Key Facts

Grief is a natural process. Healthcare professionals should be able to recognise normal grief, identify complicated grief, and signpost appropriate support.

Epidemiology

• Approximately 600,000 deaths/year in the UK → millions affected by bereavement
• 10% develop prolonged grief disorder
• Bereaved people have increased mortality (widowhood effect) — 40% higher in first 6 months
• Increased risk of depression, anxiety, cardiovascular disease, and suicide

Aetiology

Grief occurs after any significant loss:

• Death of loved one (most common context)
• Loss of health, function, independence
• Loss of role (retirement, parenthood)
• Anticipatory grief (before death in terminal illness)

Pathophysiology

• Neurobiologically, grief activates pain pathways, attachment circuits (separation distress), and reward systems (yearning)
• Cortisol dysregulation and immune suppression in acute bereavement
• Complicated grief may involve persistent activation of attachment/separation distress circuitry without resolution

Normal Grief

• Waves of intense sadness, crying
• Yearning and searching for the deceased
• Disbelief and shock (especially if sudden death)
• Anger (at deceased, healthcare, God, themselves)
• Guilt ('If only...')
• Anxiety about the future
• Sleep disturbance, appetite changes
• Physical symptoms (fatigue, chest tightness, breathlessness)
• Preoccupation with memories of the deceased
• Gradual improvement over 6-12 months

Prolonged Grief Disorder (ICD-11)

• Intense longing/yearning persisting >6 months (>12 months ICD-11)
• Preoccupation with or rumination about the deceased
• Significant functional impairment
• Difficulty accepting the death
• Emotional numbness or inability to experience positive emotions
• Difficulty engaging in social activities or planning for the future

Red Flags

• Suicidal ideation or intent
• Prolonged inability to function (work, self-care, relationships)
• Significant weight loss or self-neglect
• Substance misuse
• Grief persisting >12 months with worsening trajectory
• Pre-existing mental illness exacerbated by bereavement

Bedside

• Sensitive assessment of grief experience
• Screening for complicated grief (PG-13 scale, ICG — Inventory of Complicated Grief)
• Assess for depression (PHQ-9), anxiety (GAD-7)
• Assess for suicidal ideation
• Social support assessment
• Assess for risk factors for complicated grief

Bloods

• Not routinely needed
• Consider TFTs, FBC if physical symptoms suggest underlying cause

Imaging

• Not applicable

Special Tests

• Bereavement risk assessment (ideally before death — identifies high-risk individuals)
• Standardised grief measures (ICG, PG-13) for research or specialist assessment

Non-pharmacological

• Majority need social support, not professional intervention
• Level 1: information, self-help, social support (family, friends, community)
• Level 2: trained bereavement volunteers, peer support groups (Cruse Bereavement Support, hospice bereavement services)
• Level 3: professional counselling (for complicated grief, depression, PTSD)
• Level 4: specialist mental health services (psychiatry, clinical psychology)
• Cognitive grief therapy (CGT): evidence-based for prolonged grief disorder (Shear et al. 2005)
• Trauma-focused CBT or EMDR: for PTSD-related grief
• Children: age-appropriate information, reassurance, routine, specialist support if needed (Winston's Wish, Child Bereavement UK)

Pharmacological

• Grief itself should NOT be treated with medication (it is a normal process)
• If complicated by depression: SSRIs (sertraline 50-200mg, fluoxetine 20-60mg)
• If complicated by insomnia: short-term zopiclone or melatonin (avoid long-term)
• If complicated by anxiety: consider SSRI; short-term benzodiazepine only in extreme cases

Surgical/Interventional

• Not applicable

Referral Criteria

• Prolonged grief disorder: specialist grief therapy
• Suicidal ideation: crisis team / psychiatric assessment
• Depression or PTSD: psychological therapy service (IAPT/NHS Talking Therapies)
• Children affected: Child Bereavement UK, Winston's Wish
• Pre-bereavement support: palliative care team

• Most people adjust to bereavement over 6-12 months without professional help
• 10% develop prolonged grief disorder (responds to cognitive grief therapy)
• Widowhood effect: 40% increased mortality in first 6 months of bereavement
• Bereavement increases risk of depression (30%), anxiety, cardiovascular disease
• Good pre-bereavement care (honest communication, being present at death, saying goodbye) reduces complicated grief

Models of Grief

Risk Factors for Complicated Grief