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Key PointsProlonged Grief DisorderProlonged grief disorder is a post-loss stress syndrome in which grief after a death remains intense and preoccupying longer than is expected according to social, cultural, or religious norms (a minimum of 6 months, according to the International Classification of Diseases and Related Health Problems, 11th revision, or 12 months, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Persistent, intense yearning, longing, or preoccupation with the deceased person and other grief-related symptoms cause clinically significant distress and impairment.An estimated 3 to 10% of persons who are bereaved owing to a death by natural causes have prolonged grief disorder, with substantially higher percentages among persons whose bereavement is caused by death of a child or partner or is the result of a sudden, unexpected death (e.g., violence or suicide).A simple patient-reported rating scale can be used to screen and monitor persons with prolonged grief disorder.Clinical evaluation of possible prolonged grief disorder should also assess other mental health conditions, including depression, anxiety, post-traumatic stress disorder, alcohol and substance use, suicide risk, and effects of symptoms on social and occupational functioning.Evidence-based grief-focused psychotherapies constitute first-line treatment. Antidepressant therapy has not shown efficacy for prolonged grief disorder but can be helpful for managing co-occurring depression symptoms.

Bereavement is a common experience in adults aged 60 and older. Loss of a loved one usually leads to acute grief characterized by yearning and longing, decreased interest in ongoing activities, and frequent thoughts of the deceased. For most, acute grief naturally evolves into a state of integrated grief, where the bereaved is able to reengage with everyday activities and find interest or pleasure. About 7 % of bereaved older adults, however, will develop the mental health condition of Complicated Grief (CG). In CG, the movement from acute to integrated grief is derailed, and grief symptoms remain severe and impairing. This article reviews recent publications on the diagnosis of CG, risk factors for the condition and evidenced-based treatments for CG. Greater attention to CG detection and treatment in older adults is needed.

Complicated grief is intense grief after the death of a loved one that lasts longer than expected according to social norms and causes functional impairment. Psychotherapy directed at the loss and at restoring activities and effective functioning is recommended. Foreword This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations. Stage A 68-year-old woman seeks care from her primary physician because of trouble sleeping 4 years after the death of her husband. On questioning, she reveals that she is sleeping on a couch in her living room because she cannot bear to sleep in the bed she shared with him. She has stopped eating regular meals because preparing them makes her miss him too much; she still has meals that she cooked for him in her freezer. The patient often ruminates about how unfair it was for her husband to die, and she is alternately angry with the medical staff . . .

Complicated grief, which is often under-recognized and under-treated, can lead to substantial impairment in functioning. The Brief Grief Questionnaire (BGQ) is a 5-item self-report or interview instrument for screening complicated grief. Although investigations with help-seeking samples suggest that the BGQ is valid and reliable, it has not been validated in a broader population. A questionnaire was mailed to a randomly selected sample (n = 5000) residing in one of 4 areas of Japan. The BCQ was examined for responders who were bereaved more than 6 months and less than 10 years (n = 915). Non-specific psychological distress was assessed with the K6 screening scale. Multiple group confirmatory factor analysis supported a uni-dimensional factor structure and the invariance of parameters across gender and age. Cronbach's alpha was sufficiently high (alpha = .75) to confirm internal consistency. Average Variance Extracted (0.39) was higher than the shared covariance (0.14) between BGQ and K6, suggesting discriminant validity. The results of this study support the reliability and validity of the BGQ in the Japanese population. Future studies should examine predictive validity by using structured interviews or more detailed scales for complicated grief.

Patients' perspectives concerning impaired functioning provide important information. AIMS; To evaluate the reliability and validity of the Work and Social Adjustment Scale (WSAS). Data from two studies were analysed. Reliability analyses included internal scale consistency, test-retest and parallel forms. Convergent and criterion validities were examined with respect to disorder severity. Cronbach's alpha measure of internal scale consistency ranged from 0.70 to 0.94. Test-retest correlation was 0.73. Interactive voice response administrations of the WSAS gave correlations of 0.81 and 0.86 with clinician interviews. Correlations of WSAS with severity of depression and obsessive-compulsive disorder symptoms were 0.76 and 0.61, respectively. The scores were sensitive to patient differences in disorder severity and treatment-related change. The WSAS is a simple, reliable and valid measure of impaired functioning. It is a sensitive and useful outcome measure offering the potential for readily interpretable comparisons across studies and disorders.

Distinguishing a disorder of persistent and impairing grief from normative grief allows clinicians to identify this often undetected and disabling condition. As four diagnostic criteria sets for a grief disorder have been proposed, their similarities and differences need to be elucidated. Participants were family members bereaved by US military service death (N = 1732). We conducted analyses to assess the accuracy of each criteria set in identifying threshold cases (participants who endorsed baseline Inventory of Complicated Grief ⩾30 and Work and Social Adjustment Scale ⩾20) and excluding those below this threshold. We also calculated agreement among criteria sets by varying numbers of required associated symptoms. All four criteria sets accurately excluded participants below our identified clinical threshold (i.e. correctly excluding 86-96% of those subthreshold), but they varied in identification of threshold cases (i.e. correctly identifying 47-82%). When the number of associated symptoms was held constant, criteria sets performed similarly. Accurate case identification was optimized when one or two associated symptoms were required. When employing optimized symptom numbers, pairwise agreements among criteria became correspondingly 'very good' (κ = 0.86-0.96). The four proposed criteria sets describe a similar condition of persistent and impairing grief, but differ primarily in criteria restrictiveness. Diagnostic guidance for prolonged grief disorder in International Classification of Diseases, 11th Edition (ICD-11) functions well, whereas the criteria put forth in Section III of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are unnecessarily restrictive.

Bereavement, one of life’s most difficult experiences, usually triggers acute grief with yearning and longing for the deceased person that is often intense and preoccupying, along with frequent thoughts and memories of the person who died and relatively little interest in anything unrelated to the deceased loved one. Anxiety is a very common feature of grief that is often neglected. Anxiety is a natural response of the attachment system to separation from a loved one, seen in adults as well as children. Confrontation with one’s own death is also a natural trigger of anxiety, though we usually protect ourselves from mortality salience using terror management strategies related to cultural values and self-esteem. In addition, loss of a loved one can trigger the onset of a DSM-IV anxiety disorder that, when present, can derail the mourning process and prolong acute grief. Bereavement-related anxiety disorders need to be recognized and treated.

This paper discusses each of several potential consequences of bereavement. First, we describe ordinary grief, followed by a discussion of grief gone awry, or complicated grief (CG). Then, we cover other potential adverse outcomes of bereavement, each of which may contribute to, but are not identical with, CG: general medical comorbidity, mood disorders, post-traumatic stress disorder, anxiety, and substance use.

A minority (9%–20%) of bereaved individuals experience symptoms of persistent intense grief associated with significant distress and impairment. This recently identified distinct post-loss syndrome has been variously named complicated grief, prolonged grief disorder, traumatic grief and persistent complex bereavement disorder. The Inventory of Complicated Grief (ICG) is a self-report instrument used to reliably identify this syndrome. We undertook a study to: 1) validate the Italian version of the ICG; 2) examine its performance in a clinical of bereaved individuals with complicated grief, post-traumatic stress disorder, bipolar disorder and healthy controls. Study participants included 171 bereaved individuals clinically diagnosed with complicated grief (n=64); post-traumatic stress disorder (n=72); bipolar disorder (n=35) and 58 bereaved healthy controls. Assessments included the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I/P) and the Italian version of the ICG. The mean total ICG score was significantly different among the study groups [F(3.228)=94.19, p<.001]. Post-hoc Games–Howell comparisons indicated significantly higher scores in complicated grief patients with respect to the other three groups and significantly lower scores in healthy controls compared to all other participants. The scale demonstrated a high level of internal consistency: Cronbach’s alpha value for the whole sample was 0.947. Factor analyses demonstrated a single-factor solution. This study provides evidence of the validation of the Italian version of the ICG, tested in a large and well-characterized clinical help-seeking population. These data further support the existence of a unique grief-related syndrome different from bipolar and post-traumatic stress disorders.

To describe the burden of Generalized Anxiety Disorder (GAD), a common anxiety disorder in older adults. Cross-sectional. Late-life depression and anxiety research clinic in Pittsburgh, PA. One hundred sixty-four older adults with GAD and 42 healthy comparison participants with no lifetime history of psychiatric disorder were recruited from primary care and mental health settings as well as advertisements. Participants were evaluated with the Late Life Function and Disability Index to assess disability, the MOS 36-Item Short Form Survey Instrument to assess health-related quality of life (HRQOL), and the Cornell Service Index to assess healthcare utilization. Older adults with GAD were more disabled, had worse HRQOL, and had greater healthcare utilization, than nonanxious comparison participants, even in the absence of psychiatric comorbidity. After controlling for medical burden and depressive symptoms, higher severity of anxiety symptoms was associated with greater disability and poorer HRQOL in several domains. The greatest decrements in HRQOL and function were observed in measures assessing role functioning, including social function. This study, the largest ever of GAD in older adults, provides evidence of the significant burden of this disorder in late life. Given the high prevalence and chronicity of GAD in the elderly, these data provide a public health imperative for finding and implementing effective management strategies for this typically undiagnosed and untreated disorder.