Over the past two years, grief and loss have defined the lives of most Canadians. Some lament the loss of friendships. Others mourn a job they loved, a routine they cherished, or a time when they weren’t so worried about a deadly virus.
With Canada’s COVID-19 death toll approaching 38,000, millions are also left grieving the loss of loved ones — parents, grandparents, aunts, uncles, and siblings. For a time, gathering for funerals was made impossible by pandemic restrictions, leaving many to carry the heavy weight of grief alone.
Most will be able to carry on, the weight getting lighter with each passing year. But at a time when grief has become communal in ways rarely seen throughout human history, the American Psychiatric Association has released new guidelines on how to understand and treat intense sorrow after death, adding ‘prolonged grief disorder’ to their diagnostic manual — the newest addition of a disorder in nearly a decade.
The move follows a lengthy and controversial battle in the mental health field that spans decades on whether intense symptoms of grief could be classified as a mental disorder, or are just normal parts of the human experience.
“People who aren’t trained in mental health care talk about a person who lost a son, and ‘he was never the same,’” said Dr. David Gratzer, a psychiatrist at Toronto’s Centre for Addiction and Mental Health. “Or ‘she lost her child in an accident, and couldn’t get over it.’”
“There has been a debate in terms of how to understand that from the point of view of the diagnostic manual.”
This month, the committee behind the latest revision of the fifth Diagnostic and Statistical Manual of Mental Disorders published a set of criteria for diagnosing prolonged grief disorder, marking an end to this debate. In it, the disorder is characterized as experiencing intense yearning for 12 consecutive months after a profound loss, to the point where functioning at work or home has become difficult.
Including prolonged grief disorder in the diagnostic manual has more immediate ramifications in the United States, as American psychiatrists can now bill insurance companies for treating grief. For Canadian psychiatrists, the move is an interesting one to watch, and may give reason for pause if a patient is suffering intensely after the death of a loved one.
“When I see somebody who has lost a person and continues to struggle many months after the loss, and it undermines their ability to function on a day-to-day basis, I will pause for a moment and ask, ‘Is this really part of a normal reaction? Or is this something different?’” Gratzer said.
As for treatment, people struggling with prolonged grief disorder have shown significant improvement after going through targeted therapy focused on adapting to loss. Naltrexone, a drug used to treat addiction, is also being tested to treat prolonged grief, with the rationale that the two disorders share similar symptoms.
The inclusion of prolonged grief disorder in the latest revision of the diagnostic manual comes as many wrestle with profound feelings of loss due to the COVID-19 pandemic. Around 37,500 people have died from the virus in Canada, and the Canadian Grief Alliance estimates these deaths have left more than three million people grieving across the country.
The prevalence of grief is something psychologist Saunia Ahmad has noticed among her clients during the pandemic.
“A lot of people had family members that passed away, if not from COVID then things that appear to be related to COVID, such as not getting medical care in time,” Ahmad, director of Toronto Psychology Clinic, said. She added grief has become acute for some due to their inability to do anything about it as a result of pandemic measures, like visit friends for comfort or travel to see family.
In general, Ahmad said persistent feelings of grief are normal. Many grieve a loss year after year, and especially struggle during special dates like birthdays and anniversaries.
This normalcy has been the crux of the argument against defining a grief disorder for decades; that grief can be resolved over time, and diagnosing someone with a disorder risks pathologizing natural feelings of sadness and longing.
Ahmad said that over time, people’s grief tends to get less intense. But research in the last few decades has shown there is a distinct minority of bereaved people, about five to 15 per cent, who struggle with intense, debilitating grief that persists beyond what is expected.
“This diagnosis is really for a subgroup of people who may be severely suffering,” Ahmad said.
Conversations about mental health and grief date back to Sigmund Freud, who explored the topic in his 1917 book Mourning and Melancholia. But the case to classify intense grief as a disorder didn’t begin until the 1990s, when research was conducted to determine how prevalent intense grief is, as well as its symptoms.
In 2010, the American Psychiatric Association began holding consultations on grief as a disorder, classifying it as an area that needed further study in the first edition of their fifth diagnostic manual, published in 2013. Six years later, more studies were submitted for consideration, and the public was invited to comment on defining prolonged grief disorder in 2020. By September, a criteria for diagnosis was agreed upon.
For Gratzer, the lengthy and detailed process to view intense grief as a disorder is a testament to how mental health care is studied and defined.
“There are no biomarkers in mental health, which is a fancy way of saying we can’t run a blood test to see if someone has depression,” he said. “We have descriptions of problems, and pull them together in terms of a larger disorder.”
When announcing the decision to include the new disorder in the revised manual, the American Psychiatric Association said they hope the news will increase understanding of how grief manifests and when it is appropriate to seek help as people continue to reel from the pandemic, which “may make prolonged grief disorder more prevalent.”
If you’re struggling with grief, support and resources are available through Bereaved Families of Ontario’s Toronto Branch: https://bfotoronto.ca/ or you can contact Ontario’s crisis line at 1-866-531-2600.
Nadine Yousif is a Toronto-based reporter for the Star covering mental health. Follow her on Twitter: @nadineyousif_