelings Endorsed as Mostly orCompletely True by over 50% of Respondents

Depression Scale.'~

7977737265

5351

89878478676460

% ofrespondents

%ofrespondents

Results

Two hundred and eleven complet­ed questionnaires were receivedfrom all areas of the United States.Most of the respondents were fe­male (62%). well educated (13.7years), middle class (mean familyincome of $15,000), white (65%white, 17% black. 11% Mexican­American, 7% other), middle-aged(mean of 36.5 years with a range of19 to 74), and Protestant (47%Protestant, 26% Catholic, 13% Jew­ish. 13% other or none). The de­ceased had expired at a mean age

I am now functioning about as well as beforeI feel I have adjusted well to the lossI very much miss the personNo one will ever take his/her place in my lifeNow I can talk about the person without discomfort

I grieved for the person who diedI attended the funeralI criedI kept thinking about him/herI was depressedIt was hard to believe the person had diedI was shocked to learn he/she had diedII took me a long time to really acceptthe person's death

I felt empty inside

most closely approximated thosecharacteristics used clinically by usto help identify unresolved griefwere chosen to comprise an Unre­solved Grief Index: (I) "I feel 1have grieved for the person whodied"; (2) "Now I can talk aboutthe person without discomfort";and (3) "I feel I have adjusted wellto the loss." This somewhat arbi­trary, but clinically based, indexwill be examined further in theDiscussion.

In addition to the Grief Invento­ry and Unresolved Grief Index,each respondent was asked to care­fully complete a Zung Self-Rating

Depression, like unresolvedgrief, is a relatively common con­sequence of bereavement. The na­ture of the relationship betweendepression and unresolved grief,however, remains unclear. We havepreviously postulated that severedepression would be seen more fre­quently in unresolved grief. Thusfar we are unaware of any empiri­cal evidence that confirms the rela­tionship. This study attempts to ex­amine the relationship based on theresults of a questionnaire survey ofa nonclinical population.

The survey

In an effort to develop a reliableand valid instrument to better de­scribe and measure grief. the au­thors developed the Texas Invento­ry of Grief, a 14-item self-reportscale. 17 Based on the literature ofnormative and atypical grief reac­tions, as well as the clinical experi­ence of the authors, the original14-item inventory was expanded to58 items. ls To obtain normativedata, the instrument was sent tofriends and colleagues around thecountry so that they could ask oneor two friends or neighbors whohad lost a relative or close friend tocomplete the questionnaire.

The respondents were asked togive their age, sex, race, religion,educational level, relationship tothe deceased, length of time sincethe death, and the age of the de­ceased. They were asked to checkone of the five responses on each of24 items relating to their feelingswhen the person died (the Past Be­haviors list) and 34 items pertain­ing to present feelings (the PresentFeelings list). The possible re­sponses for each item were: com­pletely true, mostly true, partly trueand partly false, mostly false, andcompletely false. Three items that

248 PSYCHOSOMATICS

Page 3: Grief, unresolved grief, and depression

Table 4-Zung Items Significantly Relatedto Unresolved Grief I

ings list that the majorIty of re­spondents felt were mostly or com­pletely true about them. Grief­related present feelings peaked be­tween one and two years followingthe loss (P< .05), but continued tobe substantial even ten or moreyears later. Table 3 shows the per­cent of respondents endorsing eachof the three items comprising theUnresolved Grief Index. Unlike thetotal Present Feelings score, theUnresolved Grief Index score didnot change as a function of time­when present, it tended to remain.

.. 0' respondentsby category

0' respons.·t

0 1 2 3 4

I grieved for the person who died 86 1 1 1 11I feel I have adjusted well to the loss 58 19 8 3 11Now 1can talk about the personwithout discomfort 43 22 16 5 14

Table 3-Unresolved Grief IndexOn the Unresolved Grief Index,

with a score of 0 to I denotingresolved grief, and 6 or more asdefinitely unresolved grief, 14%(30) of our population showed evi­dence of unresolved grief. Thisgroup was no different from itscounterparts with resolved grief(37% or 78 persons) in terms ofeducational level, income, sex, timesince death, age of the deceased, orrelationship to the deceased. Onthe other hand, the unresolved griefgroup was younger (39 years vs 31years, P<.05), less likely to haveattended the funeral (P< .05), andmore depressed. Nine of 20 itemsand total scores on the Zung Scalewere significantly higher in theunresolved grief group, while nonewere higher for the resolved griefgroup (Table 4). Finally, the re­solved grief group had higheroverall scores on the Past.Behaviors(P<.OI) and Present Feelings(P<.OI) lists.

Discussion

The 14% of our nonpatientbereaved population with unre­solved grief and the 37% with re­solved grief are in the range ofpercentages from other studiesusing different criteria to identifyunresolved grief. For example, La­zare2° found 10% to 15% of patientsreferred to a general outpatientclinic to be suffering from unre­solved grief. DeVauP found that25% of patients seen in a psychiatricconsultation service had unre­solved grief predating the onset oftheir medical problems.

Before continuing our discus­sion, several issues of methodologicbias should be addressed. Severalitems on the questionnaire havedesirable ("No one will ever takehis/her place in my life") or unde­sirable ("I still get angry when I

(continued)

I,

I

p<

.018

.011

.011

.030

.005

.025

.003

.031

.016

--

t Oehn,tely unresolved gnel - 14% (wllh a tolal score of 6 10 12)Resolved grief - 37% (with a lotal score of 0 10 1)

• FOr each Item 0 - completely true, 1 - mostly true: 2 - partly true, partly false:3 = mostly false, 4 - completely false

I feel downhearted, blue, and sadI have crying spells or feel like itI have trouble sleeping through the nightMy mind is as clear as it used to be (negative score)I feel hopeful about the future (negative score)I am more irritable than usualI find it easy to make decisions (negative score)I feel that I am useful and needed (negative score)I still enjoy the things I used to (negative score)

I

of 54 years (range of one to 92years), and approximately 4.5 yearsprior to the survey (range of onemonth to 22 years). Most of thedeceased were first-degree rela­tives, with 27% being fathers, 16%mothers, 8% brothers, 5% sisters,3% husbands, 1% wives, 0% sons,2% daughters, 7% close friends, and24% other close family members.

Table I lists those items from thePast Behaviors list that at least halfof all respondents considered most­ly or completely true. Table 2 liststhose items from the Present Feel-

I

MARCH 1983 ' VOL 24 • NO 3 249

Page 4: Grief, unresolved grief, and depression

SINEQUAN Cdoxepin Hel)Re ereflCe 1 Barranco 5F. Thrash ML. Hac ell E Frey J. el al (Pllzer f'harmaceullCaJs. PhzerInc ow 'brl<. NY) Early onset 01 response to doxepln trealment J Clm Psychratry

26:'-269. 1979

BRIEF SUMMARYSlNEOUAN (doxepln HCI) e-.>lesIer.I Concentrateeontr.lndlcetions. 51NEOUAN Is conualnd caled ,n Indiv,duals who have shown hypersen­SJl,v'ly 10 the drug. Possibility 01 cross S nS,lJvity wllh other d'benzoxepines should be kept Inmind.

51NEOUAN 's conlralndicaled In patients w,th glaucoma or a lendency 10 unnary relentlOn.These disorders should be ruled out. part,cularly In older patientsWllrnlngs. The once·a·day dosage regimen of 51 EQUAN ,n pahents w'lh intercurrent,lIness or patients la ng olher med cations should be carefufly adjusted This Is especially,mportanl in atlenlS rece,v,ng other medicatIOns wllh anuchollnerglc effects

Uuge In erletra: The use 01 51NEOU on a once-a-day dosage reg,men In geflalncpallents should be adjusted carefully based on the pa enrs cond,uon

Uuge In PregMncy: Reproducllon studies have been performed In rats rabbits. m0n­keys and dogs and !here was no ev,dence of harm 10 the ammal lelus The relevance 10humans IS not known. Since Ihere IS no experience In pregnanr women who have receivedIhls drug. safety In pregnancy has not been estabhshed There are nodata wlih respecl to thesecretIOn of Ihe drug ,n human fTlIlk and Its e fect on Ihe nursing inlant

Uuge In Child,..,: The use of 51 EQUAN ,n chltdren under t2 years of age 's nolrecommended because safe condlloons lor 115 use ha.e nOl been established

MAO Inhlbllon: SerIOUS Side elteets and even dealh ha.e been reported follOWing Iheconcomitant use of certa n drugs With MAO Inhibitors Therefore. MAO ,nh,b'tors should bedlsconllnued at least lwe> weeks pnOltO the cauuous ,niuatlOn 01 therapy Wllh 51 EQUANThe exact length 01 tme may vary and Is dependent upon the particular MAO Inh,bltOl be,ngused. Ihe length 01 lime It has been adm,nrslered. and the dosage InllOlved.

Uuge with Alcohol: It should be borne ,n mind Ihal alcohollngesllon may Increase thedanger Inherent rn any Intanllonal 01 unintenllonal 51 EQUAN overdosage. Th,s Is espec,allyImportant,n patients who may use alcohol excesSively.Pnlc:autlons. Slnce drowsiness may occur th the use of th,s drug. patients should bewarned 01 Ihe POSslbihty and cautioned against dnvlng a car or op_hng dangerousmachInery wh,le ta Ingthe drug Palrents should also be cautIOned Ihat therr response toalcohol may be polenllated.

Since SUICide is an Inherent os In any depressed patient and may remaIn SO untilsignIficant Improvement has occurred. pallents should be closely supervised dunng !heearly course o'lherapy Prescnplrons should be wfltlen 'or the smallest feaSible amount

Should Increased symptoms 01 psychOSIS Or Sh,lI 10 man,c symptomatologyoccur. it may be necessary to reduce dosage or add a major tranquilIzer to Ihe dosageregimen....-... Reec:tlons. NOre Some of !he adverse reacllonS noled below M.e no! beenspecifically ,ePOlted 'Ih SINEQUA use. Ho.vever. due to the close Pharmac~cal

~'I~~~~~among the trlcyclics. !he reacllons should be conSidered when prescn ng

Anllclto/metglC E/fecrs. Dry moulh. blurrad vISion. conSlrpation. and unnary retention ha.ebeen reported. Illhey do no! subside wilh continued Iherapy. or become severe. It may benecessary to reduce the dosage.

Central Nervous System E/fects; Drowsiness IS the most commonly nollced Side ellect.This lends 0 disappear as Iherapy IS conlJnued. Olher inl,equenlly reported CNS Sideeffects are confusion. d,sonentation. halluclnallOns. numbness. parestheslas. ataxia. andextrapyramidal symploms and seIZures.

cardiovascular: Cardiovascular eltects Including hypotenSIOn and tachycardia have beenreporled occasionally.

Allergic S n rash. edema. photosenslllZation. and plUntus have occaSIOnally occurredHematologIc· Eoslnophll,a has been reported In a few patients. Thete nave been occa·

soonal reports of bone marrow depression man,festlng as agranulocytOSIS. leukopen,a.thrombocytopenra and purpura.

GaslfoinresMal ausea. vomiting. ,ndlgest,on. tasle disturbanCes. diarrhea. anoreXla.and aphlhous stomatllrs have been reponed (See antICholinergic effects)

Endoctlne Raised or lowered Irbldo. lestlcular swelling. gynecomastIa In males. enlarge­ment of breasts and galactOlrtlea ,n the female. raising or I<NJerrng ot blood sugar IeWlls ha.ebeen repor ed wrlh trlCYCIrC admlnlstralIOn.

Other DIZZIness. tinnitus. we,ght gain. Sweating. ch,lls. fatigue. weakness. nushlng. ",un­dice. alopecra. and headache ha.e been occaSIOnally observed as advelse effects.Douge end AdmInI_on. For most panents With ,lIness of mild to moderale severity. astarting dally dose of 7S mg IS recommended Dosage may subsequently be Increased Ordecreased at approprrate intervals and according to Individual response The usual op.timum dose range IS 7S mgJday 10 ISO mglday.

In more severely III patients higher doses may be requrred With subsequenl Ilradual,ncrease to 300 mgJday il necessary Additional therapeulrc effect is rarely to be obta,ned byexceeding a dose of 300 mglday

In palrents With very m,ld symplomatology or emotional symptoms accompanYing organicdlseasa. lower doses may su lice. Some of these pat,ents have been controlled on doses aslow as 25-SO mgJday.

The 100ai dally dosage 01 SINEQUAN may De gl.en on a divided 01 once·a·day dosageschedule Illhe once-a-dey schedule IS employed the ma><Imum recommended dose is ISOmgJday. This dose may be gIven af bedbme. TIM 150 mg CIrI*lIe a1rength I. Intended lor..........""" therepy only end I. not '""""""*oded lor InllIeIlon of IrlleImenI.

Anll·anxlety el eet is apparenl before the antidepressant elect OptImal antldepressanlelteel may no! be evldenl or two 10 Ihree weeks~.A Signs and 5ymploms

1 Mild' Drowsiness. stuPOl. blurred VISIOn. excessl.e dryness of moulh2 Severe Resp,t8IOfy depreSSion. hypOlension. coma. coovulstOns. cardiac arrnylhmlas

and tachycardias.Also unnary retenbOn (bladder atony). decreased gastrointesunaJ mol'llly (paralytic ileus).

hyperthermia (0< hypolnermla). hypertension. dilated puprls. hyperacllve reflexes.B. Managemem and Treatment

, Mild' Observatron and supporu.elherapy IS allihat Is usually neeessaJy.2 Severe. Medical management 01 severe 51 EQUAN overdosage consists 01 aggressIVe

supportive Iherapy. If Ihe palient's consclous. gastric lavage. With ap~lOQrlale precautions

:,ob~::;;:~t.~~~~a;;r::~~c~~~~::~:~cx:,::;:~::.~~sE~e~~~t~~~~gastnc tavage w,th saline 101 24 hours or mOle. An adequate airway should be established incomatose pauents and assisted .enillation used If necessary. EKG monItoring may berequited 101 several days. s,nce relapse alfel apparent recovery has been reported AI­rhylhmlas should be treated th Ihe appropriate antlarrnythmlC agent. It has been ,eportedthai many of Ihe cardiovascular and C 5 symptoms of tricyclic antidepressant poisoning inadults may be reversed by the slow Intravenous administration of 1mg to 3 mg of physostig­mine salicylate Because physostigmIne IS rapidly metabolIZed. the dosage should berepeated as required ConvulsIOns may respond to standard anticonvulsant therapy. how·ever. barbiturates may polantrate any resprratory depressIOn. DIalYSIS and forced diuresiSgenerally are no! 01 vafue In the management of overdosage due to h'gh Itssue and prolelnbinding of 51 EQUAN.More delded ~onellnlonnellon....u.bleon~

ROeRIG_

Grief and depression

think about him/her") implicationsthat may influence response. Thedata were obtained from friendsand neighbors of the investigators'friends and relatives, largely anadult, white, middle-class, profes­sional group. In addition, personswho responded to the q uestion­naire may have been biased. A po­tential respondent who is stillpreoccupied with a long-past lossmight be more inclined to completethe questionnnaire than one who isnot. Few respondents had lost chil­dren or spouses, making compari­sons with much of the literature onwidowhood tenuous. The question­naire also asked people to accu­rately recall past feelings and be­haviors associated with a period ofturmoil and disorganization, oftenyears after the fact. Despite thesereal limitations, the data do detail aconstellation of symptoms thatbereaved individuals rememberhaving had after their loss, as wellas those that they were presentlyexperiencing.

Obviously, a number ofarbitrarydecisions regarding the UnresolvedGrief Index were made. We choseto include items most closely ap­proximating the questions usedclinically by us to identify unre­solved grief.5.9 Since no generallyaccepted definition or descriptionyet exists, our index would be diffi­cult to validate. On the other hand,the relationship found by us be­tween depression and unresolvedgrief and its stability over timeseems to partially validate thescale.

The importance for researchpurposes of an operational defini­tion of unresolved grief appearsobvious. Many clinical studies de­scribe a wide variety of syndromesthat result from atypical andpathological grief.2.3.6.7.9.2o.23.25.3o Psy-

A division 01 Plizer PharmaceuticalsNew York, New York fOO17

252 PSYCHOSOMATICS

Page 5: Grief, unresolved grief, and depression

chiatric disorders, an increased riskfor the onset of medical illness, andprolonged social incapacitation areall associated with grief. Clinicalevidence suggests that unresolvedgrief may account for all or most ofthis medical risk. For example,Schmale,24 in a study of the fre­quency of loss antedating medicalhospitalization, found the effects ofhopelessness and helplessness(unresolved griet). rather than thefact of the loss itself. to be thecrucial factor. Both an increase25

and a decrease21 of acute responsesto bereavement have been relatedto later complications. Jacobs1b

suggests that the process of griefacts as a bridge between loss andillness or death, and David22 statesthat unresolved grief (not just loss)in childhood or adolescence leadsto later problems.22 Zisook27 foundunresolved grief a major charac­teristic of grief-related facsimile ill­ness, namely, the phenomenon inwhich pathologic identificationwith the deceased presented in theform of the terminal illness. At theminimum, resolution of the griefprocess appears related to healthand adjustment.

Our findings suggest a relation­ship between unresolved grief andother complications, especially de­pression. By our index, individualswith unresolved grief were signifi­cantly more depressed as measuredby total Zung scores and numerousitems on the Zung scale. Althoughno cause and effect relationship canbe defined, it does appear that per­sons who report that they havegrieved, adjusted to the loss, andcan talk about the deceased with­out difficulty are less likely to bedepressed than those who indicatethat they have not grieved.

Our results support previous re­ports that a significant proportion

MARCH 1983 ' VOL 24 ' NO 3

of bereaved individuals go througha somewhat typical grief process inthe sequence previously men­tioned. Sixty-four percent of ourpopulation acknowledged a stageof shock and disbelief. In the nextstage of acute dysphoria, 80% feltthat they had grieved for the personwho died, 84% cried, 78% keptthinking about him or her, and 67%felt they were depressed. A majori­ty of the respondents showed evi­dence of reaching the third stage ofresolution. Although 73% stillmissed the deceased and 72% feltthat no one would ever take his orher place, 79% believed that they

Once present, unresolvedgrief tended to remain,suggesting the need foractive inten'ention whenidentified.

were functioning as well as theyhad previously, 77% felt that theyhad adjusted to the loss, and 65%stated that they were able to discussthe deceased without difficulty.Present grief-related feelings andbehaviors peaked in intensity be­tween the first and second years,and gradually diminished thereaf­ter.

Unresolved grief, on the otherhand, did not significantly changeover time. Once present, it tendedto remain, suggesting the need foractive intervention when identified.Factors found in the literature3.5.2oto impede the resolution of griefinclude lack of social supports, thebereaved's psychological makeup,substance abuse, age, multipleprior losses, ambivalent or over-in­vested relationships to the de­ceased, and fortuitous factors. In a

large epidemiologic study ofwidows and widowers, Parkes25

found four major factors that pre­dicted poor outcome: low socioeco­nomic status; a short terminal ill­ness with little warning of impend­ing death; multiple life crises; andreactions to bereavement that in­clude severe distress, yearning,anger, or self-reproach. His studydid not find demographic factorsimportant, nor did he confirmMaddison's finding2M that supportfrom family relationships or closefriends was especially significant.

We found demographic factorsnot particularly related to outcome,the one exception being the age ofthe bereaved. Younger individualstended to have more unresolvedgrief. This is consistent with Parkes'and Maddison's finding thatyounger widows had more illnessesthan older widows, and with Clay­ton's finding29 that younger widowshad more physical and depressivesymptoms and hospitalizations.

In addition, our respondentsidentified as having unresolvedgrief were less likely to have at­tended the deceased's funeral. Thisis consistent with Volkan's concIu­sion30 that persons exhibitingpathologic grief often fail to par­ticipate fully in funeral rites. Ourunresolved grief group also hadoverall present and past grief scoresmore consistent with Parkes'4.25finding that, instead of delayed orinhibited grief leading to latercomplication, the most disturbedindividuals after one year werethose most disturbed three to sixweeks after bereavement.

ConclusionIn our study a significant percent­age of bereaved individuals did notcom pletely resolve their grief.These persons tended to be

(continued)

Page 6: Grief, unresolved grief, and depression

Refamca: 1. laoob!on A et aI: Psychophysi%sY7:345. Sep 1970.2. LynchT. Creme Vf: IfrColJPhys Surs 4:87-90. Ian 1975. J. lames NM. MontasueAf:NZ Med 181 :246-248. Mar 12. 1975. 4. TawsER. Brunning ,. A!enmas L: Ifni Med Res 3:417-422.lun 1975. 5. Broadhurst AD. A!enOIas L: GUT Med ResOpin 3:413-416. lui 1975.6. Data on file. HoIImann­La Roche Inc.. Nutley. NI. 7. KaJes A et a/: I Clin Phar­macoII7:207-213. Apr 1977. 8. GreenblaU 01. AllenMD. Shader R/: Clin Pharmacol Ther 21:355-361. Mar1977. 9. Monti 1M: Methods Find up Clin Pharmacol3:303-326. May 1981.

OaImane<!>(flurazepam HCVRoche)@Before presaibing, please consult complete productinformation, a summary of which foUows:Iodicalions: [flective in all types 01 insomnia character­ized by dilliculty in lalling asleep. lrequent nocturnalawakenings and/or early morning awakening: in patientswith recurring insomnia or poor sleeping habits: in aculeor chronic medical situations requiring restful sleep. Objec­tive sleep laboratory data have shown elIectiveness lor atleast 28 consecutive nights 01 administration. Sinceinsomnia is ohen transient and intermiUent. prolongedadministration is generally not necessary or recommended.Repealed therapy should only be undertaken with appro­priale patient evaluation.Contnlindications: Known hypmensilivity to flurarepamHCI: pregnancy. Benzodiazepines may cause fetal damagewhen administered during Pre.Jlancy. Several studies sug­gest an increased risk 01 congenital mallormations associ­ated with benzodiazepine use during the lirst trimester.Warn patients of the potential risks 10 the fetus shouldthe possibility of becoming pregnanl exist while receivingflurazepam. Instruct patient to discontinue drug prior tobecoming pregnant. Consider the pnssibility 01 pregnancyprior to instituting therapy.Warnings: Caution patients about possible combinedefIects with alcohol and other CNS depressants. An addi­tive eflect may occur if alcohol is consumed the day fol­lowing use for nighttime sedation. This potential may existlor several days loIlowing discontinuation. Caution againsthazardous occupations requiring complete mental alertness(e.8.. operating machinery. driving). Potential impairmentof perlormance 01 such activities may occur the day fol­lowing ingestion. Not m:ommended lor use in personsunder 15 years 01 age. Though physical and psychologicaldependence have not been reported on recommendeddoses. abrupt discontinuation should be avoided withiJaduallapering 01 dosage lor Ihose patients on medicalionlor a prolonged period 01 time. Use caution in administer­ing to addiclion-prone individuals or those who mighlincrease dosage.Precautions: In elderly and debilitated patients. it is m:­ommended thai Ihe dosage be limited to 15 rng to reducerisk of oversedation. dizzi~. conlusion and/or alaxia.Consider potential additive effects with other hypnotics orCNS depressants. I:mploy usual pm:autions in severelydepressed patients. or in Ihose with latent depression orsuicidal teridencies. or in those with impaired renal orhepatic lunction.Advme Reactions: Dizzi~. drowsi~. lightheaded­~. st~ng. ataxia and lalling have occurred. particu­larly in elderly or debilitated patients. ;-evere sedation.lethargy. disorientation and coma. probably indicative 01drug intolerance or overdosage. have been reported. Alsoreported: headache. heartburn. upset stomach. nausea.vomiting. diarrhea. constipation. GI pain. nervo~.talkativeness. apprehension. irrilability. weakness. palpita­tions. chest pains. body and joint pains and G ~ .. com­plaints. There have also been rare occurrences of leuko­penia. iJanulocytopenia. sweating. flushes. dilliculty infocusing. blurred vision. burning eyes. fainina';. hypoten­sion.~ 01 breath. pruritus. skin rash. dry mouth.biUer taste. excessive salivation. anorexia. euphoria.depression. slurred speech. confusion. restles5ness. halluci­nations. and elevaled SCOT. SGPT. Iotal and direct biliru­bins. and alkaline phosphatase: and paradoxical reactions.e.8.. excitement. stimulation and hyperactivity.Dosage: Individualize for maximum beneficial eRect.Aduhs, 30 rng usual dosage: 15 rng may suRice in somepatients. Elderly or debilitaJed paJienls, 15 rng rec0m­

mended inilially until response is determined.Supplied: Capsules containing 15 rng or 30 rngflurazepam HC!.

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Grief and depression

younger, failed or were less likely toattend the funeral, were more dis­tressed both shortly after and longafter their loss, and were more de­pressed than those individuals tra­versing an ordinary grief process.Although depression is commonand even typical of uncomplicatedgrief, it is likely to be more severewhere there is evidence of unre­solved grief. Once present, unre­solved grief tends to persist. Sincethe medical and psychiatric seque­lae of the bereaved state appearsubstantial, further research is in­dicated to identify those patientswho prolong this state. 0

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3. Engel GL: Is grief a disease? Psychosom Med23:18-22.1961.

4. Parkes CM: Bereavement: Studies ot Griet inAdult Life. New York. International Universi­ties Press. 1972.

5. DeVaul RA. Zisook S. Faschingbauer R: Clini­cal aspects of grief and bereavement. PrimaryCare 6:391-402. 1979.

6. Volkan V: The recognition and prevention ofpathological grief. Virginia Med Monthly99:535-540.1972.

7. Wahl CW: The differential diagnosis of normaland neurotic grief following bereavement.Psychosomatics 11:104-106. 1970.

8. Parkes CM: Bereavement and mental illness.Part 2. A classification of bereavement reac­tions Br J Med Psychol 38: 13-26. 1965.

9. DeVaul RA. Zisook S: Unresolved gnef: Clini­cal considerations. Postgrad Med 59:267­271.1976

256

10. Lloyd C: Life events and depressive disorderreviewed. Parls I and II. Arch Gen Psychiatry37:529-535.1980.

11. Clayton p. Desmarais L. Winokur G: A studyof normal bereavement. Am J Psychiatry125:168-178.1968.

12. Clayton PJ. Halikas JA, Maurice WL: Thebereavement of the widowed. Dis Nerv Syst32:597-604. 1971.

13. Clayton PJ. Halikas JA. Maurice WL: Thedepression of widowhood. Br J Psychiatry120:71-7&.1972

14. Clayton PJ. Halikas JA. Maurice WL: Antici­patory grief and widowhood. Br J Psychiatry122:47-51.1973.

15. Clayton PJ. Herjanic M. Murphy GE. et al:Mourning and depression: Their similariliesand differences. Can Psychiatr Assoc J19:309-312. 1974.

16. Claylon PJ: Mortality and morbidity in the firstyear of Widowhood. Arch Gen PsyChiatry30:747-750.1974.

17. Faschingbauer TR. Devaul RA. Zisook S:Development of the Texas Inventory of Grief.Am J Psychiatry 134:696-698.1977.

18. Zisook S. DeVaul RA. Click M: Am J Psychia­try. to be published. 1982.

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20. Lazare A: Unresolved Grief in Outpatient Psy­chiatry Diagnosis and Treatment. 1979. pp498-512

21. Deutsch H: Absence of grief. Psychoanal 06:12-22.1937.

22. David CJ: Grief. mourning. and pathologicalmourning. Primary Care 2:81-92.1975.

23. Hackett TP: Recognizing and trealing abnor­mal grief. Hosp PhysiCian 149-56. 1974.

24. Schmale A: Relationship of separation anddepression in disease. A report ot a hospital­ized medical population. Psychosom Med20:259-277.1958

25. Parkes CM: Determinants of outcome follow­Ing bereavement. Omega 6:303-323. 1975.

26 Jacobs S. Douglas L: Gnef. A mediatingprocess between a loss and Illness. ComprPsychiatry 20: 165-176. 1979.

27. Zisook S. DeVaul RA Grief-related facsimileillness. tnt J Psychiatry Med 7:329-336. 1977

28. Maddison DC. Walker WL: Factors affectingthe outcome of conjugal bereavement. Br JPsychiatry 113:1057-1067. 1967.

29. Clayton PJ: The effect of living alone onbereavement symptoms. Am J Psychiatry132:133-137. 1975

30. Volkan VD: Typical findings in pathologicalgrief. Psychiatr 044:231-250. 1970.

PSYCHOSOMATICS