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Family Physicians Working with Bereaved Patients
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Am Fam Physician. 2002 Mar 1;65(5):967-975.
Methods of treating bereaved patients are rarely taught in medical schools, despite the fact that almost all physicians encounter such patients. Prigerson and Jacobs offer guidelines for assessment and treatment of bereaved patients.
According to the authors, a bereaved patient is more likely to be depressed, to inappropriately use health care services, to abuse various substances, to attempt suicide, and even to die. The first task for the physician is to distinguish uncomplicated from complicated grief. In an uncomplicated grief reaction, the patient gradually adjusts and becomes more able to manage his or her life. Some manifestations of improvement include renewed interest in activities and other persons.
On the other hand, a complicated grief reaction is characterized by at least three of the following four symptoms on a daily basis or to a marked degree: (1) intrusive thoughts about the deceased, (2) yearning for the deceased, (3) searching for the deceased, or (4) excessive loneliness. If the first criterion is met, the physician should find out if the patient has four of the following eight symptoms at least daily or to a marked degree: (1) purposelessness/feeling of futility, (2) sense of numbness or absence of emotional responsiveness, (3) disbelief about the death, (4) sense of life being meaningless, (5) feeling that part of oneself has died, (6) lost sense of trust or control, (7) assuming harmful behaviors of, or related to, the deceased, or (8) excessive irritability or anger about the death. These symptoms must last for at least six months and cause functional impairment to be classified as a complicated grief reaction. It should be noted that these criteria do not appear in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., but, according to expert opinion, represent a psychiatric disorder with distinctive symptoms and outcomes.
The physician who cared for the patient who died should maintain follow-up contact with bereaved family members to express sympathy and concern, and to answer questions about the end-of-life care provided to the deceased patient. Physicians may be hesitant to do this because of uncertainty about working with a bereaved person. The accompanying table offers some suggestions about what to say and what not to say in this situation.
The authors recommend referral for psychiatric care if the patient has symptoms of a major depressive disorder or symptoms consistent with a complicated grief reaction for six months or longer. Any evidence of suicidal behavior should prompt immediate referral. Physicians caring for elderly patients should note that some may be reluctant to seek treatment from a psychiatrist; in such cases, if the primary care physician has the mental health expertise, he or she should continue treating the patient.
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Appropriate psychiatric treatment of a major depressive disorder should follow standard guidelines (regardless of the cause of the depression). However, a complicated grief reaction will probably not respond well to tricyclic antidepressants or interpersonal psychotherapy. A type of cognitive behavioral therapy called traumatic grief therapy has proved effective in treating complicated grief. Other studies demonstrate the efficacy of selective serotonin reuptake inhibitors in treating complicated grief as well as major depressive disorders.
Prigerson HG, Jacobs SC. Caring for bereaved patients. “All the doctors just suddenly go.”. JAMA. September 19, 2001;286:1369–76.
Copyright © 2002 by the American Academy of Family Physicians.
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