Jennifer Levin
I’m your host, Dr. Jennifer R. Levin, I am a traumatic grief therapist and the founder of Therapy Heals where we help organizations and individuals prepare and heal from sudden or unexpected death. And, in my Podcast Untethered: Healing the Pain from sudden death, I share resources and stories to help you go from the chaos of sudden or unexpected death to move towards healing in life.
Hi everyone and welcome to Untethered: Healing the pain from a sudden death. I am Dr. Jennifer Levin, and I specialize in traumatic death and helping individuals through the struggles, pain, trauma, and chaos of an unexpected death.
In today’s podcast I interview Dr. Mariel Tourani a psychiatrist who treats people struggling with the aftermath of a sudden or unexpected death. In the beginning of our interview Dr. Tourani shares how she got started in psychiatry. She provides us with an excellent overview about the clinical differences between grief and depression, talks about the diagnosis prolonged grief disorder and shares how medication can benefit someone who has experienced a sudden or unexpected death. We cover symptomatology related to sudden or unexpected death, how long most people stay on medications and Dr. Tourani shares as a case example that illustrates how our own perception of grief can get in the way of understanding someone else’s experience.
Hi Dr. tourani. And thank you so much for joining us today. Why don't you start off and tell us a little bit about yourself, anything you feel comfortable with.
Dr. Tourani
Sure. Well, I was born in Paris, France and came to the US at age seven and thought I was just going to be here with my family for a couple of years and we ended up staying. And so I got all my education in the US, did go back and forth to France as I was growing up to maintain, you know, the French, but went to college in Minnesota. And so I went to the University of Minnesota for undergrad in genetics and cell biology, and then went to medical school at the University of Minnesota. And after that, decided I wanted a warmer climate. So I did my residency at Cedars Sinai in Los Angeles Center, at Cedars Sinai Medical Center for residency, and graduated in 1994. And since then, have been in private practice and general psychiatry.
Jennifer Levin
What made you choose psychiatry?
Dr. Tourani
Well, that's actually interesting, because there's a grief part to that decision. When I was just finishing my residency at the time I was in internal medicine. And I thought I would do something related to genetics. Right around that time, my grandmother had metastatic renal cell cancer, which was kind of a sudden finding when her clavicle broke her, you know, her bones broke. And so I was, I did get to see her and say goodbye to her and fly back to France. But I was pretty devastated. And at that time, I made the decision that I wanted to become an oncologist because of that experience, and then I did several oncology rotations. After about three rotations, I realized that what I really liked was actually sitting and talking with the patients. And I was getting more and more frustrated that I didn't have time to do so and it was all about, you know, writing the orders for the chemotherapy. And it was what I really was drawn to was speaking to the patients about their emotions about what they were going through. And that's when I realized that that came much more naturally to me, and was much more interesting to me. And so I decided to do an elective rotation at UCLA in psychiatry, and I just loved it right away. So, you know, despite putting those several years in internal medicine, I made the decision to switch. And it was actually pretty easy because the psychiatry residency program was just a different building just across the street. So I basically I just walked across the street and started up psychiatry. And, then that's it. And then I became a psychiatrist.
Jennifer Levin
Oh, wow. I did not know that about you. Are you comfortable sharing with us your personal experiences with grief and loss?
Dr. Tourani
Well, I've been pretty lucky, I have to say, because my parents had me very young. So they're still alive, both of them. And so it was really that grandmother who was like a mother figure to me, because my mother was more like a sister. And so that was, I think, the biggest shock and grief that I had was losing that grandmother who was so important to me. And then of course, the other experiences I've had, where as a student in medicine as a resident, and also as a practicing psychiatrist, the patients that I've lost. You know, it was the most shocking when I was in internal medicine and working in the ICU. That was, I'd say, that was still that was pretty traumatic. I mean, I still occasionally have dreams about that, you know, 20 almost 30 years later, so I did you know, I had that experience with sudden loss. I even had the experience of as a resident in the ICU spending one night, holding the hand of a woman who was dying of metastatic breast cancer, and had no family and I basically just spent the night just holding her hand because there was nobody else there. So those are some of my experiences. The other one that was, I guess I could say slightly humorous. I had a patient I liked very much, an older lady who had lung cancer. And I went to say goodbye to her at the hospital, I brought her a little gift. And I knew it was the last time I was going to see her. And when I went to talk to her, she told me, she had a question for me. And she asked me, tell me what's going to happen next, what's going to happen after I die? And I was taken aback, and I thought, what? Why is she asking me that question? I thought she would tell me, you know, she's closer to it than I am. And I was hoping she would, you know, enlighten me. And instead, she was asking me, so I know when I think about that sometimes it makes me chuckle a little bit.
Jennifer Levin
And I know I'm putting you on the spot here. But I'm curious. What did you tell her?
Dr. Tourani
You know, I'm trying to remember now. I think I basically said something to the effect that I don't think I have an answer for you. I think you know, as well as I do, you know, I didn't, you know, in medicine in my field, especially when you're just training, you're kind of taught to sometimes act like you know things even when you don't. But this was a situation where I couldn't really even fake it. So I was just very honest with her about that.
Jennifer Levin
Well, even from the little bit you've shared already, it sounds like you step outside of your role in medicine, sometimes staying all night with a woman who had no family that sounded like you acting like a caring human being, and not necessarily as a doctor on call.
Dr. Tourani
Yes, yes, I think so. And well, I could tell that the nurses in the ICU were so busy running around back and forth. And, and I actually my, you know, it was, I didn't really have any other work to do that night other than go sleep in the call room. So you know, it worked out.
Jennifer Levin
So getting back to the questions today, and I'm so delighted to have you here. You know, working with clients who have experienced sudden and unexpected death. There's so many questions that come up all of the time about the symptoms that they're experiencing with grief and loss. And what's and I don't like the word normal, but what's quote unquote, normal and, and when might medical intervention and medications, you know, be appropriate. And so I'm just delighted to have your expertise on this podcast, so we can get into some of those questions. And so let's just start off, but one of the things that often comes up when I work with clients, is the the difference between grief and depression. And can you start by just addressing the clinical differences between the two?
Dr. Tourani
Sure, I'd be happy to do so. You know, in my field, we use the DSM, which is the diagnostic manual. And they have done a good job more recently in trying to explain the differences for us, for clinicians. Because it is an area that has been confusing, even in my field. And I don't even remember this really being discussed much in my training even. But hopefully, it's, it's, you know, they do a better job of it nowadays, when they train doctors. But it's interesting, because there are several categories of diagnoses, let's say when I see a patient, and I have to decide, especially if I have to write down a diagnosis for insurance purposes, what is the condition? So, we have to differentiate between normal grief, we have to also consider a prolonged grief, which would be considered more abnormal. And then we also have to consider like you said, does it turn into a major depressive disorder, and then the other diagnosis which would be more in between normal grief and a major depression would be an adjustment disorder. So those are some of the diagnoses that we work with. And of course, there's a lot of gray in between. And we have to, you know, come up with these categories, especially when we have to submit to insurance and have an official diagnosis for a patient. Also, it helps us to conceptualize it if we have a diagnosis to understand what type of treatment is most appropriate. So really, the main differentiation, there are a few days differentiating factors between grief and depression. What is similar is sadness, withdrawal, or sleep or appetite, weight loss. Those are common between both grief and depression, common symptoms, the more or the different symptoms. In normal grief, one sees patients having very painful, intense feelings that usually come in waves. They're mixed, usually with also positive memories of the person who passed away. Whereas in depression, the mood is usually continuously low. Without positive phases it doesn't really go in waves, it's more continuous. In grief, usually people maintain their self esteem. And in depression, one of the cardinal symptoms is feelings of worthlessness, low self esteem, self loathing. And suicidal ideation could occur in both but usually in grief, it's more of the wanting to join the deceased. Whereas in a major depression and a clinical depression, it's it can be just, you know, more generalized just wanting to die wanting to escape the world. Self hatred can be mixed in with that. And then again, in normal grief, usually people can function fairly normally, of course, it may take a few weeks or a few months to be able to function normally, someone in a clinical depressive episode can have quite impaired functioning, impaired thinking, impaired cognition, and be unable to work. So those are the main differences, I would say. Now, of course, one can have can end up having an overlap. So when someone goes beyond normal grief into a more severe unrelenting grief state, that is what we now call prolonged grief disorder. And that is now a new diagnosis that is in the DSM since last year. So that prolonged grief disorder actually often can have an overlap. And you can actually also diagnose major depression with the prolonged grief disorder.
Jennifer Levin
So an individual can have both a major depressive disorder and prolonged grief.
Dr. Tourani
That's right. That's right. And actually, it's pretty common to have the overlap. And then the other, there are other conditions that can overlap pretty frequently with prolonged grief disorder. And one is post traumatic stress disorder.
Jennifer Levin
I was going to ask youabout that, you talked about the different symptoms, because so many clients that I work with, you know, especially with a traumatic loss, are really showing signs of trauma and acute traumatic symptoms. And so, are you seeing PTSD with clients or patients of yours?
Dr. Tourani
Definitely, definitely. Yes. There can be, and then PTSD, there's, that also, by the way, is divided into acute stress disorder, and post traumatic stress disorder. So they say the differentiation is that the acute stress disorder is within the first three months of the event of the trauma, and post traumatic stress disorder is a more chronic state, that's after three months. And so I think, you know, in the beginning when the, the sudden death happens, you know, it's, it's really a transition time where it's really hard to make a diagnosis, and there's a lot of overlap, and people can have symptoms that look a lot like you know, acute stress disorder at that point. Which still would be just part of the the expected grief from a sudden loss. So it's more, I would say, what I look for is, if these symptoms continue, and just don't get better, that's when we would start thinking okay, we have to be careful this acute this could be an acute stress disorder, which could turn into a post traumatic stress disorder, which would be just really lingering, and that we should treat more aggressively.
Jennifer Levin
So let's actually talk about symptomology. What are some of the symptoms that a client or a patient who's experienced a traumatic, sudden or unexpected death might display or report to you, when they first come to your office for an evaluation.
Dr. Tourani
So crying spells, severe sleep issues, either, you know, difficulty falling asleep, multiple awakenings throughout the night, or waking up too early, which would in turn lead to a lot of fatigue and impaired concentration. The person could have, you know, really intrusive thoughts, thinking repeatedly about their lost loved one. They could also if they had, if it was very traumatic, let's say if they witnessed the death, they could have flashbacks, you know, very intrusive thoughts, kind of what would call like, it could be like a medical trauma, if they were in the hospital, and they witnessed, you know, the sudden death, let's say in a hospital setting. And then the other. The other symptom that you know, people might talk about is just avoidance of interacting with other people, you know, isolation, having a difficulty talking to people, not wanting to relive the loss or the trauma, you know, when, of course, you know, people, friends, family members, everybody wants to talk to the person. And they might feel like avoiding that, because it's just too painful and too, too activating for them to have to talk about it.
Jennifer Levin
Talk about anxiety, because I feel like so many clients are just on edge, either you know, the word we probably use is hyper vigilance. But clients will describe I'm just waiting for the next bad thing, waiting for the other shoe to drop. Can you talk more about what that looks like in terms of a clinical presentation?
Dr. Tourani
Sure, yes. People could definitely, you know, it's interesting, because some people have a lot of anxiety and aren't even aware of it. I see that quite a bit. Oftentimes, people are more aware of their depression than their anxiety. But yeah, it's often you know, ruminating thoughts, you know, thinking obsessively about things constant worrying, the what if's, just like you said, some people might even have a panic state, which could even look like they're having a heart attack or something. They could be having shortness of breath, they could have, they could even have pain, anxiety can present as so many physical symptoms, people could have pain in their body, they could have tingling in their extremities, a restless feeling, you know, unable to sit still.
Jennifer Levin
Unable to settle. I'm glad you talked about that. I think also so many people are unaware of the physical aspects of grief.
Dr. Tourani
Yes.
Jennifer Levin
The fatigue, how exhausted they are. But just that the pain, the physical pain, the headaches, stomach aches, the nausea that can come with it. Yes, what else?
Dr. Tourani
And also yeah, and no appetite, you know, just difficulty even remembering to eat or drink, you know?
Jennifer Levin
Yeah. Yeah. I hear the word fogginess all the time. Just a dark cloud.
Dr. Tourani
And then the other symptom, which I'm sure you hear about all the time, is this cognitive dissonance where or this feeling of, this is unreal, you know, this feeling of this can't be true, or going to sleep and waking up and suddenly hits them all over again. Oh, did this really happen? Yeah, that's very common.
Jennifer Levin
Absolutely. So how does medication actually work? How does it help or benefit someone who has experienced a sudden or unexpected death?
Dr. Tourani
So for a sudden crisis, so even outside of sudden death for any sudden crisis, there are tools that we can use medication that can help people with sleep, and with anxiety. So, the way I look at it is, you know, those first few weeks, someone might need a sleeping pill, just so they can manage and so they can at least get some rest at night. Otherwise, they're going to be so worn out from being up all night and then crying and feeling miserable throughout the day. At least if they can get some rest at night that's going to help. So even people who are, you know, weary of taking sleeping pills, I tried to reassure them that, you know, this is just short term, just to get you through the next couple of weeks. And we have, you know, prescription sleeping pills that nowadays, they're not as heavy duty as the ones that people used to hear about, you know, in the, in the 70s. And the 80s, we have some milder ones. So I'll usually choose one of those. There's some short acting ones, like Sanada, there's some longer acting ones, like Lunesta.
Jennifer Levin
What does short acting mean?
Dr. Tourani
Yes, let me explain. So short acting, would be designed to only last about an hour and a half or two hours in the person's system so that it just puts them to sleep, but they don't get much of a hangover effect. So and then the longer acting ones are designed to last maybe about six to seven hours to keep them asleep through the night. So sometimes I'll just start with a really mild one and just see how that works. People sometimes, you know, sometimes I'll just have them take something that's over the counter even like a Benadryl or a melatonin. But often the insomnia is so severe in these sudden, you know, acute losses that it usually warrants, you know, a prescription. Another medication approach would be giving a benzodiazepine like an Ativan, Xanax, Klonopin, those are the main ones. And what I use those for, they're good for cutting anxiety very rapidly. And they, most of them are very short acting. When I give that one, that one can also be used for daytime anxiety. So sometimes I'll just give someone a small amount of one of those medications they can use for daytime anxiety, if they get a panic attack during the day, or if they feel totally overwhelmed during the day. And then they can take the same thing. Because it can also help with sleep onset, especially if the person is just so anxious, they can't fall asleep. So those are some tools that we can use. And the the class of agents, the benzodiazepines, we know that those are habit forming. So those I usually like to just use short term, you know, I tell people, this is only for a few weeks, if we end up having to use it longer, be aware that we're going to have to taper it. And that taper can just be just another week or so that we just where we just gradually decrease the dose. So I warn people right up front. And if someone has a history of substance abuse, let's say they might opt not to take something like that. And then I usually come up with an alternative. We have some, there's some antidepressants that are very sedating. And what we can do is prescribe a very small dose of one of those. And that can work as a sleeping pill without addiction risks. So let's say someone who's in AA and who's been sober for years, and knows that they can't take anything addictive at all, even for a week, we have things that are acceptable, like one of them is Trazodone, we can give a small dose of that. And there's zero addiction risk with that one.
Jennifer Levin
Okay. Yeah, cuz there's a lot of concerns among clients. And I was talking someone today, who had a family member who was prescribed a benzodiazepine, and was very concerned about their family member taking it and just just not handling it. Well. And, and so I'm sure you get a lot of different reactions about whether, you know, or judgmental concerns about whether or not it's a positive or not a positive decision.
Dr. Tourani
You know, the pendulum has really been swinging to the other extreme. So, for a long time, we doctors were prescribing these medications all the time, you know, it was just a quick fix. They knew it worked right away, they would put people on them. Now, the pendulum is swinging in the other direction, where people are, you know, doctors are being told, and you know, there's a lot out there online about the risks. And so, I actually know some doctors who won't even prescribe them anymore, just because they're worried about, about those things about the addiction risk. And also in, especially in the elderly. We worry about fall risk when someone's got this in their system. So again, yeah, the pendulum is now swinging to that extreme where some people can't even get them. And I think the middle way is really to know that they are tools that we can use as long as they're well supervised. And they're used very, you know, just for brief periods of time. And they can be very useful that way.
Jennifer Levin
When I have clients who are not sleeping and haven't slept for, you know, 7-10 days, they're not functional. They can't think straight. I mean, number one, they're traumatized, and full of grief. But then without the sleep, they're, they're just not in a good space. So really, you know, I, when I was talking with somebody, it's like, well, you have to look at the pros and cons of the entire situation.
Dr. Tourani
And also for therapy. I mean, if someone's not rested, and they're trying to do therapy with someone like you, they're not going to get as much out of the therapy, if they're just completely sleep deprived.
Jennifer Levin
Tell us just real quickly, how else can medication help besides the sleep?
Dr. Tourani
Right, so what I would do is, I would look at, well, let's say, if someone ends up having PTSD, there are certain medication choices I can make, to help prevent the nightmares, and to help them you know, be able to sleep better. So, if there are certain diagnoses, we can, you know, choose the right medication for that diagnosis. So if it's PTSD, there are certain med options that we can choose. And also, if it ends up fitting the diagnosis of major depression, or major depressive episode, then what you would do, what I would do, is choose a good antidepressant because once an episode of major depression is initiated, it can last for months and months. And so that short term approach that I just explained for the acute phase, you know, once I stopped that, they may still have a very severe depression that could linger. So the key is to be able to look out for the depression. And if it's turning into a real clinical depression episode, then I would recommend an antidepressant to the person at that point.
Jennifer Levin
So, research has shown that when appropriate, the combination of therapy and medication is the best treatment. And you just mentioned that like someone is not going to be able to benefit from therapy if they're just so exhausted. And unless there's extenuating circumstances, I wait for clients to initiate a discussion about medication, it's a very personal choice. However, I sometimes think that clients do have a misperception about what it means to take medications to treat symptoms that are associated with a traumatic loss. And I'll hear clients make statements like, I don't want to take any medication because I feel like it's cheating. Or I need to do this all on my own. And I'm curious how you would respond to statements like these?
Dr. Tourani
Well, what we do know is that grief, combined with depression, when you have an untreated depression, the grief can last a lot longer, can be much more severe, and less responsive to treatment, even if the person is engaged in therapy. So, you know, the, I don't think the person should feel guilty about getting help, because it's actually going to allow them to grieve more properly, and to not have it impair their functioning and impair their life for a really long time. And, yeah, I mean, I could ask you that, do you think that people feel guilty because they feel that they're not grieving appropriately the person if they take away some of the pain that they're experiencing? Is that part of the guilt?
Jennifer Levin
Yes, that they're taking the easy way out that it should be full of, of suffering to do the grief experience justice. When clients bring this up, you know, I turn it into a medical example of, you know, well, if you had cancer, or diabetes, would you do it on your own without medication? Depression is, or anxiety is a medical condition at this point. But, you know, I am sad in with misconceptions about that. And so I was just curious about how you would respond
Dr. Tourani
Right, right? I mean, something else I tell people sometimes is, when you're not treating a depression, you're, it's not like you're doing nothing, because the depression itself is increasing your stress hormones, it's affecting your immune system. It's increasing your risk of possible heart problems, possible elevated blood pressure. So actually, by not treating the depression, there's actually some there's actually toxicity in your body. So it's not just about the mind, it's also your entire body is affected by your depression. So not, you know, they say, I don't want to put something in my body, but in a sense, you're still doing something to your body by not treating it.
Jennifer Levin
Wow. That's an interesting perspective. What would you share with somebody who's listening right now, who might be wondering if medication would be helpful for them? In terms of their grief and trauma symptoms after they've experienced the sudden or unexpected death of their loved one?
Dr. Tourani
Well, I would recommend that they really, hopefully, they have a therapist that they're talking to, and they could discuss it with their therapist and ask, you know, do you ask for the therapists point of view? Do you? Do you see me as having, you know, a normal, and of course, normal, I'm sure. You know, there are so many variations, right. But what I mean is more, you know, not as extreme severe grief, but more just mild to moderate regular grief, to ask the therapist for their advice would be one way to start. Also, I think, if the person has a history of depression in the past, or an anxiety and disorder in the past, they're going to be at higher risk, to have a complication from the grief, such as depression, or anxiety. So we do know that pre existing conditions make one even more vulnerable. That person should definitely consider medication, because any stressor even other stressors, not even just grief, even other like a job loss, other stressors can trigger these conditions, if they've had them in the past. So that would be another reason. Another thing to think about, when people suffer, when people have depression, anxiety, insomnia, sometimes they self medicate with substances like alcohol, or, you know, other substances. And if if the person is finding out, is realizing that they're doing that, that's a sign that you need to look at, you know, getting you know, a regular medication so that you don't spiral into substance abuse.
Jennifer Levin
Yeah. Yeah. Those are great points. How long do most people stay on medication after they've experienced a sudden or unexpected death? And how do you know when the right time to discontinue the use of medication is?
Dr. Tourani
That's a really good question. And, you know, I think that's where psychiatrists can really come in, and really have a better answer, because what I often see people will go to their primary care doctor and get put on something. And it's just left on board for years. And the doctor doesn't really reassess and doesn't really think about, oh, should we be taking the patient off medication. So that is a risk. When people go to their primary care physician, they really need to be aware that they need to ask their doctor, if they do choose that route, they need to ask, you know, how long do I need to stay on this? And how soon can I get off, because that often happens. Now, if it is just the acute phase that we were talking about, it could be just a few weeks, just using the as needed interventions that I talked about earlier. If it ends up that we have a major depression that meets the criteria of major depression. And what we want to do, what I wanted to do is just maybe list them real quick so people know what the criteria of depression are. So basically, the person has to have at least two weeks of either a depressed mood, or loss of pleasure in interests, and then they need an additional five or more of the following items, weight loss or weight gain of at least 5% of their body weight, insomnia or over sleeping, psychomotor agitation or retardation meaning either hyperactivity, mental hyperactivity or a very sluggish brain, fatigue and loss of energy, feelings of worthlessness and guilt, impaired concentration, and suicidal ideation or thoughts of death. So those are the criteria that we look at when we make a diagnosis. And as you can tell, there's really a lot of overlap with just regular normal grief. So, you know, it has to be for at least two weeks duration, and it has to be the majority of these items for us to be able to make that official diagnosis. Anyway, if that person, if we make that major depressive disorder diagnosis, then there are three phases of treatment. The first phase is the acute phase of treatment, which is six to eight weeks of duration. And that is usually about, it takes about a month or so to put that depression into remission, it can take two months, meaning mission, meaning that most of the symptoms go away. And then we have to do what's called a continuation phase, which is another 16 to 20 weeks. So that continuation phase is even if the person's feeling okay, we know that with an episode of major depression, that there's a very high risk of recurrence of the depression if we stop the treatment too soon. So it needs to just be continued for a while.
And then after that period of time, so that adds up to about seven months. If this is just a first episode, often at about the six to seven month mark, that's when I ask the patient, are you ready to try to taper off and see how you do. And some people do very well at that point off the medication. If the person has a prior history, or if there are other circumstances like they're under ongoing stress, if there's a lot of stress, that just is unrelenting, then we might want to do what's called a maintenance phase, which is variable, you know, it could even be another year, it could even be another two years if their situation doesn't improve. Or if they've had multiple episodes of depression, it could be even postpartum depression, but they've had multiple episodes, then I'll usually opt for a longer treatment, like about one year, just to be safe. And then one more thing I think about too, if if it's a woman, and they're entering menopause, that's another vulnerable phase for most women, when the hormone levels are dropping, so that might that might be a reason to keep the antidepressant going a little longer.
Jennifer Levin
Actually, that's really helpful. And I think that's very inspiring. I think that's very helpful or hopeful, knowing that some people, you know, they think it's a life sentence, and that, you know, what, I can really reevaluate after seven months, this may, you know, be something, that is not a life sentence.
Dr. Tourani
Exactly, exactly.
Jennifer Levin
Yeah. Um, are there any examples? Maybe you can give us, you know, just a couple that would really illustrate for the listeners, the way in which medication can decrease some of the symptoms after an unexpected death?
Dr. Tourani
Sure, sure. So I can give you an example of a pretty straightforward case, and then a little bit more complex case.
Jennifer Levin
That'd be great.
Dr. Tourani
Yeah, so a straightforward one would be, I saw a 50 year old woman whose husband had died three months prior to seeing me after having a pancreatic cancer diagnosis, which actually went very rapidly. He died. It was very rapid from the time of diagnosis to the time of death. And this was very traumatic for her because she witnessed, you know, it was very scary the situation in the hospital. I think he had a lot of bleeding and she witnessed you know some of this, and she was referred to me by her therapist. And she came in two months after his death to see me. And what she presented with was insomnia, 10 pound weight loss. And she was already you know, a very normal weight, she was not overweight. So that was pretty substantial. She, she said she felt, things felt unreal to her, she felt associated. She was really having a hard time focusing, getting just simple tasks done. And she also had what we call passive suicidal ideation, meaning I wish I were dead, no actual plan to hurt herself, but just many, many days, wishing she could just be gone. She had no prior psychiatric history of any treatment or any symptoms. And, but because she had had these symptoms for a good two months after his death, and she did meet the criteria for major depression with the symptoms that I listed. I diagnosed her with an episode of major depression. In addition to the grief, I put her on an antidepressant called Lexapro, a small dose to start. And I gave her Lunesta, which is the sleeping pill that works a little bit longer, because she was having middle of the night awakening. And I wanted her to be able to sleep through the night. Two weeks later, she actually told me at the follow up appointment, that she didn't feel overwhelmed when she felt sad, she was able to feel sad, and the suicidal thoughts had completely gone away. And I think part of the reason that she improved so rapidly is because she was finally sleeping. And we do know that when you treat depression, if you're able to treat the insomnia, the depression goes away a lot faster. She also had an improved appetite, as well at that time. And she, but she's still on, you know, follow up appointments, she was still having fluctuating phases of grief, you know, low moods, but then she would have other times when she felt normal. So I consider that normal grieving. And, and then she returned to work three months later, after I started treating her. So that was what I consider that a successful case. And, yeah, but again, helping the sleep made all the difference for this person. So that's, that's a pretty straightforward one. Do you have any questions about her?
Jennifer Levin
No I think that showed how the sleep made a huge difference.
Dr. Tourani
The one that's a little more complicated. And that I think, is an interesting, because, well, you'll see why it's interesting when I explain it. So this is a 75 year old man whose who's a retired accountant. And I have treated him for quite a long time. About I'd say, about 15 years. Yes, and he is someone from a family that has a lot of his family members have depression and anxiety disorders. And his first depression was at age 29. So that was way before way before I saw him. At that time, he was treated with one of the older antidepressants that we don't use as much these days called a trycyclic antidepressant. And then he was switched to Prozac. And he, he came to me, like I said, about 15 years ago, he was stable, and I had just kept his meds the same because I knew he was at high risk from his past history. He had his second depressive episode when he was retiring. And that was about 10 years ago. At that time, he also, he used to be very athletic when he was young. So he had had all sorts of trauma, you know, back trauma, so he had back pain. He had multiple surgeries that also contributed to the depression as well as the retirement. And so I went ahead and changed his medications, gave him some stronger medications. And he was much improved over you know, he adjusted to being retired. And about six years ago, so four years later, I asked him, he was older. At that point, I decided, you know, maybe it's time to cut back medications, you've been really stable, you've adjusted to retirement. And so I cut back his meds, he used to be on four medications, I cut him back down to two medications that were much milder. And he did very well, he was stable. Three years later, his daughter's husband died of a drug overdose. And it looks like it was probably intentional. He, this was very traumatic to him. And to his entire family, obviously, he was very concerned about his daughter, very anxious, he felt anger about what happened that his daughter had to suffer so much. He had waves of grief. And I considered that this was a normal grief, you know, and, you know, I kept checking in with him over, you know, our usual about, you know, every one to three months. About three months later, after the death, after the suicide, he reported that he was feeling depressed, and he wanted to increase his medications. I said, okay, I adjusted a little bit, the two medications, increased them. Another four months later, came to me for another appointment, still feeling depressed. I reviewed my past treatment with him. And we decided to go ahead, go full force and add the other two medications, which he had needed before. He finally started feeling better. And he actually, at the next appointment, he actually was a little bit upset with me. And, you know, he asked me why we had not given, why we hadn't done the prior treatment earlier, why did I not give them all the meds that worked before for his depression, at the bigger doses? And I tried to, I said to him, you know, I'm so sorry, I just thought this was normal grief, I thought it was normal for you to feel, you know, this amount of pain, and I didn't want to just, you know, put you on too many medications. And this was really eye opening for me. Because I realized that, you know, this was really an increase in his major depression. And I had been, I had been fooled by the grief, you know, I thought, Oh, well, this is normal. And so that was that was really a lesson for me. You know.
Jennifer Levin
Thank you for sharing that and being vulnerable in that. I mean, I think grief is such a unique experience. And it's so hard to interpret. I mean, and you said that was his daughter's husband. And so, you know, it's like, oh, once removed, and, and so it's such an individual experience. And so, and that's such an interesting lesson, because as outsiders we tend, as a society, we tend to, I don't want to use the word judge, because that's not what was happening. But as, as a society, we tend to view other people's grief from our own lens. He said to you no, you, basically you didn't get it, right, such a lesson to us all, that we all have such a unique grief experience. And in a lot of ways, unless you walk in our shoes, you don't know what we're experiencing. And I'm really appreciative that you shared that story with us.
Dr. Tourani
Sure, what you're reminding me of as well. People tell me all the time that, you know, they get people tell them, you know, aren't you over it yet? You know, you need to stop thinking about it. You know, or they'll say somebody else I know, is over their loss. And it took them three months. And and that is really frustrating for people to hear, I think.
Jennifer Levin
Especially in the world of sudden and unexpected because it is so so different. So I know we've taken so much of your time, I just have one final question for you, as from the perspective of a psychiatrist. What advice would you give to somebody, a patient who's brand new, and has recently experienced a sudden and unexpected that that they just showed up in your office? Besides mitigation What would you say to them about what to do?
Dr. Tourani
I think one of the major things I would say to them would be that they need to get support social support. In my experience, that is such an important factor in helping people heal and helping them with their emotional pain. I think that would be one of the primary things I would assess. And I would recommend to, you know, find a support group or find, find a therapist, you know, I might try to refer them to a good therapist. That would be the starting point, I think, and then and to be to be seen regularly, by a professional who can make sure that they're not getting worse. Those would be my recommendations, and also to try to give them hope, try to reassure them that this will get better, you know, you will get better, this pain will eventually lift and you will be able to have good memories of your loved one. It won't be painful. And it won't be painful in the future to remember your loved one. And it will get better. Yeah. So those would be the two main things, I think, to make sure they have social support, that they're not all alone in the world that they can use, you know, their connections, they, you know, society will help them other people will help them because it's a common experience. It's a common human experience. Yeah.
Jennifer Levin
Yeah. Well, Dr. Tourani, thank you so much for spending time with us today. This was such wonderful information. And I know there's going to be so many people listening, who have never had an opportunity to talk with a psychiatrist and to hear this information. And I know I learned a lot today. So again, thank you so much.
Dr. Tourani
Thank you for having me.
Jennifer Levin
I am so grateful to Dr. Tourani for providing us with this information today. I have so many clients with medication questions and concerns who do not have the opportunity to converse with a psychiatrist. She answered so many questions that I know individuals who are considering a pharmacological intervention may have.
I think one major take aways from this interview was the distinction between grief and depression and that even though there are specific diagnostic criteria for each it can still be messy at times. However, medication and therapy can be effective with both, especially when used in combination.
It is also important to note that individuals who experience an unexpected or traumatic loss are at increased risk for prolonged grief disorder – unexpected death complicates the grieving process and the trauma symptoms that many people experience make grief even more challenging and extend the grief continuum. And although I constantly say there is no timeline in grief, it usually takes longer to work through and process an unexpected, traumatic death than one that was anticipated.
I also want to thank Dr. Tourani for her honest reflection and acknowledgement of the assessment she shared in the final case study. She provided us with such a good reminder about how easy it is to misinterpret grief because we look at the experiences of others from our own lens. After a sudden or unexpected death, so often clients report feelings misunderstood even from their practitioners. Make sure you surround yourself with friends and professionals who take the time to understand your situation and listen to your needs. I encourage you to be patient with those in your life, this is a new experience for them as while and they may need some grace as while understanding your situation. However, If they unable to support you in the manner you need then it is time to move on.
I have had the opportunity to work collaborative with Dr. Tourani in client care for many years. She is committed to the well-being and healing of her patients and goes above and beyond to ensure they get the highest level of care. I highly respect her ability to be transparent about her experiences as a professional and that she constantly reflects and learns from her patients.
If you want an opportunity to connect with Dr. Tourani please join our facebook group “Talking about the Podcast Untethered with Dr. Levin.”
Thank you so much for joining today’s episode of Untethered Healing the Pain After a Sudden Death. Our podcast is now hosted on my website therapyheals – To learn more about hope and guidance after sudden or unexpected death please visit therapyheals.com and sign up for my newsletters at www.therapyheals.com. Bye for now.
Thank you for listening today. Be sure to subscribe to my Podcast so you never miss an episode. For guidance and hope with unexpected or sudden death please visit my website www.therapyheals.com to learn more about the services we offer. If you would like to share your story on our podcast in the service of helping others heal after a sudden or unexpected death please email us at [email protected].
