Medicalizing Grief: Drs Cheng and Shen Reply

See letter by Cacciatore and Ruby and article by Cheng and Shen

Medicalizing Grief: Drs Cheng and Shen Reply

To the Editor: We appreciate Drs Cacciatore and Ruby’s thoughtful rejoinder to our presented case, and we recognize that their disagreements with us are motivated by goals we all share—ensuring the well-being of those who seek our help and reducing the suffering and incapacity of seriously depressed patients associated with bereavement.

Ms A was a middle-aged woman whose fiancé’s sudden death was a terrible shock to her. Afterward, she was sad and anhedonic, with guilty delusion and suicidal ideation. She presented with intense negativism about herself and severe psychomotor retardation. For days, she remained not eating or drinking and was urinating and defecating directly on the bed. Then she lost consciousness and was taken to the hospital. After regaining consciousness, she presented extreme loss of motor skill, held rigid poses for hours, and was not responding to any external stimuli. She required intensive nursing care and administration of intravenous fluids for nutrition and carried a urethral catheter for bladder distention. When taking into account her past experience of grief, we noted this time she had a particularly severe presentation that included some combination of unreasonable guilt, intense negativism about herself, alienation from others, and inability to be consoled, which suggested she wasn’ t grieving in the way she had in the past, ie, in her own way. Otherwise, when considering her cultural expressions of grief, the diagnosis of major depression was made because her grief was outside of cultural norms. Medicalizing her "complicated" grief resulted in gradual improvement of life-threatening catatonic and psychotic depression. Finally, she went home and appreciated our staffs’ care.

In DSM-IV, there is an exclusion criterion for a major depressive episode that is applied to depressive symptoms lasting less than 2 months following the death of a loved one (ie, the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons.1 The first is to remove the implication that bereavement typically lasts for 2 months. Since there is no one right way to grieve, different cultures prescribe a wide variety of different lengths of time to bereave. Second, some individuals have severe, complicated grief that looks just like severe major depression and that does not get better spontaneously, as in the presented case. The longer that diagnosis and treatment are delayed, the greater an individual’s suffering, impairment, and risks. Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It shares similar patterns of comorbidity, personality characteristics, and risks of chronicity and recurrence as non-bereavement-related major depressive episodes and may be genetically influenced. Finally, the bereavement-related major depression responds to the same medication and psychosocial treatments as non-bereavement-related major depression.

We respectfully disagree with Drs Cacciatore and Ruby’s statement that "treating traumatic grief violates the inviolable: a person’s basic human right to experience extreme shock, angst, despair, and, yes, even catatonia in the face of such loss." As we report, "For days, she remained not eating or drinking and was urinating and defecating directly on the bed. Then she lost consciousness and was taken to the hospital." In such a critical case, should we still let her remain at home and grieve her own way?

If she is (mistakenly) given a diagnosis of catatonic or psychotic depression, the attendant "risks" are mainly those of entering the mental health system and receiving treatment—whether medication or psychotherapy. Both therapies may entail risk, and we are well aware of the unpleasant and sometimes harmful side effects that antidepressants or antipsychotics may produce in a minority of patients. Weighing the pluses and minuses, our call is to keep things as they are and not to normalize grief, especially those complicated ones.

Reference

1. American Psychiatric Association. Highlights of Changes From DSM-IV to DSM-5. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Publishing; 2013:809-816.

Chia-Yi Cheng, MDa

Yu-Chih Shen, MD, PhDa,b

[email protected]

aDepartment of Psychiatry, Tzu Chi General Hospital, Hualien, Taiwan

bDepartment of Psychiatry, School of Medicine, and Department of Human Development, College of Humanities and Social Sciences, Tzu Chi University, Hualien, Taiwan

Potential conflicts of interest: None reported.

Funding/support: None reported.

Published online: December 24, 2015.

Prim Care Companion CNS Disord 2015;17(6):doi:10.4088/PCC.15lr01913a

© Copyright 2015 Physicians Postgraduate Press, Inc.