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EDITOR’S NOTE: If projections from the Centers for Disease Control and Prevention (CDC) hold, there could be 534,000 deaths from COVID-19 by the end of February, slightly surpassing the 525,600 minutes in a year – or, put another way, one death per minute. That number – 525,600 – has been memorialized by the hit Broadway musical “Rent,” in which the actors explain that there are only so many grains of sand in the hourglass. Dr. H. Steve Moffic recently made the connection between the musical and the reality of the pandemic, all of which led him to ponder what psychiatrists describe as prolonged grief: a diagnosis in ICD-11. Here are excerpts from our online interview of Dr. Moffic by ICD10monitor Publisher Chuck Buck.

BUCK: Dr. Moffic, let’s spend a minute on this concept of “one death per minute,” a startling statement. But perhaps what it does is to break through a blasé attitude or numbness to the number of lost souls.

HSM: Chuck, there is an interesting backstory here, I think, that will take at least several minutes to tell, so please bear with me. Otherwise, just skip to the last two paragraphs for the abbreviated reply.

Let’s go back to Jan. 6, 2021. Remember what happened that day?! That was when our sacred U.S. Capitol building was stormed. That very afternoon was also when Psychiatric Times posted a video that I had just done the day before, titled “A Resolution to Mourn Our 2020 Losses.” To open that video, my wife Rusti sang an excerpt I had chosen from the popular song “Seasons of Love,” from the musical “Rent.” In the first part of the song, it is pointed out that there are 525,600 minutes in a year. In my follow-up comments, I substituted “loss” for “love,” because in my psychiatric opinion, we need to be sure that we are mourning our yearlong losses adequately – now including the sanctity and safety of the Capitol building – in order to move on positively. I would venture to say that most all of us are experiencing significant losses of some sort, often new COVID-related ones, though of course, the biggest are the losses of people’s lives. This is not to ignore some of the positive and heartwarming experiences over the year, but those are easier to absorb than the losses.

After doing that particular weekly video, I was haunted by that number of minutes in a year as I contemplated, like many of us, what I hoped to do in the new year of 2021. One goal was to continue to help address the pandemic as best I could from the psychiatric and personal perspectives, such as what we are doing right now, educationally. I kept watching the increase in COVID deaths each day, now up over 450,000. Then, the first anniversary of the sudden death of basketball star Kobe Bryant and others on a helicopter occurred, and I noticed how many people were still unable to get beyond it, within the usual year of normal grief.

Then it clicked – or, in psychiatric talk, the lightbulb went on – when a therapeutic insight suddenly appeared. This was our bio-psycho-social-spiritual model in societal action. The “bio” of the virus was connected to our psychological ways of coping with it, which was connected to our social policies, which were connected to what this all might mean spiritually.

If we started to address COVID-19 in mid-March 2020, how many deaths would there be at the one-year anniversary, coming mid-March 2021? Well, I did the math, over and over, and projecting the average deaths each day, I wound up with somewhere around 525,000 COVID deaths over the year – or, in other words, one COVID death per minute. As a friend commented:

“That indeed is an eerie and so sad analogy to make, yet so appropriate.”

Condensed into your title of this interview, that saying is what got the attention of CNN’s Brian Stelter, who produces the daily newsletter Reliable Sources, who on Feb. 3 discussed and linked the follow-up video posted earlier that day.

Hopefully, we won’t reach that projection, with escalating vaccination, and perhaps better social distancing and masking. Even so, though, data indicates that for every COVID death, on average, nine people are adversely affected afterwards, generally through some grieving process.

So, to finally get to your point, Chuck, it has seemed to me that the daily COVID deaths has become so routine in the news that many of us take them for granted, as if they have become our new normal. It is human nature to reduce concern after a crisis emerges, and some sort of ongoing adaptation typically occurs. It is also human nature to try to find some explanation, even an erroneous one, for such an invisible threat as the COVID virus.

In this last video, given a need to get attention quickly in our world of Twitter and social media, I tried to get to a saying that might startle, as you say, in order to rekindle concern and compassion, because there is much that any citizen and healthcare professional can do to get that number down over the next few months. 

BUCK: You say that prolonged grief can go beyond mourning and become a psychiatric disorder. What are some of the symptoms of prolonged grief?

HSM: For this question, I can provide a much shorter answer, in part because we are only recently understanding what the disorder of “prolonged grief” is all about. In the 11th revision of the International Classification of Diseases (ICD), prolonged grief disorder is a diagnosis characterized by severe, persistent, and disabling grief. One needs to experience this intense longing and yearning for at least six months. Among those other symptoms are numbness, anger, confusion, and guilt. COVID-19 especially lends itself to guilt – due or undue – when some members of a family at home get it, and some don’t, for no obvious reason.

Perhaps this conception will help us to resolve the longstanding controversies about how to separate normal grief from abnormal grief.

BUCK: Are there different stages or characteristics of prolonged grief?

HSM: As far as we know, Chuck, there are not any typical stages like we have in the usual, normal grieving stages that psychiatrist Elisabeth Kubler-Ross gave us. In fact, if left alone, the intensity of prolonged grief keeps prolonging; substance abuse is common, suicidality emerges, and our immune systems can become compromised, which in turn may make the mourner more at risk for COVID and other medical illnesses.

Prolonged grief seems to occur most often when there are mass casualties, traditional grieving rituals are not available, and live social support is missing. Sounds like our COVID times, does it not?

The characteristic symptoms that are so unique are the longing or yearning that I mentioned in a prior question. That yearning is a preoccupation with a lost person and, as it seems to be turning out, it can become almost like an addiction. Indeed, in the brain, the area of the nucleus accumbens shows increased activity, and this region of the brain is associated with reward, which isn’t the case with depression.

BUCK: Are there medications to treat depression that might be associated with prolonged grief? If not, are there processes to help alleviate or prevent prolonged grief?

HSM: Because this disorder seems unlike depression, it may not be surprising that antidepressant medication does not seem to help. What does? So far, that seems to be variations of cognitive behavioral therapy (CBT), and that can be done online.

One variation is called complicated grief treatment (CGT), which draws from interpersonal therapy for post-traumatic stress disorder (PTSD). The desired outcome is to accept the reality of the loss, and be able to envision a future with the possibility of joy, satisfaction, purpose, and meaning. Support groups for similar losses can also be of benefit.

For children and adolescents, as well as possibly for adults, another form of CBT called CBT grief-help seems to work. Studies that used nine sessions suggest the value of interventions such as imaginative exposure (that is, telling the story of the loss); direct exposure (that is, possibly visiting the scene of the death, when possible); and writing, such as a letter to the lost person about what the mourner misses most. For children, the prolonged grief is especially common after losing a parent.

BUCK: Could you offer advice as to how to prevent prolonged grief?

HSM: Prevention is the key, Chuck, because it does seem hard to treat. Especially if the circumstances are those described previously, any involved medical clinician and/or loved one should watch for the emergence and continuation of the intense yearning, and then try to intervene with processes like that of the psychotherapies. There is a Bereavement Challenges Scale (BCS) that can be given to loved ones even when the death is predicted, or afterwards. Because of the addictive nature of the disorder, working to reduce the grief should proceed slowly, but surely, in order to avoid a relapse, like which happens in substance dependence. Creative new grieving rituals should part of this process, to replace the unavailable traditional ones that might ordinarily be used.

As much as that simple saying seems to have caught on, I’d much prefer to make it obsolete, which will also cut down some on prolonged grieving.


Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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