Prolonged grief expected for approximately 360,000 people as a result of losing loved ones to the virus.
EDITOR’S NOTE: Chuck Buck, ICD10monitor publisher and program host of Talk Ten Tuesdays, interviewed Dr. H. Steve Moffic on the eve of America’s foremost health tragedy: the announcement that the U.S. recorded 1,081,392 deaths last week to COVID-19. Below are excerpts from the interview.
BUCK: The imminent milestone that we will soon have recorded one million lives lost in this country due to COVID-19 has other related tragic consequences. What are these?
HSM: Unfortunately, you are correct, Chuck. We have been rather quietly and eerily coming up upon this milestone of COVID deaths, and they are still coming, though thankfully, slowing down right now. A little over a year ago, I conveyed that we were losing about a person a minute. As Season of Love, the popular song from the musical Rent goes, there are 525,600 minutes a year. At least we have slowed a little from a COVID death per minute.
However, we have also found out that there will be psychological ripples out to not only the loved ones of those who have passed away, but really, to some extent, our entire country. In many ways, the nation has been traumatized by all that the pandemic has taken away from us, especially the people, but also jobs, our routines, and the live social interactions that are especially crucial for children. Moreover, we are in the midst of a collective movement toward opening up society again at the same time there are still pandemic risks – not only here, but looming large in China – and notwithstanding all the benefits and interpersonal conflicts of vaccination and masking. Our future in regards to COVID-19 and its variants is still uncertain, and some degree of appropriate fear is a national consequence.
Grief is an obvious offshoot and consequence of such losses. Psychiatry has long grappled with grief – that is, what is a normal grieving process and when it may be abnormal – and we can apply that to some extent to the pandemic. In the late 1990s, a psychiatric epidemiologist noticed that there was a significant percentage of those grieving where the grief wasn’t resolving as expected, and when these people were given antidepressants, the medication didn’t help. The researcher noticed that the main symptoms seemed to be yearning, opining, and craving, which were also not typical symptoms of depression. Those mourners also seemed at higher risk for ensuing cardiovascular problems. More study indicated that about 4 percent of those with atypical grief remained stuck and struggled with functioning for the longer term.
BUCK: I understand there’s a new DSM (Diagnostic and Statistical Manual of Mental Disorders) entry. What is it, and what are its implications, relative to the million milestone?
HSM: Such epidemiological studies eventually led to the new DSM diagnosis of Prolonged Grief Disorder, when the revision of DSM 5 was released about a month ago. Of course, that was not without controversy, in psychiatry and publicly. Was this medicalizing and stigmatizing normal grief? Experts decided no, that this was a subgroup not resolving their grief normally. Most importantly was the question of whether there were treatments that could help.
Going back to COVID-related deaths, other researchers found what they called a bereavement multiplier. Each COVID death corresponded to approximately nine people bereaved by losing a close relative. If we multiply one million by nine, we get 9,000,000 people suffering a significant COVID human loss. Children will be especially of concern. Go back to the 4 percent of mourning that doesn’t go well, and we can predict at least 360,000 Prolonged Brief Disorders occurring so far. The projected number is probably much higher in this epidemic time, because normal, live grieving rituals have not been so available. I’d increase the estimate to 500,000 – or half a million – Prolonged Grief Disorders and climbing.
BUCK: Please explain prolonged grief disorder. What are the symptoms, and what are some possible treatments?
HSM: So, Prolonged Grief Disorder is the grieving process that doesn’t go well. There can be many reasons why. The death can be one that seemed preventable, and worse yet, psychologically, a death where the loved one feels guilt for not doing more to prevent it. Or, the death was of a loved one where there was unresolved conflict with the mourner. Or, the one grieving had encountered too many major losses in the past. Racial issues may come into play, too, as, say, Black Americans have been more medically and unfairly vulnerable to COVID-19 due to the adverse history of structural racism in our country and medicine.
As to symptoms, ICD-11 actually beat DSM 5R to the punch, as far as I can tell, though we are still using ICD-10 in the U.S. Prolonged Grief Disorder is in ICD-11, and described as needing “to experience persistent and pervasive longing for the deceased and/or persistent and pervasive cognitive preoccupation with the deceased, combined with any of 10 additional grief reactions assumed indicative of intense emotional pain for at least six months after bereavement. Those 10 reactions are sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, an inability to experience positive mood, emotional numbness, and difficulty in engaging with social or other activities. DSM 5R extended the timing cutoff to one year, in order to be cautious against over-diagnosing.
The good news is that new treatments are emerging that can help reduce the ongoing suffering and impaired functioning, which are more specific to the disorder. One is prolonged grief therapy, 16 sessions that use the PTSD treatment technique of exposure, of going over the loss slowly but surely. This suggests a closer relationship of Prolonged Grief Disorder to trauma and PTSD than to depression. Some think it also may relate to addiction, so Naltrexone, a medication that is used for substance dependence, is being studied. In addition, I wouldn’t be at all surprised if the increasing research about the therapeutic potential of psychedelics also gets applied to prolonged grief.
BUCK: You and I, along with others, have been advocating for the equivalent of a U.S. Surgeon General for mental health. Surely there could be a major stress on our mental health system, with what could be a significant increase in those suffering from Prolonged Grief Disorder. Any thoughts on this?
HMS: Without too much hyperbole, we can say that we are at a risk for a tsunami of psychological problems.
As we can see, the need for mental healthcare is escalating, not only for Prolonged Grief Disorder, but other conditions needing help. As we know, there is often a delay after major trauma for PTSD to emerge, so we can anticipate that coming. Then there is a readjustment to a “new normal” that may produce the increasing prevalence and diagnosis of an Adjustment Disorder, also needing treatment. Besides these more formal disorders, there is much evidence of an overall increased irritability in our country, as expressed in road rage, workplace anger, family conflict, airplane passenger hostility, and the gun violence that just happened on the New York City subway.
Although the pandemic, with the use of Zoom and tele-psychiatry, have helped to enhance access to treatment, we still may be well short of the number of mental health caregivers needed for what exists now and what is coming. Not only that, but an epidemic of burning out in caregivers is limiting our own mental health and healing abilities.
All of these risks, as well as the need for accurate public messaging, suggests the need for the equivalent of a U.S. Surgeon General for mental health. Our psychiatric organizations surely need to lobby for this top-level addition to our government, for the well-being of the public. Public philanthropy can contribute, too. There is all sorts of innovation and private resources going on to explore outer space, but we need the same effort extended to the inner space of our minds. Not a moonshot project, but a mentalshot project, so to speak. There is no health without mental health.