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How do we cope with the stress of caring for loved ones, and grieving their loss? Cameron et al 1 followed up 280 caregivers of patients who had spent at least a week of mechanical ventilation in an intensive care unit. In this, the largest and longest study of its kind, almost three-quarters of the caregivers were women, and over 60% were caring for a spouse; 67% reported initial high levels of depressive symptoms, persisting in 43% a year later. Patient demographic and clinical characteristics did not consistently impact upon outcomes, but those of the carer did: younger age, greater impact on other activities, reduced social support and personal growth, and loss of a sense of control over one's life were all significantly associated with worsened outcomes. Unpaid caregivers are estimated to save the UK economy almost £100 billion per annum, and without them the NHS would be unsustainable. The toll their efforts take can be very profound, and they need to be supported.
Complicated grief is under-recognised, occurring in about 7% of bereavements. Although it is associated with low mood, it differs from depression through core symptoms of yearning and sorrow, difficulty accepting the loss, and a preoccupation with thoughts of their loved one. Shear et al 2 report the first placebo-controlled randomised clinical trial on the topic; 400 bereaved adults (75% female) with complicated grief were all given psychoeducation, grief monitoring, and encouragement to engage in activities: they were also randomised to receive either flexible-dosing citalopram or placebo, and half were given complicated grief therapy (CGT). Those who received the 16-week manualised therapy showed significant improvement over those who did not, including in reduction of suicidal ideation, and while citalopram reduced concomitant depressive symptoms when added to CGT, by itself it was no more effective than placebo; CGT would appear to be the treatment of choice at this time.
The excitement about ketamine's potential as an antidepressant is matched only by the concern about dissociative side-effects, risk of addiction, and the disappointment with the brevity of its effects. Ketamine is an antagonist at glutamatergic NMDA receptors (NMDAR) that allow influx of calcium and sodium when the membrane potential reaches a certain threshold. Zanos et al 3 show that the metabolite of the...