Grief or bereavement (normal and pathological variants): Most individuals recover from grief within a year after bereavement or the loss of a loved one. Pathological or complicated grief lasts for > 1 year.
Five stages of grief
Denial
Anger
Bargaining
Depression
Acceptance
In acute grief, it’s normal to experience intense sadness and crying, other unfamiliar dysphoric emotions, and preoccupation with thoughts and memories of the deceased person. You may also see disturbed neurovegetative functions, difficulty concentrating, and relative disinterest in other people and in activities of daily life. Auditory or visual hallucinations may occur.
Over time, acute grief typically becomes less severe and shifts into integrated grief. Integrated grief is characterized by sadness and longing for the deceased, while still allowing the sufferer to move on with life and participate in social and occupational activities.
It’s also not unusual for bereaved individuals to:
Complicated grief is intense grief that lasts longer than 1 year. It’s characterized by:
Complicated grief is associated with impairment in social and occupational functioning. There is increased risk of suicide.
If bereaved individuals meet the criteria for major depression, then they should be treated accordingly.
| Class | Mechanism of action | Adverse effects |
|---|---|---|
| Tricyclic antidepressants or TCAs: Amitriptyline, imipramine, clomipramine | Inhibit reuptake transporters for norepinephrine (NE) and serotonin (5HT) in the brain, thus increasing levels in synaptic cleft | Sedation, confusion, postural hypotension, anticholinergic effects, tachycardia, conduction defects, weight gain. “3Cs” - coma, convulsions, cardiotoxicity. Interferes with action of methyldopa, clonidine and guanethidine |
| Selective serotonin reuptake inhibitors or SSRIs: Fluoxetine, paroxetine, fluvoxamine, citalopram, escitalopram, sertraline | Inhibit SERT or serotonin reuptake transporter thus increasing 5HT levels in the synaptic cleft | Clinical effect may take 3-4 weeks. Nausea, headache, impotence, akathisia, dystonia, seizures |
| Serotonin norepinephrine reuptake inhibitors or SNRIs: Duloxetine, venlafaxine, desvenlafaxine, levomilnacipran, milnacipran | Inhibit reuptake transporters for 5HT and NE, more selective than TCAs | Withdrawal syndrome is seen after abruptly stopping venlafaxine with anxiety, tremors, palpitations. Duloxetine may cause hepatotoxicity, nausea, increase in BP. |
| Monoamine oxidase inhibitors or MAOIs: Phenelzine, selegiline, tranylcypromine, isocarboxazid | Inhibit the enzyme MAO thus preventing degradation of NE, 5HT, dopamine and tyramine | Hypertensive crises may occur if consumed with tyramine rich foods like cheese, cured meats, fermented foods, dry fruits. Alcohol, pickled foods, soy sauce etc. |
| Serotonin 5HT2 antagonists: Trazodone, nefazodone | Block 5HT2A receptor in the CNS | Sedation, severe hepatotoxicity, priapism |
| Other heterocyclics: Bupropion, amoxapine, mirtazapine | Bupropion: Inhibits reuptake of NE and dopamine. Amoxapine: Inhibits reuptake of NE. Mirtazapine: Blocks inhibitory presynaptic alpha2 receptors and blocks 5HT2 receptors | Bupropion causes anxiety, agitation, psychosis and seizures. Mirtazapine causes weight gain, sedation. Amoxapine causes akathisia, drug induced Parkinsonism, galactorrhea and amenorrhea, cardiotoxicity, seizures. |
Antidepressant therapy may be discontinued 6 months after a symptom free period in patients who have had only a single episode of depression. Treatment is extended in the presence of recurrence.
Patients with major depression who are contemplating self injury/suicide should be intensively monitored. Monitoring may include admission to an inpatient facility and close supervision by family members or by other individuals who know the patient well.
Many antidepressants are associated with weight gain, most commonly mirtazapine, phenelzine, paroxetine, amitriptyline, imipramine and doxepin.
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