1. The Grieving Patient Some Practical Questions and Answers 1,2,3 A Presentation for SOMC Medical Education Kendall L. Stewart, MD, MBA, DFAPA January 15, 2010 1 I hope to provide practical information that will assist you in your diagnosis and treatment of these patients. 2 Please let me know whether I’ve succeeded on your evaluation forms and on Facebook. 3 Refer to the presentation notes for additional information. Let me illustrate.

2. Why is this important? Grief results from any real or perceived loss. The intensity of the grief reaction depends on the degree of emotional investment in the lost object. These painful emotions are often translated into somatic symptoms. 1,2 Many patients are grieving and don’t realize it. Their physicians may not realize it either. Grief and depression often coexist and they are often confused. Grieving patients can present a considerable clinical challenge. After listening to this presentation, you will be able to answer the following questions: –Why is this important? –How do these patients present? –What other losses may trigger a grief reaction? –What are the classic stages of grief? –What medical disorders are complicated by grief? –How are grief and depression related? –What are the diagnostic criteria for major depression? –What is the role of medication? –How to people get over grief? 1 Many of our patients cannot talk about feelings directly. 2 An elderly mother who was very disappointed in her only son talked incessantly about her burning head.

3. How do these patients present? A 42 year-old mother presents after the death of her son in a motorcycle accident. “At first I just could not believe it.” “Then for days after it happened I was numb.” “I got so mad at him for refusing to wear a helmet.” “There is this awful hole in my heart, a terrible sense of loss. “I feel so guilty that I didn’t stop him from buying a motorcycle.” “I’m shaky for no reason.” “I’m agitated and jumpy.” “My chest hurts.” “I’m not interested in anything.” “I am nauseated all the time.” “I can’t eat.” “My muscles ache.” “I’m nervous and worried that something bad will happen to my other child.” “My chest hurts and I can’t sleep.” “I wake up hearing him call my name.” “I can’t stay focused on anything.” “I have a headache constantly.” You can review the classic stages of grief here.here 1 The stages of grief model has been largely debunked by Bonanno and others. 2 Bowlby has outlined the ebb and flow of processes, shock and numbness, yearning and searching, disorganization and despair and reorganization, but Kubler-Ross’s model has remained firmly entrenched in the popular culture.

4. Aside from death, what other losses may trigger a grief reaction? Any loss Loss of a job Death of a pet 1 Death of a celebrity Illness Disability Miscarriage Divorce Failed friendships Financial loss Failing health Increasing age Lost opportunity Disabled or impaired children A child’s failure Amputation Sports losses Any real or perceived loss 1 One of my patients suffered acute grief and dissociation after she mistakenly killed her pet.

5. What medical disorders are complicated by grief? Heart disease Cancer Psychiatric illnesses Duodenal ulcer The common cold Autoimmune diseases All illnesses that are negatively affected by stress

6. How long does grief last? It depends. (This is the universal answer to every question.) Protracted grief can last for many years. Each grief reaction is unique. 1 The mourner’s emotional investment in the lost object is the key variable. The available coping resources have a significant on the course. Unrecognized or illegitimate grief is particularly tough to overcome.

7. How are grief and depression related? Many of the symptoms are similar or the same. They frequently coexist and it can be difficult to distinguish between the two. At some time during the first year after the death of a spouse, 30-50% of the survivors will become depressed and meet the criteria for major depression. Physicians are sometimes mistakenly hesitant to treat major depression in the context of grief. 1,2 1 Depression is deadly and should always be treated aggressively. 2 An alarming number of physicians still think medication for depression will interfere with grief work or that depression in the context of grief is normal.

8. What are the diagnostic criteria for major depression? At least five of the following symptoms have been present for the same 2-week period and represent a change from a previous level of functioning –Depressed mood –Significantly decreased interest in or pleasure from things they formerly enjoyed –Significant weight loss not due to dieting –Insomnia or hypersomnia –Psychomotor agitation or retardation –Fatigue –Deceased concentration –Feelings of guilt or worthlessness –Recurrent thoughts of death or suicide 1 1 No one can accurately predict suicide attempts. 2 I made a judgment, arranged for follow up and the patient still attempted suicide.

9. When might medication be indicated? No medication is indicated for the treatment of grief itself. The short-term use of benzodiazepines may be helpful for incapacitating anxiety. 1 Antidepressants are indicated for the treatment of comorbid major depression. The stress of grief may trigger or exacerbate an underlying psychotic disorder. Lithium may be particularly helpful in treating bipolar patients who become suicidal—or any patient who is chronically suicidal. 1 Avoid the long-term use of benzodiazepines in the elderly and following psychological trauma.

10. How do people get over grief? They never to—entirely. They carry on in spite of it. They focus on distractions. They reinvest emotionally in other “objects.” They reach out to others. They suffer in silence. They marvel at others’ lack of understanding and misplaced priorities. They tolerate others’ impatience and stupidity poorly at times. They focus on the important things and view life very differently. They deal with it in unique ways. 1,2 1 A successful businesswoman lost both sons to drunk drivers. 2 Another mother became a auto safety activist.

11. What can you do to help? Recognize it. Identify it for the patient if necessary. Accept these feelings as normal. Listen. Offer bereavement counseling. Encourage them to write. Offer a brief description of how this process will play out. Offer hope that they will eventually feel better without suggesting they will get over it. 1 1 Parents whose children have been murdered or who have completed suicide have the steepest hill to climb in my experience.

12. The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process Introduce yourself using AIDET 1. Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. Review my laboratory data and other available records. Tell me what diagnoses you have made. Reassure me. Outline your recommended treatment plan while making sure that I understand. Repeatedly invite my clarifying questions. Be patient with me. Provide me with the appropriate educational resources. Invite me to call you with any additional questions I may have. Make a follow up appointment. Communicate with my other physicians. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

13. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000 Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008 1 Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007 2 Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005 Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3 Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007 Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008 Median, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008 Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000 Jacobson and Jacobson, Psychiatric Secrets, 2 nd Edition, 2001

14. Where can you find evidence-based information about mental disorders? 1 Explore the site maintained by the organization where evidence-based medicine began at McMaster University, http://hsl.mcmaster.ca/resources/ebpractice.htm. http://hsl.mcmaster.ca/resources/ebpractice.htm Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice at http://www.medscape.com/psychiatry.http://www.medscape.com/psychiatry Subscribe to Evidence-Based Mental Health at http://ebmh.bmj.com/.http://ebmh.bmj.com/ Search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration at http://ebmh.bmj.com/.http://ebmh.bmj.com/ Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health at http://www.medicine.uiowa.edu/ICMH/evidence/. http://www.medicine.uiowa.edu/ICMH/evidence/ 1 Please visit www.KendallLStewartMD.com to download related white papers and presentations.

15. How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center President & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1 Speaking and consultation fees benefit the SOMC Endowment Fund.

16.  Safety  Quality  Service  Relationships  Performance   Safety  Quality  Service  Relationships  Performance  Are there other questions? www.somc.org Terry Johnson, DO OUCOM 1991 Adenike Moore, DO OUCOM 2002