Around 360,000 mourners are expected following the loss of loved ones to the virus.
EDITOR’S NOTE: Chuck Buck, editor of the ICD10 monitor and host of the Talk Ten Tuesdays program, interviewed Dr. H. Steve Moffic on the eve of America’s greatest health tragedy: the news that the United States recorded 1,081,392 deaths this week last because of COVID-19. Below are excerpts from the interview.
MALE: The impending milestone that we will soon have recorded one million lives lost in this country to COVID-19 has other related tragic consequences. What is that?
HSM: Unfortunately, you’re right, Chuck. We’ve been rather quietly and strangely coming to this milestone of COVID deaths, and they’re still coming, but thankfully slowing down right now. A little over a year ago I said we were losing about one person every minute. Like Season of Love, the popular song from the musical Rent, there are 525,600 minutes per year. At least we’ve slowed down a bit of one COVID death per minute.
However, we have also discovered that there will be psychological repercussions not only for the loved ones of those who have died, but also, to some extent, for our country as a whole. In many ways, the nation has been traumatized by everything the pandemic has taken from us, especially people, but also jobs, our routines, and live social interactions that are especially crucial for children. Moreover, we are in the midst of a collective movement towards the reopening of society even as there are still risks of a pandemic – not only here, but which threaten widely in China – and despite all the benefits and conflicts vaccination and masking. Our future with respect to COVID-19 and its variants is still uncertain, and some degree of appropriate fear is a national consequence.
Grief is an obvious emanation and consequence of such losses. Psychiatry has long grappled with grief – that is, what is a normal grieving process and when it can be abnormal – and we can apply that to some degree to the pandemic. In the late 1990s, a psychiatric epidemiologist noticed that there was a significant percentage of bereaved people where the grief was not resolving as expected, and when these people were on antidepressants, the drugs weren’t helping. The researcher noticed that the main symptoms seemed to be desire, opinion and need, which were also not typical symptoms of depression. These mourners also seemed to be at higher risk for cardiovascular problems. Other studies have indicated that about 4% of people with atypical grief get stuck and have trouble functioning in the longer term.
MALE: I understand that there is a new entry in the DSM (Diagnostic and Statistical Manual of Mental Disorders). What is it, and what are its implications, in relation to the million milestone?
HSM: Such epidemiological studies eventually led to the new DSM diagnosis of Prolonged Grieving Disorder, when DSM Revision 5 was released about a month ago. Of course, this has not been without controversy, in psychiatry and publicly. Was this a normal medicalizing and stigmatizing bereavement? The experts decided no, that this was a subgroup that didn’t resolve their grief normally. Most important was the question of whether there were any treatments that might help.
Going back to COVID-related deaths, other researchers found what they called a grief multiplier. Each COVID death corresponded to approximately nine people bereaved by the loss of a loved one. If we multiply one million by nine, we get 9,000,000 people with significant human loss due to COVID. Children will be particularly affected. Back to the 4% of griefers who are not well, and we can predict at least 360,000 Brief Prolonged Troubles have occurred so far. The projected number is likely much higher in this epidemic time, as normal, living mourning rituals have not been as available. I would increase the estimate to 500,000 – or half a million – Prolonged and Escalating Grieving Disorders.
MALE: Please explain the prolonged grief disorder. What are the symptoms and what are the possible treatments?
HSM: Thus, prolonged grief disorder is the grieving process that does not go well. There can be several reasons for this. The death can be one that seemed preventable, and even worse, psychologically, a death where the loved one feels guilty for not doing more to prevent it. Or, the death was of a loved one where there was an unresolved conflict with the mourner. Or, the mourner had suffered too many significant losses in the past. Racial issues may also come into play, as, for example, black Americans have been more medically and unfairly vulnerable to COVID-19 due to our country’s adverse history of structural racism and medicine.
When it comes to symptoms, ICD-11 actually beat DSM 5R to the punch as far as I can tell, although we still use ICD-10 in the US. and pervasive longing for the deceased and/or persistent and pervasive cognitive concern for the deceased, combined with one of 10 additional grief reactions thought to indicate intense emotional pain for at least six months after the bereavement. These 10 reactions are sadness, guilt, anger, denial, blame, difficulty accepting death, feeling that you have lost a part of yourself, inability to feel a positive mood, emotional numbness and difficulty engaging in social or other activities. The DSM 5R extended the time limit to one year, to be on the safe side against overdiagnosis.
The good news is that new treatments are emerging that can help reduce persistent pain and impaired functioning, which are more specific to the disorder. One is the extended bereavement therapy, 16 sessions that use the exposition technique of PTSD treatment, of overcoming the loss slowly but surely. This suggests a closer relationship between protracted grief disorder and trauma and PTSD than with depression. Some believe it may also be linked to addiction, which is why naltrexone, a drug used for substance addiction, is being studied. Moreover, I would not be at all surprised if the growing research on the therapeutic potential of psychedelics also applied to prolonged grief.
MALE: You and I, along with others, have advocated for the equivalent of a US 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 the number of people with prolonged grief disorder. Any thoughts on this?
HMS: Without too much hyperbole, we can say that we risk a tsunami of psychological problems.
As we can see, the need for mental health care is increasing, not only for protracted bereavement disorder, but for other conditions requiring help. As we know, there is often a delay after a major trauma for PTSD to appear, so we can anticipate this coming. Then there is a readjustment to a “new normal” which can produce the increasing prevalence and diagnosis of an adjustment disorder, also requiring treatment. In addition to these more formal disorders, there is ample evidence of increased irritability in our country, as expressed in road rage, work anger, family disputes, hostility from airline passengers and violence. army that just performed on the New York subway.
Although the pandemic, with the use of Zoom and telepsychiatry, has helped improve access to treatment, we may still be well below the number of mental health caregivers needed for what currently exists and what who is coming. Not only that, but an epidemic of caregiver burnout is limiting our own mental health and healing abilities.
All of these risks, along with the need for accurate public messaging, suggest the need for the mental health equivalent of an American Surgeon General. Surely our psychiatric organizations must push for this high profile addition to our government, for the welfare of the public. Public philanthropy can also contribute. There are all kinds of innovations and private resources 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.
Note on programming: Listen to Dr. H. Steven Moffic live today on Talk Ten Tuesdays, 10 Eastern.