 Hello, I'm Professor Kay Wilhelm. I'm a consultation liaison psychiatrist at St Vincent's Hospital and that means that I deal with a lot of people with complex problems to do with grief, depression, suicidality. So I'm going to talk today about grief and depression from a psychiatric viewpoint. The first thing is some definitions. I'm not going to talk at length about grief, but just to acknowledge it is a natural response. It's a painful process. It can be expressed in many ways and it can affect people's physical and emotional health. When I talk to people about grief, I talk about it as being an emotional spring cleaning in that I think people bring out all the issues around the loss, the good and the bad, and hopefully throw out the bad and keep the good. That's what I encourage people to do. From a psychiatric point of view, a labelling point of view, grief can become complicated in various ways and that's one of the things we're going to talk about. So when does a normal mood state become abnormal? It can be when it is too intense, when it's too long lasting, when it seems appropriate to the recipient, the trigger and where is it different from depression? In depression, people seem to lack this capacity for spontaneous remission and that is one of the ways that it can be different to grief. So what is depression? Where is grief is something that you can work through? Depression, as I've said, can stay with you and people can lose this ability to be able to turn it off as they need to. But there are some things that I have in common, particularly times of lack of appetite and sleep, the more non-specific hallmarks of depression and in that way, I think they're similar but grief I've found, I've also found from my own experience, tends to come in waves and can be put away at other times and depression doesn't have that kind of feeling and it is much more persistent. It's also accompanied by loss and despair, feelings of blackness and a lot of what's called rumination going over and over about poor self-esteem, blaming and guilt and feeling of being slowed down and I'll get on to what all that's about. You might say well people when they're grieving also feel they have self-recriminations and yes it is common with grieving to say I wish I'd done more for that person or if I'd been there on that day or that sort of thing. The recriminations in depression are much more to do with the past and can bring up things that have been forgotten for decades that keep coming back so much more has this feeling of self-punishment. Just to go over what depression is though, we all have normal mood swings and that is part of life and some people have more of them than others and this can be related to their personality, their temperament and to some extent to cultures, some cultures encourage more emotional expression than others. With depression these questions about whether they feel depressed is one but whether they've lost their feeling of worthlessness, sorry whether they've lost their feeling of self-worth and become feeling worthless and feeling hopeless and much more self-critical and feel like giving up they would be hallmarks and pointers towards a clinical depression. So this is what the clinical depression looks like in psychiatric terms, in labelling terms that people have a number of symptoms and say some of the non-specific ones and some of those more specific ones and in diagnostic terms that they have a persistent change in mood that goes on for at least two weeks and the term disorder means that it's having a significant impact on their life, their functioning and or their seeking help for it. So I've mentioned that the key features are this lack of this drop in self-esteem, more self-crisis and depressed mood but not everyone expresses it as depressed mood and these rather non-specific features which can overlap with a number of other conditions and the ones I'm going to talk about that are worrisome are features to do with what I'm calling a melancholic depression and anhedonia is a loss of joy and inability to be cheered up. The ruminations which are just thoughts that just go round and round and round and relentlessly feeling hopeless and having what's called dial and mood variation where they usually in the morning feel terrible and as the day goes on feel better and then worse again the following morning and this being slowed down mentally and physically and often with cognitive changes and suicidality and in the extremes intense agitation and psychosis and that's what a melancholic looks like so it's a depression but it's got these what are called psychomotor changes and it's really important to register them. It's often the family that actually registered them so that's a melancholic depression and often people will say they can't think any longer they don't know how they managed with their life in general and the family say there is a change in in their behavior. Now there are two kinds of melancholia one is what's called a functional melancholia which occurs in younger people this has a strong genetic predisposition there's usually a family history of either depression or bipolar disorder the other group they get it though people who take stimulants I'm talking about cocaine and fetamines which in the short term make people elated but then make them feel intensely depressed and if they've got the genetic predisposition to a melancholia can go on and develop this and that is what's called a functional shutdown of these pathways which have to do with how you express emotion and tying up with memories that go along with it. Now the other group that get this melancholia are an older group and here it's not so much to do with family history but more to do with underlying physical illness generally cardiovascular disease this has been called late onset depression this is more endogenous depression is all about and it's now called vascular depression and it has an increased risk of delirium and here if you do an MRI scan the the um I'm just showing you this you see some little micro vascular infarcts along those same pathways clearly this is tied up with history of hypertension vascular disease diabetes smoking now the other important thing obviously is to think about doing a suicide risk assessment in people who've got this kind of depression and this is has got a high risk of suicide so it's important that people recognize and also that they think about depression those are some of the questions that can be asked so going back to the where this fits in with um with grief there are a number of different trajectories that can happen I'm going to go through each of these first one is that the person is grieving and they then get over the grief in what is an expected timeframe and an expected way but then they go on and develop a depressive illness and this may be because they've developed an illness it may be um the other thing is that a lot of life events can still precipitate that vascular kind of depression it could be that they've got a um they haven't been able to move on with their life even though they've grieved and they've got a sense of isolation and they're feeling rather hopeless and a bit trapped um then there are some people who develop an initial grief but it then continues and slowly morphs into a depression and other people who have been they say they've been depressed all their lives and they have more probably a history of trauma or a history of not being able to cope um what we would call a vulnerable personality style and this is just one more thing along that trajectory that they have to cope with and they do have different treatment implications so if you go with the first one and in terms of diagnostic categories you could say that this is either a new episode of depression or a complicated grief depending on how they appear in um in relationship to each other but here would be a matter of uh of dealing with the depression as it's arisen and uh at times this can be because people have developed a new illness it can be an onset of diabetes and um it's now realized that diabetes in fact a lot of it is stress related so it's it's conceivable that someone can we uh have a grief episode have to deal with that and as part of that and the stress of dealing with that that they can actually have a a reemergence or a beginning of a new physical illness which in turn can lead to depression and I'm talking about things like an autoimmune disease or a same diabetes or um also if the older it could be that they're developing a cognitive changes due to dementia now all of these can present as depression and so it's a matter of dealing with the depression and then going back and seeing if the grief has been thoroughly dealt with or new issues have emerged as part of that I guess one of the issues might be if the person has developed this sort of illness that um the person who they're grieving has had for example and that may bring up new issues the other situation is somebody has been grieving and then over time it's just not resolving and it slowly morphs into a depressive episode and that's where the real trick comes about time to work out when it's still grief and when it's become depression um when it becomes depression instead of life getting easier life is becoming harder and they're perhaps withdrawing more they maybe have started some new activities found a little bit of peace in their lives but now it's going back the other way and so asking those questions about whether they're able to be cheered up whether they're still getting joy out of their normal activities what their sleep's like and particularly if they're becoming much more slowed down and if they're ruminating and maybe bringing up um new things from the past just say on that count um our memories can play tricks on us because when you put down memories you put them down with an emotional tag so that if you have been very guilty or very sad um and you become guilty or sad again you actually retrieve old memories from the past that have got that same emotional tag which which can be um difficult and and it can sort of make sense of what can happen for some people here at some stage or other in both of those cases you may consider using an antidepressant um antidepressants I'm not advised for grief itself grief is a process that needs to be worked through and antidepressants can in fact impede the grieving process but if they are now become clinically depressed it may be um then it's worth considering giving them an antidepressant and as I say then going back and regrouping around the grieving process then there's another group of people who say they've been depressed all of their lives this generally has to do with people who've had a very unhappy life so very what we call a prejudicial childhood it may be related to some trauma events in their childhood and this grief event is just one more of a whole litany of things that's happened to them um some of this is just bad luck some of it may be things um that they've brought on themselves because of perhaps using substances which have led to the making unwise decisions etc however here the grief is still obviously important but it's equally important then to go back and try and help them address some of the other issues in their life so here um it's often the case of addressing the trauma it may be addressing substance use it may be addressing other activities they've had that are rather self-defeating so that this generally leads to a longer course it's also going to be complicated if the person who has died that they're grieving uh is part of the trauma that's been induced in the past and the other terrible irony is that if people have had a complicated relationship to the person they're grieving it's it's harder for them to grieve that that person so that if they wish they were dead for example when they die that can impede their grief process and that's where you need to go back later and try and help them work through what's actually gone so what would I do as a psychiatrist if I'm dealing with people who are in that situation obviously it's important that they can understand what's going on and there are some good um materials around to help people with that now some online some um I'm sure will be addressed by other people educating them on all of this there's a technique which I find very useful called expressive writing um where people write about trauma from their past write about what's going on for them for a number of days in a row if they've had a lot of trauma it's advised they do this with uh with the knowledge of somebody else who doesn't necessarily read what they have written but knows that what they're doing and can it address issues that come up there's a whole lot of literature around that and if anyone's interested I'm happy to pass pass that on obviously um referral for specific grief counseling is important it's a matter of working out at what point that's going to be most useful and talking to the person about that it can be a really important time to help people look after themselves better and sleep is clearly important um and helping people uh have better sleep hygiene and there's no better information about that too it's not just a matter of not having caffeine but um there are some particular exercises people can do before they sleep um exposing them to morning light can help having a wind down routine doing some writing before bed using lavender oil the pillow can all help there's a lot of information now about diet and the importance of your microbiome and I encourage people to use a Mediterranean diet and look after themselves exercise is incredibly important and can also help with dealing with both grief and depression and it's a matter of finding the right exercise using exercise exposing yourself to the morning light is extremely helpful and obviously substance use and using substances can also interfere with the grieving process and cause depression and um it's enthusiastic anti-smoker most people don't realize that smoking a packet of cigarettes a day leads to four times the rate of suicidal ideation and again can impede the grieving process it also causes new onsets of depression antidepressants have their place for some people particularly if they have a clear cut clinical depression they can also help with sleep some antidepressants can help with sleep clearly they need somebody to monitor that and it's generally GP it can be a psychiatrist and to make sure that they haven't got any suicidal ideations part of that I just have to turn my lights back on again um then there's a matter of what other mental health issues there might be and some of them might come to light for the first time for example if somebody has had a very close-knit relationship with their spouse but they're actually being socially fobic or may have a low grade schizophrenia and the spouse has protected them and it now becomes apparent if that person's not around so it can be a time as part of the grieving process to perhaps start new behaviors to perhaps be able to venture forth more I'm a great enthusiast for interpersonal therapy I'm going to mention a paper on the next page there is also something called interpersonal counseling which can be used by therapists who are not used to using interpersonal therapy but one of the specific domains in interpersonal therapy is grief and it's got a very much a flavor of getting the person personally to grief but then to take up new roles which is clearly important here and it's also useful to for depression so it can be a very useful therapy here and as I said using the whole process as mentioned emotional spring cleaning as a way of promoting growth and being able to perhaps start a new life um and just to mention on the that article I've written an article that is available in a GP magazine but I think it's fairly available about using interpersonal therapy and it shows some of the domains and questions you can ask but it may be useful the other thing that I have have which didn't unfortunately come out in these slides as a series of little cards which have some techniques that people could use but I think learning to use mindfulness skills learning problem solving skills I've mentioned the expressive writing being able to uh take up new activities and to venture forth and one of the um the the phrases that I give people is no one can go back and make a brand new start but anyone can start from here and make a brand new ending but trying to use this as an opportunity to to move forward if possible and as I say it is possible to help the person deal with grief and depression I'm going to leave it there thank you very much for your time