Mr John was brought by a concerned relative to the psychiatric clinic for evaluation. For the past one month, Mr John had been experiencing low mood, constant ruminations (long deep thoughts & worry), feelings of hopelessness, sleep disturbances, and loss of weight due to loss of appetite. He has not been able to go to work due to these symptoms. Under usual circumstances, Mr John would be given the diagnosis of major depressive disorder and started on treatment. However, this was not your usual circumstances; Mr John’s wife had recently passed away.
Under the previous edition of the diagnostic and statistical manual of mental disorders (DSM IV-TR), the diagnosis of depression will be excluded if there is a loss of loved ones within the past two months. The term “bereavement” was used instead and management was different from depression. This exclusion had been omitted in the latest DSM 5 because it is now recognised that bereavement is a major stressor that can cause depression very quickly in certain individuals. It is also recognised now that for some, bereavement does not just last for 2 months.
When then, do we seek help for intervention?
When a person experiences a loss of a loved one, they will experience a range of emotional and cognitive changes by grieving. The grieving duration and intensity varies between individuals. It depends on a number of factors, such as the individual’s personality, relationship to the deceased, age, and even culture.
In uncomplicated grief, the affected individual will experience periods of low mood that comes in “waves” that are triggered by thoughts or items that is associated with the deceased. It will be mixed with positive emotions and humour in between; causing a roller coaster of “ups and downs”. The individual will also be preoccupied with thoughts and memories of the deceased. They might even start blaming themselves for “failing” the deceased, such as not spending enough time with the deceased. Given time, the individual will soon learn to accept and incorporate the deceased into their own life. Recalling the deceased might still bring about sadness, but it will become an acceptable part of the individual and as the cliche goes, “life goes on”.
Some strategies have been suggested to help grieving individual move on. Talking with a family member or friend about the deceased will help with accepting the passing of the deceased. Sharing it with someone else who is experiencing similar loss can help both to cope with it better. Some even celebrate the life the deceased had to help with the grieving and ease acceptance. It depends largely on one own’s preference and culture.
In about 10% of people, the transition does not go as smoothly. They remained in the state where grieving is prolonged and complicated. Yearning for the deceased becomes a major focus in their life and the sadness experienced is intensify. Maladaptive behavior will begin to surface, such as overindulging in activities that the deceased used to do, spending a huge amount of time at the deceased’s grave, or even becoming withdrawn socially for a prolonged duration. Daily activities will be impaired. Individuals with complicated grief have been found to have increased risk of cancer, cardiac conditions, hypertension, abusing illicit drugs and even committing suicide.
Intervention is usually indicated for complicated grief. The affected individual should seek help from a health professional. Psychotherapy that focuses on complicated grief usually will be helpful. If necessary, medications such as antidepressants can even be started.
While grief is a normal process that will be experienced by almost everyone sooner or later, it should not be prolonged and persistent. Recognising complicated grief and seeking help will ease the pain and difficulties that one goes through.
“And when your sorrow is comforted (time soothes all sorrows) you will be content that you have known me. You will always be my friend. You will want to laugh with me. And you will sometimes open your window, so, for that pleasure . . . And your friends will be properly astonished to see you laughing as you look up at the sky! Then you will say to them, ‘Yes, the stars always make me laugh!’ And they will think you are crazy. It will be a very shabby trick that I shall have played on you…”
– Chapter 26, The little prince by Antoine de Saint-Exupéry
By Dr Eugene Koh
Dr. Eugene Koh (MB BCh BAO, Penang Medical College) is a psychiatric trainee lecturer in a local university.