This question was recently posed to Dr. Wolfelt – “Is the best and probably only way to get through complicated grief antidepressants?” See his answer below.
My short answer is absolutely not! Why? Because we know that antidepressants alone (even when indicated) are not an appropriate means to provide comprehensive support to someone in grief. In my experience, the biggest challenge is to train clinicians in what is called a “differential diagnosis” between the normal sadness/depression that often accompanies grief and that of a clinical depression where antidepressants may be an appropriate adjunct to one’s helping role.
We also need to keep in mind that as it relates to “complicated” grief there are numerous risk factors and influences to take into consideration. These include but are not limited to: societal contributors, circumstances of the death, the griever’s unique personality, the griever’s relationship with the person who died, the griever’s loss history, the griever’s access to and use of support, other concurrent stressors in the griever’s life, the griever’s family system issues, participation in meaningful ceremonies, and the list goes on. It would be simplistic and inappropriate to think anyone with complications of their grief would be a candidate for antidepressant medication.
What a pleasure to provide the following context to assist your readers in better understanding this naturally challenging topic of complications in grief and the use of antidepressants.
Sadness and Depression
Sadness and reactive depression are natural, authentic emotions after a loss. I often refer to them as the hallmark emotions of grief. It’s normal for grievers to feel profound pain and a muting of desire and pleasure. Yet these are among the most challenging emotions for grievers to befriend, especially in a culture that often vilifies pain and encourages “getting over it” as quickly as possible. “They wouldn’t want you to be sad!” is the oft-repeated refrain.
In grief, sadness and depression play an essential role. They force us to regroup—physically, cognitively, emotionally, socially, and spiritually. When we are sad, we instinctively turn inward. We withdraw. We slow down. It’s as if our soul presses the pause button and says, “Whoa, whoa, whoaaa. Time out. I need to acknowledge what’s happened here. I need to allow for my soul work— downward movement of my psyche.”
The necessary sadness of grief can also be referred to as “sitting in your wound.” When you sit in the wound of your grief, you surrender to it. You acquiesce to the instinct to slow down and turn inward. You shut out the world for a time so that, eventually, you have created space and energy to let the world back in.
Even in normal grief, it often takes weeks or months before grievers arrive at the full depth of their sorrow. I have observed that the pain almost always gets worse before it gets better. This fits with the organic, recursive nature of grief. And so, profound sadness and being pressed down can be considered normal and necessary. Yet, sadness and depression may be sufficiently debilitating or prolonged in some grievers to be considered markers of naturally complicated grief.
Naturally Complicated Grief: I define this as when someone experiences normal, necessary grief that has gotten stuck or off track somehow. It has encountered barriers or detours of one kind or another and has as a result become stalled, waylaid, or denied altogether. It is not abnormal or pathological, yet it is naturally complicated. In the case of depression some people experience forms of clinical depression that sometimes benefit from the use of antidepressant medications.
Normal Grief or Clinical Depression?
For centuries, most people viewed depression as a sign of physical or mental weakness, not as a real health problem. But today, clinical depression is recognized as a common health challenge—an illness with a biological basis that is often exacerbated by psychological and social stress. In fact, each year about ten percent of American adults experience some form of clinical depression.
Are these numbers falsely inflated by the trend toward the medicalization of normal existential troubles? Probably. But while I worry that we are diagnosing clinical depression too liberally because we as a culture misunderstand the role of pain and suffering, I am not a depression denier. I do believe that clinical depression is a real phenomenon that may require additional helping efforts, including appropriately prescribed medication.
There are a number of influences that can play a role in the development of depression, including genetics, stress (such as the death of someone you love), and changes in body and brain function. Many people with clinical depression have abnormally low levels of certain brain chemicals and slowed cellular activity in areas of the brain that control mood, appetite, sleep, and other functions. Clinical depression affects not only your mood but also how you think about things, making your thoughts more negative and pessimistic. It affects how you feel about yourself, lowering your sense of self-worth. It impacts how you act, often making you more ambivalent or disinterested in life and can make you easily upset about even minor things.
Everyone experiences times of sadness in response to the stresses and losses of life. Part of being human is to have some “proper sorrows of the soul” along life’s path. The feelings that go along with these stressful events are naturally unpleasant. Yet the occasional sadness that we all sometimes feel because of life’s disappointments and stresses is very different from clinical depression. Unlike normal feelings of sadness and loss, clinical depression can be debilitating. In many ways, depression and grief are similar. Common shared symptoms are feelings of sadness, lack of interest in usually pleasurable activities, and problems with eating and sleeping. The central difference is that while grief is a normal, natural, and healthy process, clinical depression is not.
One area to pay particular attention to is feelings of self-worth. While people who are grieving a death often feel guilty over some aspect of the relationship or the circumstances of the death, they do not typically feel worthless. In other words, people with grief depression may feel guilty and even hopeless for a time, while people with clinical depression often experience a generalized sense of low self-worth and hopelessness.
| Normal Grief
You may have normal grief if you… |
Clinical Depression
You may be clinically depressed if you… |
| o respond to comfort and support. | o do not accept support. |
| o are capable of being openly angry. | o are irritable and complain but do not directly express anger. |
| o relate your depressed feelings to the loss experience. | o do not relate your feelings of depression to a particular life event. |
| o can still experience moments of enjoyment in life. | o exhibit an all-pervading sense of gloom. |
| o exhibit feelings of sadness and emptiness. | o project a sense of hopelessness and chronic emptiness. |
| o may have transient physical complaints. | o have chronic physical complaints. |
| o express guilt over some specific aspect of the loss. | o have generalized feelings of guilt. |
| o feel a temporary loss of self-esteem. | o feel a deep and ongoing loss of self-esteem. |
The difference between the normal sadness of grief and clinical depression can also be measured by how long the feelings last and to what extent your daily activities are impaired. Characteristics of grief and mourning soften over time; whereas with clinical depression they often get described by the person as: “I feel stuck.”
Depression can complicate grief in two ways. It can create short-term symptoms that are more severe and debilitating than those normally associated with grief. In addition, clinical depression can cause symptoms of grief to persist longer than normal and potentially worsen.
Obviously, grievers who have suffered from clinical depression in the past, before coming to grief or apart from loss, should be closely monitored for the potential of clinical depression after a loss. Be sure to encourage anyone who is currently taking antidepressants for properly diagnosed depression to stay on them. Sometimes the natural confusion and lethargy of grief interfere with medication compliance.
The bottom line is that the boundaries that separate normal grief, complicated grief, traumatic grief, and clinical depression are blurry and somewhat arbitrary. In determining how best to help struggling grievers, grief companions must always use their body of knowledge and advanced level counseling skills.
If the griever meets the criteria for clinical depression, including functional impairment, medication management should be considered in addition to intensive companioning. And there is the key- anyone that is an appropriate candidate for an antidepressant should also be receiving supportive, insight-oriented counsel from a grief-informed caregiver. Even if the depression can be attributed wholly to the loss, the griever may need relief from their depressive symptoms in order to more fully engage with the central needs of mourning and reclaim hope.
The Six Needs of Mourning
- Acknowledge the reality of the death
- Embrace the pain of the loss
- Remember the person who died
- Develop a new self-identity
- Search for meaning
- Let others help you – now and always
These needs will help the griever be an active participant in authentically mourning and help soften the normal depressive symptoms of grief.
If you or someone who cares about you thinks you may be clinically depressed, I invite you to review the above chart and make a checkmark next to any symptoms you think apply to you. If you place checkmarks in the clinical depression column, that means it’s time to see your primary-care provider or a counselor. They will help you discern what’s going on and get you the extra care you need. Remember— getting help is not a sign of weakness; it is a sign of strength.
The good news is that clinical depression is treatable. With appropriate assessment and treatment, most people with clinical depression find significant relief. Untreated depression, on the other hand, can raise your risk for a number of additional health problems. It will also prevent you from moving forward in your journey through grief. You deserve to get help so you can continue to mourn in ways that help you heal. Choose life!
If you are depressed
Please keep in mind that if you are depressed (normal grief or clinical depression) you are not weak, and there is nothing to be ashamed of. However, it is crucial to not keep the depression to yourself. You both need and deserve human contact. Without it, your depression will deepen, and you risk complete withdraw from the world around you.
When you seek out help, I hope you will find the support of those who take a “companioning” approach that I advocate for in my book Companioning the Bereaved: A Soulful Guide for Caregivers. Even if clinical depression or complicated grief are blocking your path to healing, I suggest that this spiritual-companioning model of care, when used with up-to-date medical understanding, provides aa compassionate approach to help you out of the darkness of depression and into the light of a new tomorrow.
For those of you wanting to learn more about my perception of the complexities of depression and the use of antidepressants, allow me to suggest the following resources. For the lay person: The Depression of Grief: Coping with Your Sadness and Knowing When to Get Help. For the clinician: When Grief is Complicated: A Model for Therapists to Understand, Identify, and Companion Grievers Lost in the Wilderness of Complicated Grief.
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Dr. Alan Wolfelt has been recognized as one of North America’s leading death educators and grief counselors. His books have sold more than a million copies worldwide and have been translated into many languages. Founder of the Center for Loss and Life Transition in Fort Collins, Colorado Dr. Wolfelt speaks on grief-related topics, offers trainings for caregivers, and has written many bestselling books and other resources on grief for both caregivers and grieving people. For more information visit www.centerforloss.com
