CG is characterized by excessive avoidance of reminders of the loss, troubling maladaptive rumination about circumstances or consequences of the death, and persistence of intense and impairing acute grief symptoms beyond what is expected according to social and cultural norms [109]. Of course, views on grief differ across cultures, and data are lacking to inform this determination. Shear describes that “CG goes beyond the normal grieving process and leaves loved ones in an immovable stage of hopelessness” [2]. To put it simply, could be years since the loss, but based on the patient’s response, one would think it was yesterday. The differential diagnosis of CG includes normal grief (CG is a severe grief reaction that persists for at least 12 months or 6 months in children; i.e., acute grief become chronic), depressive disorders (CG is characterized by a deep and persistent focus on the loss to the exclusion of anything else), PTSD (preoccupation with the loss and yearning for the deceased are absent in PTSD), and separation anxiety (separation from current attachment figures versus separation from a deceased individual). Delicate and thoughtful clinical judgement should be used when determining who may be suffering from CG. CG diagnosis may be difficult to diagnose in the first several months post-loss [87, 110].

The clinical interview for assessment is of critical importance. Questions about important losses should be part of a standard diagnostic evaluation, especially in the case of older patients, for whom loss is common. The presence of thoughts and behaviors that are indicative of CG should be assessed. Intense grief is not pathological; however, complicating thoughts and behaviors that impede adaptation to the loss should be identified along with grief that is excessively intense and prolonged. Patients are sometimes ashamed of their persistently intense grief, and it is important for clinicians to ask direct questions in a sensitive and empathic way. Because comorbidities are common, the clinical evaluation of a bereaved person should also include screening for other psychiatric and medical disorders. Careful evaluation of suicidal intent and suicide plans should always be a part of the assessment. Patients should be asked about passive suicidal ideation, often exemplified by unusual risk-taking behaviors and/or the neglect of health problems [87].

A valid tool to measure CG is the Inventory of complicated grief (ICG) [1]. CG has been shown to be reliably detected by the ICG and it has been tested for people with intellectual disabilities [111] and validated in other languages [112]. Assessment by the ICG consists of reporting on 5-point scales (0 = “never,” 1 = “rarely,” 2 = “sometimes,” 3 = “often,” 4 = “always”), the frequency of 19 statements about affects, thoughts, and behaviors related to the loss of a loved one. A total score can be calculated by summing the response to all the items [113]. Scores of 30 or greater are considered to be consistent with a syndromal level of CG and warrant further evaluation and clinical intervention. The DSM5 has also recently introduced new CG symptoms (e.g., difficulty in positive reminiscing; maladaptive self-appraisals) that are not assessed by the ICG [77, 114, 115]. The ICG is a good tool for documenting the presence of symptoms and changes over time. The ICG is also useful for educating patients about their symptoms and pinpointing which ones may be the focus of intervention efforts.

Another clinically useful instrument is the Structured Clinical Interview for Complicated Grief (SCI-CG) [113]. The SCI-CG is a structured clinical interview comprising 31 symptom ratings. An optional screening section assesses characteristics related to the death, including relationship to the deceased, cause of death, and time since the death (<6 months, between 6 and 12 months, or >12 months). Each of 31 CG symptom ratings is graded on a 3-point scale (1 = “Not present,” 2 = “Unsure or equivocal,” 3 = “Present”) over the prior month. A total score ranging from 31 to 93 is calculated by summing the scores of these items. The SCI-CG and assessment guidelines are directly available to clinicians and researchers from the website www.​complicatedgrief​.​org.

Clinical Point: Nosology, classification and diagnostic approaches for identifying CG is a topic of ongoing and intense scientific development, needed in order to mainstream optimal diagnostic criteria.

Given the significant burden associated with CG, there is enormous interest in whether clinicians can encourage resilience after a significant loss through preventive efforts. In a systematic review of nine preventive interventions, researchers concluded that there was inconsistent support for their effectiveness in decreasing CG symptoms [134]. However, this finding does not mean that interventions aimed at preventing CG do not have any value. At the time the review was conducted (2011), there were no published guidelines for CG in the DSM; therefore, studies varied in the way they defined and measured CG (which makes it hard to compare results across studies). This finding also highlights the possibility that prevention studies are more difficult to conduct among older adults. While clinicians may know who is at risk for CG after a significant loss, older adults may perceive their grief symptoms to be “normal” and may not seek help. It is very difficult to connect with older adults who are not treatment seeking.

Preventive interventions for CG can be divided into primary interventions and secondary interventions. Primary preventive interventions are those that are available to all bereaved elders, regardless of whether an intervention is needed. Examples include support group meetings and psychoeducation sponsored by counseling organizations, local churches, or senior centers. Secondary interventions are those that target people who have been identified through screening procedures as exhibiting a risk factor and therefore vulnerable to the mental health effects of bereavement. Risk factors for CG include: a history of mental health problems, heavy caregiving prior to loss, social isolation, dependent attachment style, compromised medical health, low educational attainment, and traumatic circumstances of loss, among others [5, 136].

After we screen and identify older adult who are at risk for CG, how do we intervene and facilitate adaptation to loss? In other words, what is the content of the intervention? Figure 6.2 depicts a conceptual model of the trajectory from bereavement to mental and physical health. A preventive intervention that targets known changes post-death may help promote a healthy adaptation to widowhood. For example, bereavement triggers changes in daily routines associated with physical activity, food preparation and eating, and sleep/wake regularity [137, 138]. Because physical health declines more rapidly in the later years when bereavement is most commonly experienced, bereaved elders may be especially vulnerable to the negative consequences of unhealthy lifestyle practices, such as lack of physical activity, poor nutrition, and lack of sleep. Therefore, an intervention that targets routine health behaviors may help bereaved elders reengaged with constructive activities and promote a health adaptation to widowhood. An intervention development study at the University of Pittsburgh (WELL trial) is currently testing the effects of a lifestyle intervention to promote health and welling following spousal bereavement. This intervention will test whether monitoring physical activity, healthy eating, and good sleep practices (on a tablet, daily for 12 weeks) helps adults establish a routine which in turn promotes resilience to bereavement.

Continued identification of effective prevention strategies is important for clinical practice. Whether a lifestyle intervention could prevent incident episodes of CG or clinical depression in at-risk older adults is not clear, given the limited evidence. However, the case can be made that lifestyle modification should at least be considered a favorable option for prevention and future clinical trials are warranted. The field should also seek to understand the relative efficacy of lifestyle modification compared to other prevention strategies like increasing social engagement or psychotherapy.