What is the recommended management for an adult patient experiencing grief, including self‑care, support, psychotherapy, and criteria for initiating an SSRI (e.g., sertraline) for complicated grief?

Managing Grief in Adults: A Practical Guide

Grief is a normal response to loss that typically does not require medication, but when symptoms become persistent, disabling, and interfere with daily functioning—termed complicated grief—evidence-based psychotherapy (specifically Complicated Grief Therapy) should be initiated, with SSRIs like sertraline considered as adjunctive treatment only when grief remains refractory after 8 weeks of psychotherapy or when comorbid major depression is present. 1, 2

Understanding Normal vs. Complicated Grief

Normal Grief Characteristics

• Preoccupation with the loss, somatic distress, waves of sadness, and temporary withdrawal from usual activities are expected responses 3
• Most bereaved individuals do not require professional intervention beyond supportive care 1
• Grieving is normal and generally takes time to resolve naturally 4

Recognizing Complicated Grief

Complicated grief requires formal intervention when the following symptoms persist beyond 6-12 months: 4, 1

• Recurring intrusive thoughts about the loss that interfere with daily functioning 4
• Persistent preoccupation with sorrow and ruminating behavior 4
• Excessive bitterness and anger 4
• Alienation from social contacts and difficulty accepting the loss 4
• Loss of perceived purpose in life 4
• Considerable morbidity and mortality risk 1

Critical distinction: Complicated grief differs from major depression—grief symptoms focus specifically on the loss and the deceased person, whereas depression involves pervasive hopelessness and loss of self-worth across all domains 3

Self-Care Recommendations for Normal Grief

Provide these specific self-care instructions to all grieving patients: 4

• Physical basics: Eat regular, nutritious meals; maintain hydration; exercise regularly even when unmotivated 4
• Routine maintenance: Try to maintain usual daily routines as much as possible 4
• Social connection: Stay connected with others (including digitally) and talk openly about feelings 4
• Emotional acceptance: Allow yourself to experience negative emotions without judgment—the grieving process fluctuates over time and cannot be rushed 4

When to Seek Professional Support

Refer patients for psychosocial support when they experience: 4

• Anticipatory grief concerns (e.g., "What do I tell my children?" "How will my family cope?") 4
• Descriptions of profound loss (loss of role, identity, income, purpose) 4
• Signs of complicated grief as described above 4
• Comorbid depression or anxiety symptoms 4
• Risk of self-harm or suicidal ideation 4

Evidence-Based Psychotherapy: First-Line Treatment

For complicated grief, initiate Complicated Grief Therapy (CGT), a specialized evidence-based intervention that addresses seven core themes: 1

1. Understanding and accepting grief as a normal but painful process 1
2. Managing painful emotions through specific coping strategies 1
3. Planning for a meaningful future without the deceased 1
4. Strengthening ongoing relationships with living family and friends 1
5. Telling the story of the death in a therapeutic context 1
6. Learning to live with reminders of the deceased 1
7. Establishing an enduring connection with memories while moving forward 1

Cognitive-behavioral therapy techniques form the foundation of effective complicated grief treatment, with both face-to-face and internet-based formats showing efficacy. 5

Refer to: Social workers, counselors, psychologists, psychiatrists, or clergy trained in grief therapy 4

Pharmacological Treatment: When and How

Criteria for Initiating an SSRI

Consider sertraline or another SSRI only in these specific circumstances: 2, 5

• After 8 weeks of psychotherapy with inadequate response to grief-specific interventions 2, 5
• When comorbid major depressive disorder is diagnosed using validated tools (PHQ-9 score ≥10) 4
• As adjunctive treatment alongside ongoing psychotherapy—never as standalone treatment 2

Important Caveats About Medication

• SSRIs may be more effective for depressive symptoms than grief-specific symptoms 2
• Evidence for medication effectiveness in complicated grief remains limited and equivocal 5
• Therapeutic interventions for complicated grief may be more effective when combined with SSRI administration 2
• Do not prescribe antidepressants for normal grief—this is inappropriate treatment 3

Dosing When Indicated

• Sertraline: Start 50 mg daily, may titrate upward after one week if needed 6
• Escitalopram: Alternative option, start 10 mg daily 6

Treatment Algorithm

Follow this stepped approach:

1. Immediate assessment: Screen for suicidal ideation first in all patients—refer emergently if present 4, 6
2. Distinguish normal from complicated grief: Use time course (>6-12 months) and functional impairment as key indicators 4, 1
3. For normal grief: Provide self-care education, normalize the experience, and schedule follow-up 4
4. For complicated grief: Refer immediately to specialized grief therapy (CGT) 1
5. Reassess at 8 weeks: If minimal improvement despite good therapy adherence, consider adding SSRI 2, 5
6. Screen for comorbid depression: If major depression is present (PHQ-9 ≥10), treat depression first—this often improves grief symptoms secondarily 4, 6

Common Pitfalls to Avoid

• Never prescribe antidepressants for normal grief—this medicalizes a natural process 3
• Do not delay psychotherapy referral while "watching and waiting"—early intervention prevents chronicity 1
• Avoid assuming all bereaved persons will develop complicated grief—most will not 4
• Do not use medication as standalone treatment—psychotherapy is the primary evidence-based intervention 1, 5
• Never dismiss cultural, religious, or spiritual factors that shape grief expression and coping 4

Supporting Ongoing Relationships and Meaning

Help patients: 4

• Explore the meaning of their loss in the context of their values and beliefs 4
• Identify local bereavement support resources and groups 4
• Connect with spiritual support from chaplains when spiritual distress is identified 4
• Maintain connections with family and community during the grieving process 4