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NEW HAVEN, Feb. 21 -- The negative emotions of grief -- yearning, depression, and anger -- following the death of a family member from natural causes usually peak within six months.

Grief that lingers for longer than six months "suggests the need for further evaluation of the bereaved survivor and potential referral for treatment," said Paul K. Maciejewski, Ph.D., of Yale, and colleagues.

In a bereavement study of 233 mourners, reported in the Feb. 21 issue of the Journal of the American Medical Association, the Yale investigators also debunked the stage-theory of grief, which is widely accepted and taught in medical schools.

They found that contrary to longtime common wisdom, yearning for the departed rather than depression is the extended hallmark of grief. Disbelief is not the initial dominant grief indicator, while acceptance was the item most often endorsed, they found.

Moreover, yearning and not depression was the most frequent negative psychological response in the first year or two after the natural loss of a loved one, said the Yale team.

The notion that a natural response to loss involves an orderly progression through distinct stages of bereavement was refined by psychiatrist Elizabeth Kübler-Ross, M.D., to five stages describing the response of terminally ill patients to their diagnosis: denial-dissociation-isolation, anger, bargaining, depression, and acceptance.

Subsequently the stage theory of grief was refined to disbelief, yearning, anger, depression, and acceptance, although the theory has never been tested empirically, the researchers said.

In a longitudinal cohort study, 233 participants in the Yale Bereavement Study were followed from one to 24 months after their loss and interviewed at a mean of 6.3 months after their loved one's death. Each grief indicator was evaluated at one to six months, six to 12 months, and 12 to 24 months.

Among the findings:

• Within each period, acceptance was greater than disbelief, yearning, anger and depression P<0.001.
• Within each period, yearning was greater than disbelief, anger, and depression P<0.001.
• With each period depression was greater than anger P<0.001.
• Between one and six months following the death of family member or loved one, disbelief and yearning decreased and acceptance increased.
• From six to 12 months and continuing from 12 months to 24 months all negative emotions declined and acceptance increased.
• When the death occurred within six months of a person's terminal diagnosis, grief persisted for longer periods (P=0.03), and there was less acceptance of death at 12 to 24 months (P=0.008).

These findings "offer a point of reference for distinguishing between normal and abnormal reactions to loss," the authors wrote.

Since the negative motions peaked within six months, individuals "who experience any of the indicators beyond six months postloss would appear to deviate from the normal response to loss," they said.

Grief beyond six months, the researchers said, can be considered a diagnostic criterion for prolonged grief disorder, which would indicate the need for evaluation for psychiatric complications of bereavement, such as major depressive disorder and post-traumatic stress disorder.

The authors noted that the study was limited by its design, which delayed assessing individuals until at least a month following the death of a family member and limited follow-up to three sessions. Monthly follow-up, they said, would have provided more data.

Nonetheless the data were consistent in that they indicated that the natural history of grief was about six months.

The study was supported by the National Institutes of Health. The authors had no financial disclosures.

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