Complicated Grief

Complicated grief (prolonged grief disorder) is a persistent and disabling grief response after the death of a close person, in which intense longing for the deceased or preoccupation with them continues for at least 6 to 12 months after the death (6 months in children and adolescents), and causes marked distress and impairment well beyond cultural and social expectations.

• Affects about 5 to 10 percent of bereaved adults, and 40 to 50 percent after the sudden or violent death of a child or a partner.
• Risk factors: sudden, violent or traumatic death (suicide, homicide, accident), death of a child, a dependent or ambivalent relationship, prior depression, anxiety or trauma, low social support, caring for the dying person, and lack of preparation.
• It is distinct from normal grief (which fluctuates and gradually becomes integrated) and from major depressive disorder and post-traumatic stress disorder, although all three often coexist.
• Associated outcomes: major depression, anxiety, post-traumatic stress, substance misuse, sleep disturbance, cardiovascular illness, and suicidal ideation and behaviour.

• Persistent yearning or preoccupation with the deceased, daily or almost daily.
• Identity disruption (feeling part of oneself has died), marked sense of disbelief about the death, avoidance of reminders, intense emotional pain (anger, bitterness, guilt), difficulty reintegrating (making friends, pursuing interests), emotional numbness, feeling that life is meaningless, and intense loneliness.
• Rumination about the circumstances of the death, self-blame, or reluctance to change the deceased person's belongings.
• Functional impairment: work, parenting, social withdrawal, neglect of health.
• Suicidal thoughts, including a wish to join the deceased.
• Assess: time since death, circumstances, relationship, cultural and religious context, support, other losses, physical health, substance use, and risk to self.

• Clinical interview confirming the symptom profile and the time criterion, with impairment.
• Use structured scales: Inventory of Complicated Grief (score 30 or more suggests caseness) or the Prolonged Grief Disorder-13 scale.
• Screen for depression (PHQ-9), anxiety (GAD-7), post-traumatic stress (PCL-5), alcohol and substance use (AUDIT), sleep, and suicide risk (direct questioning).
• Physical assessment and basic blood tests (FBC, TSH, glucose, vitamin B12, liver function) when physical symptoms or fatigue are prominent, since bereavement worsens existing illness.
• Differentials: normal grief (including longer cultural mourning), major depressive disorder, post-traumatic stress disorder, adjustment disorder, anxiety disorders, substance use disorder, and psychosis (hearing the deceased's voice that is brief and comforting is normal).

General support (all bereaved people)

• Acknowledge the loss, normalise grief, and avoid pathologising early grief; give practical help with funeral, finance and care arrangements; encourage social contact, routine, sleep, nutrition, physical activity and cultural or religious rituals that give meaning.
• Offer follow up at 1 to 3 months for those at risk.

Psychological treatment (first line for prolonged grief disorder)

• Grief focused cognitive behavioural therapy, or Complicated Grief Treatment: about 16 weekly sessions of 60 to 90 minutes. Components: psychoeducation about grief, restoring a sense of purpose and goals, imaginal revisiting of the death story, situational revisiting of avoided reminders, memory work, and interpersonal repair.
• Trauma focused cognitive behavioural therapy or eye movement desensitisation and reprocessing when post-traumatic stress is prominent.
• Support groups for bereaved parents, or those bereaved by suicide, as an addition.
• Psychotherapy outperforms antidepressants for the core grief symptoms.

Medicines (for comorbid depression, anxiety, or severe insomnia)

• Sertraline 25 to 50 mg orally once daily, increasing to 100 to 200 mg after 2 to 4 weeks according to response, or escitalopram 5 to 10 mg increasing to 20 mg, or citalopram 10 mg increasing to 20 mg (maximum 20 mg in those over 60). Review at 2 weeks and 4 to 6 weeks; monitor for activation, suicidality in young adults, hyponatraemia in older adults, bleeding with anticoagulants or NSAIDs.
• Antidepressants alone do not resolve prolonged grief; combining sertraline with grief focused therapy treats depressive symptoms without reducing the benefit of therapy.
• Insomnia: sleep hygiene and cognitive behavioural therapy for insomnia first; avoid benzodiazepines beyond 2 to 4 weeks, since they may impede processing of grief and cause dependence.
• Naltrexone and other agents have limited evidence.

Risk management

• Ask directly about suicidal thoughts; make a safety plan; limit access to means; arrange urgent psychiatric assessment if there is intent, a plan, or psychosis.
• Refer to mental health services when symptoms last beyond 6 to 12 months, when function is severely impaired, there is risk, or comorbid depression, post-traumatic stress, or substance misuse.

Follow up

• Review every 2 to 4 weeks during treatment; use the same scale to track progress; continue support through anniversaries and holidays.

Special groups

• Children and adolescents: use age appropriate explanations of death, maintain routines, family based and child focused grief therapy; the time criterion is 6 months.
• Older adults: screen for cognitive decline, loneliness, and physical illness; start antidepressants at half the usual dose (for example sertraline 25 mg).