Grief and Bereavement: What Psychatrists Need to Know
Zisook S~~Shear K~~~
Unfortunately, grief is not a topic of in-depth discussion at most medical schools or general medical or psychiatry residency training programs. Thus, myth and innuendo substitute for evidence-based wisdom when it comes to understanding and dealing with this universal, sometimes debilitating human experience. When Engel 1 raised the question ÒIs grief a disease?Ó as the title of his now classic article on the subject, he argued convincingly that grief shares many characteristics of physical diseases, such as a known etiology (in this case, death of a loved one), distress, a relatively predictable symptomatology and course and functional impairment. And while healing usually occurs, it is not always complete. In some bereaved individuals with preexisting vulnerabilities, for example, the intense pain and distress festers, can go on interminably (as Òcomplicated griefÓ), and the loss may provoke psychiatric complications, such as major depression. Engel’s work, followed by several empirical studies on the phenomenology and course of grief, and its complication and treatment, has legitimized the study of grief for mental health practitioners. Yet, to this day, the bulk of what is known about grief and its biomedical complications has not been widely disseminated to clinicians. This review is meant to help fill that gap. In order to appreciate how grief can go awry and transition from a normal response to a disabling condition warranting medical attention, the clinician must first know the characteristics of normal grief and how to differentiate normal grief from complicated grief and/or grief-related major depression. Consequently, this review begins with a section on ÒnormalÓ grief, followed by sections on the phenomenology, differential diagnosis, course and treatment of ÒcomplicatedÓ grief, and grief-related major depression. Since psychiatrists themselves are not immune to the potential ravages of grief, a final section focuses on the personal and emotional consequences of one of our most disturbing occupational hazards, a patient’s suicide.