Bereavement related depression and consoling a new widow

I am really enjoying my geriatrics rotation.

Although my attending preceptor is primarily a geriatrician, and practices deep in the heart of retiree central in southeast Florida, he also sees some patients who are younger. I took a history on a patient who was younger than me today, in her early thirties.

She started off complaining about insomnia and headaches, and then said she had some sort of an “attack” earlier this week. She quickly added that her husband died suddenly three weeks ago, and her therapist recommended that she come to see her doctor. I immediately offered her my condolences.

My mind quickly flipped to a frequent practice board question as I gently asked her about other symptoms.

A 40 year old man presents to an outpatient clinic complaining of insomnia, poor appetite, and feeling helpless and lonely. He frequently thinks of dying to join his wife. He lost his wife of 18 years five weeks before.

Was she suffering from loss of appetite? Was she able to return to work? Had she thought about hurting herself? What did she mean by an “attack”?

Telling the difference between bereavement-related depression (BRD) and major depressive disorder (MDD) is a frequent sample board question that I have come across in various forms as I have been doing patchwork board review. Bereavement is an exemption from a MDD diagnosis for two months after the death of a loved one, while the duration of depressive symptoms only needs to be for two weeks otherwise. Board review questions often dance around this time period. This BRD exemption (and the duration of symptoms for MDD diagnosis in general) is also the subject of some controversy as experts are constructing the new Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V), which is the guide to diagnosing mental illness.

I snapped out of my board review musings and continued to question and console the new widow. When I got up to leave the room, I strongly considered asking the patient if I could hug her. Since it was only my third day on the rotation and I was in the room with the physician’s assistant, I decided against it. I think if this would be my own patient in my own practice in the future, I would not hesitate to ask. When I left the room and told the other student about it, I teared up.

I guess my empathy toggle switch is still operating just fine.

“MomTFH” is a medical student who blogs at Mom’s Tinfoil Hat.

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  • joanne

    Why did the therapist send her over to see you? Maybe it was for a prescription for antidepressant/sleep med/anti anxiety agent?It was a referral, I think…so I am unclear as to the nature of the visit…

  • MomTFH

    I think the therapist sent her over because she described what happened at work as some sort of an “attack”. She wasn’t sure if it was a panic attack or something physically wrong. I also think both she and her therapist were thinking a psychiatric medication may help her out.

    It is a complicated topic as to whether grief should be treated with medication.

  • BobBapaso

    It is not, “A complicated topic as to whether grief should be treated with medication.” It should not be, except for a little Ativan (or similar) for sleep and briefly for dysphoria. Complaints typical of depressive illness may represent: Normal sad feelings, Grief, Psychogenic Depressive Illness, Biological Depressive illness (bipolar, toxic, etc), or Depressive Personality Disorder. You must distinguish which the patient suffers before you can choose an appropriate treatment, and will find little help in any edition of the DSM. Also, keep in mind that if the normal period of withdrawal during the grieving process goes on too long it can lead to psychogenic depressive illness and you may need to treat both at once.

  • MomTFH

    That’s what the board questions generally say – grief is not pathological, and should not be medicated.

  • joanne

    It is important, I think, to remember that we are not treating grief. We are treating the person in the real world…a small but important difference.
    How long has she been in therapy? Prior to her husband’s death?Possibly…and for what?
    What does the referral list as her dx? Are there kids? Is she able to function, take care of the kids, keep her job?
    Chemical support vs. ‘toughing it out.’
    Maybe a collaborative decision between us and the patient…remember that antidepressants take weeks to work, too.
    I would want to know more about her situation.

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