A public health perspective on Prolonged Grief Disorder

Two women sit on a couch while in emotional distress and grieving

Chris Giang

Bachelor’s student in Public Health Sciences

November 17, 2023

Every day, millions of Americans grieve the death of a loved one. Some bereaved individuals will find their grief so emotionally intense that it persists an unusually long time, causes various problems and interferes with daily life. As of March 2022, the American Psychiatric Association now calls this Prolonged Grief Disorder (PGD).

PGD can prevent healthy adjustment following the death of a loved one, and  PGD is associated with major public health concerns, such as increased suicidality and suicidal thinking, risk for cardiovascular health, and substance misuse for bereaved individuals. PGD may also have disproportionate effects on communities of color, with studies showing Black individuals reporting more severe maladaptive grief reactions compared to white individuals due to the increased exposure to homicide among Black individuals and communities. Additionally, losing a loved one during the COVID-19 pandemic is a risk factor for PGD, with communities of color potentially being at higher risk due to racial disparities in COVID-19 deaths. Other predictors of PGD include a history of depression, relationship to the deceased, and experiencing the death of a loved one that happens very suddenly or under traumatic circumstances (e.g., youth witnessing death from gun violence).

In March 2022, PGD became the newest disorder to be added to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision. There were many contributing factors that led to PGD finally being recognized as a distinct disorder in the DSM-5-TR. One of these factors was COVID-19, with many bereavement experts believing that the unprecedented amount of deaths from COVID-19 would lead to an increase in incidences of PGD—making PGD a major public health concern.

Definitions and diagnostic criterias relevant to PGD

According to the American Psychological Association, bereavement is the condition of having lost a loved one to death, while grief is the psychological or behavioral response arising from bereavement. The bereaved person may experience a wide range of grief reactions, and it should be noted that individual grief reactions and mourning responses may vary from person to person. Furthermore, despite the long held belief that grief can be categorized into stages (denial, anger, bargaining, depression, acceptance), there has not been any compelling empirical evidence supporting the notion that grief reactions and trajectories can fit into clear stages. Instead, current bereavement literature views grief as a natural response to the death of a loved one, with grief reactions gradually decreasing over time for most bereaved individuals.

Only a small subset of bereaved individuals will continue to feel intense grief reactions, which is where PGD fits into the DSM-5-TR. Approximately 10% of bereaved children and adults experience PGD and its symptoms, although almost no studies have examined the incidence or prevalence rates of PGD in youth, which can manifest differently than in adults. PGD is characterized by intense and persistent grief reactions that can become maladaptive if these reactions cause impairment to daily life, as well as hinder a bereaved individual's ability to be able to successfully cope with their grief in a healthy way. These maladaptive grief reactions may include distressing thoughts about the death, yearning for their deceased person to return, and disruption in one’s identity or purpose in life after the death of their loved one. Other maladaptive reactions seen in bereaved individuals may also include substance misuse, self-harm, and social withdrawal. PGD often occurs alongside other mental disorders, such as PTSD, anxiety, and depression, which can make it harder to grieve for bereaved individuals. 

One criticism of the inclusion of PGD in the DSM-5-TR is that it may pathologize the normal grieving process and stigmatize bereaved individuals. To avoid pathologizing the normal grief process, the DSM-5-TR committee specifically chose 12 months as the cutoff point at which a bereaved adult can be diagnosed for PGD; for children, that cutoff point is 6 months. Despite concerns related to stigma, a study found that more than 90% of the bereaved respondents reported feeling relieved to know that having a diagnosis was indicative of a recognizable psychiatric condition, with 100% of participants reporting interest in receiving treatment for their severe grief symptoms. Additionally, another study found that labeling PGD symptoms with a diagnosis does not produce additional public stigma than those already associated with grief reactions.

Treatments and interventions for PGD

For any treatments and interventions pertaining to PGD, it is important to help facilitate adaptive grief reactions and promote healthy coping techniques for bereaved individuals. Potential treatments for PGD include Prolonged Grief Disorder Therapy (PGDT), which focuses on seven “Healing Milestones” that include understanding grief, managing emotions, seeing a promising future, strengthening relationships, narrating the story of the death, learning to live with reminders, and connecting with memories of the person who died. Another treatment that accomplished similar grief themes, but with an emphasis on adolescents, is Trauma and Grief Component Therapy for Adolescents (TGCTA), which addresses the needs of adolescents facing traumatic bereavement and accompanying developmental disruption.

There are many more potential treatments and interventions that can be successfully utilized by trained clinicians, therapists, and mental health professionals to treat PGD and promote more adaptive grief reactions in bereaved individuals. 

Some examples of adaptive grief reactions include finding meaningful ways to feel connected to the deceased loved one, honoring the legacy of their deceased loved one, and participating in prosocial efforts to transform the circumstances of the death into something meaningful that can help others to avoid similar types of deaths (e.g., advocating for firearm safety legislation if a loved one died from a firearm injury).

Locally here in Michigan and Washtenaw County is Ele’s Place, a nonprofit and community-based organization dedicated to providing support for grieving children and their families. Using peer support groups, Ele’s Place helps families cope with the death of a parent, sibling, or other close family member or friend. These peer support groups are for both children and their caregivers, allowing them to interact with other families who have suffered similar losses, as well as express their emotions in a secure and empowering environment.

PGD as a serious public health issue

There are many public health benefits now that PGD is in the DSM-5-TR. Insurance companies can now cover the cost of treatment for bereaved individuals diagnosed with PGD. Mental health clinicians would be more knowledgeable and now have a better understanding of grief. Furthermore, there are now much clearer benchmarks for research, which will improve communication for researchers and clinicians. Additionally, there is now greater public awareness and recognition of PGD as a public health issue. 

PGD is a public health issue that can lead to significant adverse physical and mental health problems for years to come. Not only have millions of Americans lost loved ones to the COVID-19 pandemic (including more than over 200,000 children who lost a parent to COVID-related deaths), but many others continue to lose loved ones every day to other public health issues, such as chronic diseases (e.g., heart disease and cancer), gun violence (e.g., homicide and suicide), and drug overdoses. Bereaved individuals with PGD should be provided with the assistance and support needed in order to prevent adverse health outcomes, while also promoting adaptive grief reactions that can help them reintegrate into a life without this important person they lost.

Julie Kaplow, PHD, ABPP, and Alison Miller, PHD also contributed to this article.

About the author

Chris GiangChris Giang is a senior majoring in Public Health Sciences at the University of Michigan School of Public Health. He is currently working as an research assistant for the Child Health and Development Lab at Michigan Public Health, the Trauma and Grief Center at The Hackett Center for Mental Health/Meadows Mental Health Policy Institute, and the Center for the Study of Drugs, Alcohol, Smoking and Health at the University of Michigan School of Nursing. He is interested in how trauma and bereavement during childhood affects developmental trajectories and mental health outcomes, with a focus on how risk and protective factors can influence the grieving process for bereaved children in underserved populations and marginalized communities.

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