How do I know when grief has become prolonged grief disorder?

Prolonged grief disorder (PGD) is distinguished from normal grief by three features: duration (symptoms persisting beyond 12 months in adults), severity (substantial functional impairment at work, in relationships, or in self-care), and specific symptom profile (intense yearning for the deceased or preoccupation with circumstances of death, plus at least three of the eight DSM-5-TR additional criteria). Normal grief, even when intense, follows a trajectory of gradual integration. In PGD, grief remains as raw and functionally impairing after 12 months as it was in the first weeks. Screening with a validated tool such as the Prolonged Grief Disorder-13 (PG-13) questionnaire can assist clinical assessment.

Should I prescribe an antidepressant for grief?

Not unless a comorbid depressive episode or anxiety disorder meets diagnostic threshold independently of the grief. The HEAL trial (2014, JAMA Psychiatry) found citalopram was no better than placebo for PGD symptoms. SSRIs remain appropriate for grief complicated by a concurrent major depressive episode — but the target in that case is the depression, not the grief itself. Prescribing an SSRI for grief without comorbidity risks medicalising a normal response to loss and may delay engagement with effective psychological care.

What is Complicated Grief Therapy and can patients access it in Australia?

Complicated Grief Therapy (CGT) is a 16-session manualised protocol developed by M. Katherine Shear at Columbia University that integrates motivational interviewing, revisiting and imaginal exposure to the circumstances of the death, cognitive restructuring, and work to re-engage with life goals. It outperforms Interpersonal Therapy (IPT) for PGD in randomised trials. In Australia, access is through psychologists with specific CGT training — referral via a MHTP (MBS items 2715/2717 for GP-prepared Mental Health Treatment Plan). The Australian Centre for Grief and Bereavement (ACGB) provides practitioner training and a referral directory.

When is a patient's grief after suicide loss different from other bereavement?

Suicide bereavement (suicide loss survivorship) carries additional risk factors including elevated rates of PGD, PTSD, depression, and suicide risk in the bereaved. Survivors often experience guilt, stigma, and unanswerable questions about why. StandBy Support After Suicide (1300 727 247) is a national 24/7 peer-supported service specifically for suicide-bereaved individuals and the natural first community connection after a suicide death. Assess suicide risk in bereaved patients at every consultation in the acute phase, particularly in those with PGD or prior mental health history.

Are grief support groups recommended?

Peer support groups are appropriate for many bereaved people, particularly those without a strong social support network, and for specific populations such as parents bereaved by infant or child death (Red Nose Grief and Loss) or those bereaved by suicide (StandBy). Groups work through normalising the grief experience and reducing isolation. They are not a substitute for CGT in diagnosed PGD. Community grief support lines — GriefLine 1300 845 745 and the ACGB online directory — can help patients identify local or online group options. For ATSI communities, grief responses are culturally embedded in sorry business practices; refer to community Elders and ACCHO mental health workers rather than mainstream Western grief counselling.

Prolonged grief disorder

Grief and bereavement: normal grief, prolonged grief disorder, and AU GP care

By Dr HB Lo, FACRRM Reviewed 3 July 2026 10 min read

Most bereaved people integrate grief without clinical intervention. GPs support this through psychoeducation and community connection, not routine counselling. Cochrane evidence shows routine bereavement counselling does not accelerate integration.

Prolonged grief disorder (PGD) affects ~7–10% of bereaved people: symptoms persist ≥12 months in adults (≥6 months in children), with intense yearning plus ≥3 of eight specified symptoms. Complicated Grief Therapy (CGT, 16 sessions) is first-line — superior to Interpersonal Therapy in RCTs. SSRIs treat comorbid depression but not PGD itself.

Grief is a universal human response to loss. The general practice encounter with a bereaved patient is one of the most common and important in clinical medicine — yet formal training in bereavement care is limited, and GPs frequently underestimate their capacity to help. This article sets out a structured GP approach to grief: validating normal grief, identifying the minority who develop prolonged grief disorder (PGD), applying appropriate psychological treatment, and connecting patients to Australian bereavement support resources without medicalising a universal human experience.

A — Clinical assessment: normal grief versus prolonged grief disorder

Normal grief: the Dual Process Model

The Kübler-Ross five-stage model (denial, anger, bargaining, depression, acceptance) is deeply embedded in lay and clinical culture but is not supported by prospective research. The stages do not occur in sequence, are not universal, and absence of a stage does not indicate pathology. The Dual Process Model (Stroebe and Schut, 1999) better describes how bereaved people actually function: they oscillate between loss-orientation (confronting the loss — crying, remembering, yearning, experiencing emotional pain) and restoration-orientation (attending to daily life, new roles, identity adjustments). This oscillation is adaptive and naturally shifts over time as restoration-orientation occupies more bandwidth.

Acute grief is intense and appropriate. Features include:

Waves of sadness and tearfulness, often triggered by reminders
Intense yearning to see or speak to the deceased
Disbelief or emotional numbness in the early weeks
Disrupted sleep, reduced appetite, difficulty concentrating
Social withdrawal and reduced engagement with activities
Guilt, regret, or rumination about the relationship or circumstances of death

These symptoms do not constitute a disorder. A GP who conveys that acute grief is normal, that the painful oscillation is healthy, and that time alters (not erases) the grief provides something more valuable than any prescription.

Prolonged grief disorder: DSM-5-TR 2022 criteria

PGD (ICD-11: 6B42; DSM-5-TR: 296.99) is a distinct condition affecting approximately 7–10% of bereaved adults. It was formalised in DSM-5-TR in 2022, resolving years of nosological debate. Diagnosis requires:

Duration: symptoms present for ≥12 months after bereavement in adults; ≥6 months in children
Core criterion (A): clinically significant preoccupation with the deceased (intense yearning/longing, or preoccupation with thoughts or memories of the deceased)
Functional impact: clinically significant distress or impairment in social, occupational, or other important areas of functioning
Symptom criterion (B): ≥3 of the following since the death, at a clinically significant level:
- Identity disruption (feeling part of oneself has died)
- Marked sense of disbelief about the death
- Avoidance of reminders of the reality of the loss
- Intense emotional pain related to the death
- Difficulty reintegrating into relationships and activities
- Emotional numbness or detachment
- Feeling that life is meaningless without the deceased
- Intense loneliness as a result of the death
Exclusions: the disturbance exceeds the expected norms for the bereaved person’s cultural or religious context, and is not better explained by major depressive episode, PTSD, or substance use disorder

Practical screening: The Prolonged Grief Disorder-13 (PG-13) questionnaire, available free from the Center for Complicated Grief at Columbia University, is a validated 13-item tool usable in general practice.

Differentiating PGD from major depression and PTSD

PGD, major depressive episode (MDE), and PTSD can co-occur but are distinct:

Feature	PGD	MDE	PTSD
Core affect	Yearning, longing	Pervasive sadness, anhedonia	Fear, hyperarousal
Focus of intrusion	The deceased, memories	Pervasive hopelessness	Traumatic aspects of death
Positive memories	Often comforting	Associated with sadness	May trigger flashbacks
Treatment	CGT	SSRIs + psychotherapy	Trauma-focused CBT/EMDR

When trauma characterised the circumstances of death (sudden, violent, witnessed), PTSD and PGD frequently co-occur; trauma processing may need to precede grief-focused work.

B — Psychological treatment evidence

Complicated Grief Therapy (CGT)

CGT, developed by M. Katherine Shear and colleagues at Columbia University, is the first-line treatment for PGD with the strongest evidence base. The 2005 RCT (Shear et al., JAMA) compared 16 sessions of CGT versus 16 sessions of IPT in 83 participants with complicated grief. Response rate (PGD symptom reduction to non-caseness) was 51% for CGT versus 28% for IPT — nearly double. A subsequent larger trial replicated these findings.

CGT integrates:

Motivational interviewing and goal-setting
Monitoring and situational processing of grief reactions
Imaginal revisiting: graded exposure to the memory of the death and its circumstances
In-vivo approach to avoided situations
Cognitive restructuring of maladaptive thoughts about the death or the bereaved person’s future
Work to re-engage with long-term life goals and other relationships

In Australia, CGT-trained practitioners can be located through the ACGB practitioner directory. A GP-prepared Mental Health Treatment Plan (MHTP) with referral to a CGT-trained psychologist is the standard access pathway.

Absence of pharmacological evidence for PGD

The HEAL trial (Shear et al., JAMA Psychiatry 2014) randomised bereaved adults with complicated grief to CGT + citalopram, CGT + placebo, clinical management + citalopram, or clinical management + placebo. Key findings:

CGT superior to clinical management (response rates 70% vs 32%)
Citalopram showed no benefit over placebo for PGD symptoms in any arm
The CGT arms outperformed medication-only arms on every PGD outcome measure

The implication is clear: SSRIs have no role in treating PGD as a primary indication. Benzodiazepines are inappropriate in the bereaved — they blunt the emotional processing required for grief integration and increase the risk of dependence in a vulnerable population.

Grief counselling for uncomplicated bereavement

A Cochrane systematic review of grief counselling for bereaved adults without PGD found that routine grief counselling does not accelerate the resolution of normal grief and may produce modest harms (higher distress in some low-risk participants receiving counselling versus no-intervention controls). This evidence supports a targeted approach: psychoeducation and monitoring for all bereaved patients, CGT or structured intervention only for those meeting PGD criteria or showing clear clinical deterioration.

C — Clinical management in general practice

The GP role in the bereavement consultation

The bereaved patient coming to the GP is often doing so for the first time after a death — the GP may be the first clinical person they speak to. The consultation has several functions:

Psychoeducation: explain that grief is painful, normal, and not time-limited by a fixed schedule; validate the oscillation between loss and restoration
Safety assessment: screen for suicidal ideation (elevated in PGD and suicide-bereaved patients), severe functional decline (not eating, not sleeping, not leaving the house for weeks), or substance misuse
Monitoring for PGD: review at 3 months and again at 12 months with a brief structured enquiry; apply the PG-13 if clinical concern
Community connection: provide information about GriefLine (1300 845 745), local support groups, and condition-specific resources
Comorbidity treatment: if MDE or PTSD develops independently, treat according to their own evidence bases

Prepare the environment for grief integration

Sleep disruption is nearly universal in early bereavement. Sleep hygiene advice and brief CBT-I techniques are appropriate; hypnotics should be used with great caution and only for very short periods — they can reduce the emotional processing that is central to grief integration and are not indicated for grief-related insomnia beyond the acute crisis period.

When to refer for psychological support

Refer to a psychologist with CGT training when:

PGD is diagnosed or strongly suspected after 12 months
There is significant functional impairment preventing return to work, relationship breakdown, or total social withdrawal
Suicidal ideation is passive but persistent without acute safety risk requiring emergency care
The patient’s grief is complicated by PTSD from traumatic bereavement (witnessed accident, suicide, homicide, disaster)
The bereaved person specifically requests structured psychological support beyond what the GP can provide

D — Australian operational context: MBS items, community services, and cultural considerations

Relevant MBS items

Item	Description
23 / 36 / 44 / 2199	Standard GP consultation for bereavement assessment and management
2715 / 2717	Mental Health Treatment Plan preparation (unlocks Better Access allied health sessions)
80000–80015	Focused Psychological Strategies by GPs with FPS training
80100–80115	Psychologist sessions under Better Access (10 sessions/calendar year base; extended to 20 with review at 10)
965 / 967	Longer GP consultations for complex bereavement in chronic disease or aged care context

Australian community services

Service	Contact	Population
ACGB — Australian Centre for Grief and Bereavement	grief.org.au	All bereaved; clinical and education hub
GriefLine	1300 845 745	General bereavement telephone and online support
GriefLink	grieflink.org.au	Directory of Australian grief services
StandBy Support After Suicide	1300 727 247	Suicide bereavement; 24/7 follow-up and peer support
Red Nose Grief and Loss	rednose.org.au	Pregnancy loss, infant death, SIDS
Compassionate Friends	compassionatefriends.org.au	Parent and sibling bereavement
13YARN	13 92 76	ATSI community 24/7 crisis and grief support

Notification and medico-legal context

Grief is not a notifiable condition. However, if a bereaved patient discloses information suggesting suicide risk to self or others, standard duty-of-care and jurisdictional mental health legislation obligations apply. Where the death involved trauma — motor vehicle accidents, industrial accidents — GPs should ask about insurance and legal proceedings, as these processes can delay grief integration and complicate psychological treatment timing.

Australian cultural diversity in grief

Australia’s cultural diversity means grief expressions vary enormously. Southeast Asian, Middle Eastern, Pacific Islander, and African communities may have specific mourning rituals, timelines, and community structures that differ from Anglo-Celtic norms. Assess the bereaved person’s cultural context before inferring pathology from unfamiliar expressions of grief. Engage with community-specific services and interpreters as needed.

E — Special populations

ATSI communities and sorry business

Sorry business encompasses the complex cultural, spiritual, and ceremonial obligations ATSI people fulfil following a death. These obligations may require extended time away from work, significant travel, financial contribution to funeral costs, and observance of restrictions on speaking the deceased’s name or showing photographs. GPs working with ATSI patients should ask about sorry business obligations, support time off work as medically appropriate, and refer to ACCHO mental health workers rather than mainstream Western grief counsellors who may not understand the cultural context. 13YARN (13 92 76) provides ATSI-specific crisis and grief support.

Children and adolescents

Children’s grief expressions depend on developmental stage. Young children (under 5) may not understand the permanence of death; school-age children may show academic decline, behavioural changes, or somatic complaints rather than explicit sadness. Adolescents may suppress grief in peer settings and show apparent resilience that masks significant distress.

PGD criteria for children use a 6-month (not 12-month) duration threshold. Referral to a child psychologist with experience in childhood bereavement is appropriate when grief is significantly disrupting school attendance, peer relationships, or family functioning at 6 months. The Australian Child and Adolescent Trauma, Loss and Grief Network (ACATLGN) provides practitioner resources.

Suicide-bereaved individuals

People bereaved by suicide have elevated rates of suicide themselves — a finding that reflects shared psychosocial risk factors and the traumatic nature of suicide loss. The GP should proactively assess suicide risk at every bereavement consultation in this population. StandBy Support After Suicide (1300 727 247) provides immediate, 24/7 community follow-up specifically for suicide-bereaved individuals and families, and is a nationally funded program under Australian Government mental health initiatives.

Aged care patients

Grief in older adults occurs in the context of cumulative losses — spouse, siblings, friends, physical capacity, independence — that may compound each other. PGD is more common in older adults who lose a spouse. The absence of expressed distress in a residential aged care resident does not exclude PGD; cognitive impairment may mask presentation. Social connection interventions, resident chaplaincy, and volunteer visitor programs complement clinical care.

Perinatal bereavement

Miscarriage, stillbirth, and neonatal death are traumatic losses that are frequently minimised by family members and health systems. Acknowledge the significance of the loss explicitly. Red Nose Grief and Loss provides condition-specific peer and professional support. Offer a review consultation at 6 weeks and again at 12 months with deliberate attention to the bereaved parent’s grief trajectory.

When to escalate

Refer for urgent psychiatric assessment or emergency care when:

Active suicidal ideation with plan or intent
Psychotic features (rare but described in severe acute grief)
Severe self-neglect (not eating, not drinking, medical complications)
Substance use at a level that presents immediate risk

Refer to a psychologist (CGT-trained) when PGD is diagnosed or strongly suspected after 12 months in adults or 6 months in children, or when grief is complicated by PTSD.

What this article is and is not

This article is written for clinicians practising in Australian general practice. It reflects eTG Psychotropic 2024, DSM-5-TR (2022), ACGB clinical guidance, and trial evidence current to mid-2026. It is not a substitute for clinical assessment of individual patients, and does not replace specialist consultation for complex presentations. Cultural statements about ATSI communities are general guidance only; individual and community variation is significant.

Sources cited

Frequently asked questions

How do I know when grief has become prolonged grief disorder?

Prolonged grief disorder (PGD) is distinguished from normal grief by three features: duration (symptoms persisting beyond 12 months in adults), severity (substantial functional impairment at work, in relationships, or in self-care), and specific symptom profile (intense yearning for the deceased or preoccupation with circumstances of death, plus at least three of the eight DSM-5-TR additional criteria). Normal grief, even when intense, follows a trajectory of gradual integration. In PGD, grief remains as raw and functionally impairing after 12 months as it was in the first weeks. Screening with a validated tool such as the Prolonged Grief Disorder-13 (PG-13) questionnaire can assist clinical assessment.
Should I prescribe an antidepressant for grief?

Not unless a comorbid depressive episode or anxiety disorder meets diagnostic threshold independently of the grief. The HEAL trial (2014, JAMA Psychiatry) found citalopram was no better than placebo for PGD symptoms. SSRIs remain appropriate for grief complicated by a concurrent major depressive episode — but the target in that case is the depression, not the grief itself. Prescribing an SSRI for grief without comorbidity risks medicalising a normal response to loss and may delay engagement with effective psychological care.
What is Complicated Grief Therapy and can patients access it in Australia?

Complicated Grief Therapy (CGT) is a 16-session manualised protocol developed by M. Katherine Shear at Columbia University that integrates motivational interviewing, revisiting and imaginal exposure to the circumstances of the death, cognitive restructuring, and work to re-engage with life goals. It outperforms Interpersonal Therapy (IPT) for PGD in randomised trials. In Australia, access is through psychologists with specific CGT training — referral via a MHTP (MBS items 2715/2717 for GP-prepared Mental Health Treatment Plan). The Australian Centre for Grief and Bereavement (ACGB) provides practitioner training and a referral directory.
When is a patient's grief after suicide loss different from other bereavement?

Suicide bereavement (suicide loss survivorship) carries additional risk factors including elevated rates of PGD, PTSD, depression, and suicide risk in the bereaved. Survivors often experience guilt, stigma, and unanswerable questions about why. StandBy Support After Suicide (1300 727 247) is a national 24/7 peer-supported service specifically for suicide-bereaved individuals and the natural first community connection after a suicide death. Assess suicide risk in bereaved patients at every consultation in the acute phase, particularly in those with PGD or prior mental health history.
Are grief support groups recommended?

Peer support groups are appropriate for many bereaved people, particularly those without a strong social support network, and for specific populations such as parents bereaved by infant or child death (Red Nose Grief and Loss) or those bereaved by suicide (StandBy). Groups work through normalising the grief experience and reducing isolation. They are not a substitute for CGT in diagnosed PGD. Community grief support lines — GriefLine 1300 845 745 and the ACGB online directory — can help patients identify local or online group options. For ATSI communities, grief responses are culturally embedded in sorry business practices; refer to community Elders and ACCHO mental health workers rather than mainstream Western grief counselling.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.