Imagine a support group gathering in a typical church basement, complete with a table with lukewarm coffee in the corner, folding chairs arranged in a circle, and fluorescent lights humming overhead. Someone is discussing their child. Another person is sobbing softly. Then a woman who hasn’t spoken in months abruptly and unapologetically declares that she takes Prozac and that she doesn’t think she would have survived without it. There is a brief silence in the room. Others then acknowledge the same, one by one.
The entire complex weight of this conversation is captured in miniature in that scene, which was described by a doctor writing for the Tragedy Assistance Program for Survivors. Grief and medication have always coexisted uncomfortably. Both cultural and clinical factors contribute to the discomfort. In both therapy offices and support groups, there is an unspoken but enduring belief that reaching for a prescription during a time of grief indicates a lack of strength. You must endure that genuine, appropriate grief without the use of medication. That a pill indicates that you’re not doing it correctly.
That already contentious discussion now takes on a new aspect. The Diagnostic and Statistical Manual of Mental Disorders, sometimes referred to as the “bible of psychiatric diagnosis,” officially included prolonged grief disorder in its fifth edition in 2022. Excessive grief that lasted too long had been officially reclassified as a condition. And the issue of treatment almost always arises when a condition is present. This leads us to naltrexone.
| Topic | The Ethics of Medicating Grief — Prolonged Grief Disorder, Naltrexone, and the DSM-5 Debate |
|---|---|
| Key Diagnosis | Prolonged Grief Disorder (PGD) — added to DSM-5 text revision in 2022 |
| PGD Definition | Intense yearning for the deceased interfering with daily life for 12+ months (adults); 6+ months (adolescents) |
| Estimated Prevalence | As low as 3.3% of grieving people, according to researchers |
| Primary Proposed Drug | Naltrexone — originally approved in 1984 for alcohol and opioid addiction |
| Mechanism of Proposed Use | Theorized to reduce “reward center” activation triggered by thoughts of the deceased |
| Key Researcher (Pro-PGD) | Dr. Holly Prigerson — Professor, Cornell University |
| Key Critic | Kara Thieleman — Grief Researcher, Arizona State University |
| DSM Conflict of Interest Concern | 55 of 92 U.S. physicians contributing to DSM-5 had financial ties to pharmaceutical industry (2023 study) |
| Alternative Treatment | Prolonged Grief Therapy (cognitive behavioral approach developed by Katherine Shear) |
| Key Concern | Naltrexone may disrupt social bonding capacity — potentially harmful during bereavement |
| Reference Links | The Walrus – The Pill That Promises to Cure Grief / Hospice Foundation of America – Medication Is Not a Cure for Grief |
The medication was first created in 1984 to treat alcohol and opioid addiction by preventing the brain’s association of the substance with pleasure. A different application is suggested by recent research led by Cornell University professor Holly Prigerson: in individuals with prolonged grief disorder, thinking about the deceased activates the brain’s reward center in a manner similar to addiction. According to the theory, naltrexone might lessen that compulsive focus and restore functioning. Under this framework, the drug is usually taken for a duration of twelve weeks to a year. Earlier this year, a clinical trial evaluating its efficacy was supposed to be finished.
It’s a really intriguing theory. Additionally, a number of grief researchers find it extremely problematic, and their objections go beyond the typical skepticism regarding a novel drug application. Arizona State University grief researcher Kara Thieleman raises an issue that is difficult to ignore after some thought: naltrexone blocks endogenous opioids, which are neurotransmitters involved in emotional intimacy and social bonding. You might be trading one issue for a much worse one if you diminish a bereaved person’s ability to connect with those around them at the exact time when human connection is most desperately needed. According to Thieleman, “it can disrupt social networks,” reducing users’ capacity for intimacy. In other words, the very thing that is most essential to healing could be corroded by the remedy.
As this debate develops, it seems like the medical establishment is attempting to fit complex human experiences into a preexisting framework. There has been criticism of the DSM procedure itself. 55 of the 92 American doctors who contributed to the DSM-5 had financial connections to the pharmaceutical industry, according to a 2023 study. More than half of DSM contributors had received compensation from pharmaceutical companies in some capacity, according to research conducted as early as 2006. University of Calgary grief researcher Kaori Wada has drawn attention to the committee process’s lack of transparency in deciding what goes into the handbook. This does not necessarily imply that the prolonged grief disorder diagnosis is incorrect. It does imply that the process that led to it merits examination, particularly in light of the financial incentives that often result from new clinical categories.
It is worthwhile to carefully consider the ethical stakes. The experience of grief is not consistent. The long-term suffering of a parent who lost a child in an unexpected violent accident differs greatly from the grief experienced by someone who witnessed a grandparent pass away over many years. Depending on when and how they manifest, both could meet the diagnostic requirements for prolonged grief disorder. However, combining those experiences into a single clinical category and possibly giving both patients the same medication removes the very context that makes grief understandable. The diagnosis of prolonged grief disorder, according to Thieleman, shifts the clinical focus away from the patient’s experiences and how their life, culture, and relationships have influenced their grieving process.
Compared to both camps, Marney Thompson, who oversees bereavement services at Victoria Hospice in British Columbia, takes a more composed stance. She acknowledges that some people can make sense of being stuck by naming debilitating grief. However, she is concerned about what would happen if a doctor with a prescription pad and twelve minutes for each patient came across someone who was deeply grieving. The issue isn’t that taking medication is always bad; rather, it’s that reaching for the pad too soon prevents you from doing the more challenging and ultimately important tasks. Thompson receives training in prolonged grief therapy, a cognitive behavioral technique created by Katherine Shear that aims to assist the bereaved in overcoming grief without becoming engulfed in it. According to her, the objective is to assist someone in entering those intolerable areas in a methodical manner, experiencing what is there, and still being able to leave.
The medicate-or-don’t debate tends to hide the fact that grief is not a problem that needs to be solved, something that the general public seems hesitant to acknowledge. It is a response to an irreversible loss. The attachment is proportionate to the sadness. Many therapists have quietly stated that grief is the gauge of love. Even though it is painful, treating it primarily as a dysfunction that needs to be fixed misses a crucial aspect of what it means and the role it plays in the life of the person who has lost someone they can never get back.
All of this does not imply that medicine has no role whatsoever in grieving. Some people find that the weight of loss makes their pre-existing anxiety or depression truly intolerable. Some people are unable to eat, sleep, or perform even the most basic tasks. Some of them might be able to participate in the grief work they would otherwise be too exhausted to do with thoughtful short-term pharmaceutical support. The doctor who wrote for TAPS years ago used the crutch analogy, which is still relevant today: it is immoral to deny someone a crutch if they require it to get the help they require. It’s merely withholding. The problem is that if a grief pill is available, it won’t be given to just a select few. In a healthcare system that is overburdened and focused on efficiency, it will be provided to anyone who appears depressed enough for a sufficient amount of time.
