SIDNEY ZISOOK, M.D.
RICHARD A. DeVAUL, M.D.
Grief, unresolved grief,
and depression
ABSTRACT: For examination of relationships between grief, process and therefore prefer the
unresolved grief, and depression, 211 subjects completed term “¿unresolved grief.―9 While
questionnaires designed to measure grief, identify unresolved unresolved grief may present clini
grief, and measure depression. Fourteen percent of the study cally in various forms, such as psy
population showed evidence of unresolved grief. This group was chotic denial, pathologic identifica
tion with the deceased, or chronic
younger, less likely to have attended the funeral, and more
depression, this report explores the
depressed than the resolved-grief group. Depression is likely to
relationships between grief, unre
be more severe with unresolved grief, which tends to persist once solved grief, and depression.
present. The results are discussed in relation to the relevant The relationship between loss
literature. and depression is well established.
As recently reviewed by Lloyd,'0
Grief, the constellation of signs and deviant, and one or more of the childhood bereavement and a vari
symptoms following a personally phases of grief is absent, delayed, ety of adult losses, including be
significant loss, is generally con intensified, or prolonged. This oc reavement, increase the risk for de
ceptualized as a dysphoric but self currence has been variously de pression. In a series of studies by
limited process. As experienced by scribed as morbid,2 atypical,4 depres
Clayton and associates,' 1-16
an adult, it ordinarily follows an pathologic,6 or neurotic7 grief. sion was found to be a common
overlapping sequence of phases Symptoms of deviant grief seem to accompaniment of widowhood.
beginning with a brief period of differ in degree rather than in kind This depression could not be dis
shock and denial, merging into a from ordinary grief.8 We have pre tinguished from the depression of
phase of acute dysphoria, and end viously conceptualized these syn the nonbereaved control groups on
ing with a period of resolution.15 dromes as effects of nonresolution the basis of symptoms. However,
Occasionally this process becomes of the usual stages of the grief depression following death of a
spouse was not more common in
Dr. Zisook is associate proftssor of psychiatry at the University of California, San
women than in men, not associated
Diego, School of Medicine and Dr. De Vaul is associate professor of psychiatry and with a family history of depression
behavioral sciences at The University of Texas Medical School at Houston. Reprint or with previous depressive epi
requests to Dr. Zisook, Department of Psychiatry, University of Cal(fornia, San sodes, not likely to be treated by
Diego, School of Medicine, Gifford Mental Health Clinic, 3427 Fourth A venue, San psychiatrists, nor associated with a
Diego, CA 92103. subjective sense of being ill.
MARCH 1983 . ‘¿VOL NO 3
24- 247
Grief and depression
Depression, like unresolved
grief, is a relatively common con
BehaviorsEndorsedas Mostlyor
Table 1—¿Past
sequence of bereavement. The na
CompletelyTrue by over50% of Respondents
ture of the relationship between
depression and unresolved grief,
however, remains unclear. We have %of
previously postulated that severe respondents
depression would be seen more fre I grieved for the person who died 89
quently in unresolved grief. Thus I attended the funeral 87
far we are unaware of any empiri I cried 84
cal evidence that confirms the rela I kept thinking about him/her 78
tionship. This study attempts to ex I was depressed 67
amine the relationship based on the It was hard to believe the person had died 64
results of a questionnaire survey of I was shocked to learn he/she had died 60
a nonclinical population. It took me a long time to really accept
the person's death 53
The survey I felt empty inside 51
In an effort to develop a reliable
and valid instrument to better de
scribe and measure grief. the au most closely approximated those Depression Scale.'9
thors developed the Texas Invento characteristics used clinically by us
ry of Grief, a 14-item self-report to help identify unresolved grief Results
scale.'7 Based on the literature of were chosen to comprise an Unre Two hundred and eleven complet
normative and atypical grief reac solved Grief Index: (1) “¿I I feel ed questionnaires were received
tions, as well as the clinical experi have grieved for the person who from all areas of the United States.
enc'e of the authors, the original I
died―; (2) “¿Now can talk about Most of the respondents were fe
14-item inventory was expanded to the person without discomfort―; male (62%), well educated (13.7
58 items.'8 To obtain normative feel
and (3) “¿I I have adjusted well years). middle class (mean family
data, the instrument was sent to to the loss.―This somewhat arbi income of $15,000), white (65%
friends and colleagues around the trary, but clinically based, index white, 17% black, 11% Mexican
country so that they could ask one will be examined further in the American, 7% other), middle-aged
or two friends or neighbors who Discussion. (mean of 36.5 years with a range of
had lost a relative or close friend to In addition to the Grief Invento 19 to 74), and Protestant (47%
complete the questionnaire. ry and Unresolved Grief Index, Protestant, 26% Catholic, 13% Jew
The respondents were asked to each respondent was asked to care ish, 13% other or none). The de
give their age, sex, race, religion, fully complete a Zung Self-Rating ceased had expired at a mean age
educational level, relationship to
the deceased, length of time since
the death, and the age of the de Table 2--Present FeelingsEndorsedas Mostlyor
ceased. They were asked to check CompletelyTrue by over 50% of Respondents
one of the five responses on each of
24 items relating to their feelings % of
when the person died (the Past Be respondents
haviors list) and 34 items pertain
ing to present feelings (the Present I am now functioning about as well as before 79
Feelings list). The possible re I feel I have adjusted well to the loss 77
I very much miss the person 73
sponses for each item were: com
No one will ever take his/her place in my life 72
pletely true, mostly true, partly true Now I can talk about the person without discomfort 65
and partly false, mostly false, and
completely false. Three items that
248 PSYCHOSOMATICS
On the Unresolved Grief Index,
Table 3—Unresolved Index
Grief with a score of 0 to 1 denoting
resolved grief, and 6 or more as
definitely unresolved grief, 14%
% of respondents (30) of our population showed evi
by category dence of unresolved grief. This
of responset group was no different from its
0 1 2 3 4 counterparts with resolved grief
(37% or 78 persons) in terms of
I grieved for the person who died 86 1 1 1 11
educational level, income, sex, time
I feel I have adjusted well to the loss 58 19 8 3 11
since death, age of the deceased, or
Now I can talk about the person
14 relationship to the deceased. On
without discomfort 43 22 16 5
the other hand, the unresolved grief
f Definitely unresolved grief = 14% (with a total score of 6 to 12)
Resolvedgrief 37% (with a total score of 0 to 1) group was younger (39 years vs 31
‘¿For
eachitem:0 = completelyrue;1
t mostlytrue;2 = partlytrue,partlyfalse; years, P<.05), less likely to have
3 = mostly false; 4 = completely false attended the funeral (P<.05), and
more depressed. Nine of 20 items
and total scores on the Zung Scale
of 54 years (range of one to 92 ings list that the majority of re were significantly higher in the
years), and approximately 4.5 years spondents felt were mostly or com unresolved grief group, while none
prior to the survey (range of one pletely true about them. Grief were higher for the resolved grief
month to 22 years). Most of the related present feelings peaked be group (Table 4). Finally, the re
deceased were first-degree rela tween one and two years following solved grief group had higher
tives, with 27% being fathers, 16% the loss (P< .05), but continued to overall scores on the Past.Behaviors
mothers, 8% brothers, 5% sisters, be substantial even ten or more (P<.0l) and Present Feelings
3% husbands, 1% wives, 0% sons, years later. Table 3 shows the per (P<.Ol) lists.
2% daughters, 7% close friends, and cent of respondents endorsing each
24% other close family members. of the three items comprising the Discussion
Table 1 lists those items from the Unresolved Grief Index. Unlike the The 14% of our nonpatient
Past Behaviors list that at least half total Present Feelings score, the bereaved population with unre
of all respondents considered most Unresolved Grief Index score did solved grief and the 37% with re
ly or completely true. Table 2 lists not change as a function of time solved grief are in the range of
those items from the Present Feel when present, it tended to remain. percentages from other studies
using different criteria to identify
unresolved grief. For example, La
Table 4—Zung
ItemsSignificantlyRelated f
zare2°ound 10% to 15% of patients
G
to Unresolved rief referred to a general outpatient
clinic to be suffering from unre
solved grief. DeVaul5 found that
p< 25% of patients seen in a psychiatric
I feel downhearted, blue, and sad .018 consultation service had unre
I have crying spells or feel like it .011 solved grief predating the onset of
I have trouble sleeping through the night .011 their medical problems.
My mind is as clear as it used to be (negative score) .030 Before continuing our discus
I feel hopeful about the future (negative score) .005 sion, several issues of methodologic
I am more irritable than usual .025 bias should be addressed. Several
I find it easy to make decisions (negative score) .003 items on the questionnaire have
I feel that I am useful and needed (negative score) .031 desirable (“No one will ever take
I still enjoy the things I used to (negative score) .016
his/her place in my life―)or unde
sirable (“Istill get angry when I
(continued)
MARCH 1983'VOL24@NO3 249
nHCI)
SINEQUANd0xepI
1 S
Reference Barranco FThrash Hackett ,Frey
ML E P Pfizer
J.etat(Pfizer harmaceuticals,
N Y.)
Inc . New ‘¿ibrk, Early onset of response to doxepin treatment J C/in Psychiatry
40 265-269. 1979 Grief and depression
BRIEFSUMMARY
S1NEOUAN (doxepin H@I)C.p*UI../OraI Concentrate
Contralndicatlons. SINEQUANis contraindicatedin individualswho havesh@vnhypersen
sitivityto the drug. Possibilityof crosssensitivitywith otherdibenzoxepinesshouldbe kept in
mind.
SINEQUANiscontraindicatedin patientswithglaucomaor a tendencyto urinaryretention. think about him/her―) implications
Thesedisorders should be ruled out, particularly in older patients.
Warnings. The once-a-day dosage regimen of SINEQUAN in patients with intercurrent that may influence response. The
illnessor patients taking other medications should be carefullyadjusted This is especially
importantin patients receivingother medicationswith anticholinergiceffects data were obtained from friends
Usage In Geriatrics: The use of SINEQUAN on a once-a-day dosage regimen in geriatric
patientsshould be adjusted carefullybased on the patient'scondition. and neighbors of the investigators'
Usage In Pregnancy: Reproduction studies have been performed in rats rabbits, mon
keysand dogs and therewas no evidenceof harmto the animalfetus The relevance to friends and relatives, largely an
humans is not known.Since there is no experience in pregnantwomenwho have received
this drug, safety in pregnancy has not been established. There are no data with respect to the
secretionofthe drug in humanmilk and its effect on the nursing infant.
adult, white, middle-class, profes
Uug. In Children: The use of SINEQUAN in children under 12 years of age is not sional group. In addition, persons
recommendedbecause safe conditions for its use have not been established.
MAO Inhibitors: Serious side effects and even death have been reported following the who responded to the question
useofcertaindrugswithMAOinhibitors.
concomitant MAOinhibitors
Therefore, shouldbe
discontinued at least two weeks prior to the cautious initiationof therapy with SINEQUAN naire may have been biased. A po
The exact length oftime may vary and is dependent upon the particular MAO inhibitor being
used, the length of time it has been administered,and the dosage involved. tential respondent who is still
Uug. with Alcohol: It shouldbe bornein mindthatalcoholingestion mayincreasethe
danger inherentin any intentionalor unintentionalSINEQUANoverdosage Thisis especially preoccupied with a long-past loss
importantin patientswho mayuse alcohol excessively.
Precautions. Since drowsiness may occur with the use of this drug, patients should be might be more inclined to complete
warned of the possibility and cautioned against driving a car or operating dangerous
machinery while taking the drug. Patientsshould also be cautioned that their responseto the questionnnaire than one who is
alcohol may be potentiated.
Since suicideis an inherentrisk in any depressedpatientand may remainso until not. Few respondents had lost chil
significant improvementhas occurred, patients should be closely supervised during the
early course oftherapy. Prescriptionsshould be writtenfor the smallestfeasibleamount. dren or spouses, making compari
Should increased symptoms of psychosis or shift to manic symptomatology
occur, it may be necessary to reduce dosage or add a major tranquilizer to the dosage sons with much of the literature on
regimen.
Adverse Reactions. NOTE: Some of the adverse reactions noted below have not been widowhood tenuous. The question
d
specifically reported with SINEQUAN use. Hc@ever, ue to the close pharmacological
similarities among the tricyclics, the reactions should be considered when prescribing naire also asked people to accu
SINEOUAN.
Anticho/inergicEffects Drymouth,blurredvision,constipation,and urinaryretentionhave rately recall past feelings and be
been reported. Ifthey do not subside with continued therapy, or become severe, it may be
necessaryto reduce the dosage. haviors associated with a period of
N
Central ervous System is
Effects.Drowsiness themostcommonly noticedsideeffect.
O r
Thistendsto disappearas therapyis continued. therinfrequentlyeportedCNSside turmoil and disorganization, often
effects are confusion, disorientation,hallucinations,numbness, paresthesias,ataxia, and
extrapyramidalsymptomsand seizures. years after the fact. Despite these
Cardiovascular
Cardiovascular. effects hypotension
including h
andtachycardia avebeen
reported occasionally. real limitations, the data do detail a
Allergic Skinrash,edema, photosensitization,and pruritushaveoccasionallyoccurred.
Hemato/ogic h in T
Eosinophiliaasbeenreported a fewpatients. herehavebeenocca constellation of symptoms that
sional reports of bone marrow depression manifesting as agranulocytosis, leukopenia,
thrombocytopenia,and purpura. bereaved individuals remember
Gastrointestinal:Nausea,vomiting, indigestion, taste disturbances, diarrhea, anorexia,
andaphthous h (
stomatitis avebeenreported. Seeanticholinergic effects) having had after their loss, as well
Endocrine Raisedor loweredlibido, testicular swelling,gynecomastiain males,enlarge
mentof breastsand galactorrheainthe female,raisingor loweringof blood sugar levelshave as those that they were presently
been reported with tricyclic administration.
Other Dizziness,tinnitus,weight gain, sweating.chills, fatigue.weakness,flushing,jaun experiencing.
dice, alopecia, and headachehavebeen occasionallyobservedas adverseeffects.
Dosage and Administration. For most patients with illness of mild to moderate severity, a Obviously, a number of arbitrary
Dosage
startingdailydoseof 75mgis recommended. b or
maysubsequentlye increased
decreased at appropriate intervals and according to individual response. The usual op decisions regarding the Unresolved
timum dose range is 75 mg/day to 150mg/day.
In more severely ill patients higher doses may be required with subsequent gradual
increase to300 mg/dayifnecessary. Additional
therapeuticeffectisrarelytobeobtainedby
Grief Index were made. We chose
exceedinga doseof300 mg/day. to include items most closely ap
In patientswith verymild symptomatologyor emotionalsymptomsaccompanyingorganic
disease,Icwver S
dosesmaysuffice. omeotthesepatients havebeencontrolled ondosesas proximating the questions used
low as 25-50 mg/day.
The total daily dosage of SINEQUANmay be given on a divided or once-a-day dosage clinically by us to identify unre
schedule. Ifthe once-a-day schedule is employed the maximum recommended dose is 150
mg/day.This dose may be given at bedtime.The 150mg capsule strength is intended for solved grief.5'9 Since no generally
maintenance therapy only and is not recommended for initiation of treatment.
Anti-anxietyeffect is apparent before the antidepressanteffect Optimal antidepressant accepted definition or description
effect may not be evidentfor two to threeweeks.
A. SignsandSymptoms yet exists, our index would be diffi
1. Mild: Drowsiness, stupor, blurred vision, excessive dryness of mouth.
2. Severe Respiratory depression, hypotension, coma, convulsions, cardiac arrhythmias cult to validate. On the other hand,
andtachycardias. the relationship found by us be
Also:urinaryretention(bladder stony).decreasedgastrointestinalmotility(paralyticileus),
hyperthermia(or hypothermia),hypertension,dilated pupils, hyperactivereflexes. tween depression and unresolved
B. Management and Treatment
1.Mild: Observationand supportivetherapy is all that is usuallynecessary. grief and its stability over time
2. Severe: Medical management of severe SINEQUAN overdosage consists of aggressive
therapy.
supportive Ifthepatientisconscious,
gastriclavage, ithappropriate
w precautions seems to partially validate the
to prevent pulmonary aspiration, should be performed even though SINEQUANis rapidly
absorbed. Theuse of activatedcharcoal has been recommended,as has been continuous scale.
gastric lavagewith salinefor 24 hoursor more.An adequateairwayshouldbe establishedin
comatose patients and assisted ventilation used if necessary. EKG monitoring may be The importance for research
required for several days, since relapse after apparent recovery has been reported. Ar
rhythmiasshould be treatedwith the appropriateantiarrhythmicagent. It has been reported purposes of an operational defini
thatmanyofthecardiovascular andCNSsymptoms oftricyclicantidepressantpoisoning in
adults may be reversedby the slowintravenousadministrationof 1mg to 3 mg of physostig tion of unresolved grief appears
mine salicylate. Because physostigmine is rapidly metabolized, the dosage should be
repeated as required. Convulsionsmay respond to standard anticonvulsanttherapy.h@ obvious. Many clinical studies de
ever,barbiturates may potentiate any respiratorydepression. Dialysis and forced diuresis
generallyare not of value in the managementof overdosagedue to high tissue and protein scribe a wide variety of syndromes
binding of SINEQUAN.
More detailed professional information available on request that result from atypical and
Psy
pathological grief.2'3'6'7'9'2023'25'3°
RO@RIGE@
of
A division PfizerPharmaceuticals
NewYork,NewYork10017
252 PSYCHOSOMATICS
chiatric disorders, an increased risk of bereaved individuals go through large epidemiologic study of
for the onset of medical illness, and a somewhat typical grief process in widows and widowers, Parkes25
prolonged social incapacitation are the sequence previously men found four major factors that pre
all associated with grief. Clinical tioned. Sixty-four percent of our dicted poor outcome: low socioeco
evidence suggests that unresolved population acknowledged a stage nomic status; a short terminal ill
grief may account for all or most of of shock and disbelief. In the next ness with little warning of impend
this medical risk. For example, stage of acute dysphoria, 80% felt ing death; multiple life crises; and
Schmale,24 in a study of the fre that they had grieved for the person reactions to bereavement that in
quency of loss antedating medical who died, 84% cried, 78% kept dude severe distress, yearning,
hospitalization, found the effects of thinking about him or her, and 67% anger, or self-reproach. His study
hopelessness and helplessness felt they were depressed. A majori did not find demographic factors
(unresolved grief), rather than the ty of the respondents showed evi important, nor did he confirm
fact of the loss itself, to be the dence of reaching the third stage of Maddison's finding28 that support
crucial factor. Both an increase25 resolution. Although 73% still from family relationships or close
and a decrease2' ofacute responses missed the deceased and 72% felt friends was especially significant.
to bereavement have been related that no one would ever take his or We found demographic factors
to later complications. Jacobs26 her place, 79% believed that they not particularly related to outcome,
suggests that the process of grief the one exception being the age of
acts as a bridge between loss and the bereaved. Younger individuals
illness or death, and David22 states Oncepresent,unresolved tended to have more unresolved
that unresolved grief (not just loss) grief. This is consistent with Parkes'
grieftended to remain,
in childhood or adolescence leads and Maddison's finding that
to later problems.22 Zisook27 found the
suggesting needfor younger widows had more illnesses
unresolved grief a major charac activeinterventionwhen than older widows, and with Clay
teristic of grief-related facsimile ill identified. ton's finding29 that younger widows
ness, namely, the phenomenon in had more physical and depressive
which pathologic identification symptoms and hospitalizations.
with the deceased presented in the were functioning as well as they In addition, our respondents
form of the terminal illness. At the had previously, 77% felt that they identified as having unresolved
minimum, resolution of the grief had adjusted to the loss, and 65% grief were less likely to have at
process appears related to health stated that they were able to discuss tended the deceased's funeral. This
and adjustment. the deceased without difficulty. is consistent with Volkan's conclu
Our findings suggest a relation Present grief-related feelings and sion3° that persons exhibiting
ship between unresolved grief and behaviors peaked in intensity be pathologic grief often fail to par
other complications, especially de tween the first and second years, ticipate fully in funeral rites. Our
pression. By our index, individuals and gradually diminished thereaf unresolved grief group also had
with unresolved grief were signifi ter. overall present and past grief scores
cantly more depressed as measured Unresolved grief, on the other more consistent with Parkes'4-25
by total Zung scores and numerous hand, did not significantly change finding that, instead of delayed or
items on the Zung scale. Although over time. Once present, it tended inhibited grief leading to later
no cause and effect relationship can to remain, suggesting the need for complication, the most disturbed
be defined, it does appear that per active intervention when identified. individuals after one year were
sons who report that they have Factors found in the literature3-5-20 those most disturbed three to six
grieved, adjusted to the loss, and to impede the resolution of grief weeks after bereavement.
can talk about the deceased with include lack of social supports, the
out difficulty are less likely to be bereaved's psychological makeup, Conclusion
depressed than those who indicate substance abuse, age, multiple In our study a significant percent
that they have not grieved. prior losses, ambivalent or over-in age of bereaved individuals did not
Our results support previous re vested relationships to the de completely resolve their grief.
ports that a significant proportion ceased, and fortuitous factors. In a These persons tended to be
(continued)
MARCH 1983-VOL 24' N03 253
1. Jacobson el a!: Psthoçd@y@Iogy
REf€@eflc@S: A
7:345, Sep1970. 2. Lynch1. Greene VT:1k Ccl!
Phys Swg 4:87-90, Jan 1975. 3. James NM, Montague
Af:NZMed/81:246-248, Mar 12, 1975. 4.Taws
ER. Brunning J' Axenilas L: lint MedRes 3:417-422,
AD, L:
Jun1975. 5. Broadhurst Arenillas CurrMedRes
Opin 3:413-416, Jul 1975. 6. Data on file, Hoffmann
La Roche Inc., Nutley, NJ. 7. Kales A et a!: /Chn Phar
Grief and depression
DJ,Allen
macc!17:207-213, Apr 1977.8. Greenblatt
S RI:C!in
MD, hader Ther Mar
Pharmacol 21:355-361,
9. JM: Find Chit
1977. Monti MethOdS Exp Pharmaco!
3:303-326, May 1981.
@ younger, failed or were less likely to 10. Lloyd C: Life events and depressive disorder
reviewed. Parts I and II.Arch i3en Psychiatry
@ HC1/Rcx'heX@
DaImane®(flti@aze@ attend the funeral, were more dis 37:529-535, 1980.
11. Clayton P, Desmarais L, Winokur G: A study
@ Beforeprescribing,pleaseconsultcompleteprodud tressed both shortly after and long
information,a summaryofwhich follows: of normal bereavement. Am J Psychiatry
in
Indications:Effective all types insomnia
of character
after their loss, and were more de 125:168-178, 1968.
@ f
izedby difficultyin fallingasleep,requent octurnal
n pressed than those individuals tra 12. Clayton PJ, Halikas JA, Maurice WL: The
awakenin@ and/orearlymorning awakening; patients
in bereavement of the widowed. Dis Nerv Syst
@ with recurring insomnia or poor sleeping habits: in acute
versing an ordinary grief process. 32:597-604, 1971.
@ s
or chronicmedical ituationsequiring
r restful leep. bjec
s O Although depression is common 13. Clayton PJ, Halikas JA, Maurice WL: The
tivesleeplaboratory datahaveshowneffectiveness at
br depression of widowhood. Br J Psychiatry
@ n
least28 consecutiveights administration.
of Since
and even typical of uncomplicated 120:71-76, 1972.
@ insomnia isoftentransientandintermittent,
prolonged grief, it is likely to be more severe 14. Clayton PJ, Halikas JA, Maurice WL: Antici
adrnintstration
isgenerally necessary recommended.
not or patory grief and widowhood. Br J Psychiatry
Repeated therapy w
shouldonly beundertaken ith appro
where there is evidence of unre 122:47-51, 1973.
@ e
pilatepatient valuation. solved grief. Once present, unre 15. Clayton PJ, Herjanic M, Murphy GE, et a):
Contraindications: nownhypemensih@ flurazepam
K to Mourning and depression: Their similarities
@ HCI; regnancy.
p Benzodiazepines fetal
maycause damage
solved grief tends to persist. Since and differences. Can Psychiatr Assoc J
@ whenadmintstered duringpregnancy.Several studies ug
s the medical and psychiatric seque 19:309-312, 1974.
gest n increased
a riskof congenital
malformations associ 16. Clayton PJ: Mortality and morbidity in the first
@ atedwith benzodiazepine useduringthefirsttrimester.
lae of the bereaved state appear year of widowhood. Arch Gen Psychiatry
Warnpatients f thepotential isksto thefetus
o r should substantial, further research is in 30:747-750, 1974.
thepossibility f becoming
o pregnantexistwhilereceiving 17. Faschingbauer TR, Devaul RA, Zisook 5:
dicated to identify those patients Development of the Texas Inventory of Grief.
flurazepam.Instruct patient to discontinuedrug prior to
becoming regnant.
p t
Considerhepossibility f pregnancy
o who prolong this state. 0 Am J Psychiatry 134:696-698, 1977.
priorto instituting
therapy. 18. Zisook 5, DeVaul RA, Click M: Am J Psychia
Warningu Cautionpatients boutpce@bkombined
a c try, to be published, 1982.
w An
effects ith alcoholandotherCNSdepressants. addi 19. Zung WW. A self-rating depression scale.
t
tiveeffectmayoccurif alcoholisconsumedheday fot
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@adual of
tapering dosage those
for o
patients n medication 23:18-22, 1961. 24. Schmale A: Relationship of separation and
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d
increaseosage. ties Press, 1972. 20:259-277, 1958.
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t
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a w
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suicidalendencies, in those
or with impaired renalor 7. WahI CW: The differential diagnosis of normal illness. Int J Psychiatry Med 7 :329-336, 1977.
hepaticfunction. and neurotic grief following bereavement. 28. Maddison DC, Walker WL: Factors affecting
AdverseReactions:Dtrrniess, drowsiness, lightheaded Psychosomatics 11:104-106, 1970. the outcome of conjugal bereavement. Br J
s
ness, ta@enng, ataxiaandfallinghaveoccun'ed, particu 8. Parkes CM: Bereavement and mental illness. Psychiatry113:1057-1067, 1967.
patients.everesedation,
ladyin elderlyor debilitated Part 2. A classification of bereavement reac 29. Clayton PJ: The effect of living alone on
lethargy,disorientationand coma, probably indicative of tions. Br J Med Psychol 38:13-26, 1965. bereavement symptoms. Am J Psychiatry
drugintolerancer overdosage,
o A
havebeenreported. lso 9. DeVaulRA, Zisook 5: Unresolved grief: Clini 132133-137, 1975.
reported: eadache,
h u
heartburn, pset tomach, ausea,
s n cal considerations. Postgrad Med 59:267- 30. Volkan VD: Typical findings in pathological
271, 1976. grief Psychiatr 0 44:231-250, 1970.
c GI
vomiting,diarrhea, onstipation, pain,nervousness,
talkativeness,apprehension,irritability, weakness,palpita
p
tions,chest ains,bodyandjointpainsandG com
plaints.There have also been rare occurrencesof leuko
penia, @anukxytopenia, sweating, difficultyin
flushes,
focusing,blurredvision,burning eyes,faintness. hypoten
of s
sion,shortness breath,pruritus, kinrash,dry mouth,
e
bittertaste, xcessive a e
salivation, norexia, uphoria,
depression,slurred speech, r
confusion,estlessness, halluci
a
nations, ndelevated SGOT,SGPTtotalanddirectbiliru
bins,andalkaline phosphatase: andparadoxical reactions,
e.g., excitement,stimulation and hyperactivity.
for
Dosage:Individualize maximum effect.
beneficial
Adults: 30 mg usual dosage; 15 mg may suffice in some
Elderlyor debilitated
patients. patients:15 mgrecom
mended isdetermined.
initiallyuntil response
Supplied:Capsules 15
containing mgor 30 tog
flurazepam HCI.
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