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. 1998 Aug 22;317(7157):538. doi: 10.1136/bmj.317.7157.538a

Bereavement in adult life

GPs should be accessible, not intrusive

David Mazza 1
PMCID: PMC1113765  PMID: 9712614

Editor—Parkes summarises issues associated with bereavement in adulthood but risks medicalising a fundamental life experience.1 The concept that grief is a process with discrete phases which must be passed through before final adjustment to the loss can take place has been challenged.2 A more sociological model would suggest that rather than working their way through a range of emotions, bereaved people attempt to construct an accurate story about the life of the deceased which allows their memory of the dead to become part of their lives. This biography is created by people who knew the individual, not by detached professionals.

Many general practitioners try to visit families at home shortly after a death has occurred; this may be, at least partially, related to the general practitioner’s own needs since there is no compelling evidence that it is beneficial to the family. Indeed, it may be that a general practitioner’s desire to do something to ease the pain of bereavement leads to more prescribing of benzodiazepines for those visited at an early stage.3 Some commentators have suggested that general practitioners should visit bereaved relatives at intervals during the year after a death to ensure that the grieving process is progressing.4 This suggestion ignores the trend away from time consuming home visits in primary care, the changes in society which make any unsolicited visit a potential threat or intrusion, and the lack of evidence for the benefits of such a paternalistic approach.

It is clear that a large number of bereaved people experience psychological disorders and ill health. The question is whether this gives doctors and others a mandate to step into an individual’s grief and look for risk factors and evidence of progress through the grieving process. It is our responsibility to be accessible and approachable rather than intrusively proactive during this most fundamental of human experiences.

References

  • 1.Parkes CM. Coping with loss: bereavement in adult life. BMJ. 1998;316:856–859. doi: 10.1136/bmj.316.7134.856. . (14 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Walter T. A new model of grief: bereavement and biography. Mortality. 1996;1:7–25. [Google Scholar]
  • 3.Cartwright A. The role of the general practitioner in helping the elderly widowed. Br J Gen Pract. 1982;32:215–227. [PMC free article] [PubMed] [Google Scholar]
  • 4.Doyle D. Domiciliary palliative care. Oxford: Oxford University Press; 1994. [Google Scholar]
BMJ. 1998 Aug 22;317(7157):538.

Psychotropic drugs may be appropriate treatment

Jennifer Barraclough 1, Sue Palmer 1, Alex Dombrowe 1

Editor—Parkes’s review of bereavement in adult life considers the psychosocial aspects of care but does not discuss psychotropic drugs.1-1 Two questions commonly arise in clinical practice: whether hypnotic or anxiolytic drugs should be offered to recently bereaved people and, in the longer term, whether antidepressants are indicated for treating mood disorders after bereavement.

At one time, benzodiazepines were prescribed to bereaved relatives so freely that long term dependency could easily occur. This practice is now rightly discredited but perhaps the pendulum has swung too far. A woman recently contacted our unit in distress after asking her general practitioner for a one week supply of sleeping tablets after her husband’s death; this request had been refused on the grounds that drugs would “block the grieving process.” This attitude reflects the teaching encountered by medical students and junior doctors today—for example, through the widely attended advanced life support course; the manual for the course states that “a request for sedation for a relative should usually be gently refused.... The pain has to be experienced at some stage and delaying makes it worse.”1-2 In contrast, the British National Formulary sanctions short term prescribing of anxiolytic and hypnotic drugs “to alleviate acute conditions.”1-3 Though not all recently bereaved relatives want or need medication, some do find it helpful during this difficult experience.

As stated in Parkes’s review, about a quarter of widows and widowers develop clinical depression or anxiety during the year following bereavement. Clinical depression may not be recognised in this context because its manifestations overlap with those of grief. Even when the condition is correctly diagnosed many doctors and patients consider drug treatment inappropriate. However, clinical experience and research evidence both support the view that antidepressant drugs are effective when the syndrome of major depression is present, whether or not there is an understandable cause such as bereavement or medical illness.1-4

Psychotropic drugs are sometimes dismissed as an inferior substitute for psychosocial care. In reality optimal management often combines both approaches.

References

  • 1-1.Parkes CM. Coping with loss: bereavement in adult life. BMJ. 1998;316:856–859. doi: 10.1136/bmj.316.7134.856. . (14 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Handley AJ, Swain A, editors. Advanced life support manual. London: Resuscitation Council; 1996. [Google Scholar]
  • 1-3.British Medical Association; Royal Pharmaceutical Society of Great Britain. British national formulary. London: BMA, RPS; 1998. p. 155. . (No 35.) [Google Scholar]
  • 1-4.Reynolds CF. Treatment of depression in special populations. J Clin Psychiatry. 1992;53(Suppl):45–53. [PubMed] [Google Scholar]
BMJ. 1998 Aug 22;317(7157):538.

Author’s reply

Colin Murray Parkes 1

Editor—Although Mazza’s warnings of the dangers of medicalising normal grief and of the inappropriate use of benzodiazepines are apt, the fact remains that a minority of bereaved people will develop psychiatric or psychosomatic disorders and may even die from heart disease or commit suicide if prompt and effective help is not given. They may be too depressed to ask for help or ignorant of the services that exist to help them. Doctors are often the only people in a position to assess risks from bereavement and to steer people in the right direction. For this reason alone I hope that Mazza will continue his practice of proactively visiting families after a bereavement. They will see this as an act of kindness rather than a form of medical imperialism.

I agree with Barraclough et al. Since anxiety and depression commonly coexist after bereavement and since some people are at risk of suicide it is wise to use an antidepressant drug that is anxiolytic and of low toxicity. For this reason, when indicated, I prescribe a selective serotonin reuptake inhibitor such as fluoxetine.

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