Grief is a normal response to loss and usually does not require treatment. Prolonged grief disorder, where intense yearning and impairment persist beyond a year, affects about 7 to 10 percent of bereaved people and responds to grief-focused therapy. Grief that brings major depression, suicidal thoughts or PTSD symptoms warrants psychiatric evaluation, and antidepressants help when depression is present.
Stedfast Psychiatry offers grief counseling and psychiatric evaluation for people whose grief has become stuck, who are not sure whether what they feel is grief or depression, or who are facing a loss alongside other mental health conditions. Many of our offices serve communities with large retiree populations, where loss of a spouse is a frequent and under-treated reason for decline.
Symptoms of grief
- Intense yearning or longing for the person who died
- Preoccupation with thoughts or memories of the deceased
- Feeling that part of yourself has died
- Disbelief or difficulty accepting the death
- Avoiding reminders of the loss, or being unable to stop seeking them
- Intense emotional pain, anger, bitterness or guilt related to the death
- Difficulty re-engaging with friends, interests or plans
- Emotional numbness or feeling that life is meaningless
- Loneliness or feeling detached from others
- Symptoms lasting more than a year and impairing daily functioning
Causes and risk factors
Whether grief becomes prolonged depends on the loss and on the person. Losses that are sudden, violent, by suicide or overdose, of a child, or of a spouse after a long marriage carry higher risk. So do a very close or dependent relationship, lack of social support, multiple losses in a short time, prior depression or anxiety, insecure attachment style, and losses complicated by unresolved conflict or by the circumstances of the pandemic, when many people could not be present or hold rituals. The brain's attachment and reward systems, which encoded the relationship, do not update quickly after a death, and in prolonged grief the yearning response stays active in a way that resembles craving. Grief-focused therapy helps those systems adapt.
Prolonged grief disorder affects an estimated 7 to 10 percent of bereaved adults, with higher rates after sudden or violent deaths.
Source: American Psychiatric Association, DSM-5-TR (2022); Lundorff et al., Journal of Affective Disorders, 2017
Prolonged grief disorder therapy produced response in 71 percent of patients compared with 32 percent for interpersonal psychotherapy in the original randomized trial.
Source: Shear et al., JAMA, 2005
In a four-site trial, grief-focused therapy was effective for prolonged grief while the antidepressant citalopram alone was not better than placebo for grief symptoms, though it helped co-occurring depression.
Source: Shear et al., JAMA Psychiatry, 2016
Widowed adults have an elevated risk of death in the months after a spouse's death, sometimes called the widowhood effect, with risk highest in the first three months.
Source: Moon et al., PLOS ONE, 2011 meta-analysis
How we diagnose it at Stedfast Psychiatry
A grief evaluation at Stedfast Psychiatry begins with listening: who you lost, how, and what your days look like now. We use the Prolonged Grief Disorder scale (PG-13) and the Inventory of Complicated Grief to measure intensity, and the PHQ-9, GAD-7 and PCL-5 to assess whether depression, anxiety or trauma symptoms are also present, since each calls for a different plan. We distinguish prolonged grief from major depression: in grief, the pain is focused on the loss and comes in waves alongside moments of connection and even humor, with self-esteem usually intact; in depression, the mood is pervasively low across all areas, with worthlessness, and often loss of interest in everything. We assess suicide risk carefully, particularly in older widowed men and in parents who have lost a child. We also review sleep, alcohol use, appetite and physical health, since all are affected by loss.
Treatment options
Medication management
Medication does not treat grief itself, and we do not medicate normal grief. When grief has brought on major depression, antidepressants such as sertraline, escitalopram or bupropion are effective, and treating the depression allows grief to proceed. For insomnia after a loss, short-term use of low-dose trazodone, doxepin or mirtazapine helps restore sleep without the risks of benzodiazepines or zolpidem, which we avoid because they blunt emotional processing and raise fall risk in older adults. When PTSD symptoms follow a traumatic death, SSRIs and prazosin for nightmares are used as in PTSD. Anxiety that spikes around anniversaries may be managed with short-term hydroxyzine. We review and often simplify medications in older adults who have lost a spouse, since the person who managed their pills may be gone.
Psychotherapy
Grief counseling provides a place to tell the story of the loss, make sense of it, and find a way to carry it, and for many people a few sessions are enough. For prolonged grief disorder, prolonged grief disorder therapy (developed by Dr. Katherine Shear, formerly called complicated grief treatment) is the best-studied approach: 16 sessions that combine revisiting the death, gradual re-engagement with avoided situations, strengthening the ongoing bond with the person who died, and rebuilding goals; it outperformed both interpersonal therapy and antidepressants in randomized trials. CBT for grief and meaning-centered approaches are also effective. For traumatic loss, trauma-focused therapy may come first. We also connect patients with support groups through hospices, GriefShare, The Compassionate Friends for bereaved parents, and survivors of suicide loss groups.
What to expect
Your first visit is a 45 to 60 minute conversation, in person or by video, with no expectation that you be composed. We assess where you are, whether what you are experiencing is grief alone or grief with depression, trauma or anxiety, and what would help. Some patients need a few counseling sessions, some need a structured course of grief therapy, and some need treatment for depression first. Follow-ups are scheduled to your needs. Telehealth is available throughout Florida and South Carolina and is often easier in the months after a loss.
When to seek help
Seek help if, a year or more after a loss, you are still unable to function, if you feel your life ended with theirs, or if you are avoiding everything connected to the person. Seek help sooner if you are not eating or sleeping, drinking more, unable to work or care for yourself, or if depression has settled in. If you are having thoughts of joining the person who died or of ending your life, call or text 988 or go to the nearest emergency room; these thoughts are common in grief and they are treatable. Wanting to die is not the same as wanting to be with them, and we can help you see the difference.
Types of loss and grief
Bereavement after a death is the most studied form, but grief follows many losses: divorce, miscarriage and stillbirth, infertility, loss of health or mobility, job loss, retirement, a child leaving home, a pet's death, and the slow loss of a person to dementia, which is called anticipatory or ambiguous grief. Disenfranchised grief describes losses that others do not recognize as warranting grief, such as an ex-spouse, an affair partner, a pregnancy loss or a death by overdose, and it is often harder because support is absent. Traumatic grief follows sudden, violent or unexpected deaths and combines grief with trauma responses that may need trauma-focused treatment. Each is real, and each can become prolonged.
Prolonged grief disorder
DSM-5-TR added prolonged grief disorder in 2022 after decades of research showing that a minority of bereaved people develop a distinct, persistent syndrome that does not respond to antidepressants or generic support. The criteria require at least 12 months since the death in adults, daily intense yearning or preoccupation, and at least three of a set of symptoms including identity disruption, disbelief, avoidance, intense emotional pain, difficulty reintegrating, numbness, meaninglessness and loneliness, with clinically significant impairment. Naming it is not pathologizing grief; it identifies the people for whom a specific, effective treatment exists.
Grief and physical health
Grief affects the body. Sleep disruption, appetite changes, fatigue, chest tightness and a weakened immune response are common in the early months, and the risk of heart attack and death rises in the weeks after losing a spouse. Older adults who lose the person who prepared meals or managed medications are at risk of malnutrition and medication errors. Alcohol use often increases. We attend to these directly, coordinate with primary care, and treat the insomnia that, left alone, deepens depression.
What helps
There is no correct way to grieve and no timeline. What helps most people is being able to talk about the person without others changing the subject, maintaining basic routines of sleep and meals, allowing both pain and moments of relief without guilt, gradually approaching avoided places and tasks rather than avoiding them indefinitely, and finding ways to keep the relationship alive through memory, ritual or continuing what the person valued. Support groups with people who have had similar losses reduce the isolation that makes grief heavier. Anniversaries, holidays and birthdays are predictably hard, and planning for them helps.
Outlook
Most people adapt to loss over time, and adapting does not mean forgetting. For those whose grief becomes prolonged, grief-focused therapy works for the majority, and treating co-occurring depression or PTSD restores the capacity to grieve and to live. The goal is not to stop missing the person. It is to carry them in a way that leaves room for the rest of your life.
Frequently asked questions
How do I know if my grief is normal or something more?
Normal grief is painful and can last a long time, but it changes: the waves become less frequent, you reconnect with people and activities, and you can think about the person with warmth as well as pain. Grief that is stuck looks the same at 18 months as at 3 months, with constant yearning, avoidance of reminders or inability to stop seeking them, and a sense that life cannot go on. If you are not sure, that itself is a good reason for a conversation with a clinician.
What is the difference between grief and depression?
Grief centers on the loss and comes in waves; you can still feel moments of connection and your self-worth is usually intact. Depression is pervasive, flattens everything, and brings worthlessness, guilt unrelated to the death, and loss of interest in all areas. The two can coexist, and about one in five bereaved people develops major depression in the first year. Depression responds to antidepressants and therapy; grief itself responds to grief-focused therapy. We assess both.
Do I need medication for grief?
Not for grief itself. Grief is not a disorder, and antidepressants do not reduce grief in clinical trials. Medication is appropriate when grief has triggered major depression, severe insomnia, or PTSD after a traumatic death, and in those cases it helps the person engage in grief work. We are careful not to medicate away a normal process, and equally careful not to miss a treatable depression.
What is grief counseling and how long does it take?
Grief counseling is supportive therapy that helps you process a loss, understand your reactions, and find ways to honor the person while rebuilding your life. For most people, a handful of sessions over a few months is enough. For prolonged grief disorder, a structured 16-session therapy has the best evidence. Support groups, which are free and widely available through hospices and community organizations, complement individual work.
Can grief counseling be done by telehealth?
Yes, and many people prefer it in the early months when leaving the house is hard, when they are exhausted from caregiving and funeral arrangements, or when they live far from an office. Grief counseling, prolonged grief therapy and psychiatric evaluation for depression all work by video, and we see patients across Florida and South Carolina. In-person visits are available at all 13 offices for those who prefer them.
Is grief counseling covered by insurance?
Psychiatric evaluation and psychotherapy are covered by most major insurance plans and Medicare as outpatient mental health care, billed with a diagnosis such as adjustment disorder, prolonged grief disorder or depression as appropriate. Our self-pay rate for a new evaluation is $185. Hospice bereavement programs offer free support to families for 13 months after a death, whether or not the person was in hospice.
How do children grieve, and when should a child see someone?
Children grieve in bursts, moving between sadness and play, and may show it through behavior, sleep, school problems or physical complaints rather than words. Their understanding of death and their questions change with age. Most children do well with honest, age-appropriate information and a stable caregiver. See a clinician if a child's functioning has not recovered after several months, if they are withdrawn or anxious about other losses, or if the death was traumatic. Our child and adolescent providers treat grieving children and support parents.
I lost my spouse after 50 years. Is it normal to feel like I cannot go on?
It is very common and it is also the situation we watch most closely. Older adults who lose a long-term spouse face the loss of their companion, their daily structure, and often the person who managed health, meals or finances, and the risk of depression, decline and suicide rises in the first year. Grief counseling, treatment of depression if it develops, attention to sleep and nutrition, and reconnection with community make a measurable difference. You do not have to do this alone.
Where to get treatment for grief, loss and complicated grief
Evaluation and treatment for grief, loss and complicated grief is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.