From the Editor
After the unexpected loss of his spouse, my patient sank deeply into grief. He was tearful during our sessions, explaining that a part of him had died, too. Weeks turned to months. Was this a normal response to a profound loss? Or something more problematic? DSM-5 seeks to clarify the issue by recognizing prolonged grief disorder – though the disorder is controversial and has attracted much criticism. When The New York Times covered the topic in 2022, Joanne Cacciatore (of Arizona State University) commented: “I completely, utterly disagree that grief is a mental illness.”
Clare Killikelly (of the University of Zurich) and her co-authors shed light on prolonged grief disorder with a new review, just published in The Lancet. They write about the disorder, the differences from grief, its treatment, and more, drawing on 142 citations. “Grief is a universal experience. However, for a minority of individuals, grief becomes a debilitating, devastating mental health disorder with serious implications on a personal and societal level.” We examine the review, highlight four take-aways, and reflect on the broader debate.
Spring forward, fall back. Twice a year, we adjust our clocks (and our brains) to and from daylight saving time. In the second selection, Dr. David Dongkyung Kim (of the University of Toronto) and his co-authors argue that daylight saving time should be eliminated. In their JAMA Commentary, they draw on the literature. “Daylight saving time transitions cause acute disruptions in human circadian rhythm, and the medical literature shows detrimental effects for public health.”
Finally, in the third selection, Dr. Joanne Hickey (of Memorial University) discusses anxiety and her expectations. In a personal CMAJ paper, the hematologist reflects on her work – and on her own journey, including her anxiety, the decision to take medications, and her need to come to terms with her perfectionism. “Anxiety has been my life companion, though I often didn’t recognize it. It masqueraded as that internalized need to control.”
DG
Selection 1: “Prolonged grief disorder”
Clare Killikelly, Kirsten V. Smith, Ningning Zhou, et al.
The Lancet, 3-9 May 2025
Prolonged grief disorder is a mental health disorder included in diagnostic guidelines worldwide, including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), published in 2022, and the International Classification of Diseases, 11th Edition (ICD-11), published in 2018. This inclusion marks an important step in recognising atypical grief as distinct from normative grief processes. Historically, atypical grief was not formally recognised in earlier versions of the ICD; it was classified under adjustment disorders or misclassified as depressive episodes when bereavement-related symptoms of depression were severe or prolonged…
So begins a paper by Killikelly et al.
Definition
Controversy
“Experts in grief and bereavement largely agree that a minority of bereaved individuals experience severe, debilitating grief that requires intervention. However, the inclusion of prolonged grief disorder as a mental disorder initiated critical debate. The different views about the prolonged grief disorder diagnosis can be grouped into two themes: the existential or philosophical theme and the critique of diagnostic culture. Existential arguments discuss the decentralised role of death in society, grief as an existential experience leading to other mental health conditions, and grief as a foundational emotion connecting humans to love and death. Critiques of diagnostic culture argue that universal human experiences are being reduced to medical categories.”
Differentiation from typical grief
“Individuals who have prolonged grief disorder have prolonged, intense bereavement-related distress and dysfunction, setting them apart from most bereaved individuals who either maintain stable, healthy functioning after a loss or recover following a brief period of disruption.”
Prevalence rates
“In a German representative bereaved sample, 30 (3%) of 914 individuals met prolonged grief disorder DSM-5-TR criteria… Prolonged grief disorder rates are frequently higher in indicated samples and contexts, signifying its clinical utility and construct validity. For example, people who lost a partner or a child had a higher risk of developing prolonged grief disorder (complicated grief) compared with those who lost a parent or a sibling.”
Differential: Depression
“Core symptoms of major depressive disorder include low mood (dysphoria), lack of interest or enjoyment of usual activities, along with physical symptoms, such as fatigue and low energy. Cognitive and psychological variables also include difficulty concentrating, low self-esteem, feelings of guilt and hopelessness, and suicidal thoughts. Central to the distinction between prolonged grief disorder and major depressive disorder is whether the symptoms relate to the loss of a close person. Although accessory prolonged grief disorder symptoms might overlap with symptoms of major depressive disorder (ie, dysphoria, guilt, anger, or hopelessness), in prolonged grief disorder these are directly related to the death of the close person.”
Treatment
“A tiered approach to bereavement care, which allocates services based on need and acknowledges the limited resources of health-care systems, has long been recommended. Bereavement support is often underfunded and overlooked in community and health-care settings despite guidelines such as: printed psychoeducation for low-risk individuals; community groups and trained volunteer support for at-risk individuals; and specialist support for high-risk groups, including people with prolonged grief disorder. Research consistently shows that targeted psychological therapies effectively relieve distress and aid adaptation in individuals with prolonged grief disorder.”
In terms of types of treatment:
- “Numerous randomised controlled trials on prolonged grief treatment (previously complicated grief treatment) report statistically significant and sustained effects on prolonged grief disorder symptoms. Most studies have focused on variations of CBT, which emphasises the interplay of memories, negative beliefs, and maladaptive coping behaviours to reduce emotional suffering.”
- “Other psychological treatment approaches, such as eye movement desensitisation, reprocessing and compassion-focused therapy, and mindfulness, have yet to prove efficacious.”
- “Pharmacological interventions remain underexplored, with only one randomized controlled trial to date examining the role of the selective serotonin reuptake inhibitor, citalopram, alongside psychological therapy. This study observed that, although depressive symptoms decreased when antidepressants were added to prolonged grief disorder treatment, no additive therapeutic effects of the drug in combination with therapy were found for grief symptoms…”
A few thoughts:
1. This is a concise and thoughtful review, published in a major journal.
2. Here are four take-aways:
- It’s not common. Only 3% of those with grief develop the disorder.
- It takes time. By definition, prolonged grief disorder occurs between six and 12 months.
- Therapy helps. CBT in particular.
- Pills, not so much. There is limited evidence for antidepressants (though limited study, too).
3. The authors describe well controversy over this new diagnosis. Readers can decide for themselves where they stand on the existential theme-diagnostic culture divide.
The full Lancet review can be found here:
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)00354-X/abstract
Selection 2: “A Call to End Daylight Saving Time – Implications for Public Health”
David Dongkyung Kim, Eric Poon, Candice S. Kung, Michael S. B. Mak
JAMA, 29 April 2025
In most of the United States and Canada, daylight saving time (DST) begins on the second Sunday in March and ends on the first Sunday in November at 2 am. When it begins, the clock is advanced 1 hour ahead of standard time (ST); hence, the mnemonic ‘spring forward and fall back.’ The rationale was that by implementing DST, individuals following a schedule would make more use of the solar day, with a longer period of daylight during waking hours. The practice is prevalent in Europe and North America, but many other countries… have abolished the policy… Recently there has been increased political momentum for eliminating twice-a-year clock changes in the United States. We call for the elimination of DST and establishment of permanent ST because of clear evidence in the medical literature and expert consensus implicating DST as detrimental for public health.
So begins a paper by Kim et al.
They note the effects of clock transitions: “The 1-hour shift in the spring causes individuals to awaken an hour earlier, leading to acute sleep loss and sleep debt. Sudden circadian rhythm misalignment leading to poor sleep can lead to increased production of inflammatory markers, changes in metabolism, and altered myocyte gene expression, among other pathologic cellular processes. These disturbances ultimately have implications for health in various other bodily systems.”
They review the literature:
- MI. “A meta-analysis of 7 studies indicated that there was a significantly higher risk for acute myocardial infarction observed in the 2 weeks after the spring shift.”
- Atrial fibrillation. “One study of 6089 admissions to the hospital found that women had an increase in atrial fibrillation admissions after the DST spring transition.”
- Road Safety. “A systematic review from 2017 could not support or refute the connection between DST and road safety. However, other studies since then have shown an association between spring DST transition and traffic crashes. One large study analyzing 732 835 fatal motor vehicle crashes in the United States from 1996 to 2017 concluded that spring DST transition increases fatal crash risk by 6%, and removing DST could prevent approximately 28 fatal crashes per year.”
- Mental health. They note “mixed” outcomes with depression, manic episodes, and suicide.
How to proceed? Some, including members of the US Senate, favour “abolishing the twice-yearly time transition and permanently adopting DST; that is, the clock time going forward would be 1 hour ahead of ST.”
“We, along with expert consensus, oppose the establishment of a permanent DST and recommend a yearlong ST instead. A large study surveying 55 000 individuals showed that the timing of sleep on days not reliant on external schedules (free days) followed the seasonal progression of dawn for ST, but not DST.”
A few thoughts:
1. This is a thoughtful Commentary, weighing in on a public policy issue, published in a major journal.
2. The recommendation is very practical: “We call for the abolishment of DST worldwide and reversion to a permanent ST.”
3. For the record, I’m persuaded.
4. Sleep has been considered in past Readings. In a 2023 podcast interview, Dr. Mak (a co-author of the JAMA Commentary) observed: “The lines between sleep, health, and mental health in general are blurred.” You can find that Reading here:
The full JAMA Commentary can be found here:
https://jamanetwork.com/journals/jama/article-abstract/2833363
Selection 3: “Monday morning”
Joanne Hickey
CMAJ, 6 May 2024 Online First
It’s a Monday morning and I don’t have to drive my daughter to school – glorious professional development day; a little taste of freedom. She will be tucked away at home with her dad, and I can take my time, unencumbered by the drop-off deadline. This morning, the world of hematology/oncology can wait, and I decide to do something for myself. I have been a little low lately. Maybe I have broken my own cardinal rule and stretched that intention to take time off every three months. Maybe it’s the work politics that linger after a few long weeks. Maybe it’s too much time on the rectangle of existential crisis (my favourite recent description of my cellphone). Whatever it is, I decide this morning to start the week off right. First, grab a book and dig in (good for the mind: check). Sweet relief. With the sounds of the ocean playing in the background, I find peace and contentment, getting lost in someone else’s story.
So begins a paper by Dr. Hickey.
The quiet is interrupted. “My watch vibrates. Even as I am coming out of downward-facing dog, I look and see the text message. ‘______ is in the ICU.’ I curse out loud – swearing is therapy for me. I remind myself that I’m not on call. This notification is just for my information, a well-meaning teammate assuming that I want to know what is happening with one of my toughest patients. I do not have to jump into action right now.”
She talks about her journey. “[Anxiety] hid in plain sight, as my desire to go above and beyond to achieve perfection. Ironically, these were qualities that I and others often viewed as strengths – even keys to my success. I used to joke that if I treated my anxiety, I wouldn’t be as good a doctor. I was so young and arrogant. In retrospect, these exaggerated tendencies, fuelled by anxiety, held me back and contributed to my burnout.”
She discusses her care. “Ironically, I will be forever grateful to the anxiety triggered by the COVID-19 pandemic. This extreme discomfort finally broke through my denial and forced me to seek treatment. Before starting my blessed SSRI, I would ruminate over decisions. I would weigh every possible outcome, trying to make a perfect decision. In the business of medicine, perfect decisions, perfect outcomes, are not possible. Control is an illusion, a truth that tortured me as I desperately tried to make a perfect decision in those pre-SSRI days. Now decisions come faster and with more certainty. The anxiety takes the back burner and allows my clinical judgment the freedom to do its job. I trust myself more, and with that freedom has come a concerted effort to put myself ahead of the work.”
She worries about her patient. “But this morning’s interruption has unleashed a wave of self-doubt about my journey as a practitioner. In my attempts to protect myself, my time, and my life, have I become too clinical and detached? Has the pendulum swung too far? Is it a good thing that I can experience the news of a negative outcome for a patient and not assume that I did something wrong? My chest begins to tighten.”
“I arrive to a ray of hope. My co-worker is already there and, as the on-call physician, this patient is her responsibility. As usual, she is competently and confidently handling everything. I realize that no one needs me desperately. I can feel the weight lift off my shoulders as I watch her bustle about and hustle me off.”
She comments on her own progress. “There is no final resolution – only progress. For me, reflecting on this experience has concretely exposed substantial barriers to my wellness. I identified my perfectionism as a manifestation of my anxiety. I saw with clarity how my own thoughts and beliefs were toxic to my wellness. I identified the supports and realities around me that challenged my false beliefs. Now I had something specific – and, even more importantly, within my power – to work on.”
She closes:
“We live and work in a world where so much that affects our life is out of our control. For me, seeking wellness must focus on the things that I can change, and self-reflection is the tool I can use to identify them.”
A few thoughts:
1. This essay is well written and relatable.
2. It’s also honest. There are no miracles here, but steps in the right direction.
3. Who doesn’t fret about a patient or two even on a morning off?
4. A comment I’ve made before: I always appreciate the honesty of our colleagues when discussing their mental-health journeys.
The full CMAJ paper can be found here:
https://www.cmaj.ca/content/196/17/E599
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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