Initiate an SSRI for the major depressive episode and refer for standard cognitive-behavioral therapy to address maladaptive cognitions about the loss and restore behavioral activation

Standard CBT effectively targets the depressive cognitive triad and behavioral withdrawal that maintain both grief and depressive symptoms. The SSRI will address neurovegetative symptoms including insomnia and appetite loss. Once depressive symptoms improve with this combination, the grief symptoms are expected to resolve as the underlying depression remits. While an SSRI is appropriate for the comorbid major depressive episode, standard CBT does not adequately address the specific mechanisms of prolonged grief disorder. Research demonstrates that prolonged grief disorder and major depression are distinct conditions that require targeted interventions.

Initiate supportive counseling focused on normalizing the grief process and providing psychoeducation that grief follows no fixed timeline. Avoid pharmacotherapy initially

Since the depressive symptoms may be an appropriate grief response that will resolve with time and support. Monitor closely for worsening suicidal ideation while allowing the natural grieving process to unfold. If symptoms persist beyond 12 months, reassess for pharmacotherapy and structured psychotherapy at that time. This approach fails to address the severity of the current presentation. A PHQ-9 of 22 indicates severe depression with passive suicidal ideation that warrants active pharmacologic intervention, not watchful waiting. Prolonged grief disorder at 10 months with this severity of functional impairment requires structured treatment rather than supportive counseling alone.

Begin an SSRI such as escitalopram to address the major depressive episode and neurovegetative symptoms, and refer for complicated grief treatment

This integrates elements of CBT and interpersonal therapy with grief-specific techniques including revisiting the loss narrative and restoration-focused goals. CGT has demonstrated superiority to standard interpersonal therapy for prolonged grief and addresses the unique mechanisms maintaining pathological grief. The SSRI targets the comorbid depression while CGT specifically addresses the grief disorder components. This dual-target approach appropriately addresses both diagnoses with their respective evidence-based treatments. Complicated grief treatment has been shown in randomized controlled trials to be superior to standard psychotherapies for prolonged grief disorder. SSRIs address the comorbid major depressive episode with its neurovegetative features and suicidal ideation.

Start mirtazapine for depression with the added benefit of appetite stimulation and sleep improvement, and refer for interpersonal therapy focused on role transitions associated with the loss of her husband

IPT is a first-line psychotherapy for depression and its role transition module directly addresses the identity disruption following spousal loss. Mirtazapine's dual mechanism of noradrenergic and serotonergic enhancement combined with histamine antagonism addresses weight loss and insomnia as priority targets. This combination efficiently addresses the most functionally impairing symptoms. While mirtazapine may address weight loss and insomnia, and standard IPT is effective for depression, this plan does not include a grief-specific psychotherapy for the prolonged grief disorder diagnosis. Research by Shear and colleagues demonstrated that complicated grief treatment was superior to standard IPT for prolonged grief symptoms.