Complicated grief therapy for clinicians: An evidence-based protocol for mental health practice.

In the United States alone, about 10 million persons are newly bereaved each year. Most do not require professional intervention or treatment, but many can benefit from targeted support. However, a significant minority of bereaved persons experience intense, prolonged and disabling grief symptoms associated with considerable morbidity and mortality (aka, "Complicated Grief"). Individuals with Complicated Grief require more formal interventions. In this article, we describe a compassionate and evidence-based approach to bereavement-care that can be provided in varied mental health settings. For individuals struggling with acute grief, clinicians can help by providing recognition and acceptance of the grief, eliciting and compassionately listening to their narratives of their relationship with the deceased and the death, and regularly "checking in" regarding their grief experiences. For bereaved persons who are experiencing Complicated Grief, we recommend an evidence-based approach to bereavement-care, complicated grief therapy (CGT), that involves helping the individual accept and cope with the loss while simultaneously assisting them with adaptation to life without the deceased. We describe ways of implementing CGT's seven core themes: (1) understanding and accepting grief, (2) managing painful emotions, (3) planning for a meaningful future, (4) strengthening ongoing relationships, (5) telling the story of the death, (6) learning to live with reminders, and (7) establishing an enduring connection with memories of the person who died. This work can be done in a variety of settings, taking into consideration the needs of the patient, the limitations of the setting, and the skills and experiences of each clinician.

Gender differences among medical students, house staff, and faculty physicians at high risk for suicide: A HEAR report.

BACKGROUND: In comparison with the general population, physicians, and physicians-in-training are at greater risk for suicide. Although key gender differences in suicide risk factors and behaviors have been identified in the general population, the extent to which these differences apply to physicians and physicians-in-training is unclear. Here, we aimed to identify gender differences in risk factors, clinical presentation, and help-seeking behaviors of medical students, house staff, and physician faculty at high risk for suicide. METHODS: We explored gender differences among 450 physicians and trainees meeting criteria for high suicide risk on anonymous online questionnaires completed between 2009 and 2017. RESULTS: High-risk female trainees and physicians had higher mean Patient Health Questionnaire-9 (PHQ-9) scores compared with the males (11.1, standard deviation [SD] 5.1 vs. 9.8, SD 4.7) and were more likely to endorse feeling worried (73.8% vs. 61.2%), irritable (60.4% vs. 49.4%), and stressed (79.6% vs. 70%). High-risk male trainees and physicians were more likely than females to endorse suicidal thoughts (31.2% vs. 22.1%), intense anger (24.3% vs. 16.1%), drinking too much (31.2% vs. 22.3%), and recreational drug or prescription medication use without clinically appropriate follow-up (9.4% vs. 4.3%). There were no gender differences in help-seeking behaviors. CONCLUSIONS: This is the first study to report gender differences among risk factors, presentation, and help-seeking behaviors of physicians, and trainees at high risk for suicide. Our findings are mostly consistent with those of the general population and show that only a minority of at-risk men and women in healthcare sought treatment, highlighting the importance of intervention and suicide prevention in this population.

Web-Based Tools and Mobile Applications To Mitigate Burnout, Depression, and Suicidality Among Healthcare Students and Professionals: a Systematic Review.

OBJECTIVE: Being a healthcare professional can be a uniquely rewarding calling. However, the demands of training and practice can lead to chronic distress and serious psychological, interpersonal, and personal health burdens. Although higher burnout, depression, and suicide rates have been reported in healthcare professionals, only a minority receive treatment. Concerns regarding confidentiality, stigma, potential career implications, and cost and time constraints are cited as key barriers. Web-based and mobile applications have been shown to mitigate stress, burnout, depression, and suicidal ideation among several populations and may circumvent these barriers. Here, we reviewed published data on such resources and selected a small sample that readily can be used by healthcare providers. METHODS: We searched PubMed for articles evaluating stress, burnout, depression, and suicide prevention or intervention for healthcare students or providers and identified five categories of programs with significant effectiveness: Cognitive Behavioral Therapy (online), meditation, mindfulness, breathing, and relaxation techniques. Using these categories, we searched for Web-based (through Google and beacon.anu.edu.au -a wellness resource website) and mobile applications (Apple and mobile. va.gov/appstore ) for stress, burnout, depression, and suicide prevention and identified 36 resources to further evaluate based on relevance, applicability to healthcare providers (confidentiality, convenience, and cost), and the strength of findings supporting their effectiveness. RESULTS: We selected seven resources under five general categories designed to foster wellness and reduce burnout, depression, and suicide risk among healthcare workers: breathing (Breath2Relax), meditation (Headspace, guided meditation audios), Web-based Cognitive Behavioral Therapy (MoodGYM, Stress Gym), and suicide prevention apps (Stay Alive, Virtual Hope Box). CONCLUSIONS: This list serves as a starting point to enhance coping with stressors as a healthcare student or professional in order to help mitigate burnout, depression, and suicidality. The next steps include adapting digital health strategies to specifically fit the needs of healthcare providers, with the ultimate goal of facilitating in-person care when warranted.

Complicated grief after suicide bereavement and other causes of death.

The authors compared baseline demographic characteristics, clinical features, and grief-related thoughts, feelings, and behaviors of individuals bereaved by suicide, accident/homicide and natural causes participating in a complicated grief (CG) treatment clinical trial. Severity of CG and depression and current depression diagnosis did not vary by loss type. After adjusting for baseline demographic features, time since death and relationship to the deceased, those with CG after suicide had the highest rates of lifetime depression, preloss passive suicidal ideation, self-blaming thoughts, and impaired work and social adjustment. Even among this treatment-seeking sample of research participants with CG, suicide survivors may face unique challenges.

Ketamine for the treatment of depression in patients receiving hospice care: a retrospective medical record review of thirty-one cases.

BACKGROUND: Depression is prevalent in patients receiving hospice care. Standard antidepressant medications do not work rapidly enough in this setting. Evidence suggests that ketamine rapidly treats treatment refractory depression in the general population. Ketamine׳s role for treating depression in the hospice population warrants further study. METHODS: A retrospective medical record review of 31 inpatients receiving hospice care who received ketamine for depression on a clinical basis was conducted. The primary outcome measure was the Clinical Global Impression Scale, which was used retrospectively to rate subjects׳ therapeutic improvement, global improvement, and side effects from ketamine over 21 days. Additionally, time to onset of therapeutic effect was analyzed. RESULTS: Using the Clinical Global Impression Scale, ketamine was found to be significantly therapeutically effective through the first week after ketamine dosing (p < 0.05), with 93% of patients showing positive results for days 0-3 and 80% for days 4-7 following ketamine dosing. Patients experienced global improvement during all 4 studied time periods following ketamine dosing (p < 0.05). Significantly more patients had either no side effects or side effects that did not significantly impair functioning at each of the 4 assessed time periods following ketamine dosing (p < 0.05). Additionally, significantly more patients experienced their first therapeutic response during days 0-1 following ketamine dosing (p < 0.001) than during any other time period. CONCLUSIONS: These data suggest that ketamine may be a safe, effective, and rapid treatment for clinical depression in patients receiving hospice care. Blinded, randomized, and controlled trials are required to substantiate these findings and support further clinical use of this medication in hospice settings.

Perceived barriers and facilitators for an academic career in geriatrics: medical students' perspectives.

OBJECTIVE: There is a growing concern about a shortage of physician scientists. This problem is particularly severe in certain subspecialties such as geriatrics in general and geriatric psychiatry in particular. This study sought to obtain medical students' perspectives on barriers and facilitators toward pursuing a career in academics and/or in geriatric psychiatry or geriatic medicine. METHODS: The study surveyed 27 first-year medical students from six US medical schools, who had demonstrated a clear interest in academic geriatrics by completing a mentored summer research training program in geriatric medicine or geriatric psychiatry, funded by the National Institute on Aging. The survey included open-ended and close-ended questions about likely career choice and factors affecting it. RESULTS: Sixty percent of students reported they were likely to pursue an academic career, 44 % a career in geriatric psychiatry or geriatic medicine, and only 36 % a career in academic geriatrics. The most frequently perceived barriers were a lack of knowledge about academic careers and lack of exposure to geriatrics, financial concerns due to loan debts and low compensation, and negative impressions of research and of working with older adults. Facilitators included positive experiences with or positive impressions of research and research mentors and of older adults, and the growing demand for geriatric care. CONCLUSIONS: Attracting capable and motivated medical students to academic careers in fields such as geriatric psychiatry or geriatic medicine should be a priority in seeking to expand the number of physician scientists and to add to the health-care workforce in underserved subspecialty areas. Necessary approaches should include opportunities to work in academic settings; availability of sustained and dedicated mentorship; early, consistent, and positive exposure to older adults; and financial incentives.

Bereavement: course, consequences, and care.

This paper discusses each of several potential consequences of bereavement. First, we describe ordinary grief, followed by a discussion of grief gone awry, or complicated grief (CG). Then, we cover other potential adverse outcomes of bereavement, each of which may contribute to, but are not identical with, CG: general medical comorbidity, mood disorders, post-traumatic stress disorder, anxiety, and substance use.

The removal of the bereavement exclusion in the DSM-5: exploring the evidence.

Since 1980, the DSM-III and its various iterations through the DSM-IV-TR have systematically excluded individuals from the diagnosis of major depressive disorder if symptoms began within months after the death of a loved one (2 months in DSM-IV), unless the depressive syndrome was 'severely' impairing and/or accompanied by specific features. This criterion became known as the 'bereavement exclusion'. No other adverse life events were noted to negate the diagnosis of major depressive disorder if all other symptomatic, duration, severity and distress/impairment criteria were met. However, studies since the inception of the bereavement exclusion have shown that depressive syndromes occurring after bereavement share many of the same features as other, non-bereavement related depressions, tend to be chronic and/or recurrent if left untreated, interfere with the resolution of grief, and respond to treatment. Furthermore, the bereavement exclusion has had the unintended consequence of suggesting that grief should end in only 2 months, or that grief and major depressive disorder cannot co-occur. To prevent the denial of diagnosis and the consideration of sometimes much needed care, even after bereavement or other significant losses, the DSM-5 no longer contains the bereavement exclusion. Instead, the DSM-5 now permits the diagnosis of major depressive disorder after and during bereavement and includes a note and a comprehensive footnote in the major depressive episode criteria set to guide clinicians in making the diagnosis in this context. The decision to make this change was widely and publically debated and remains controversial. This article reports on the rationale for this decision and the way the DSM-5 now addresses the challenges of diagnosing major depressive disorder in the context of someone grieving the loss of a loved one.

A tale of two veterans: homeless vs domiciled veterans presenting to a psychiatric urgent care clinic.

BACKGROUND: The relationship between homelessness among veterans and mental illness and suicidality has not been clearly defined. To further examine this relationship, we compared rates of mental illness and suicidality among homeless and domiciled veterans seeking urgent psychiatric care at a US Department of Veterans Affairs (VA) facility. METHODS: Information was collected by survey from 482 consecutive veterans seeking care at the Psychiatric Emergency Clinic (PEC) at the VA San Diego Healthcare System. A total of 73 homeless veterans were designated the homeless group and 73 domiciled veterans were randomly selected as the domiciled group. Suicidality and mental illnesses were assessed by self-assessment questionnaires and chart review of diagnoses. RESULTS: The homeless group had significantly higher rates of past suicide attempts (47% vs 27%) and recent reckless or self-harming behavior (33% vs 18%) compared with the domiciled group but significantly lower rates of depressive disorder (25% vs 44%), as diagnosed by a PEC physician. There were no differences between groups on the questionnaires for posttraumatic stress disorder (PTSD), depression, or alcohol abuse. Nor were there differences in diagnoses of bipolar disorder, PTSD, anxiety disorder, schizophrenia/schizoaffective disorder, or alcohol abuse. CONCLUSIONS: Veterans seeking help from a VA-based urgent psychiatric care clinic often are burdened by substantial depression, alcohol use disorders, PTSD, and both past and present suicide risk.

The bereavement exclusion and DSM-5.

BACKGROUND: Pre-DSM-III (where DSM is Diagnostic and Statistical Manual), a series of studies demonstrated that major depressive syndromes were common after bereavement and that these syndromes often were transient, not requiring treatment. Largely on the basis of these studies, a decision was made to exclude the diagnosis of a major depressive episode (MDE) if symptoms could be "better accounted for by bereavement than by MDE" unless symptoms were severe and very impairing. Thus, since the publication of DSM-III in 1980, the official position of American Psychiatry has been that recent bereavement may be an exclusion criterion for the diagnosis of an MDE. This review article attempts to answer the question, "Does the best available research favor continuing the 'bereavement exclusion' (BE) in DSM-5?" We have previously discussed the proposal by the DSM-5 Mood Disorders Work Group to remove the BE from DSM-5. METHODS: Prior reviews have evaluated the validity of the BE based on studies published through 2006. The current review adds research studies published since 2006 and critically examines arguments for and against retaining the BE in DSM-5. RESULTS: The preponderance of data suggests that bereavement-related depression is not different from MDE that presents in any other context; it is equally genetically influenced, most likely to occur in individuals with past personal and family histories of MDE, has similar personality characteristics and patterns of comorbidity, is as likely to be chronic and/or recurrent, and responds to antidepressant medications. CONCLUSIONS: We conclude that the BE should not be retained in DSM-5.

Relationship between burnout and Major Depressive Disorder in health professionals: A HEAR report.

BACKGROUND: Burnout is a "normal" albeit concerning response to workplace stress, whereas Major Depressive Disorder (MDD) is a serious illness associated with impairment and suicide risk. Because of symptomatic overlap between the two conditions and MDD-associated stigma, individuals reporting work-related stress and depression often are "diagnosed" with burnout at the expense of recognizing and treating MDD. Our study aimed to leverage organizational implementation of the American Foundation of Suicide Prevention's Interactive Screening Program to elucidate relationships among burnout, depression, and other suicide risk factors. METHODS: 2281 of about 30,000 (~7.6 %) medical trainees, staff, and faculty responded to an anonymous online stress and depression questionnaire. Respondents were grouped into four cohorts: screened positive for burnout alone (n = 439, 19 %), depression alone (n = 268, 12 %), both conditions (n = 759, 33 %), or neither condition (n = 817, 36 %), and compared on multiple measures of distress and other suicide risk factors. RESULTS: Burnout alone and depression alone each predicted greater distress and suicide risk compared with neither condition. Depression was a stronger predictor than burnout and demonstrated a consistent association with other suicide risk factors regardless of whether burnout was present. In contrast, burnout was not consistently associated with other suicide risk factors when depression was present. LIMITATIONS: The sample was limited to one state-supported academic medical center; to individuals who elected to take the online survey; and relied on a single item, non-validated measure of burnout. CONCLUSION: When emotional distress is reported by healthcare workers, attention should not stop at "burnout," as burnout frequently comingles with clinical depression, a serious and treatable mental health condition.

Learning Outcomes in a Live Virtual versus In-Person Curriculum for Medical and Pharmacy Students.

Background: The coronavirus disease (COVID-19) pandemic has been a source of disruption, changing the face of medical education. In response to infection control measures at the University of California, San Diego, the hybrid in-person and recorded preclerkship curriculum was converted to a completely virtual format. The impact of this exclusive virtual teaching platform on the quality of trainee education is unknown. Objective: To determine the efficacy of a virtual course, relative to traditional hybrid in-person and recorded teaching, and to assess the impact of supplementary educational material on knowledge acquisition. Methods: A retrospective observational cohort study was performed to assess an introductory course, held mostly in person in 2019 versus completely virtual in 2020, for first-year medical students and second-year pharmacy students at the University of California, San Diego, School of Medicine and Skaggs School of Pharmacy and Pharmaceutical Sciences. Results: The midterm and final examination scores were similar for the hybrid and virtual courses. There was no association between the hours of recorded lectures watched and final examination scores for either course. In the 2019 in-person and recorded course, students who demonstrated consistent on-time use of practice quizzes scored statistically higher on the final examination (P = 0.0066). In the 2020 virtual course, students who downloaded quizzes regularly had statistically higher scores on the midterm examination (P < 0.0001). Conclusion: The similar examination scores for the hybrid in-person and recorded and exclusively virtual courses suggest that the short-term knowledge acquired was equivalent, independent of the modality with which the content was delivered. Consistent on-time use of practice quizzes was associated with higher examination scores. Future studies are needed to assess the difference between a completely in-person versus virtual curriculum.

The impact of a medical improv curriculum on wellbeing and professional development among pre-clinical medical students.

Medical students experience rising rates of burnout throughout their training. Efforts have been made to not only mitigate its negative effects, but also prevent its development. Medical improv takes the basic ideas of improvisational theatre and applies them to clinical situations. Given improv's focus on self-awareness and reflection, in addition to its spontaneous nature, we hypothesized it had the potential to serve as a creative outlet, a way to prevent and/or mitigate the negative effects of stress, burnout, and fatigue, and provide a learning environment to develop skills necessary to succeed as a physician. University of California (UC) San Diego School of Medicine developed a medical improv elective for pre-clinical students and assessed its effects on student development and wellbeing. Students enrolled in the elective between Fall 2019 and Fall 2020 at UC San Diego School of Medicine were surveyed pre- and post- course completion using both qualitative and quantitative methods. Students noted significant improvement in domains related to proactivity in their professional career (3.15 to 4.00, p = 0.02), wellbeing (3.0 to 4.4, p < 0.001), engagement with their studies (3.85 to 4.52, p = 0.02), and communication (3.75 to 4.3, p = 0.04) after completion of the medical improv elective. We describe a pilot-study demonstrating the positive effects of improv on medical student wellbeing and professional development, laying the groundwork for both future study of improv on student wellness and its implementation in the pre-clinical curriculum.

Treatment of Complicated Grief in Survivors of Suicide Loss: A HEAL Report.

OBJECTIVE: Suffering associated with complicated grief (CG) is profound. Because suicide loss survivors are susceptible to developing CG, identifying effective treatments for suicide loss survivors with CG is a high priority. This report provides data on the acceptability and effectiveness of antidepressant medication and complicated grief therapy (CGT), a CG-targeted psychotherapy, for suicide loss survivors with CG identified by an Inventory of Complicated Grief score ≥ 30. METHODS: This is a secondary analysis of data collected from March 2010 to September 2014 for a 4-site, double-blind, placebo-controlled randomized trial comparing the effectiveness of antidepressant medication alone or in combination with CGT for participants with CG (score ≥ 30 on the Inventory of Complicated Grief) who were bereaved by suicide (SB; n = 58), accident/homicide (A/H; n = 74), or natural causes (NC; n = 263). Using mode of death as a grouping factor, we evaluated acceptability of treatments by comparing 12-week medication and 16-session CGT completion; we evaluated effectiveness by comparing response at week 20, defined by a score of 1 or 2 on the Complicated Grief Clinical Global Impressions-Improvement scale (CG-CGI-I), and additional secondary response measures. RESULTS: Among participants receiving medication alone, SB medication completion rates (36%) were lower than rates for A/H (54%) and NC (68%; χ² = 11.76, P < .01). SB medication completion rates were much higher for SB individuals receiving CGT (82%; χ² = 12.45, P < .001) than for SB individuals receiving medication alone. CGT completion rates were similar in the 3 groups (SB = 74%, A/H = 64%, NC = 77%; χ² = 2.48, P = .29). For SB participants receiving CGT, CG-CGI-I response rates were substantial (64%), but lower compared to the other groups (A/H = 93%, NC = 84%; χ² = 8.00, P < .05). However, on all other outcomes, changes from baseline for SB participants were comparable to those for A/H and NC participants, including number and severity of grief symptoms, suicidal ideation, and grief-related impairment, avoidance, and maladaptive beliefs. CONCLUSIONS: These results raise concern about the acceptability of medication alone as a treatment for complicated grief in treatment-seeking suicide-bereaved adults. In contrast, CGT is an acceptable and promising treatment for suicide-bereaved individuals with complicated grief. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01179568.

Yearning to be heard: what veterans teach us about suicide risk and effective interventions.

BACKGROUND: Patients with serious mental illness can be at higher risk for suicide. Most research has focused on determining the risk factors for suicide-related events using quantitative methodologies and psychological autopsies. However, fewer studies have examined patients' perspectives regarding the experience of suicidal events. AIMS: To better understand suicide experiences from the perspective of patients diagnosed with serious mental illness. METHOD: This study purposively sampled and qualitatively interviewed 23 patients within the Veterans Affairs Hospital who were diagnosed with serious mental illness and who had attempted suicide. Using a phenomenological design, hermeneutic interviews included questions about the precursors, characteristics, and treatment of the suicide events, as well as patients' recommendations for care. RESULTS: Loneliness, isolation, depression, and hopelessness were commonly described as emotional precursors to the suicide events for all patients, while command hallucinations were reported among patients with schizophrenia-spectrum disorders. When evaluating whether treatments were effective, patients focused primarily on the level of empathy and compassion shown by their providers. CONCLUSION: The most common recommendation for the improvement of care was to increase clinicians' empathy, compassion, and listening skills. Additionally, efforts to bolster social supports were highlighted as a means to diminish suicide events.

Grief, depression, and the DSM-5.

Based on a review of the best available evidence and the importance of providing clinicians an opportunity to ensure that patients and their families receive the appropriate diagnosis and the correct intervention without necessarily being constrained by a somewhat arbitrary 2-month period of time, the DSM-5 Task Force recommended eliminating the "bereavement exclusion" (BE) from the diagnosis of major depressive disorder. This article reviews the initial rationale for creating a BE in DSM-III, reasons for not carrying the BE into DSM-5, and sources of continued controversy. The authors argue that removing the BE does not "medicalize" or "pathologize" grief, "stigmatize" bereaved persons, imply that grief morphs into depression after 2 weeks, place any time limit on grieving, or imply that antidepressant medications should be prescribed. Rather, eliminating the BE opens the door to the same careful attention that any person suffering from major depressive disorder deserves and allows the clinician to provide appropriate education, support, hope, care, and treatment.

Daily oral ketamine for the treatment of depression and anxiety in patients receiving hospice care: a 28-day open-label proof-of-concept trial.

BACKGROUND: Depression and anxiety are prevalent and undertreated in patients receiving hospice care. Standard antidepressants do not work rapidly or often enough to benefit most of these patients. Ketamine has many properties that make it an interesting candidate for rapidly treating depression and anxiety in patients receiving hospice care. To test this hypothesis, a 28-day, open-label, proof-of-concept trial of daily oral ketamine administration was conducted in order to evaluate the tolerability, potential efficacy, and time to potential efficacy in treating depression and anxiety in patients receiving hospice care. METHODS: In this open-label study, 14 subjects with symptoms of depression or depression mixed with anxiety warranting psychopharmacological intervention received daily oral doses of ketamine hydrochloride (0.5 mg/kg) over a 28-day period. The primary outcome measure was the Hospital Anxiety and Depression Scale (HADS), which was used to rate overall depression and anxiety symptoms at baseline, and on days 3, 7, 14, 21, and 28. RESULTS: Over the 28-day trial there was significant improvement in both depressive symptoms (F5,35=8.03, p=0.002, η(2)=0.534) and symptoms of anxiety (F5,35=14.275, p<0.001, η(2)=0.67) for the eight subjects that completed the trial. One hundred percent of subjects completing the trial responded to ketamine for both anxiety and depression. A significant response in depressive symptoms occurred by day 14 for depression (mean Δ=3.5, d=1.14, 95% CI=1.09-5.9, p=0.01) and day 3 for anxiety (mean Δ=2.4, d=0.67, 95% CI=1.0-3.7, p=0.004). These improvements remained significant through day 28 for both depression (mean Δ=4.0, d=1.34, 95% CI=2.3-5.9, p=0.001) and anxiety (mean Δ=6.09, d=1.34, 95% CI=3.6-8.6, p<0.001). Side effects were rare, the most common being diarrhea, trouble sleeping, and trouble sitting still. CONCLUSIONS: Patients who received daily oral ketamine experienced a robust antidepressant and anxiolytic response with few adverse events. The response rate for depression is similar to those found with IV ketamine; however, the time to response is more protracted. The findings of the potential efficacy of oral ketamine for depression and the response of anxiety symptoms are novel. Further investigation with randomized, controlled clinical trials is necessary to firmly establish the efficacy and safety of oral ketamine for the treatment of depression and anxiety in patients receiving hospice care or other subject populations.

Suicide bereavement and complicated grief.

Losing a loved to suicide is one is one of life's most painful experiences. The feelings of loss, sadness, and loneliness experienced after any death of a loved one are often magnified in suicide survivors by feelings of quilt, confusion, rejection, shame, anger, and the effects of stigma and trauma. Furthermore, survivors of suicide loss are at higher risk of developing major depression, post-traumatic stress disorder, and suicidal behaviors, as well as a prolonged form of grief called complicated grief. Added to the burden is the substantial stigma, which can keep survivors away from much needed support and healing resources. Thus, survivors may require unique supportive measures and targeted treatment to cope with their loss. After a brief description of the epidemiology and circumstances of suicide, we review the current state of research on suicide bereavement, complicated grief in suicide survivors, and grief treatment for survivors of suicide.

New wine in old bottle: late-life psychosis.

Psychosis is common in late-life and exacts enormous costs to society, affected individuals, and their caregivers. A multitude of etiologies for late-life psychosis exist, the two most prototypical being schizophrenia and psychosis of Alzheimer disease (AD). As such, this article focuses on the nonaffective, neuropsychiatric causes of chronic psychosis in the elderly, specifically schizophrenia, delusional disorder, and the psychosis of AD and other dementias.

Oral ketamine for the rapid treatment of depression and anxiety in patients receiving hospice care.

Depression is prevalent and undertreated in patients receiving hospice care. Standard antidepressants do not work rapidly or often enough to benefit most of these patients. Here, two cases are reported in which a single oral dose of ketamine provided rapid and moderately sustained symptom relief for both depression and anxiety. In addition, no adverse effects were noted. Further investigation with randomized, controlled clinical trials is necessary to firmly establish the effectiveness of oral ketamine for the treatment of depression and anxiety in patients receiving hospice care. Ketamine may be a promising safe, effective, and cost-effective rapid treatment for depression and anxiety in this population.