Grief is a natural response to losing a loved one that often causes intense yearning, longing and preoccupation with the person who died, along with sadness, anger, anxiety and loneliness. Over time, grief changes and usually subsides with support of family and friends.
While grief and mourning are common rituals after losing someone, when intense grief persists for more than a year, you may be suffering from prolonged grief. The American Psychiatric Association has classified this form of prolonged grief as its own mental disorder and added it to its official psychiatric diagnostic handbook.
As the country faces nearly one million deaths caused by COVID-19, prolonged grief is becoming more prevalent than ever. “The escalating number of deaths during the pandemic made grief more common and more talked about in the mainstream media,” says Dr. Katherine Shear, professor of psychiatry at Columbia University School of Social Work in New York City. “The ways in which people died during the pandemic are especially challenging and will likely lead to higher rates of prolonged grief disorder.”
Dr. Amy Bloch, a psychiatrist in Westchester, New York, has been seeing more bereaved people over the past two years. “With people losing loved ones from COVID-19, I’m seeing quite a few people coming in with persistent intense grief that’s lasted more than 12 months.”
What Is Prolonged Grief?
Prolonged grief happens after losing someone close and is characterized by a persistent and debilitating grief response lasting at least 12 months for adults or six months for children and adolescents. The research around prolonged depression began in the 1980s when doctors noticed that some people in mourning did not respond to antidepressants or interpersonal psychotherapy for depression. “This led to a groundswell of research worldwide that includes more than 1,000 papers on this area of grief research,” Shear adds.
In prolonged grief disorder, the grieving individual experiences intense longings for their loved ones or preoccupation with thoughts and memories of them most of the day, nearly every day for at least a month. The persistence of intense grief exceed social, cultural or religious norms and are unrelated to other mental disorders such as major depression, anxiety and post-traumatic stress disorder, or PTSD.
Health Risks of Severe Grieving
Prolonged grief disorder can sometimes lead to other serious health consequences – from heart disease to other mental health disorders. Studies show that those with prolonged grief disorder have significantly increased risk of hospitalization for heart attacks, heightened risk of high blood pressure and cancer, sleep disturbance and are susceptible to substance abuse.
“We have also seen a significant risk of suicidal thoughts and behavior so it’s critical to recognize this condition to help avoid these physical and mental effects,” says Dr. Holly Prigerson, professor of geriatrics and co-director of Cornell’s Center for Research on End-of-Life Care in New York City.
Symptoms of Prolonged Grief
Researchers looked at results from 14 separate studies and found that an estimated one in 10 people mourning the loss of a loved one may experience prolonged grief. The study found people with prolonged depression are typically older and at greater risk of long-term mental and physical health problems.
In addition to intense longing for the person who died or preoccupation with thoughts and memories of them, symptoms of prolonged grief disorder may include:
- Avoiding reminders that the loved one passed away.
- Feeling detached from others.
- Difficulty moving on with life, including problems engaging with friends, pursuing interests and planning for the future.
- Emotional pain, including anger, bitterness and sorrow.
- Extreme loneliness.
- Feeling that life is meaningless.
- Identity issues, including feeling as though part of oneself has died.
- Interruption in daily functioning.
Diagnosis of Prolonged Grief Disorder
Doctors have several tools at their disposal to screen for prolonged grief disorder. The most widely used questionnaire is the Inventory of Complicated Grief that includes 19 questions rated on a five-point scale. There’s also a five-question self-assessment that is available through the Center for Prolonged Grief.
Acute grief does not usually require treatment and support from a mental health professional because people learn to adapt over time and the intensity of grief decreases. However, prolonged grief disorder usually requires diagnosis and treatment by a doctor or other mental health professional.
Treating Prolonged Grief
There are several ways to manage prolonged hair. Psychotherapy is considered the standard treatment for prolonged grief. In addition, psychiatrists have developed a tailored therapy called complicated grief treatment that has been tested under three National Institute of Mental Health-funded grants and extensively studied in global research. This approach focuses on helping people identify and resolve grief, accept the reality of the loss and restore their capacity for well-being.
The way it works, describes Shear, is that a therapist works with the bereaved individual over a 16-week period to help them come to terms with their loss and restore their capacity to thrive. They focus on learning to accept grief as a natural, lasting response, finding ways to manage emotions, beginning to see some promise in the future, strengthening their relationships, narrating a story of the death, gaining a comfort level in living with reminders of their loss and connecting with memories of the person who died.
Shear led one study that about 150 grieving older adults receiving psychotherapy for depression compared to examined tailored grief treatment. The study showed that both treatments helped, but individuals who received tailored grief treatment were more than twice as likely to experience improvement in grief.
Some people find help through bereavement support groups where they meet other people facing similar grieving issues. These groups are typically available through community centers or local churches. Mindfulness and meditation exercises can also be helpful, and practicing self-care such as nutritious eating, adequate rest, exercise and socializing are recommended, Prigerson says.
“We are finding that those who use daily journaling are having significant reductions in the intensity of their symptoms in a short time frame,” Prigerson explains.
Antidepressants are often used in the management of prolonged grief disorder, but there have only been a few studies to test their efficacy. One study divided nearly 400 bereaved adults into four groups: those receiving the antidepressant citalopram alone, placebo, complicated grief treatment with citalopram and complicated grief treatment plus placebo. At the conclusion of the study, researchers showed that citalopram did not improve the response rate to complicated grief treatment.
A follow-up paper from this study examined 58 people who lost someone to suicide. The patients were treated with citalopram plus complicated grief support versus people treated with placebo with simple grief support or complicated grief support. The study showed that adding the antidepressant to complicated grief support provided no additional benefit over placebo and grief support.
“These studies show that complicated grief treatment is the optimal therapy for prolonged grief and the addition of citalopram only helps the co-occurring symptoms of depression,” Shear says.