Case one:

Harry, aged 64 years, is a widower who lives alone. Harry's wife, Jean, died suddenly in a car accident 8 months ago. Her car collided with a truck that was travelling on the wrong side of the road. The driver was found to have a high blood alcohol reading. The local community was appalled at the accident and there was media coverage at the time. The court case surrounding the incident has recently commenced. Harry is a difficult man to communicate with at the best of times. He tends to avoid doctors wherever possible, and when he does visit you, your enquiries about 'how he's getting on' are usually answered with one syllable.

You receive a phone call from his son, Patrick, who is concerned for Harry's wellbeing. (He asked his father if he could organize a check up for him.) Patrick tells you Harry has lost weight and doesn't seem to be looking after himself very well. When you see Harry, You are surprised at his appearance. He looks unkempt and has lost weight.

Further history

You encourage Harry to talk but it is difficult. You restrain yourself from filling up the silences and eventually Harry fills you in a little. He is not eating or sleeping and feels guilty that he should have somehow prevented Jean's death. He knows this is irrational, but he cannot help feeling responsible. On further questioning, he admits to feeling suicidal saying, 'sometimes he just can't get out of bed because there is nothing worthwhile anymore'. You check he has no plans to act on these feelings and no means to commit suicide. He feels unable to help himself and sees no point in living. He has withdrawn from his social network and is on indefinite leave from his company where he worked as a storeman.

Further history

A systems review, physical examination and preliminary investigations do not suggest any organic cause for Harry's symptoms. You convince Harry to try medication and start him on a low dose of an SSRI. You choose this drug because Harry has a history of troublesome constipation and you think tricyclic antidepressants may exacerbate this. You also organize for Patrick to stay with him for a few weeks to help with establishing a routine. After a couple of weeks, Patrick reported that Harry seemed a little better - his eating and sleeping had improved - but then he stopped improving and lapsed into inactivity again. You try to introduce pleasant events scheduling, but Harry doesn't have the motivation.

Further history

You change Harry's medication to venlafaxine and gradually he begins to improve. You encourage him to return to work in a graded way, and to re-involve himself in social networks. You are encouraged to hear him talking about Jean and discover he has no idea about cooking or other household tasks. You institute some problem solving strategies by suggesting a local TAFE course, and together with Patrick, attend to some practical difficulties in Harry's transition to living alone successfully.

Answer 1

Grief varies between individuals and individual circumstances, but the stages of the experience can be divided into:

• numbness lasting for hours or days
• pining - episodes of separation distress during activities which are carried out in an apathetic or anxious way
• disorganisation and despair - the memory of the event is never far from the mind, and the grieving person ruminates over the events. Sometimes the grieving person can see, hear or feel the presence of the deceased
• reorganisation.

These stages are not rigid, and a person can revisit any of the stages at any time, especially during anniversaries or other reminders.

Answer 2

The glib answer is when it fulfils the diagnostic criteria, however, in general practice the most pertinent question is when do the depressive symptoms require intervention? Harry exhibits many of the features of major depression and they have been present for more than 2 weeks. His symptoms include at least five of the following:

• depressed mood
• loss of interest and pleasure
• insomnia
• significant weight loss
• psychomotor retardation or agitation
• fatigue or loss of energy
• feelings of worthlessness or excessive guilt
• impaired thinking or concentration
• indecisiveness
• recurring thoughts of death or suicidal thoughts.

Therefore, Harry could be diagnosed with clinical depression, and given the functional impairment, the depression is moderate to severe.

Answer 3

Given the severity of Harry's symptoms and the degree of psychomotor retardation, medication should be considered. It is difficult to initiate psychological therapies in some patients and severe depression usually requires both medication and psychological strategies to achieve remission. At the same time, supportive therapies should be instituted including regular visits with you to encourage and monitor Harry's condition, simple advice on diet, exercise, social engagement, sleep hygiene, and mobilisation of other resources such as support groups, family and friends and local networks.

Answer 4

The first step is to optimise the dose of the existing drug and to leave it at the maximum tolerated dose for 4-6 weeks. If there is no improvement, and you are sure the diagnosis is correct and compliance is good, it is often wise to change to another therapeutic class with appropriate 'washout' time for the initial therapy. If there is still insufficient improvement, it is usually necessary to involve a psychiatrist for further advice.

Answer 5

The best organisations for Harry are likely to be the ones he has been involved in before. In addition, there are organisations specifically targeted towards grief (eg. National Association for Loss and Grief) and depression (see Resources).