Bereavement in later life — assessment and management (MEQ)

(i) Definitions and clocks. Bereavement is the state of loss by death; grief is the multidimensional response; mourning is culturally patterned expression. Adaptive grief is not a mental disorder. DSM-5-TR PGD in adults requires the death to have occurred at least 12 months earlier plus yearning/preoccupation, additional symptoms, impairment, and exceeding cultural norms. ICD-11 uses an atypically long period more than 6 months. Name the system; do not invent hybrids.[3][8]

(ii) Discrimination. Adaptive grief would show oscillating intensity with progressive restoration. This man is 15 months post-loss with empty-house rituals, avoidance, meaning collapse, and high prolonged-grief scores — consistent with PGD if cultural-norm and impairment criteria are met. PHQ-9 of 8 without pervasive anhedonia or full neurovegetative syndrome argues against current full MDD, but screen carefully and reassess over time; MDD can co-occur and is diagnosable during bereavement when full criteria are met (no bereavement exclusion). Dual-process framing: stuck loss-orientation with failed restoration.[3][4][7][8]

(iii) Suicide risk. Older bereaved men living alone have high-lethality risk. Explore "want to be with her" for intent, plan, preparation, means (medicines, firearms, heights), alcohol use, prior attempts, protective factors (children, faith, pets). Means restriction, family involvement under privacy law, and escalate setting if needed. Do not dismiss reunion language as mere poetry.[5][6][8]

(iv) Psychological treatment. First-line for PGD is grief-focused psychotherapy. Complicated Grief Treatment (CGT) ingredients: psychoeducation, aspirational goals, revisiting the death story, imaginal conversation, graded exposure to avoided cues, restoration activation. Landmark elderly evidence: Shear 2014 JAMA Psychiatry RCT — CGT superior to grief-focused IPT (about 70.5% vs 32.0% CG responders). Original Shear 2005 JAMA RCT established CGT versus IPT in general complicated-grief samples.[1][2]

(v) Medication and practical care. Antidepressants are not first-line monotherapy for pure PGD when therapy is available; treat comorbid MDD with start-low-go-slow older-adult SSRIs if depression criteria emerge. Avoid chronic benzodiazepines. Practical supports are clinical: meals, alcohol reduction plan, social contact, finances, GP liaison, anniversary planning, and medical surveillance for bereavement-related health decline.[1][5][6][8]