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Dear Dr. Debug:
My father, who is 62, has been prescribed Prozac for symptoms related to my brother's death more than a year ago. My brother died in an auto accident. He was drunk and lost control of his car. No one else was in the car or injured. My father had a much more anguished grief response than my mother. He blamed himself for spoiling my brother and not trying hard enough to get my brother to shape up. Dad was never depressed before in his life, so I am wondering whether Prozac is really the right thing for him. -- Signed: Puzzled About Prozac.
Normal grieving is a very complex and individual process. What may shock and hurt one person may not have the same meaning to the next person. Different members in the same family of the deceased can have widely varying reactions to the loss of that family member.
Normal grieving frequently produces episodic depression, listlessness, difficulty concentrating, loneliness, increased fears, social withdrawal, increased physical complaints and problems, increased irritability, low frustration tolerance, and sleep and appetite disturbances. Often, there are significant one-year anniversary reactions in which the grieving person experiences increased symptoms.
The major myths about mourning are (1) there is a predictable, orderly set of stages to mourning, (2) it's best to move away from grief rather than toward it, and (3) following the death of a loved one, the goal is to "get over" it. It is significant to note that in 1927 Emily Post reported that a widow's formal mourning period was three years. Yet, in 1972, Amy Vanderbilt advised a bereaved person to pursue, or try to pursue, a usual social course within a week or so after a funeral. Current society tends to pressure for quick recoveries. Although three years is thought of as a bit lengthy, resuming regular social activities in a week is definitely too short.
How we handle losses (mourning) has much to do with our resilience. Factors that contribute to resiliency are flexibility, creativity, optimism, sociability, physical exercise, openness to learning, and the ability to redefine loss or failure in terms that allow for continued learning. Trauma and loss can give rise to personal transformations and growth, or, if very overwhelming, to symptom complexes that may include chronic anxiety and depression.
Because the symptoms of a complicated grief may be similar but only more intense or longer lasting, it is a challenge to decide when grieving has become unusual or problematic. In fact, we cannot even agree on terminology -- should unusual grieving be called "pathological," "traumatic," or "complicated?"
The Diagnostic and Statistical Manual of Mental Disorders, Volume IV, does not currently contain any disorders specifically related to grieving. Since there is no official diagnostic category for complicated grieving, it is often classified as major depressive disorder (clinical depression), adjustment disorder (especially depressed and anxious mood, or disturbance of emotions and conduct), substance abuse, or posttraumatic stress disorder (PTSD).
I use the terms "complicated" or "uncomplicated" to describe what is going on with a particular person. The term "pathological" is open to too much misinterpretation. All losses are "traumatic." It is important to note that there are degrees of complicated grief -- mild, moderate and severe.
Complicated grief is generally identified by a duration of symptoms longer than one month and more than 14 months after the loss. There is prolonged disruption of social functioning or avoidance of people, places, or activities that are reminders of the deceased. There may be withdrawal from work, friends, and recreation. There may be intrusive symptoms such as easy crying, and severe emotions related to losses (anger, bitterness, hostility). Return of symptoms from previous episodes of any mental illness or new symptoms of clinical depression or PTSD may indicate a complicated grief process.
The risk factors for complicated grief include death of spouse, child or parent; sudden, unexpected or untimely death; deaths by suicide; deaths by murder; vulnerable survivor (low self-esteem, low trust in others, previous mental illness, previous suicide attempts or threats, absent or unhelpful family); and, unresolved conflicts or emotional issues with the deceased.
If your father's symptoms fit the criteria for major depressive disorder, then Prozac® may be helpful. Chronic stress related to his very traumatic and guilt-ridden reaction to his son's death can produce enough damage to hippocampus brain cells to produce clinical depression. You can read more about the relationship between stress and clinical depression at www.hippocampus.us. Whether Prozac® or a trial of another antidepressant is helpful or not, I think it would be important for your father to seek counseling and work on issues related to his guilt about his son's death.
I hope this is helpful. For more information about complicated grieving, please visit www.AllAboutGrief.org. -- Best wishes, Dr. Debug.
Ron Sterling, M.D. (Dr. Debug) is an award-winning psychiatrist in Seattle, Washington. He has been writing for newspapers and magazines since 1998 on subjects ranging from good manners to senior mental health. He hosts and maintains the well-known Internet mental health center, DearShrink.com. The Doctor Debug column is dedicated to assisting with the "debugging of malfunctioning elements in our own personal programming."
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