Complicated Grief: A Case Series Using Escitalopram

To The Editor: The syndrome of complicated grief is not formally recognized in DSM-IV, but it is associated with significant functional impairment and distress (1) . A grief-focused psychotherapy, complicated grief therapy, recently demonstrated efficacy for complicated grief in a randomized controlled trial (1) . To our knowledge, there are no randomized controlled trials of pharmacotherapy for complicated grief. An open-label study of paroxetine in combination with a version of complicated grief therapy did not allow determination of medication efficacy beyond that of psychotherapy on grief symptoms (2) . Open-label bupropion showed modest effects for grief (3) , but nortriptyline demonstrated no significant effect on grief in open-label (4) and randomized controlled trial (5) studies of bereavement-related depression.

We prospectively examined four individuals with a primary diagnosis of complicated grief (defined as a score of ≥25 on the Inventory of Complicated Grief ≥6 months after the death of a loved one) in a 10-week pilot study of open-label escitalopram. The institutional review board of Massachusetts General Hospital approved the study. Participants gave written informed consent and received escitalopram flexibly in doses of 10 to 20 mg daily.

Given the limitations of a small cohort size and open-label assessments, these preliminary results suggest that selective serotonin reuptake inhibitor (specifically escitalopram) pharmacotherapy alone may result in significant improvement without concomitant psychotherapy in individuals with complicated grief and that randomized controlled trials examining pharmacotherapy for complicated grief are needed.