Introduction: Addressing the Silent Burden of Prolonged Grief
Bereavement is a universal human experience, yet for a significant subset of individuals, the natural mourning process becomes arrested, leading to Prolonged Grief Disorder (PGD). Characterized by intense longing for the deceased, emotional numbness, and difficulty moving forward with life, PGD is now formally recognized in the DSM-5-TR and ICD-11. Older adults are particularly vulnerable to this condition due to the higher frequency of loss and potential social isolation. While individual Grief-Focused Cognitive Behavioral Therapy (GF-CBT) is the gold standard, the increasing demand for mental health services necessitates exploring more scalable, cost-effective delivery models, such as group therapy.
Study Highlights
This landmark randomized clinical trial (RCT) provides robust evidence for the clinical utility of group-based interventions. The key takeaways include:
- Group GF-CBT is noninferior to individual GF-CBT in reducing PGD symptoms at a 6-month follow-up.
- Both treatment formats yielded large effect sizes (Cohen’s d > 1.4), indicating significant clinical improvement.
- Secondary outcomes, including symptoms of PTSD, depression, and anxiety, showed similar patterns of noninferiority for the group format.
- The group format offers potential therapeutic advantages, such as peer support and the normalization of grief, which may be particularly beneficial for older populations.
Background: The Clinical Challenge of PGD in Geriatrics
In older adults, PGD often co-occurs with other psychiatric morbidities, including major depressive disorder and posttraumatic stress disorder. Untreated PGD is associated with significant functional impairment, reduced quality of life, and increased risks of physical health complications. Historically, individual CBT has been the primary evidence-based approach. However, individual therapy is resource-intensive and limits the number of patients a clinician can treat. Group therapy has long been theorized to be effective in bereavement because it directly counters the loneliness and social withdrawal often seen in grieving individuals. Prior to this study, however, empirical evidence comparing these two formats in a head-to-head noninferiority trial was lacking.
Study Design and Methodology
The study, conducted by Komischke and colleagues, was a noninferiority randomized clinical trial involving 113 older adults (aged 65 and older). Participants were recruited from naturalistic clinical practices between April 2021 and May 2025. Inclusion criteria required participants to meet clinical cutoffs for PGD or related disorders on validated self-report scales.
Intervention Protocol
Participants were randomized 1:1 into two arms:
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GF-CBT Individual:
12 weekly sessions, each lasting 1 hour.
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GF-CBT Group:
12 weekly sessions, each lasting 2 hours, typically involving small groups of peers.
Both interventions utilized the same core therapeutic components delivered in the same sequence: exposure therapy (revisiting the story of the loss), cognitive restructuring (challenging maladaptive beliefs about the death or the self), and behavioral activation (re-engaging in meaningful life activities). The primary endpoint was the change in PGD symptoms measured by the Prolonged Grief-13 (PG-13) questionnaire at 6 months post-treatment.
Key Findings: Noninferiority and Clinical Efficacy
The results of the intention-to-treat analysis, using mixed linear models, revealed that both delivery formats were highly effective. At the 6-month primary endpoint, the reduction in PGD symptoms in the group format was statistically noninferior to the individual format.
Primary Outcome Data
The effect sizes were remarkably high for both groups. The group format achieved a Cohen’s d of 1.74, while the individual format achieved a d of 1.46. The difference between the two formats was minimal (d = 0.09; 95% CI, -0.06 to 0.25), comfortably falling within the predefined noninferiority margin. These findings suggest that patients do not sacrifice clinical gain when choosing a group setting over individual therapy.
Secondary Outcomes and Comorbidities
Beyond PGD symptoms, the study looked at a broad range of secondary measures. Group GF-CBT was found to be noninferior to individual treatment for:
- PTSD symptoms
- Depression and anxiety
- Social support and loneliness
- Functional impairment and overall quality of life
Interestingly, the group format showed particularly strong results in reducing loneliness, likely due to the inherent social interaction involved in the treatment delivery.
Expert Commentary: Mechanistic Insights and Practical Considerations
The findings of this trial have significant implications for health systems. From a mechanistic perspective, group therapy provides a unique ‘social laboratory’ where patients can see their experiences mirrored in others. This normalization can reduce the shame and isolation that often accompany prolonged grief. Furthermore, the exposure component—telling the story of the loss—may be amplified in a group setting as it provides a supportive audience, potentially accelerating the habituation to painful memories.
Limitations and Generalizability
While the study is robust, clinicians should note the demographic skew; over 81% of the participants were female. While this reflects the general help-seeking population in bereavement services, more research is needed to determine if these findings translate equally to older men. Additionally, the dropout rates (23% for group vs 19% for individual) suggest that while both are acceptable, some patients may still find the group environment more challenging or less private than individual therapy.
Conclusion: A Shift in Bereavement Care Delivery
This randomized clinical trial provides high-level evidence that group-focused CBT is a viable, effective, and noninferior alternative to individual therapy for older adults suffering from prolonged grief. Given the large effect sizes and the secondary benefits for depression and anxiety, clinicians should feel confident in recommending group GF-CBT. This delivery model not only addresses the clinical needs of the patient but also provides a more efficient use of mental health resources, potentially expanding access to care for a vulnerable and underserved population.
Funding and Registration
This research was registered at ClinicalTrials.gov (Identifier: NCT04694807). Data analysis and study execution were supported by institutional research funds dedicated to geriatric mental health and evidence-based psychotherapy.
References
- Komischke K, Boelen PA, Maccallum F, O’Connor M. Group Vs Individual Grief-Focused Cognitive Behavioral Therapy for Older Adults: A Randomized Clinical Trial. JAMA Psychiatry. 2026 Jan 14:e254106. doi: 10.1001/jamapsychiatry.2025.4106.
- Prigerson HG, Kakarala S, Gang J, Maciejewski PK. History and Status of Prolonged Grief Disorder as a Psychiatric Diagnosis. Annu Rev Clin Psychol. 2021;17:109-126.
- Boelen PA, Smid GE. The Cognitive Behavioral Structure of Prolonged Grief Disorder. Front Psychiatry. 2017;8:161.
