Bereavement

Bereavement is the objective state of having lost someone significant through death. Grief is the personal emotional, cognitive, physical and behavioural reaction to that loss. Mourning is the publicly and culturally patterned expression of grief — rituals, funerals, observances.

The process of grief begins from the time a life-limiting illness is diagnosed or health starts to deteriorate — not at the moment of death. For elderly couples who have lived together many years this marks the beginning of a very painful parting, and for the surviving partner the loss of a lifelong companion is equivalent to part of their own personal dying.

Bereavement is formally the final stage of the palliative care continuum — palliative care runs from diagnosis, through illness progression and end-of-life or hospice care, and culminates in bereavement support for family and caregivers (as staged by the Palliative Care Outcome Collaboration, Australia). Such relatives themselves require a care plan that includes bereavement.

Bereavement is near-universal in later life — spouse, siblings, friends, sometimes children. Losses of family and friends are listed among the social factors predisposing older people to depression, alongside isolation, loss of job and loss of income.

Bereavement is associated with declines in health, increased utilisation of healthcare resources, and an increased risk of death. Grieving relatives have increased rates of depression, cardiac events, intercurrent infections and mortality.

Recent death of a spouse and widowhood are major suicide risk factors in older people. The high-risk profile is: male, white, widowed or divorced, recently bereaved, living alone, isolated, recently moved, retired, poor physical health, terminal illness, pain, depression, alcohol use and loneliness. Older adults give fewer warnings, use deadlier methods, and have an attempt-to-completion ratio of about 4:1 (versus 200:1 in adolescents) — and 20– 50% have seen their primary care physician in the week before suicide.

Normal (uncomplicated) grief presents as waves of yearning, sadness, tearfulness, sleep and appetite disturbance, transient hallucinations of the deceased, guilt and anger — gradually attenuating over months as the person re-engages with life. Most bereaved people recover with the support of friends and family and need no professional intervention.

Complicated (prolonged) bereavement may be distinct from major depression, and formal criteria have been proposed. Its features are:

extreme levels of "traumatic distress"

numbness

a feeling that part of oneself has died

assuming the symptoms of the deceased

disbelief or bitterness

symptoms enduring beyond six months It is listed among the depressive disorders in geriatric psychiatry and is one of the conditions in older adults that does not fit the conventional paradigm of disease.

The DSM-5 "bereavement exclusion" (criterion E of DSM-IV) has been removed. The presence of depression during a period of mourning is now judged entirely by the clinician, regardless of the period of bereavement. This is of great importance in geriatrics because a large proportion of older people are dealing with recent loss and were previously denied both diagnosis and treatment. Distinguishing the three entities:

Sudden unexpected death · 2. Traumatic death · 3. Loss of a child · 4. Loss of a partner with an ambivalent relationship ("can't live with, can't live without"). Additional risks: pre-existing depression or anxiety, poor social support, prior caregiver strain, multiple concurrent losses, financial insecurity, and the person's own previous experience of being bereaved.

How a person dies shapes how the survivor grieves. As Dame Cicely Saunders said, "The way people die remains in the memory of those who live on." Until about 20 years ago morphine was rarely used in dying patients because of a mistaken belief that it hastened death; many were left with unrelieved pain and distress, and those memories still colour older people's perception of death and their fears about their own dying.

The most effective bereavement intervention is good care of the dying person. Relatives must be made aware of what is happening, encouraged to be involved in care, and have their concerns listened to. Even when frail and elderly, or a child, they may want to be at the bedside of the person they love — to deny them the ability to be present does them a great disservice.

Identify vulnerable caregivers before the death. Caregivers reporting emotional stress have a significantly increased mortality rate; physician identification of vulnerable caregivers and referral to social workers and community resources can be lifesaving.

The period immediately after hospice referral is one of particular vulnerability — patients and families feel abandoned by their physicians. Make follow-up appointments, telephone the family, express thanks and appreciation for the privilege of caring for the patient, and say goodbye to patient and family where appropriate. Clinicians must be aware of both normal and complicated grief and screen for them appropriately.

At follow-up, screen for sleep and appetite change, weight loss, alcohol use, functional decline, financial and social change, and suicidal thoughts. Use standard instruments — Geriatric Depression Scale (GDS-15/30), PHQ-2 and PHQ-9, Cornell Scale for Depression in Dementia — and for grief specifically the Inventory of Complicated Grief. Also screen for loneliness and social isolation, which are highly prevalent in older adults and independently associated with increased mortality and functional decline; routine screening with individual and community-based interventions is recommended.

Most bereaved people need support, not treatment. Blanket counselling for everyone is neither necessary nor effective — target intervention at those with risk factors or established prolonged grief.

Psychological therapies significantly reduce grief symptoms in complicated bereavement: brief dynamic psychotherapy, traumatic grief therapy, crisis intervention, and support groups. Grief-specific therapy combines elements of interpersonal therapy and CBT — revisiting the loss, cognitive restructuring, and restoring relationships and personal goals.

Antidepressants may also be considered to treat complicated bereavement, and are indicated where major depression is present. Apply late-life prescribing rules — SSRIs first, start low and go slow, review regularly. Avoid benzodiazepines, which do not treat grief and add falls, delirium and dependence.

Spiritual and religious support matters. Religiosity and spirituality provide a sense of meaning that buffers stress and assists coping, and a network of like-minded people who serve as social resources, promoting self-esteem and personal growth. Referral to a chaplain or the person's own clergy should be routinely considered. Healthcare professionals have a moral obligation to address spiritual concerns — doing so signals concern for the whole person.

Hospice bereavement services — hospice programmes provide bereavement follow-up for approximately one year after the death: a trained volunteer or counsellor visits the survivors at specific intervals, plus telephone and letter contact, the opportunity to join support groups, and onward referral to medical or professional care where necessary.

Byock's "Five Things" — thank you; forgive me; I forgive you; I love you; goodbye — offered to families before the death, ease the grief that follows.

Bereaved grandchildren. For many children a grandparent is the most secure adult in their life, as social disintegration and mobility may leave the child very dependent on them. On average, in every UK school class about two children are bereaved of someone close such as a grandparent, and one of a parent or sibling. The way clinicians care for the dying patient and their family therefore influences the next generation's ability to cope with illness and death.

Bereavement and sexuality — depression, bereavement and grief reactions are recognised psychological inhibitors of sexual activity in older people, alongside poor self-image, cultural beliefs and social isolation.

Prolonged Grief Disorder (PGD) has been added to both ICD-11 and DSM-5-TR (2022) — the single most important change in this field. Core features: yearning for, or persistent preoccupation with, the deceased, accompanied by intense emotional pain (sadness, anger, bitterness, disbelief, identity disruption, avoidance of reminders, emotional numbness, loss of meaning and purpose, difficulty re-engaging socially), causing clinically significant functional impairment, and persisting beyond what is expected given the person's social, cultural or religious norms.

The two systems differ in their time criterion — a favourite exam point:

ICD-11 — the reaction must persist for an atypically long period, minimum 6 months

DSM-5-TR — the death must have occurred at least 12 months ago (6 months for children and adolescents), with symptoms present nearly every day for at least the past month

Consequently the prevalence differs: point prevalence among the bereaved ranges roughly 4.7– 6.8%, with DSM-5-TR yielding significantly lower rates than ICD-11. Raising the ICD-11 threshold to 12 months brings the two into near-perfect agreement.

The time thresholds are now actively contested. A cross-national study (UK, Ireland, Ontario, 2025) found grief symptoms were not markedly higher in those bereaved within the previous 6 months, and that bereaved people themselves do not regard 6 months as the normative point at which one should have come to terms with a loss. The argument advanced is that grief symptoms are pathological by their nature, not by their chronicity — so rigid time thresholds are unlikely to prevent false-positive diagnoses but will increase false negatives, with under-treatment as the practical consequence.

Criterion validity favours ICD-11. In longitudinal analysis controlling for depression and insomnia, ICD-11 prolonged grief symptoms predicted quality of life at 6-month follow-up, whereas DSM-5-TR symptoms did not.

A 2025 Lancet Review endorses the current conceptualisation: PGD is a diagnosable mental health condition with core symptoms of yearning and/or preoccupation, associated with emotional pain, identity disturbance, loss of meaning and purpose, and functional impairment, with a typical onset 6 to 12 months after the death.

Psychotherapy is first-line, and it must be grief-specific. Grief-focused CBT and Prolonged Grief Disorder Therapy (PGDT, formerly Complicated Grief Therapy) — combining exposure and revisiting the loss, cognitive restructuring, behavioural activation and restoration of personal goals — have the strongest evidence. Internet-delivered CBT is effective, with more sessions producing greater benefit.

Bryant et al., JAMA Psychiatry 2024 — head-to-head randomised trial of grief-focused CBT versus mindfulness-based cognitive therapy in 100 adults with PGD:

Both treatments produced substantial symptom reduction (large effect size)

Grief-focused CBT was superior at 6-month follow-up for core PGD symptoms, depression and grief-related cognitions — though not for anxiety

Interpretation: mindfulness works, but grief-specific exposure and cognitive work works better

Pharmacotherapy is secondary. The landmark four-arm randomised trial (citalopram + clinical management, citalopram + PGDT, placebo + PGDT, placebo + clinical management; 333 patients aged 18–95) established that PGDT drives the benefit — an antidepressant alone is not sufficient. A 2025 machine-learning re-analysis found that higher baseline depression severity, greater grief-related functional impairment, and not receiving PGDT each predicted poorer response. Tricyclic antidepressants and benzodiazepines have not proved effective for PGD.

New neurobiological hypothesis — PGD may involve the reward and attachment circuitry rather than classical depression pathways, i.e. it may be conceptually closer to a disorder of attachment or addiction. This underpins randomised, triple-blinded, placebo-controlled trials of oral naltrexone (opioid receptor antagonist, 8-week course) for PGD. The evidence remains preliminary and not yet practice-changing.

Validated diagnostic instruments now exist for both criteria sets — notably the Aarhus Structured Clinical Interview for Prolonged Grief Disorder (A-PGDi, 2024), covering both ICD-11 and DSM-5-TR.