Case 4: A widower who would rather join his wife

01The case

A 49-year-old man lost his wife five months ago. Since then he has felt low and irritable. His children say he hardly eats any more, and he has visibly lost weight. He wakes at about four in the morning and cannot get back to sleep. When they urge him to go out and see his friends, he answers that it is too late, that everything is over, and that he would rather join his wife.

02Summary

Diagnosis

A severe depressive episode with melancholic features, triggered by bereavement. Its place in the course of depressive disorder depends on whether he has had episodes before.

What points to it

• Persistent low mood, loss of interest and pleasure: he no longer meets his friends.
• Melancholic (somatic) features: loss of appetite and weight, waking early in the morning.
• A sense of doom and hopelessness: "everything is over".
• A wish to die, voiced as wanting to join his wife: a hint of suicidal thinking.
• How long it has lasted and how much it disables him, which set it apart from a normal mourning reaction.

What else it could be

Normal grief comes in waves of longing for the dead person, and self-esteem and the ability to enjoy other things are usually kept. ICD-11 also has prolonged grief disorder: intense longing or preoccupation with the dead person lasting at least six months and beyond what his culture expects. Depression can coexist with it. A physical cause of weight loss, and alcohol, should be looked for.

Management

• Ask him directly about thoughts of suicide, plans and means. A widowed middle-aged man who is not eating and wishes to be with his dead wife carries a high suicide risk; the risk decides where he is treated.
• An antidepressant, usually an SSRI first, with close follow-up of suicide risk, especially in the first weeks.
• Psychological therapy, and once the mood lifts, work on making sense of the loss (grief work).
• Admission if the risk is high or he gets worse, and ECT if the depression is severe and does not respond, or he stops eating and drinking.
• Involve his children: they can watch for warning signs and help keep him safe.

Outlook

Good for the episode with treatment, though depression after a loss tends to recur, and grief may still need working through after the mood has lifted.