Grief and Bereavement: Information for Primary Care
- Grief is the normal process that one encounters when faced with the loss of a loved one
- Although grief and loss are inevitable in life, there is nonetheless “good grief” versus “complicated grief”
- Good grief is healthy
- Complicated grief is unhealthy
- Grief: Process of psychological, social, physical and spiritual reactions to a loss
- Bereavement: The state of having suffered a loss
- Mourning: The cultural response to grief
- Complicated grief: Grief that is excessive, difficult, complicated or abnormal, e.g. where the individual develops low self-esteem, and thoughts of ending one’s life
- Prevalence: 100% of the population will face grief, because loss is inevitable. The majority of those facing grief will have ‘normal grief’.
- Prevalence: 4-7% of general population experiences complicated grief after major bereavement (Kersting, 2011)
- Mood symptoms include problems with sadness, crying spells, anxiety, but can also include irritability.
- Neurovegetative symptoms includes problems with sleep, appetite and energy
- Loss of function during the grieving period
- Normal grief is not a clinical diagnosis
Grief has been classically described as having five stages
- These can occur in any order, and do not necessarily need to occur sequentially
- Classic phases of grief
- Denial, disbelief or numbness that the loss has occurred
- Anger, blaming others for the loss
- Bargaining (e.g. “If my cancer gets better, I promise to never smoke again”; “If my son doesn’t die, I promise I’ll never miss his hockey games”)
- Depressed mood, sadness, crying
- Acceptance and coming to terms with the loss
- With normal grieving, symptoms are time-limited and improve over time, e.g. within a few days, weeks or months
DDx of Normal vs. Complicated Grief
- Symptoms such as sadness, tearfulness following a loss
- Generally fades within a few months
- Does not cause significant, ongoing impairment in function
- Mourning and sadness that tends to persist and does not improve over time
- Similar symptoms to major depression (e.g. poor self-esteem, hopelessness, or significant neurovegetative symptoms)
- Causes impairment in function
Screening / diagnostic tools
Two screening questions used together have shown sensitivity of 90% for patients with complicated grief
- “Do you feel that you have really grieved?”
- “Do you feel that you are now functioning about as well as you were before the death?”
- Answering NO to both questions indicates a high risk of having complicated grief.
- Two screening questions used together have shown sensitivity of 90% for patients with complicated grief
Screening for symptoms of depression
- Consider SIGECAPS screening, including
- Clinician: “With all this stress, has it gotten to the point where you’ve felt that life isn’t worth living?”
- Clinician: “How is your self-esteem these days?” “Have you been feeling down on yourself?”
- There are no specific physical exam findings for grief and bereavement.
- There are no specific laboratory investigations for grief and bereavement
Grief counseling in primary care
Supportive counseling therapy techniques such as the BATHE technique can be very helpful in supporting the bereaved patient in a primary care setting
- Clinician: Tell me about your loss
- Clinician: I am so sorry to hear about your loss.
- Clinician: “How are you feeling about this?” “How has this affected you?”
- Clinician: “What troubles you the most about this?”
- Clinician: “How have you been handling this situation?” “For example, have you been able to get support from family or friends?” “Have you been able to cry about your loss?” “Or have the feelings been all bottled up inside?”
- Clinician: “Thank you for sharing this with me. You clearly cared very much for your father. Your feelings sound very normal for this situation. I can completely appreciate how you would be feeling this way.”
- Grieving a significant loss (such as a spouse) can take 1-2 years
Send a personal note to the patient to express sympathies regarding the loss, which patients have cited as being particularly meaningful
- Supportive counseling therapy techniques such as the BATHE technique can be very helpful in supporting the bereaved patient in a primary care setting
Provide the patient with information about the grieving process
- Provide the patient with information about the grieving process
- If indicated, recommend that the bereaved take time off work
- For simple grief, medications are usually not indicated
For more complicated grief, medications may have a role for specific symptoms
- For sleep problems, consider sleep medications such as Trazodone
- For symptoms of major depressive disorder, consider antidepressant medication such as SSRIs
- When the patient is having significant stress from the loss
- When the patient is unable to function, e.g. school, work, home and relationships
- Consider grief and bereavement mutual support groups such as Bereaved Families of Ontario
- For complicated grief with signs/symptoms of depression, consider referral to mental health professional, e.g. counselor/therapist, social worker, psychologist, psychiatrist
Published 2011 Produced By British Columbia Medical Association Ages Served All ages Website http://www.bcguidelines.ca/pdf/palliativ...
Grief and Bereavement: Care for the Patient with Incurable Cancer or Advanced Disease
Published 2009 Produced By World Psychiatry Ages Served All ages Website http://www.ncbi.nlm.nih.gov/pmc/articles...
Grief and Bereavement: What psychiatrists need to know
Published 2012 Produced By Centre for Palliative Care at St. Vincent's Hospital & a collaborative centre of The University of Melbourne , Melbourne, Australia Ages Served All ages Website http://www.ncbi.nlm.nih.gov/pmc/articles...
Guidelines for the psychosocial and bereavement support of family caregivers of palliative care patients
- Comforting a Grieving Parent, Am Fam Physician, 2011 Jan 1;83(1):79-80. Available at http://www.aafp.org/afp/2011/0101/p79.html. Accessed Oct 4, 2012
Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.
Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.
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Date of Last Revision: Sep 15, 2017