Evidence summary

A subset of people experience extreme and disabling grief. [1,2] There has been considerable debate about how and when grief should be identified as abnormal. Intense debates over issues related to abnormal grief in the last few decades have resulted in a range of different and conflicting terminologies.

The most common terms used in clinical practice are 'complicated grief' and 'prolonged grief disorder'. [3] Both are used to describe extreme and abnormal grief, characterised by a yearning and longing for the deceased that impacts negatively on a person’s relationships, employment and life. [1,4] The release of DSM-5 in 2014 introduced another term, Persistent Complex Bereavement-Related Disorder (PCBRD), and highlighted a need for further research. [5-9]

The following circumstances can potentially increase the risk of abnormal grief: [10,11]


  • perception of the death as traumatic and/or sudden
  • witnessing extreme distress
  • death of a child is often associated with lasting and intense grief. [12]

Factors About the Bereaved Person:

  • past history of depression can increase the risk of abnormal grief
  • coexisting stressors such as financial difficulties can intensify grief
  • pre-bereavement depression may be associated with escalation of depression in bereavement
  • widowers and mothers tend to express more intense grief
  • abnormal grief is more likely having experienced multiple losses
  • childhood loss of parent can lead to abnormal grief later in life [13,14] (however, quality of remaining parental care and child’s personality contribute as predictors of outcome)
  • insecure attachment style, childhood abuse and serious neglect, childhood separation anxiety can increase the risk of abnormal grief.

However, whilst it has been shown that treatment interventions can diminish the symptoms of abnormal grief, as yet high level evidence has not shown preventive interventions to be effective, [15] although promising approaches are developing. [3,16]

Tools which measure grief responses have reported good reliability and validity - however their feasibility for use in the Australian palliative care setting is yet to be established [17] and there is also no clear consensus about how screening and assessment of bereavement risk should be performed by palliative care services. [18] A recent Australian report examining services and needs of people experiencing complicated grief examined the available screening tools and while the Bereavement Risk Index (BRI) tool is acknowledged as being commonly used there is limited evidence to support its validation. [19] Specific assessment tools have been proposed for parental bereavement in the PICU. [20]

Cognitive behavioural therapy-based interventions are being studied in bereavement and appear to show evidence of benefit. [21] Provision of bereavement support by volunteers may be effective. [22] Pharmacological treatment of depression may possibly be beneficial for symptoms of depression in bereavement [23] but the interrelationship of grief and depression is controversial, and has been the subject of considerable debate recently. [5]

Transitional hospital-based services for bereaved parents have been shown to be of benefit following the loss of a child. [24]

Children’s grief camps have been shown to be a beneficial strategy for children who are bereaved. [25] Interventions for bereaved children and adolescents were more effective when those who were more symptomatic were targeted. Modalities that showed some evidence of benefit included music therapy, grief-focused school based brief psychotherapy and group based therapy. [26,27]

Practice implications

  • Models of bereavement support services need to continue to evolve in response to new evidence about assessment strategies and effectiveness of different interventions. [21,28,29]
  • The Bereavement Risk Index tool is commonly used but validation studies are lacking.

  1. Prigerson HG, Jacobs SC. Traumatic grief as a distinct disorder: a rationale, consensus criteria, and a preliminary empirical test. In: Stroebe MS, Hansson RO, Stroebe W, Schut H, editors. Handbook of bereavement research: consequences, coping, and care. Washington (DC): American Psychological Association; 2001.
  2. Lundorff M, Holmgren H, Zachariae R, Farver-Vestergaard I, O'Connor M. Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis. J Affect Disord. 2017 Apr 1;212:138-149. Epub 2017 Jan 23.
  3. Dodd A, Guerin S, Delaney S, Dodd P. Complicated grief: Knowledge, attitudes, skills and training of mental health professionals: A systematic review. Patient Educ Coun. 2017 Aug;100(8):1447-1458. doi: 10.1016/j.pec.2017.03.010. Epub 2017 Mar 6.
  4. Zhang B, El-Jawahri A, Prigerson HG. Update on bereavement research: evidence-based guidelines for diagnosis and treatment of complicated bereavement. J Palliat Med. 2006 Oct;9(5):1188-203.
  5. American Psychiatric Association. Highlights of changes from DSM-IV-TR to DSM-5 (343kb pdf). Arlington (VA): American Psychiatric Publishing; 2013.
  6. Boelen PA, Prigerson HG. Commentary on the inclusion of persistent complex bereavement-related disorder in DSM-5. Death Stud. 2012 Oct;36(9):771-94.
  7. Shear MK, Simon N, Wall M, Zisook S, Neimeyer R. et al. Complicated grief and related bereavement issues for DSM-5. Depress Anxiety. 2011 Feb; 28(2):103-17.
  8. Rosner R. Prolonged grief: setting the research agenda. Eur J Psychotraumatol. 2015 May 19;6:27303. eCollection 2015.
  9. Bryant RA. Prolonged grief: where to after Diagnostic and Statistical Manual of Mental Disorders 5th Edition? Curr Opin Psychiatry. 2014 Jan;27(1):21-6.
  10. Stroebe M. Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007 Dec 8;370(9603):1960-73.
  11. Kristjanson L, Lobb L, Aoun S, Monterosso L. A systematic review of the literature on complicated grief. Perth: Commonwealth of Australia Department of Health and Ageing; 2006.
  12. Hendrickson KC. Morbidity, mortality and parental grief: a review of the literature on the relationship between the death of a child and the subsequent health of parents. Palliat Support Care. 2009 Mar;7(1):109-19.
  13. Hart MB. Best practices for treating unresolved grief In children: A qualitative meta-analysis [Dissertation]. Minneapolis (MN): Capella University; 2006.
  14. Morris S, Fletcher K, Goldstein R. The Grief of Parents After the Death of a Young Child. J Clin Psychol Med Settings. 2018 Nov 28. doi: 10.1007/s10880-018-9590-7. [Epub ahead of print]
  15. Wittouck C, Van Autreve S, De Jaegere E, Portzky G, van Heeringen K. The prevention and treatment of complicated grief: a meta-analysis. Clin Psychol Rev. 2011 Feb;31(1):69-78. Epub 2010 Sep 24.
  16. Litz BT, Schorr Y, Delaney E, Au T, Papa A, Fox AB, et al. A randomized controlled trial of an internet-based therapist-assisted indicated preventive intervention for prolonged grief disorder. Behav Res Ther. 2014 Oct;61:23-34. Epub 2014 Jul 24.
  17. Agnew A, Manktelow R, Taylor B, Jones L. Bereavement needs assessment In specialist palliative care: a review of the literature. Palliat Med. 2010 Jan;24(1):46-59. Epub 2009 Sep 17.
  18. Sealey M, O'Connor M, Aoun SM, Breen LJ. Exploring barriers to assessment of bereavement risk in palliative care: perspectives of key stakeholders. BMC Palliat Care. 2015 Oct 14;14:49.
  19. Thompson C, Williams K, Masso M, Morris D, Kobel C, Duncan C, et al. Research into services and needs for people experiencing complicated grief: Final report (1.86MB pdf). Wollongong (AU): Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong; 2017.
  20. Meert KL, Schim SM, Briller SH. Parental bereavement needs in the pediatric intensive care unit: review of available measures. J Palliat Med. 2011 Aug;14(8):951-64. Epub 2011 Jun 1.
  21. Currier JM, Neimeyer RA, Berman JS. Effectiveness of psychotherapeutic interventions for bereaved persons: a comprehensive qualitative review. Psychol Bull. 2008 Sept;134(5):648-61.
  22. Arthur A, Wilson E, James M, Stanton W, Seymour J, University of Nottingham. Bereavement care services: a synthesis of the literature. London: Department of Health; 2011 Jan. p.73
  23. Forte A, Hill M, Pazder R, Feudtner C. Bereavement Care Interventions: a systematic review. BMC Palliat Care. 2004 Jul 26;3:3.
  24. Donovan LA, Wakefield CE, Russell V, Cohn RJ. Hospital-based bereavement services following the death of a child: a mixed study review. Palliat Med. 2015 Mar;29(3):193-210. Epub 2014 Nov 13.
  25. Clute MA, Kobayashi R. Are children's grief camps effective? J Soc Work End Life Palliat Care. 2013;9(1):43-57.
  26. Rosner R, Kruse J, Hagl M. A meta-analysis of interventions for bereaved children and adolescents. Death Stud. 2010 Feb;34(2):99-136.
  27. Bergman AS, Axberg U, Hanson E. When a parent dies - A systematic review of the effects of support programs for parentally bereaved children and their caregivers. BMC Palliat Care. 2017 Aug 10;16(1):39. doi: 10.1186/s12904-017-0223-y.
  28. Remedios C, Thomas K, Hudson P. Psychosocial and bereavement support for family caregivers of palliative care patients: A review of the empirical literature (896kb pdf). Melbourne: Centre for Palliative Care; 2011. p.71
  29. Wilson S, Toye C, Aoun S, Slatyer S, Moyle W, Beattie E. Effectiveness of psychosocial interventions in reducing grief experienced by family carers of people with dementia: a systematic review. JBI Database System Rev Implement Rep. 2017 Mar;15(3):809-839.

Last updated 27 August 2021