- Expressions of grief can vary widely from person to person
- Most people who experience normal grief do not require specialist counselling, but would benefit from reassurance, acknowledgement of their losses, and access to information
- A proportion of people who grieve may experience intense distress over a prolonged period
- A number of options for referral for bereavement difficulties exist:
- Specialist bereavement counsellors
- Palliative care services usually offer bereavement follow up to their clients, often based on bereavement risk assessment, and may also sometimes accept referrals from other sources
- Other mental health professionals with appropriate skills and expertise.
Bereavement refers to the event of death of a person with whom there has been an enduring relationship.
Grief is how bereavement affects us personally, with effects across several domains – emotional, cognitive, social, physical, financial and spiritual. Grief often causes disruption and disturbance of everyday life. However, grief can be expressed in very different ways: some people do not experience an intense reaction. Most people experience fluctuating reactions for a period of time while others can develop an intense and prolonged grief response. [1,2] Culture plays a major role in the expression of grief. 
Common expressions of grief are varied and can include: 
- Loss of pleasure
- Shock and numbness.
- Thinking all the time about the person who has died
- A sense that the dead person is still about
- Over or under activity
- Social withdrawal
- Loss of appetite
- Sleep disturbances
- Susceptibility to illness.
What is known
For most people, grief is accommodated over time with support of family and friends.  Identifying the fact that there may also be positive outcomes of bereavement, including the potential for post-traumatic growth, is a recent development within the field;  'resilience' is one of the key concepts that is being used to understand and acknowledge the way that people deal with their grief and bereavement. 
There is no evidence that sharing and disclosure of feelings will lead to ‘healthy’ or less intense grieving for those people who experience normal grief reactions.  There is also no evidence that grief counselling improves outcomes for people who experience normal grief. [8-10]
Protective factors in the health outcomes of bereavement may include: 
- Responsive health care for the dying patient and reduction of patient distress before death
- Optimistic and resilient personality characteristics of bereaved individuals
- Secure relationships with family and community.
Common patterns of response to spousal bereavement have been identified. Spousal loss occurs most frequently in later life, more often affects women, and for many bereaved spouses, it interacts with and compounds other health concerns. Maintaining independence is a common challenge in this situation for older people. 
Bereavement is a period of increased mortality for spouses. A meta-analysis has confirmed that men who are widowed are particularly at risk, and the first six months is the highest risk period.  The risk is associated with both expected and unexpected deaths, but social support may reduce the risk. Patient end-of-life interventions may positively influence bereavement outcomes for spouses.  The increased risk is unrelated to the age of the bereaved person. Cardiovascular risk for the spouse who survives is increased, particularly in the first few weeks.  The vulnerability may be due to both the physiological impacts of grief, and also to altered health behaviours. There is evidence that in late-life spousal loss health behaviour changes can affect sleep, alcohol use, and nutritional intake causing involuntary weight loss. 
Bereavement in childhood is common. About 5% of children will lose a parent or sibling, and up to 75% will experience the loss of a relative or friend before the age of 16.  Most often this is associated with short term negative impact, but few longterm difficulties.
The impact of caregiving on grief and bereavement is being studied. High levels of social and emotional support can modify bereavement distress, and there is some evidence that receiving support from palliative care services, and home deaths, may improve bereavement outcomes for caregivers. 
Active research areas / controversies
- There is a trend in research which is critical of stage-based models of grief that suggest bereaved people ‘move on’ from their grief and relinquish the bond or connection to the dead person. [4,18]
- Research suggests that normal grief differs from abnormal grief in a variety of ways, and that abnormal grief is distinct from other psychiatric diagnoses such as depression, anxiety and PTSD. Associated assessment tools and new treatment strategies are evolving based on improved understandings of these phenomena. [18,19]
- Research is needed into the personal profile of those at risk of abnormal grief, including psychological characteristics and interpersonal factors, such as their perception of social and community supports. [3,5] Issues of screening, referral and how to match intervention to the individual require further research.
- Specific grief considerations for different groups such as parents, [9,21,22] fathers,  children,  spouses,  those from different cultural backgrounds,  in the setting of perinatal loss,  and in indigenous populations, need further investigation.
- Research into the efficacy of bereavement interventions needs attention. While specific bereavement interventions appear to assist those people experiencing abnormal grief, more detail is needed. Cost effectiveness of bereavement services has not been well studied. 
- Little is known about how and to what extent bereaved people are cared for in primary care, nor the impact of that care. 
- The grief experiences of health care providers have not been well-studied, but these may have significant impact on health service delivery, and result in both emotional and economic costs to the system.