Priority Topic: Grief

Key Feature 1: In patients who have undergone a loss, prepare them for the types of reactions (ex: emotional, physical) that they may experience. 
Skill: Patient Centered, Communication
Phase: Treatment

Key Feature 2: In all grieving patients, especially those with a prolonged or abnormal grief reaction, inquire about depression or suicidal ideation. 
Skill: Clinical Reasoning, Patient Centered
Phase: Hypothesis generation, History

Key Feature 3: Recognize atypical grief reactions in the very young or the elderly (ex: behavioural changes). 
Skill: Clinical Reasoning, Patient Centered
Phase: Diagnosis

Key Feature 4: In patients with a presentation suggestive of a grief reaction without an obvious trigger, look for triggers that may be unique to the patient (ex: death of a pet, loss of a job). 
Skill: Patient Centered
Phase: History

A middle-aged man presented to clinic last month. He was coming in for a prescription refill and when asked, he didn't have any new concerns he was hoping to address at the visit. I had never met him before, so I asked how things were going in his life. He shared that he was having a bit of a hard time actually, as yesterday was the day his family spread the ashes of his 21 year old daughter who died in a freak car accident while traveling abroad exactly one year ago. My heart sank. I expressed sympathy to him, and he shared a bit more about what he and his family were going through as his eyes welled up in tears. Despite the emotion that was certainly overwhelming him, he was composed, and articulate, and he thanked me for my interest and compassion. He seemed to be coping well, but I clarified to be sure. He said he had been gradually getting back to what was normal life for him, as normal as might be expected after such tragedy. He was back to full time work, physical activities, and some of his favourite hobbies. I asked him about his mood, and he said he was usually not feeling depressed anymore, and when asked, he confirmed he did not have any suicidal thinking. This patient was bereaving and his response appeared to be in keeping with a normal grief reaction. I thanked him in return for sharing his story with me, expressing how hard it must have been to spread the ashes. I provided reassurance that grief, as he's probably now familiar with, can manifest in a multitude of emotional and physical ways, and that if he finds he's having a harder time again, to not hesitate to make a follow-up appointment. Although unlikely in this particular patient given his grief trajectory thus far, it is possible for normal grief to evolve into complicated grief, which the UpToDate article, ​Complicated grief in adults: Epidemiology, clinical features, assessment, and diagnosis (2018), defines as "a form of acute grief that is unusually prolonged, intense, and disabling; troubling thoughts, dysfunctional behaviors, dysregulated emotions, and/or serious psychosocial problems impede adaptation to the loss." Because the acute phase of loss of a loved one can normally have such a varied and impairing course, the diagnosis of complicated grief is generally reserved for those patients who continue to experience impairment from grief about 6 to 12 months after their initial loss.

Of note, if a patient is presenting with symptoms or signs of depressed mood, I gather a psychiatric history that includes asking about possible sources of loss in their life recently. This may affect management as I may consider counselling therapy as higher on the priority list for treatment strategies than pharmacotherapy, given that the precipitant of the depressed mood may be a factor that is transient, and starting a long-term medication may be overkill. Of course, if the patient does meet the diagnostic criteria for depression, they warrant treatment with an antidepressant if it is something they think they will benefit from, particularly knowing that someone who has become depressed may not recover quickly even if the inciting factor was one that is expected to attenuate with time. While antidepressant therapy is generally continued for at least 6-12 months after resolution of depressed mood, it is not a medication that must be taken beyond this if there is no reason, and having a bit of assistance to get one's life back in order could be more helpful than what may be a longer and more consequential depression with a more prolonged negative impact on the individual's life.