Grief, Insomnia, and a Request for a Benzodiazepine
Mr. D is a 70-year-old retired postal worker whose wife died five months ago after six years of COPD, during which he was her sole caregiver. He now has insomnia, has lost 6 kg, cries daily, and feels guilty about signing her do-not-resuscitate order. He briefly senses her presence at night but denies hearing voices during the day. He avoids her belongings and has stopped seeing friends; he denies suicidal ideation and says life feels 'empty and pointless.' PHQ-9 is 14 and GAD-7 is 8. He asks for alprazolam 0.5 mg nightly 'because it helped her.' His 11-year-old grandson, who lived nearby, has stopped talking about his grandmother and has new school refusal.
1. Is this normal grief, major depression, or prolonged grief disorder? What distinguishes them, and what would you do now?
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Elements of all three are present, and the distinction drives treatment.
- Normal grief includes waves of yearning, crying, insomnia, weight loss, transient sense of the deceased's presence, and guilt about caregiving decisions. These are not inherently pathological at five months.
- Major depression requires pervasive anhedonia or depressed mood plus neurovegetative and cognitive symptoms for at least two weeks; worthlessness, hopelessness, and suicidal ideation are more typical. His 'empty and pointless' comment and PHQ-9 of 14 warrant a careful suicide risk assessment and a depression interview.
- Prolonged grief disorder (DSM-5-TR) requires persistent yearning or preoccupation plus at least three associated symptoms, with clinically significant impairment, lasting beyond 12 months in adults (beyond 6 months in children and adolescents). At five months he does not meet the duration threshold, though he has risk factors: sole caregiver, avoidance, social withdrawal.
Now: assess safety, screen for depression, normalize the grief, and schedule close follow-up rather than labeling him prematurely.
2. How do you respond to his request for alprazolam, and what do you offer for sleep and mood?
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Decline the benzodiazepine, but do not simply say no. Explain that benzodiazepines blunt the emotional processing that grief requires, worsen sleep architecture, increase fall and cognitive risk at 70, interact with alcohol and opioids, and carry dependence risk. They are not recommended for bereavement-related insomnia.
Offer instead:
- CBT for insomnia, including stimulus control (bed only for sleep, fixed wake time, no daytime napping) and sleep restriction.
- Behavioral activation and scheduled social contact; consider referral to a grief support group or individual therapy, with complicated-grief treatment if symptoms persist past 12 months or impair function severely.
- An SSRI only if major depression is confirmed; it treats depression but is not a grief cure. Avoid starting multiple agents at once.
- Treat the guilt directly: review the DNR decision and explain that signing it was an act of love consistent with her wishes, not abandonment.
Document the risk assessment, the rationale for avoiding benzodiazepines, and a follow-up plan in 2–4 weeks.
3. What do you advise about the grandson's new school refusal and silence about his grandmother?
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Children's grief is developmental and often expressed through behavior rather than words; school refusal and silence at age 11 are common and not automatically pathological. Ask the family what he has been told, who told him, and whether he attended the funeral. Advise simple, honest language, avoiding euphemisms such as 'she's in a better place' or 'she went to sleep,' which foster confusion and fear.
Encourage the grandfather to share memories and to say that sadness is allowed, and to invite rather than force conversation - for example, looking at photos or cooking her recipe. Notify the school counselor so the refusal is addressed supportively and absences do not spiral. Screen for depression, anxiety, and suicidal ideation in the child, and refer to child life or bereavement services if symptoms persist beyond six months, impair school or friendships, or include guilt about the death. Finally, support the grandfather's confidence in talking to his grandson; his own avoidance is part of the problem.