Diagnosis of Prolonged Grief Disorder (PGD) Among Older Adults: Mapping Physicians' Knowledge and Practice, and Evaluating the Effectiveness of a Brief Targeted Training Program

Background Prolonged Grief Disorder (PGD) is a mental health condition recently included in the ICD-11 [1] and DSM-5-TR [2]. It is characterized by unique core symptoms, including intense yearning for the deceased, persistent preoccupation with the deceased, or both. These symptoms are commonly accompanied by emotional pain, disruption of personal identity, loss of meaning and purpose in life, and impaired daily functioning [3]. PGD is distinct from other psychiatric diagnoses such as Major Depressive Disorder, Generalized Anxiety Disorder, and Post-Traumatic Stress Disorder, and is associated with a range of negative outcomes, including physical health problems [4], increased risk of suicidal ideation or attempts, reduced life satisfaction, functional impairment, and greater utilization of health services. Epidemiological studies indicate that among bereaved populations, the prevalence of PGD is relatively low in representative samples (approximately 3-4%), while higher rates, up to 16%, are reported in non-probability or convenience samples [5].

Aging is naturally accompanied by experiences of loss and bereavement, and as individuals age, they encounter an increasing number of losses, including traumatic ones and various life-course separations. Consequently, older adults are considered at elevated risk for disruptions in the normative grief process in general, and for the development of PGD in particular [6, 7]. Supporting evidence includes, for example, a meta-analysis of over 60,000 participants, which identified spousal loss and pre-death grief (experienced while caring for a terminally ill relative) as two major risk factors for PGD [8]. Both phenomena, whose prevalence increases with age, illustrate older adults' heightened vulnerability to the loss of significant others and its adverse consequences. Additionally, multiple studies have linked the loss of a close person, especially a spouse among older adults, to serious health outcomes, including immune dysfunction, increased cardiovascular risk, chronic pain, and even elevated mortality rates [e.g., 9-11].

These findings indicate that PGD not only impacts individual quality of life but also imposes a significant economic burden on healthcare systems. Additional costs include medical treatments, medications, hospitalizations, and mental health services, alongside impaired daily functioning and productivity. Early identification and tailored intervention can therefore improve patient outcomes while reducing systemic costs [e.g., 12-14] Consistent with the gap between academic research and its systematic application in clinical practice [15], healthcare providers' knowledge of complications in the normative grief process is often limited [16]. Furthermore, given that PGD is a relatively new diagnosis not yet widely recognized among clinicians, raising awareness among physicians and mental health professionals is crucial for enabling early identification and appropriate intervention [6]. This issue is especially relevant for older adults, given the evidence of underdiagnosis and undertreatment of psychological distress in this population [e.g., 17, 18].

For example, although suicide rates among older adults in Israel and globally are higher than in any other age group, epidemiological studies show that the prevalence of clinically significant depression and anxiety is comparatively lower in older adults than in younger populations. Moreover, older adults with depression often report fewer typical cognitive-emotional symptoms (e.g., dysphoria, guilt, or feelings of worthlessness) and instead emphasize physical symptoms such as fatigue, somatic complaints, and difficulties with memory and concentration [19].

In fact, research indicates that many older adults who engaged in suicidal behavior had visited a physician shortly beforehand, yet their psychological distress remained undetected. This phenomenon stems, in part, from a lack of knowledge and appropriate skills among healthcare professionals regarding assessment and treatment in older populations. Additionally, research indicates the presence of ageist attitudes among clinicians, manifesting, for example, in reduced confidence in the effectiveness of interventions for the elderly. At the same time, many older adults avoid seeking mental health care for generational, social, personal, or practical reasons, making the primary care physician often the sole gateway to identifying psychological distress and referring patients for appropriate care [19]. These findings highlight the need for targeted professional training to enhance understanding of the clinical characteristics unique to older adults and to facilitate effective, tailored intervention.