My mother is widely regarded in many circles as something of a medical expert. What she lacks in actual knowledge is made up for by unbridled confidence. For one thing, she proudly gabbles the names of drugs and diseases after the first syllable so conversations quickly degenerate into a medical guessing game. She was also very concerned for my wellbeing during my psychiatry rotation, due to a misplaced fear of the contagiousness of mental illness. I will be the second doctor in my family, but the first to have gone through medical school.
Recently, a conversation with her turned to one of my friends who is recently bereaved. Citing a friend of her own in a similar position, she recommended my friend try antidepressants, specifically citalopram (With the malapropism I heard, it was a choice between that or cisplatin). I nodded but my initial reaction was one of uneasiness. Unlike that black dog, depression, bereavement is one of those unpleasant universalities that we all must go through. It should be allowed to run its mournful course.
But why must it be unpleasant? I wondered later. To say that bereavement must be painful is the same basic argument saying that childbirth should be painful, as if it were somehow morally proper. We already medicate ourselves in mourning anyway with everything from alcohol to throwing ourselves into work. Why not use something that actually works? Bring on the soma and the blissful emotional numbness of this brave new world!
Except for the small matter that there is no strong evidence that antidepressants do much for those who grieve. Even most therapy has as much efficacy as chicken soup.
However, there are two sub-populations of bereaved who may just benefit from my mum’s advice. Firstly, some people do develop clinical depression in their bereavement, in the same way that it may set in after unemployment or rape. Just because we understand the cause for someone’s depression, that is no reason not to help them. Though it can meld with and be masked by grief, depression in bereavement does not differ significantly from depression otherwise and does respond as well to treatment. There is currently strong discussion over the proposed removal of the clause that precludes diagnosis of depression within two months of personal loss in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Secondly, while the ache of loss and grief begins to heal with time for most people, a minority continue to experience high levels of distress and impairment. This has been termed complicated grief, or persistent grief disorder as the eleventh edition of the International Statistical Classification of Diseases and Related Health Problems (ICD) may or may not choose to classify it. This has been described as an attachment disorder with elements similar to depression and PTSD but distinct from either of them. In keeping with these disorders, antidepressants, such as citalopram, and therapy can attenuate the grief these people feel.
Grief is a difficult subject for psychiatry. Bereavement is associated with poorer health outcomes, both mental and physical. But grief is not a disorder to be treated. We have to resist the medicalisation of the ordinary distress of modern living. Conversely, we must not normalise depression in bereavement or complicated grief as something natural that must be suffered through alone.
But, in all this talk of antidepressants and grief, we mustn’t forget the most important thing. As an editorial in the Lancet earlier this year put it, for those who are grieving, doctors would do better to offer time, compassion, remembrance and empathy, than pills.
Rhys Davies is a fifth year medical student at Imperial College London.