Mourner’s Little Helper: The Use of Psychotropics in the Treatment of Grief-Related Distress From Opium to Opioid Antagonists

Abstract

The value of diagnosing the pathologically bereaved, as affected by a distinct disorder from depression, anxiety, or post-traumatic stress disorder, has long been debated by clinicians and scholars alike. Disputes continue over whether a specific diagnosis would help those struggling after loss, even after prolonged grief disorder gained official status in 2022 as a condition recognized and defined in the Diagnostic and Statistical Manual of Mental Disorders. This paper examines how different medical conceptualizations of grief have helped shape the development and use of pharmaceutical interventions to treat the bereaved over the past century. Using a Foucauldian-inspired approach and a biopolitics framework, this paper traces the multifaceted history of grief as a condition that can be targeted and treated through medication and medical interventions.

Introduction

The inclusion of diagnostic criteria for Prolonged Grief Disorder (PGD) was the main revision in the latest version of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 TR), released in April 2022. The value of a specific diagnosis for the “pathologically” bereaved—which sets it apart from existing conditions triggered by loss, such as depression, anxiety, and even PTSD—has long divided clinicians and scholars, with arguments for and against its inclusion in works from various fields over the past couple of centuries. Disputes among scholars and medical professionals about whether a diagnosis would genuinely help those who have experienced a significant loss and are struggling to adapt have not diminished, even after the condition gained official disorder status.

If anything, the divide appears to have widened, with the new PGD diagnosis facing strong criticism from some mental health scholars and professionals, particularly those critical of what they term a “drug-based paradigm” in the psychological disciplines and beyond (Bandini, 2015; Granek, 2015). Bandini is among the scholars concerned that a grief-specific diagnosis could be more harmful than helpful and might lead to “overdiagnosis and overtreatment, a potential expanded market for pharmaceutical companies, and the loss of traditional and cultural methods of adapting to the loss of a loved one” (Bandini, 2015, p. 347).

The paradigmatic divide between scholars and clinicians who support or oppose the creation of a grief-specific disorder can be seen as, among other things, a discursive dispute over who has the right to define what is considered normal and pathological in grief and bereavement and to what end. After all, what are the boundaries of normality? What benefits might a diagnosis bring? Would it necessarily result in better patient outcomes? These are essential questions to consider from a classical Foucauldian perspective, like the one guiding this paper, as “the different ways in which madness, criminality or delinquency is spoken about justify different forms of intervention” (Arribas-Ayllon, 2017, p. 115).

The present paper is therefore not an investigation into the evidence or efficacy of psychotropic interventions for treating grief-stricken individuals. Instead, it examines how different ways of conceptualizing grief from a medical perspective have led to various pharmaceutical interventions over the last century. Developed from a Foucauldian-inspired perspective and a theoretical framework centred around the concept of biopolitics, this article examines the history and development of the idea of grief as a pathology, and therefore, as something that pharmacological treatments and interventions can either improve or resolve.

Biopolitics and the Disciplines of the Mind

Using a Foucauldian framework of analysis as a starting point, Sandra Caponi (2012) poses the question: “is it possible to understand the current expansion of psychiatric diagnosis of everyday behaviours as a hegemonic biopolitical strategy that is almost universally accepted? ¹ ” (Caponi, 2012, p. 103). Foucault first introduced the concept of biopolitics of the populations in the first volume of The History of Sexuality (1978) as a “series of interventions and regulatory controls” that will slowly supplant “ [t]he old power of death that symbolized sovereign power” with “the administration of bodies and the calculated management of life” (Foucault, 1978, pp. 139–140). Biopolitics and its complementary concept, biopower, are intrinsically connected to the emergence of capitalism as a prevailing orthodoxy. Foucault states that capitalism would not have been possible:

Without the controlled insertion of bodies into the machinery of production and the adjustment of the phenomena of population to economic processes. But this was not all it required; it also needed the growth of both these factors, their reinforcement as well as their availability and docility; it had to have methods of power capable of optimizing forces, aptitudes, and life in general without at the same time making them more difficult to govern. (Foucault, 1978, p. 141).

In this scenario, the emergence and consolidation of psy disciplines and knowledges (especially psychiatry and psychology) from the 19th century onwards have been frequently framed by authors of a constructionist or critical theoretical tradition (Epstein, 2008; Rabinow & Rose, 2006; Rose, 1979) as a central discourse that held the legitimacy to establish the thresholds of the normalcy/pathology in the human population, which is one of the prime characteristics of biopolitics (Caponi, 2012). Caponi establishes that in order to understand the complex weaving of life/bios and the political proposed by Foucault it would be essential to examine how scientific discourses and classifications are constructed, while also analyzing the specific intervention practices that affect people’s lives (Caponi, 2012, p. 109).

Rabinow and Rose’s definitions of these twin concepts are also instrumental: to the authors, biopower “serves to bring into view a field comprised of more or less rationalized attempts to intervene upon the vital characteristics of human existence” (Rabinow & Rose, 2006, p. 196). Biopolitics, on the other hand, refers to the “specific strategies and contestations over problematizations of collective human vitality, morbidity and mortality; over the forms of knowledge, regimes of authority, and practices of intervention that are desirable, legitimate and efficacious” (Rabinow & Rose, 2006, p. 197). Biopolitics and biopower are therefore about governing and managing the ways populations live, learn, reproduce, work, trade, organize, die, and, as discussed next, mourn. At the core of this extensive operation is the need to clearly distinguish between normal and abnormal behaviour, because as Foucault states, the modern state is: “as a very sophisticated structure, in which individuals can be integrated, under one condition: that this individuality would be shaped in a new form and submitted to a set of very specific patterns” (Foucault, 1982, p. 783).

The thresholds of normalcy and pathology, largely determined in contemporary nation-states by the medical sciences, help establish what kind of personhood and behaviours societies expect at a given time (Caponi, 2012, p. 110). This interpretation sheds light, for example, on the constant shifts and transformations that can be observed over short periods concerning mental disorders’ conceptualizations and treatments. From this theoretical perspective, the psy disciplines help shape the health of populations and, equally important, their productive capacity by producing extensive knowledge about pathologies and disorders that can affect individuals and impair their productivity; at the same time, they create and legitimize interventions to reintegrate people experiencing psychic suffering back into normalcy.

Connecting biopower back to grief, the reality is that a bereaved person, just like an individual who is physically or mentally ill, is hardly “maximized as a useful force” (Foucault, 1995, p. 221), which Foucault identifies as being the ultimate pursuit of capitalist economies. Caponi adds that, through biopower, “new interventions on populations are validated by the promises of medical and psychiatric knowledge,” heavily focused on “anticipating risks,” “avoiding pain,” and pursuing the “goal of a life without suffering” (Caponi, 2012, p. 103).

Although it may not appear obvious at first, grief plays a crucial role in politics, legislation, and bureaucracy. For example, the common understanding that a significant loss can cause intense suffering and disability has led to bereavement rights being included in collective agreements, laws, and even constitutions across various nations. These legal frameworks also set deadlines by which a mourner is expected to recover and return to their duties.

Throughout history, various terms have been used to describe abnormal grief, usually highlighting three aspects of inadequacy: “grief that is too intense, too long, and impairs functioning” (Walter, 2006, p. 75). The longer it takes for someone to return to their original self, the more they stray from societal norms of proper mourning. This deviation prompts the need to define and measure how normal and abnormal grief differ. Although shaping human body and mind to fit cultural standards is not unique to Western cultures, it can be argued that the rationalization involved—through tools, instruments, and institutions—is particularly sophisticated in the West. Furthermore, this apparatus is highly adaptable; over just a little more than a century, perceptions of what constitutes “too intense” or “too long” have shifted significantly, both influencing and responding to broader sociocultural changes. The same applies to medical interventions designed to help mourners readjust. In the upcoming sections, I will examine three pharmacological responses to grief across different historical periods within the framework of biopower.

Treatments and Interventions

A Drug Which Melted Sorrow

Pointing out that grief has entered the realm of medical interventions, especially over the past century, is not meant to deny that sorrow has historically been seen as a condition that could be fixed or, at least, alleviated, by specific drugs and remedies. In a foundational text of the Western canon and philosophy, The Odyssey, we already encounter references to such treatments.

But Helen, of the line of Zeus, called to mind another resource. Into the wine they were drinking she cast a drug which melted sorrow and sweetened gall, which made men forgetful of their pains. Whoso swallowed it mixed within his cup would not on that day let roll one tear down his cheeks, not though his mother and his father died, not though men hacked to death his brother or loved son with the cutting edge before him and he seeing it with his eyes. (Homer, 2015).

It is widely accepted by literature scholars and historians that The Odyssey was composed between the seventh and eighth centuries BCE (Allan, 2016; Manoledakis, 2015). This source markedly differs from all other texts examined in this paper – moving forward, the analysis will primarily focus on medical texts from the past two centuries – but even a work of fiction nearly three thousand years old can offer valuable insights into ancient healing practices. For instance, the passage indicates that the Greeks were aware of opium at that time, recognising its property of alleviating sadness. In fact, the passage highlights the use of the substance as a remedy for grief, describing that the person who took it “would not on that day let roll one tear down his cheeks, not though his mother and his father died, not though men hacked to death his brother or loved son (...)” (Homer, 2015).

Having established that treatments for grief were acknowledged in the ancient Western world—although it is difficult even to speculate how widespread such knowledge or practices were—I propose shifting the focus to more recent medical practices and texts. As noted by authors such as Haller (1989) and Huber (2020), the peak of opium use in the Western world occurred during the Victorian era. Haller states, “ [u]sed and abused by layman, charlatan, and practitioners alike, opium represents one of the most significant - and confusing - episodes in the history of medicine” (Haller, 1989, p. 591).

Opium was prescribed in the 19th century to treat a wide range of conditions, both physical and mental (Haller, 1989). These included ulcers, inflammation, pain, tetanus, diarrhea, and, of course, mental ailments such as hysteria, hypochondriasis, insanity, and melancholia (Cooke, 1853; Hudson, 1860), which led Soares to refer to opium as a “protopsychopharmaceutic” (Soares, 2022, p. 142). It is important to note that these examples are far from complete, since opium has one of the “longest histories of constant use in the whole of the materia medica” (Carlson & Simpson, 1963, p. 112).

In the 19th century, opium was commonly used in various forms, dosages, and preparations within the medical practices of Western countries like Germany, the United States, France, and England. Carlson and Simpson (1963) note that each nation had its own prevailing theories, trends, and schools of thought regarding opium use. However, there was also a flow of ideas facilitated by journals, conferences, and travelling scholars to expand knowledge. For instance, Benjamin Rush, often regarded as the father of American psychiatry, was influenced by his training in Edinburgh under the physician John Brown. This experience seems to have shaped Rush’s view of opium as a stimulant that caused sedation through posthumous exhaustion.

To understand the connection between the use of opium specifically in the treatment of grief, it is vital to investigate how the events of grief and mourning were conceived within the nosological complex of early psychiatrists. For instance, Philippe Pinel, widely considered “the founder of modern psychiatry” (Pichot, 2004, p. 84) discusses grief in at least ten passages of his seminal work Medico-Philosophical Treatise on Mental Alienation (Pinel, 2008). That being said, Pinel conceives of grief more as a trigger for what he calls mental alienation than as a condition in itself. As explained by Pichot, Pinel saw mania, melancholia, dementia and idiotism as expressions of a single disease, mental alienation, which, in turn, could be prompted by specific events or predispositions:

This illness has, in some cases, a common origin and stems basically from an event or combination of similar events which must be regarded as its determinant cause. Amongst these must be numbered hereditary disposition, intense mental affections such as deep grief, thwarted love, extreme excitement over religious principles, or indeed profound immorality. (Pinel, 2008, p. 9).

In a different passage, Pinel discusses melancholia, which “may stem from a natural disposition,” but also describes individuals who are “seen of a cheerful character, full of vivacity, who because of genuine grief sink into gloomy moroseness, seek solitude, and lose their appetite and sleep” (Pinel, 2008, p. 43). In this context, we find instances where Pinel describes an opium preparation used to treat melancholia: “It is only by combining the use of cinchona with opium that one can address melancholia marked by atony and extreme despondency, of which I could quote many examples” (Pinel, 2008, pp. 131–132). It is therefore reasonable to assume that cases of melancholia incited by grief would have been treated in a similar manner by Pinel and possibly other physicians from the same era and similar schools of thought in France and beyond.

Similarly, in the United States, Benjamin Rush wrote his own study on mental distress called Medical Inquiries upon the Diseases of the Mind (Rush, 1962), where grief is addressed in over thirty passages and thoroughly explored in a whole chapter dedicated to its symptoms, treatments, and course. It is essential to establish that Rush’s view of health and medicine is much more theologically influenced than, for example, Pinel’s. This becomes apparent in his explanation of the different faculties involved in diseases of the mind: “understanding, memory, imagination, passions, the principle of faith, will, the moral faculty, conscience, and the sense of Deity” (Rush, 1962, p. 10). On this point, the distinction between a disease of the mind and a passion becomes less clear. For instance, Rush describes grief as a passion: “Those of them [passions] which are most subject to derangement, or to an unreasonable and morbid excess, are love, grief, fear, and anger” (Rush, 1962, p. 314). However, Rush does acknowledge that a “deranged” passion may develop into a disease (Rush, 1962, p. 314) and, therefore, might be treated as such. In fact, when discussing grief, Rush states: “The first remedy that is indicated in recent grief is opium. It should be given in liberal doses in its first paroxysm, and it should be repeated afterwards, in order to obviate wakefulness” (Rush, 1962, p. 320). Opium, in fact, is his only pharmacological recommendation. The other suggested treatments include bleeding, crying, and a combination of social support and shielding (not being reminded of the dead by others).

Although Rush supported practices now considered barbaric, like bleeding and purging patients, his and Pinel’s legacies share many similarities. Both men are regarded as “fathers” of psychiatry, recognized for the significant changes they brought to asylums in their countries, and celebrated for their pioneering humanistic views on mental suffering. A less commonly noted similarity between Rush and Pinel is that both studied, lived, and worked during the formative period of their respective modern nation-states — the United States and France: the American Revolution and the French Revolution. Benjamin Rush was a founding father and a signer of the Declaration of Independence. Likewise, Pinel is remembered for defending and promoting the unshackling of asylum patients, undoubtedly in alignment with humanistic principles of the French Revolution. Therefore, the somewhat novel approaches of avoiding patient restraint whenever possible and promoting free access to care for the impoverished cannot be separated from the larger philosophical ideals of equality and nationhood that inspired both revolutions. This new, more humanistic approach was made possible largely through the use of substances like opium, which were employed to calm and treat those who, perhaps for the first time, were seen not as madmen but as fellow men with mental illness. Soares says:

Among the events that mark the process of transforming madness into mental illness, the gesture of the physician Philippe Pinel (1745–1826) stands out. At the Bicêtre hospital in 1793, he would liberate the mad from their chains, in the company of the heterogeneous characters of unreason captured in the great confinement (libertines, heretics, homosexuals, etc.). For Foucault (ibid.), Pinel’s “liberating” act, elevated to the founding myth of the history of psychiatry, was in reality a new mode of subjugation to madness, which, ceasing to be merely a social, moral, and legal issue of segregation, also became an object of scientific knowledge that would be subjected to the discipline of the medicalized asylum and to psychiatric medicine. (Soares, 2022, p. 61).

When examining both major and minor sociocultural transformations — such as the rise of nation-states with new principles of governance and personhood, the development of knowledge and a new medical discipline of the mind called psychiatry, and innovative approaches to treating mental illness largely enabled by medicalization – it becomes clearer how medical knowledge evolved into a key tool in shaping the modern individual and managing large populations. As we will discuss next, within the framework of a new form of governance Foucault refers to as biopower, disciplines of the mind establish their legitimacy, and the importance of pharmaceuticals grows as methods for controlling mental suffering, including grief.

The Age of Depression

The idea of blurred boundaries between depression and grief persisted and dominated much of the 20th century. Opium, both in its pure form and in preparations, declined sharply in popularity, especially within medical settings, as evidence grew regarding addiction and other health issues related to the substance (Carlson & Simpson, 1963; Weber & Emrich, 1988). These two simultaneous conceptual shifts, along with the expanding reach and legitimacy of psychology and psychiatry, led to a major change in how grief was treated with psychotropic medicines. The move toward using drugs like antidepressants and antianxiety medications to help bereaved patients was also facilitated by a profound shift in how normality and abnormality in human emotions are understood.

Several transformations in medicine, science, and social life in general illuminate the discursive shifts of interest for this analysis. The first factor to consider, as previously mentioned, is the strengthening of disciplines dedicated to studying the function (and dysfunction) of the mind: psychology, psychiatry, and psychoanalysis being the main fields of expertise for most of the 20th century. This represents a notable departure from the body of knowledge primarily developed by physicians, which had been the norm since Hippocrates (c. 460–c. 370 BC). Significantly, having a set of disciplines wholly focused on investigating and conceptualizing the mind reflects not only a trend of hyperspecialization aligned with the principles guiding science and medicine in that era but also, more deeply, a shift away from a medical perspective that viewed mental disorders as reflections of bodily dysfunctions in the blood, bile, or elsewhere. For the first time, mental disorders were systematically understood as originating within the mind itself.

Another significant shift in the pharmaceutical landscape arises from a complete change in the subject of psychological intervention. Horwitz and Wakefield state: “By the early 1950s, the center of gravity in American psychiatry had shifted from state hospitals, which focused on psychotic cases, to psychodynamic outpatient therapy of less severe pathology” (Horwitz & Wakefield, 2007, p. 85). This shift parallels a profound theoretical transformation in the understanding of mental suffering through a quite literal widening of the conceptual borders regarding mental health and illness. Horwitz and Wakefield highlight the novelty of the “belief that depression is a widespread phenomenon” (2007, p. 5), despite various attempts across different periods and regions to define a symptomatology of intense, reasonless sadness. The authors argue that it was largely contemporary psychiatry that conflated “two distinct categories of normal sadness and depressive disorder” (Horwitz & Wakefield, 2007, p. 6). The undeniable expansion of the scope of mental health disciplines is crucial to understanding how antidepressants ultimately replaced opium in treating the symptoms we now link to depression, as well as sadness caused by grief.

In multiple ways, the dominant view in past centuries, especially throughout most of the 20th century, was that grief and depression (or melancholia) were deeply intertwined and difficult to distinguish, apart from one key difference: grief was intense sadness with a clear cause, while depression involved intense sadness without an identifiable reason. This perspective was endorsed by various disciplines, scholars, and practitioners over the last hundred years, but two examples of this theorization are especially representative: Sigmund Freud’s influential work Mourning and Melancholia (Freud, 1917) and the Diagnostic and Statistical Manual of Mental Disorders (APA, 1980).

It is well established that psychoanalysis was the first and most prominent of the psy disciplines to enter, so to speak, the realm of death (Hagman, 2016; Parkes, 1987; Stroebe et al., 2001). Perhaps unsurprisingly, Freud’s Mourning and Melancholia is widely regarded as a foundational text in bereavement studies. Several models and frameworks for explaining grief would eventually develop from the author’s analysis. Colin Murray Parkes explains that Freud’s influential paper “recognized that bereavement is sometimes a cause of depression” and “ (…) coined the term ‘grief work’ on the supposition that grief is a job of psychological work that we neglect at our peril.” (Parkes, 1987, p. 26).

The concept of “grief work” has been extensively examined and critiqued over the past century, yet it remains, to a large degree, the framework used to evaluate and compare new models of bereavement (Hagman, 2016; Parkes, 1987; Rando, 1993; Stroebe et al., 2001). Although it lacked novelty, the distinction between grief and depression (or mourning and melancholia) defended by Freud nonetheless helped solidify two fundamental aspects of this perspective: grief was fundamentally different from depression, yet grief could potentially develop into depression. Freud states:

The correlation of melancholia and mourning seems justified by the general picture of the two conditions. Moreover, the exciting causes due to environmental influences are, so far as we can discern them at all, the same for both conditions.

Mourning is regularly the reaction to the loss of a loved person, or to the loss of some abstraction which has taken the place of one, such as one's country, liberty, an ideal, and so on. In some people the same influences produce melancholia instead of mourning and we consequently suspect them of a pathological disposition. (Freud, 1917, pp. 243–244).

Freud’s view that “ [i]t is really only because we know so well how to explain it [mourning] that this attitude does not seem to us pathological” (Freud, 1917, p. 244), alongside the belief that a meaningful loss could, in some people, produce melancholia instead of mourning, would be echoed by several authors from both Freudian and other traditions (Lindemann, 1944; Parkes, 1964). Most importantly, this idea would be reinforced by the Diagnostic and Statistical Manual of Mental Disorders and its bereavement exclusion clause for diagnosing Major Depressive Disorder. The centrality of the manual to mental health disciplines is well summarised by Horwitz.

The DSM gained prominence only in 1980, after the publication of its third edition, which became the heart of professional education, practice, and research. Since that time it has been the reference point for all mental health professionals, even those who disdain it. The manual establishes which psychiatric conditions are taught in medical and other professional schools, determine eligibility for disability payments for patients and insurance compensation for providers, are targeted by pharmaceutical advertisements, become objects of psychiatric research, and shape public formulations of mental illness. It is also firmly embedded in the administrative apparatus of hospitals, private practices, the judicial system, and all other institutions that deal with mental disorder. Moreover, the DSM shapes the way individuals conceive of their own psychological problems. (Horwitz, 2021, p. 3).

DSM-III marked a true revolution in how knowledge about the mind was collected, produced, organized, and taught. Its impact is extensively examined in several papers and books, but a brief list of reasons for its greater significance over editions one and two includes its alignment with positivist methods and data collection, its penetration into the collective imagination, its success in centralising knowledge and establishing legitimacy, and finally, its symptom-based approach to disease classification (Horwitz, 2021).

It was the DSM-III that, aligning with the prevailing view among bereavement scholars, proposed a definition for Major Depressive Disorder that clarified that, for a diagnosis to be made, the symptoms could not be better explained by grief: “States of depression, not specifiable as manic-depressive, psychotic or neurotic, generally transient, in which the depressive symptoms are usually closely related in time and content to some stressful event” (APA, 1980, p. 438), such as a grief reaction. This effectively recognised that bereavement and depression could present similarly or even identically. However, DSM IV would be even more explicit in stating that a mourner should not be considered depressed (or disordered) unless “after the loss of a loved one, the symptoms persist for longer than 2 months or are characterised by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation” (APA, 2000, p. 355).

Because grief was virtually indistinguishable from depression in terms of symptoms, it is understandable that their treatments often overlapped. For example, opium and its preparations were commonly used to treat melancholia and were also explicitly employed as remedies for grief, as previously explained. Although the use of such substances declined, the idea that grief and depression are similar persists as new substances gain popularity. For instance, in his 1944 influential work on grief, Symptomatology and Management of Acute Grief, Erich Lindemann prescribes a mix of benzedrine sulphate (amphetamine) and sodium amytal (barbiturate) to treat bereaved patients displaying significant depressive symptoms (Lindemann, 1944, p. 147), both substances that were widely experimented on for treating depressive states at that time (Guttmann & Sargant, 1937; Myerson, 1936; Reifenstein & Davidoff, 1939).

Later on, with the pharmaceutical revolution of sedatives and tranquillizers—especially benzodiazepines—this class of medication also came to be used in managing grief. Drugs like Miltown and Valium were early examples of what would later be called blockbuster drugs. Horwitz and Wakefield note that by the late 1960s, Valium was the most prescribed drug in the United States, with up to 25% of the population surveyed indicating they had used tranquillizing drugs at some point in their lives (Horwitz & Wakefield, 2007). The authors also state: “Research showed that only about a third of the prescriptions for these drugs were written for people with diagnosed mental disorders, whereas most medications were given to those experiencing psychic distress, life crises, and psychosocial problems” (Horwitz & Wakefield, 2007, p. 180). It is not a stretch to assume that “life crises” included grief, especially considering that Colin Parkes, a prominent contemporary bereavement researcher, observed that up to half of the bereaved people in the United Kingdom in the 1960s had been prescribed tranquillisers after losing a spouse (Parkes, 1964; Parkes & Weiss, 1983).

Interestingly, both lines of treatment (amphetamines and benzodiazepines) would face a similar backlash experienced by opiates due to their addictive properties and potential for misuse, leading to their gradual (but not total) discontinuation in psychiatric and general medicine settings across various Western countries (Horwitz & Wakefield, 2007; Warner et al., 2001). The pharmaceutical influence over intense sadness, anxiety, and other psychiatric conditions would, nonetheless, only strengthen in the final decades of the 20th century, primarily due to the success of DSM-III and the rise of antidepressant medications. Horwitz and Wakefield explain that the DSM-III focus on symptoms “was particularly well suited for expanding the market for psychotropic drugs because it inevitably encompassed many patients who formerly might have been thought to be suffering from problems of living” (Horwitz & Wakefield, 2007, p. 184). In this scenario, antidepressants fit well with the principles of a biopolitical paradigm that heavily emphasizes controlling health service use and cutting costs, a view widely adopted in the United States under the term managed care and in several other countries under various names and extents. Horwitz and Wakefield say:

Because medication therapy takes considerably less practitioner and patient time than most psychotherapy, it is more amenable to the cost /benefit logic of managed care organizations. Most managed care plans, therefore, provide more generous benefits for pharmaceutical than for psychotherapeutic treatments and usually place no barriers on SSRI use. Conversely, these plans usually place severe limits on payment for psychotherapies, which they view as less necessary and more wasteful than medication. Medication thus involves lower out-of-pocket costs for patients than psychotherapy does, which also influences patients themselves to prefer drug treatments. (Horwitz & Wakefield, 2007, p. 184).

That being said, it is difficult to determine how often antidepressants are prescribed to bereaved individuals. In a comprehensive review of literature on the use of psychotropic medication among traumatically bereaved individuals, Cacciatore and Thieleman state that “Antidepressants are among the most-studied drugs for treating bereavement-related depression” (Cacciatore & Thieleman, 2012, p. 558). By the end of the 20th century, many studies of varying sizes had examined the effectiveness of antidepressants in alleviating grief symptoms (Jacobs et al., 1987; Muskin & Rifkin, 1986; Widera & Block, 2012). However, there is still limited data on how many patients may have been prescribed antidepressants (or other psychotropic drugs) after experiencing bereavement. Part of this knowledge gap relates, once again, to the way mental distress is understood. Since grief was then regarded as a trigger for depression and other mental health conditions, specific data on grief treatment remains scarce.

It is possible, based on patterns observed in previous centuries and even millennia, to conjecture that antidepressants have been regularly prescribed to mourners reporting distress. More importantly, the bereavement literature tends to support the use of psychotropics in cases of grief that are considered abnormal due to their duration or severity. For example, Kellner et al., in one of the earliest systematic studies on the psychopharmacological treatment of grief, state that the patients:

Should be told that psychotropic drugs will not abolish the void, the painful emptiness or the feeling of loss—that all they can do is partially relieve some of the symptoms. However, if the distress is unusually severe or substantially interferes with continuing family functions (such as a widow who has become unable to care adequately for her small children) or with essential employment, psychotropic drugs should be prescribed as in other severe adjustment reactions. Under these circumstances the bereaved may be encouraged to take drugs as a temporary crutch, albeit a necessary one, to facilitate coping with the crisis. (Kellner et al., 1986, p. 189).

The authors do advocate for caution when prescribing medication to treat grief-related distress, but repeatedly highlight that pharmacologic treatment may be important “if the distress is unbearable or incapacitating, if psychiatric or psychosomatic complications occur, and if the response to psychotherapy is inadequate” (Kellner et al., 1986, p. 196). Their general recommendation is that tranquillizers should be considered (primarily benzodiazepines) “during the mourning phase” (Kellner et al., 1986, p. 190) and antidepressants if “the patient reports feeling worse after anxiety is relieved or not feeling anxious any longer but feeling more depressed” (Kellner et al., 1986, p. 192). That suggestion makes sense within the context of the DSM-III and the bereavement exclusion clause for diagnosing Major Depressive Disorder. The clause prevented recently bereaved individuals from being diagnosed with MDD. However, the diagnosis would be possible after only two months of losing a loved one, and as previously established, the symptoms of grief and depression are very similar. Additionally, Horwitz and Wakefield state that the managed care model in healthcare “encourages the use of general physicians, who almost always prescribe medication, instead of mental health specialists” and that physicians have “increasingly supplanted psychiatrists as the primary source of prescriptions for antidepressant drugs” (Horwitz & Wakefield, 2007, p. 184).

As previously indicated, the tendency for physicians to treat psychiatric conditions is not limited to managed care organisations or Western countries. Several nations with different healthcare models favour medication over other types of therapies for mental health care, because it requires less time and costs less than, for example, psychotherapy sessions, which are rarely covered by insurance (Horwitz & Wakefield, 2007; Luhrmann, 2000; Olfson et al., 1999).

Finally, it would be impossible to discuss the pharmaceuticalization of grief treatments within the context of biopower without considering the profound transformations in how Western cultures conceive of and relate to work over the last century. After all, from a Foucauldian perspective, the effects of capitalism and neoliberalism on an individual level are bound to have impacted the “urgency” of overcoming not only grief, but sadness and distress in general. Soares say that in neoliberalism, “a biopolitical art of governing conduct is established in which the economic rationality of the market and its decision-making criteria (costs, investments, supply, demand, and profits) are generalized over domains previously not considered economic” (Soares, 2022, p. 47). This particular facet of biopower can be seen, for example, in an article by Forbes that states that “One in nine employees faces a loss yearly, and grief-related losses may cost organizations around $75 billion annually” (Corbett, 2025), which is just one of hundreds of websites and news outlets reporting the figure from a study by James and Friedman (2003) called Grief index: The “hidden” annual costs of grief in America’s workplace.

Since most regulations and legislations in contemporary workplaces only grant employers a few days of bereavement leave, it is not surprising that studies have found that both the productivity and well-being of workers are often affected upon their return to work (O’Connor et al., 2010). Challenges in the workplace are, therefore, likely to influence individuals’ decisions to use and practitioners’ decisions to prescribe antidepressants to help the bereaved resume their full work duties and increase productivity. In fact, when prolonged grief became a DSM-recognized condition in 2022, finally disentangled from purely depressive disorders, one of the diagnostic criteria explicitly referred to work-related challenges: “The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2022, p. 323). The final separation between grief and depression as distinct conditions reflects many other social and cultural changes, and there is strong evidence that this might lead to shifts in pharmacological treatment as well.

Prolonged Grief Disorder

In Mourning and Melancholia, Freud states that “although mourning involves grave departures from normal life, it never occurs to us to regard it as a pathological condition and to refer it to medical treatment” (Freud, 1917, p. 244). More than a century later, this perspective has changed immensely, leading us to consider some forms of grief as pathological and to seek medical treatment for both normal and abnormal grief. The recent Prolonged Grief Disorder (PGD) diagnosis perfectly illustrates this conceptual shift.

In 2022, PGD was the principal revision in the fifth edition of the DSM. It was recognized as a standalone condition, classified alongside other trauma- and stressor-related disorders “in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion” (APA, 2022, p. 295). The recognition of grief disorder as a distinct condition separate from major depression has been a lifelong effort by Prigerson and colleagues, who have published a series of papers over more than twenty years, gradually developing the diagnostic criteria that would eventually form the basis for PGD. Other research groups (Horowitz et al., 1993, 1997; Reynolds et al., 2017; Shear et al., 2001, 2011) have also proposed their own diagnostic criteria and assessment tools, with varying degrees of acceptance, but ultimately, Prigerson et al.'s framework was favoured in the manual. Accordingly, it will be the focus of this section.

Two factors are worth highlighting regarding the inclusion of PGD in the DSM, almost a decade after the first publication of the most recent edition of the manual. First, it is important to emphasise that the inclusion was the result of decades of campaigning by various scholars who successfully offered an alternative to the prevalent discourse around grief as pathology: if, for most of the 20th century, the disciplines of the mind had agreed on an entanglement (in whatever form) of depression and pathological grief, by the end of that very century, a growing number of bereavement researchers and scholars were convinced of the need for a distinction. Second, research on antidepressants in the treatment of grief played a surprisingly significant role in the success of the push for differentiating depression and grief. In 1993, sociologist and postdoctoral fellow Holly Prigerson was part of the group that published the paper The temporal course of depressive symptoms and grief intensity in late-life spousal bereavement (Pasternak et al., 1993) where they found that “ [d]epressed subjects (…) reported greater grief intensity, a difference that persisted over 18 months despite antidepressant treatment and attenuation of depressive symptoms” (Pasternak et al., 1993, p. 48). The unresponsiveness that patients with “greater grief intensity” had to antidepressants became a core point of defence to those who saw manifestations of grief deemed pathological as an entity separate from depression. Prigerson and colleagues would champion this view:

Tricyclic antidepressants alone and with interpersonal psychotherapy have proven ineffective relative to placebo for the reduction of PGD symptoms [50–52]. By contrast, randomized, controlled trials of psychotherapy designed specifically for PGD have demonstrated efficacy for PGD symptom reduction [53,54]. The efficacy of a PGD-specific treatment highlights the benefits of an accurate diagnosis. (Prigerson et al., 2009, p. 2).

In an article published shortly after PGD was successfully included in the revised DSM-5, the authors provided a historical overview of psychiatric perspectives on grief, highlighting their achievement. They also recalled that: “while several elements of PGD resemble melancholia/depression (e.g., loneliness, loss of meaning or purpose without the deceased person), PGD diverges from depression in several important respects, not the least of which is a lack of response to antidepressant medications” (Prigerson et al., 2021, p. 113).

It is certainly interesting that the perceived failure of a pharmacological entity would be so strongly and effectively used as evidence to distinguish between the two conditions. Firstly, because psychotropics are not classified based on their intrinsic properties; for example, they can be viewed as antidepressants, tranquillizers, or anxiolytics, depending on how their clinical trials are structured and which groups pharmaceutical companies target for marketing (Horwitz & Wakefield, 2007). Secondly, because it is also established that not everyone responds to antidepressants and psychotherapy, a phenomenon known as Treatment-Resistant Depression (TRD). According to Idlett-Ali et al., “ [e]stimated failure rates of MDD treatment are as high as 10–30%” while it is important to note that “the type and number of treatments as well as the length of administration required for TRD diagnosis are inconsistently defined in the literature” (Idlett-Ali et al., 2023, p. 2).

Nonetheless, the search for a pharmaceutical treatment for grief continues. It is likely that antidepressants will remain a popular option for grief-related distress because they are well-established and affordable, especially considering that PGD is still relatively new as a fully realized diagnosis, and its nosology and etiology are probably less well-known than, for example, MDD’s. However, Prigerson and colleagues already have a suggestion for where to begin looking for “interventions that target symptoms of prolonged grief rather than symptoms of depression” (Prigerson et al., 2021, p. 122). In their 2021 review article, they claim to “believe that the neurobiological evidence supports trialling naltrexone for reduction of PGD, given that it targets reward pathways” (Prigerson et al., 2021, p. 123). There is anecdotal evidence, in the words of Prigerson et al., from neurobiological research indicating a link between PGD and a dysregulated reward signalling, similar to what occurs in addiction. In a 2024 paper, the authors restated that “we have hypothesized that naltrexone might release a mourner from an exclusive focus on, and reward from, the deceased person, thereby, promoting an openness to exploring relationships with living people” (Prigerson et al., 2024, p. 530). Further research on the use of the opioid antagonist naltrexone to improve PGD symptoms is currently underway. However, it is too early to speculate on the medication’s effectiveness, marketing potential, or broader acceptance.

The narrowing gap between psychological knowledge and neuroscience can be viewed, within the Foucauldian biopolitical framework, as a new series of powerful mechanisms that help sustain and bolster the legitimacy of certain psy disciplines, especially those that more closely align with the methods of contemporary sciences and medicine. While the 20th century marked a shift away from the idea that mental suffering originated in the body, the 21st century appears to be increasingly prioritizing the brain over the mind. As Angel and Amaral (2023) explain, the so-called “neurological dimensions” hold significant influence in both scientific and lay perspectives. The authors also note that organizations such as the American Psychological Association and the National Institute of Mental Health have recently prioritized studies utilizing neuroimaging and other brain measurement techniques. Neurotechnologies, therefore, can be viewed as components of biopolitics’ power strategies, establishing legitimate thresholds of normal biology that individuals and populations are encouraged to pursue (Angel & Amaral, 2023). As demonstrated in Prigerson et al. (2021, 2024), this recent shift towards focusing on brain function within mental health sciences is likely to pave the way for new pharmacotherapeutic approaches.

Conclusion

The search for a substance capable of alleviating the intense pain and anguish that follow the death of a loved one is not a new phenomenon by any means. However, how this search is conducted, by whom, and what outcomes are aimed for are questions that depend on time and place. Pharmacological interventions for grief, like other psychiatric treatments, aim to bring individuals back within the bounds of normalcy – in the case of grief, that means experiencing normal levels of suffering, appropriate symptoms, and a reasonable timeline for recovery.

Evidently, reducing suffering and discomfort – and if possible, even eliminating them – are intrinsic parts of medical disciplines. However, within contemporary Western societies, they also serve as regulatory knowledges that help “establish an equilibrium, maintain an average, establish a sort of homeostasis, and compensate for variations within this general population and its aleatory field” to “optimize a state of life” as well as “maximize and extract forces” (Foucault, 2003, p. 246). In this context, even grief – as a potentially disruptive and unpredictable event – must be precisely measured, and if it proves too disruptive and unpredictable, it needs to be guided back to a normal, expected course. Meanwhile, the pursuit of a drug that “melts sorrow” continues, as does biopower’s aim of “taking control of life and the biological processes of man-as-species and of ensuring that they are not disciplined, but regularized” (Foucault, 2003, p. 247).