It was a typical meeting of Compassionate Friends, the organization for parents who have lost a child. We were discussing what helped us cope with the death of our child. Joanna, a quiet lady who seldom spoke, suddenly blurted out, “I take Prozac. I couldn’t have made it without it, and I don’t care what anyone thinks.” After a few seconds of stunned silence, several others confessed to “using drugs.”
As a physician, I have been uneasy with what seems to be an almost blanket disapproval of medication by support groups, psychologists and counselors. We are encouraged to cry, scream, beat on pillows, journal, or whatever it takes to deal with our grief. Each must grieve in one’s own way and that is okay, we are told. But, if one must take medication, there is a subtle, and often not so subtle, message that we are not grieving properly.
The great physician, William Osler, said, “the desire to take medicine is perhaps the greatest feature that distinguishes man from animals.” Americans in particular seem to think that there is a chemical solution to every problem—too fat, take a pill—too thin, take a pill—can’t sleep, take a pill—can’t stay awake, take a pill—no energy, take a pill—hyperactive, take a pill.
While those groups mentioned above tend to condemn medication, doctors as a group have a propensity to prescribe too freely. Caution must be exercised in deciding whether or not medications are needed. Just as important, caution is needed in deciding what drug should be used when one is needed. (See Table 1.)
Most bereaved parents require no medication. However, some will undergo much unnecessary pain, and a few may not survive without it.
I have found it useful to think of depression in two categories: Situational Depression (SD) and Chemical Depression (CD). Most people with SD do very well without medication. On the other hand, CD usually requires medication as part of its treatment plan.
Situational Depression (SD) occurs in response to the stresses and losses we experience in life: divorce, loss of a job, children moving away, problem children, death of a loved one, etc. Grief is a form of SD. From my own personal experience, I think the death of a child entails the severest form of SD. For this discussion, the terms SD and grief are interchangeable.
There are several cornerstones in coping with grief.
1. Make a conscious decision that you will survive, no matter what.
2. Talk about and share your loss—over and over again. I found The Compassionate Friends invaluable for this.
3. An individual counselor is often helpful, but be sure that they are familiar with parental loss.
4. Grief work is that painful process of intentional preoccupation with your dead child. Perhaps just a little at a time at first, but you make yourself do it. If we are to survive the loss intact we must hold up the image of what was and review it in detail again and again. Talk about it. Study old picture albums and scrapbooks even though it hurts.
5. Get enough rest. Insomnia is a common companion of grief. The old standbys of a bedtime routine and a warm bath are helpful. Use medication for sleep with caution. Avoid benzodiazipines and alcohol entirely. Benadryl, trazadone, Remeron, and Ambien are safe but should not be used nightly and may leave you drowsy the next morning.
6. Physical activity such as jogging or walking can burn off a lot of frustration.
7. Eat regularly but watch sugars and sweets. Too much of these can cause swings in blood sugar, which can affect mood and energy levels.
8. Spend some time alone each day. This is your time. Journal, read, cry, meditate or whatever gets you out of the daily hustle and bustle.
9. Do something social each day. Just as you need time alone, you also need human interaction. It doesn’t have to be big—call a friend on the phone, have lunch with them or go for a walk with them.
Chemical Depression (CD) results from lowered levels of substances in the brain called neurotransmitters, primarily the chemicals serotonin and norepinephrine. It is generally believed that 10-15% of the population is genetically predisposed to CD. Bipolar disease is the best known form of CD. If the neurotransmitter level is low enough, deep, potentially suicidal depression may occur, often for no apparent reason. Those predisposed to CD may do well until something happens that lowers the neurotransmitter level. A classic example is the depression that results from taking certain types of blood pressure medicines or cortisone preparations. The hormones associated with pregnancy and delivery can trigger a chemically induce postpartum depression. More pertinent to us, the stress of the severe grief reaction and SD that accompanies the death of a child may bring on CD.
Medications used to treat CD serve to raise the levels of neurotransmitters in the brain. Unless a near normal level of these is restored, the depression will persist. To imply that “drugs are bad” and that if one were only stronger or had more moral fiber, or worked hard enough they should be able to overcome their depression is wrong. It makes as much sense to tell a diabetic, who is deficient in insulin, that if they were stronger and worked hard enough they would not need “drugs”, i.e. insulin.
People who have had previous bouts of clinical depression or have a strong history of depression in their family are more prone to CD. Many times, however, it is impossible to differentiate between a severe SD or a CD. Often a trial of antidepressant medication is the only way to tell. I will take 3-4 weeks to see if there is a response. I always caution my patients that antidepressants will not make you feel good. They make you feel more near whatever is normal for you. Unfortunately for bereaved parents that normal is the usual degree of SD that goes with grief. You don’t feel good, but you’re now in the same boat as the others in your group and you are more able to do your grief work and benefit from it.
It’s important to remember that that medication may be a necessary aid to recovery in a small percentage of bereaved parents, but, they, just like the rest of us, still must use the coping skills learned in TCF and utilize the previous suggestions for dealing with the SD that accompanies the death of a child. Medication may be a necessary aid, but it is only one part of the healing process.
One final observation: I have often heard medication referred to as a “crutch.” Some may view it as such. But if a person can get to TCF or their counselor because of a broken leg, would we deny them a crutch. The same goes for those unfortunate enough to have CD at the worst time of their life.
Medications to be avoided-Addictive, tend to make depression worse
Alcohol-to be avoided when used as a medication, e.g. for sleep or to ease stress and anxiety and when drunk in larger quantities than previously.
Barbiturates (Nembutal, Seconal, Phenobarbital)- older drugs, seldom used but extremely dangerous when used as sleep aids.
Medications to be used with caution-potentially addictive, may make depression worse.
Benzodiazipines-Xanax (alprazalam), Valium (diazepam), Ativan (lorazepam)
Librium (chlordiazepoxide) Klonopin (clonazepam) May be used for short term
relief of anxiety and agitation.
Newer antidepressants-non-addictive, safe, generally have few side effects
Prozac, Paxil, Zoloft, Wellbutrin, Effexor, Lexapro, Lamictal
Remeron and trazadone are often used as sleep aids and are safe and non-addictive.
Older antidepressants-non-addictive, significant side effects. May aggravate heart or prostate conditions. Used primarily when there is no response to the newer antidepressants.
Elavil (amitriptyline), Sinequan(doxepin), Norpramin (desipramine),
Nardil and Parnate are a class of antidepressants that can have severe and potentially fatal side effects. Require extreme caution with other medications and diet. Should be used only under the supervision of a specialist familiar with their use.