When should antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), be prescribed to individuals experiencing grief?

When to Give Antidepressants in Grief

Antidepressants should be prescribed when grief is accompanied by major depressive disorder (MDD) or complicated grief (CG) with significant functional impairment, not for normal bereavement alone.

Distinguishing Normal Grief from Depression Requiring Treatment

• Approximately 40% of bereaved individuals meet criteria for major depression within one month of death, but this drops to 15% at one year and 7% at two years, indicating most grief resolves without pharmacological intervention 1
• Antidepressants should be considered when depressive symptoms persist beyond the expected trajectory or when complicated grief develops with profound functional impairment 2
• The key distinction is whether the bereaved person meets full criteria for MDD or complicated grief syndrome, rather than experiencing normal bereavement reactions 1

Evidence for SSRI Use in Grief-Related Conditions

• SSRIs are the preferred first-line agents when antidepressants are indicated, with preliminary evidence supporting their effectiveness for both depression and grief-specific symptoms 2
• Four open-label trials (50 participants total) suggest SSRIs may be effective both as standalone treatment and in conjunction with psychotherapy for complicated grief 2
• Paroxetine and nortriptyline have shown effectiveness in open-label trials for traumatic grief, though controlled trial data remains limited 1

Treatment Response Patterns

• When antidepressants are used for bereavement-related depression, depressive symptoms typically improve more than grief-specific symptoms 1
• Open-label trials of tricyclic antidepressants (desipramine, nortriptyline) and bupropion SR showed promising results, with one double-blind controlled trial supporting nortriptyline use 1
• Therapeutic interventions for complicated grief may be more effective when combined with SSRI administration rather than either approach alone 2

Specific Clinical Scenarios Warranting Antidepressants

• Prescribe when the bereaved individual has co-morbid major depression meeting DSM criteria with vegetative symptoms (sleep disturbance, appetite changes, anhedonia) beyond grief alone 1
• Consider for complicated grief characterized by intense yearning, difficulty accepting the death, bitterness, and inability to move forward that persists beyond 6-12 months 2
• SSRIs may be indicated for managing multiple symptoms in palliative care settings, including depression, anxiety, pain, sleep disturbances, and poor appetite 3

SSRI Selection in Grief-Related Depression

• Sertraline is preferred among SSRIs due to extensive safety data in cardiovascular disease and lower risk of QTc prolongation compared to citalopram or escitalopram 3
• Fluoxetine has substantial empirical support and FDA approval for depression, though it requires starting with a subtherapeutic test dose due to potential initial anxiety increase 4
• Avoid monoamine oxidase inhibitors and tricyclic antidepressants due to significant cardiovascular side effects including hypertension, hypotension, and arrhythmias 3

Important Clinical Caveats

• Do not prescribe antidepressants for uncomplicated normal grief - the natural bereavement process does not require pharmacological intervention in most cases 1
• Antidepressants are often discontinued in the final days of life (96.1% not administered on day of death) due to difficulty swallowing or decreased consciousness, so consider tapering to avoid discontinuation syndrome 5
• Benzodiazepines should be avoided in bereaved patients with any suicidal ideation, as they may reduce self-control and potentially disinhibit some individuals 6, 7
• Psychotherapy (particularly traumatic grief treatment or interpersonal therapy) should accompany medication management for optimal outcomes in complicated grief 2, 1