Grief, bereavement and complicated grief

Definitions. Bereavement is the objective fact of loss; grief is the emotional response; mourning is its social and cultural expression. Anticipatory grief begins from the moment a life-limiting illness is diagnosed — for an elderly couple this marks the start of a painful parting.

Normal grief. Waves of yearning, sadness, disbelief and searching behaviour, sometimes with transient hallucinations of the deceased (culturally normal). Functioning gradually returns over weeks to months. No active treatment is required.

Complicated (prolonged) grief. Characterised by extreme traumatic distress, numbness, disbelief, bitterness, feeling that part of oneself has died, and assuming the symptoms of the deceased, with symptoms enduring beyond 6 months and causing functional impairment.

Warning signals / risk factors. Sudden or unexpected death, traumatic death, loss of a child, and loss of a partner with an ambivalent relationship ("can't live with, can't live without"). Also — lack of social support, female sex, older age, previous psychiatric illness, and death in an ICU.

Consequences. Decline in health, increased healthcare utilisation and increased mortality — highest in the first 6 months. Bereaved elders are at risk of depression, cardiac events (including takotsubo cardiomyopathy), intercurrent infection, and suicide. In India, widowhood also brings loss of income, social status and property rights — link to the MWPSC Act 2007 and Elder Line 14567.

Management. Normal grief needs support, not medication — family, faith and community, support groups, and practical help. Complicated grief responds to grief-specific psychotherapy (complicated grief therapy), brief dynamic psychotherapy, and crisis intervention. Antidepressants are for comorbid major depression, not for grief itself. Hospice programmes provide bereavement follow-up for about one year.

Prolonged Grief Disorder is now a formal diagnosis — in DSM-5-TR (2022) requiring ≥12 months since the death in adults, and in ICD-11 requiring ≥6 months. The Lancet 2025 Seminar on prolonged grief disorder and RCTs in JAMA Psychiatry (Bryant 2024; Rosner 2025) confirm grief-specific CBT / Prolonged Grief Therapy as first-line, superior to interpersonal and present-centred therapy, with antidepressants adding no benefit over psychotherapy alone.