Published by the American Psychiatric Association in 2024 (ISBN 978-1-61537-463-2) this book addresses the issues of bereavement, grief and prolonged grief disorder (PGD) in response to changes to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria. This remains applicable in the Irish setting as the International Classification of Diseases 11th Revision (ICD-11) criteria for prolonged grief disorder largely align with those of DSM-5-TR. This book stresses the importance of distinguishing typical adaptive grief from grief that remains for years or even decades and that results in major impairment and suffering. The authors assert that those who criticise this diagnostic category as the medicalisation of a natural process fail to appreciate the wide spanning risks to those with PGD including poor physical health, shortened life expectancy, loneliness and suicide. Furthermore it is highlighted that those bereaved by suicide are more likely to suffer from pain, physical illness and general ill health than those bereaved as a result of ‘natural’ causes.
A series of case studies is used to illustrate recent research into bereavement. While the first case example of a ‘well-respected businessman’ and ‘elder in his local church’ might appear narrow initially, subsequent case studies broaden out to include more diverse characters with an array of complications that complement the narrative. The importance of strong social networks and goodbye rituals in improved bereavement outcomes is highlighted along with the effect of the absence of such rituals during the COVID-19 pandemic. Notably the authors make sure to acknowledge differences according to race and ethnicity, particularly given inequities in access to healthcare in the US. Unfortunately for those working in an Irish setting the issue of bereavement among the traveller community is naturally missing from this handbook.
For me, one of the most useful aspects of this handbook was the guide to adults on how to support younger members of their family through bereavement. Primarily working with adults, I have become accustomed to managing adult bereavement but know much less about useful approaches for adolescents and children, who possess a limited ability to communicate the pain of loss. Bereavement in ones developmental years is more likely to be compounded by a depressed remaining caregiver and this age group are more likely to be bereft of suicide, factors that further complicate the grieving process and that are relevant to mental health services.
A section of this handbook is dedicated to suicide and bereavement among clinicians including clinicians who lose patients to suicide and clinicians who lose colleagues to suicide. It is noted that at least half of psychiatrists will lose a patient to suicide in the course of our careers and that those early in their training experience higher rates than do seasoned clinicians. Furthermore it is noted that unlike our colleagues in medicine, psychiatrists often do not think of the illnesses we treat as potentially fatal. Suicide among physician colleagues is noted to be common in the US with risk increasing throughout one’s career and suicide among nurses is in fact more common than that of the general population.
Diagnostic criteria, assessment and treatment are clearly addressed. The effort made by the respective working groups to align ICD-11 and DSM-5-TR criteria is outlined and the merits of each are compared; namely that ICD-11 is less useful to researchers as it includes symptoms that are not empirically validated. However it is more flexible than DSM-5-TR in everyday clinical use. Lastly the treatment of PGD is outlined, though it is acknowledged that even standard therapies such as cognitive behavioural therapy and attachment-based modalities are not always available among community mental health teams or feasible in the clinic setting. Usefully advice on brief methods to validate and psycho-educate patients is provided in an earlier section.
I would highly recommend this book. It is clinically useful, adheres to an evidence base and is applicable to general psychiatric practice in Ireland, both in diagnosing PGD and as an aid to existing patients that experience bereavement. While ‘there is no vaccine for grief’, the burden of a complicated bereavement can be identified and treated and even brief interventions in the clinic setting are helpful.
