Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial

A comprehensive investigation of comorbidities of prolonged grief disorder in a bereaved inpatient psychiatric sample

Prolonged Grief Disorder (PGD) was recently added to ICD-11 and DSM-5-TR. Depression and Posttraumatic Stress Disorder (PTSD) are frequent comorbidities, but findings regarding comorbid somatoform disorder and personality disorders remain mixed and studies with severely impaired patients are scarce. It was therefore the objective of the present study to examine comorbidities of PGD in a bereaved inpatient psychiatric sample. We assessed N = 101 bereaved inpatients in a psychiatric hospital with clinical interviews and self-report questionnaires. We calculated differences between patients with and without a PGD-diagnosis in number and type of comorbid disorders as well as associations between the severity of PGD and comorbid disorders. On average, patients had 2.53 comorbid psychiatric diagnoses. Patients with and without a PGD-diagnosis did not differ in their number of comorbid diagnoses, and there was no association between number of comorbid diagnoses and PGD-severity. However, patients with PGD, had significantly more comorbid diagnoses belonging to neurotic-, stress-related and somatoform disorders of the ICD-10. Patients with PGDICD-11 also had significantly higher scores in self-reported depressive, PTSD-, and somatoform symptoms, as well as the negative affectivity personality domain than those without a PGD diagnosis. To the best of our knowledge, this is the first study to provide insights into comorbidities of PGD in a bereaved inpatient psychiatric sample. It highlights the importance of considering PGD symptoms as part of the complaints of bereaved patients to achieve a tailored treatment approach. Future longitudinal studies are needed to unveil relationships between pre-existing mental disorders and PGD.

Cognitive Behavior Therapy vs Mindfulness in Treatment of Prolonged Grief Disorder: A Randomized Clinical Trial

Importance

Although grief-focused cognitive behavior therapies are the most empirically supported treatment for prolonged grief disorder, many people find this treatment difficult. A viable alternative for treatment is mindfulness-based cognitive therapy.

Objective

To examine the relative efficacies of grief-focused cognitive behavior therapy and mindfulness-based cognitive therapy to reduce prolonged grief disorder severity.

Design, Setting, and Participants

A single-blind, parallel, randomized clinical trial was conducted among adults aged 18 to 70 years with prolonged grief disorder, as defined in the International Classification of Diseases, 11th Revision, and assessed by clinical interview based on the Prolonged Grief-13 (PG-13) scale. Those with severe suicidal risk, presence of psychosis, or substance dependence were excluded. Between November 2012 and November 2022, eligible participants were randomized 1:1 to eleven 90-minute sessions of grief-focused cognitive behavior therapy or mindfulness-based cognitive therapy at a traumatic stress clinic in Sydney, Australia, with follow-up through 6 months.

Interventions

Both groups received once-weekly 90-minute individual sessions for 11 weeks. Grief-focused cognitive behavior therapy comprised 5 sessions of recalling memories of the deceased, plus cognitive restructuring and planning future social and positive activities. Mindfulness-based cognitive therapy comprised mindfulness exercises adapted to tolerate grief-related distress.

Main Outcomes and Measures

The primary outcome was change in prolonged grief disorder severity measured by the PG-13 scale assessed at baseline, 1 week posttreatment, and 6 months after treatment (primary outcome time point), as well as secondary outcome measures of depression, anxiety, grief-related cognition, and quality of life.

Results

The trial included 100 participants (mean [SD] age, 47.3 [13.4] years; 87 [87.0%] female), 50 in the grief-focused cognitive behavior therapy condition and 50 in the mindfulness-based cognitive therapy condition. Linear mixed models indicated that at the 6-month assessment, participants in the grief-focused cognitive behavior therapy group showed greater reduction in PG-13 scale score relative to those in the mindfulness-based cognitive therapy group (mean difference, 7.1; 95% CI, 1.6-12.5; P = .01), with a large between-group effect size (0.8; 95% CI, 0.2-1.3). Participants in the grief-focused cognitive behavior therapy group also demonstrated greater reductions in depression as measured on the Beck Depression Inventory than those in the mindfulness-based cognitive therapy group (mean difference, 6.6; 95% CI, 0.5-12.9; P = .04) and grief-related cognition (mean difference, 14.4; 95% CI, 2.8-25.9; P = .02). There were no other significant differences between treatment groups and no reported adverse events.

Conclusions and Relevance

In this study, grief-focused cognitive behavior therapy conferred more benefit for core prolonged grief disorder symptoms and associated problems 6 months after treatment than mindfulness-based cognitive therapy. Although both treatments may be considered for prolonged grief disorder, grief-focused cognitive behavior therapy might be the more effective choice, taking all factors into consideration.

Trial Registration

anzctr.org.au Identifier: ACTRN12612000307808.

The Grief Debate, the DSM, and Clinical Practice

There has been an ongoing debate regarding grief, whether it may be at times pathological, and whether it is different from depression. This article addresses those questions by tracking the changing course of the Diagnostic and Statistical Manuals of Mental Disorders (DSMs) since DSM-III and by reviewing the debate concerning grief and depression. At the time when DSM-III was being prepared in the late 1970s (it was published in 1980), there was a concern that normal bereavement (or grief) was being diagnosed as major depression. To address this concern, the editors of DSM-III added a category of "uncomplicated bereavement." The fourth edition of the DSM (DSM-IV), published in 1994, then followed by a minor change. However, the editors of DSM-5 decided to eliminate the bereavement exclusion entirely. Their concern was simply whether the individual did or did not suffer from major depression. Since an individual might not warrant a diagnosis of major depression but might still be experiencing grief, the DSM discussion leads directly into the question of whether grief-later called prolonged grief disorder-and depression are separate conditions. Advocates for prolonged grief disorder maintained that grief is different from depression but that patients may present with a mix of grief and depressive symptoms that are clinically difficult to distinguish. Advocates of separate conditions have in fact developed an inventory of symptoms that identify prolonged grief disorder. However, inasmuch as a typical grief presentation will include depressive symptoms, the clinical challenge is to distinguish prolonged grief disorder and major depression, as well as to distinguish both from normal grief. Given the temporal limits of an average consultation, this article argues that making the required distinctions is an unrealistic expectation. Finally, researchers have developed specific treatment programs for prolonged grief disorder, but a conflict between the 2 primary researchers involved and the generalities in which the programs are phrased have led to the suggestion of a different approach to treatment that replaces generalities with a person-centered approach.

Psychedelic Experiences After Bereavement Improve Symptoms of Grief: The Influence of Emotional Breakthroughs and Challenging Experiences

Grief, a common reaction to loss, can frequently become problematic or impairing. Available treatments for prolonged grief disorder are promising but leave room for considerable improvement. Qualitative accounts of psychedelic experiences after bereavement reveal themes that parallel core components of prolonged grief disorder therapy. However, few studies have investigated the therapeutic potential of psychedelics for symptoms of grief. The present study surveyed recreational psychedelic users (N = 363) who had suffered a bereavement event. They reported retrospective grief symptoms before and after the psychedelic experience as well as subjective reactions to the psychedelic, including emotional breakthroughs and challenging experiences. Results indicate improvements in grief symptoms after a psychedelic experience, with a large effect size (Cohen's d = 0.83). The occurrence of emotional breakthroughs was positively associated with improvements in symptoms of grief, while the converse relation was observed for challenging experiences. Findings provide preliminary evidence that support the development of a psychedelic-assisted therapy protocol to target symptoms of grief. Psychedelic-assisted therapy might offer an alternative to current grief treatment options.

Psychotherapies for prolonged grief disorder in adults: A systematic review and network meta-analysis

BACKGROUND

Prolonged grief disorder (PGD), a condition characterized by severe, persistent, and disabling grief, is newly included in ICD-11 and DSM-5-TR. Psychotherapies are among the most recommended treatments for PGD, but which should be considered as first-line treatment needs to be clarified. The purpose of this systematic review and network meta-analysis was to synthesize the available evidence to compare five outcomes of different psychotherapies on PGD in adults and identify the optimal psychotherapy modality to inform clinical decision-making for the treatment of PGD.

METHOD

A comprehensive search was conducted in 7 databases from inception until March 20th, 2023. In the frequentist framework, pairwise and network meta-analyses using random-effects models were performed for outcomes with 95 % confidence interval (CI).

RESULTS

There were 2962 records found and 55 studies (1,0330 participants) assessing 11 different psychological interventions were included. Compared with the waiting list, behavioral therapy (SMD=-1.05; 95 %CI=-1.71, -0.38), third-wave cognitive behavior therapy (SMD=-1.00; 95 %CI =-1.41, -0.58), family therapy (SMD=-0.87; 95 %CI=-1.59, -0.16), psychodynamic therapy (SMD=-0.88; 95 %CI=-1.67, -0.10) and cognitive therapy (SMD=-0.84; 95 %CI=-1.57, -0.12) were statistically effective in reducing grief symptom. Only cognitive behavior therapy (OR =0.48; 95 %CI = 0.27, 0.85) was more acceptable than waiting list. In terms of secondary outcome, third-wave CBT can statistically significantly reduce depression (SMD= -0.60; 95 %CI =- 0.84, -0.36), PTSD (SMD=-0.99; 95 %CI =- 1.62, -0.36) and anxiety (SMD= -1.44; 95 %CI =-2.63, -0.25) respectively.

CONCLUSIONS

Most psychological interventions are effective, but only cognitive behavior therapy has the highest acceptability. Third-wave CBT with higher efficacy rates may be more beneficial for reducing secondary outcomes. To provide more robust evidence, high-quality trials should be conducted in the future.

Support needs of Australians bereaved during the COVID-19 pandemic: A cross-sectional survey study

BACKGROUND

COVID-19 disrupted access to bereavement support. The objective of this study was to identify the bereavement supports used by Australians during the COVID-19 pandemic, perceived helpfulness of supports used, prevalence and areas of unmet support need, and characteristics of those with unmet support needs.

METHODS

A convenience sample of bereaved adults completed an online questionnaire (April 2021-April 2022) about their bereavement experiences including support use and perceived helpfulness, unmet support needs and mental health. Multiple logistic regression was conducted to determine sociodemographic correlates of unmet needs. Open-ended responses were examined using content analysis to determine key themes.

RESULTS

1,878 bereaved Australians completed the questionnaire. Participants were mostly women (94.9%) living in major cities (68%) and reported the death of a parent (45%), with an average age of 55.1 years (SD = 12.2). The five most used supports were family and friends, self-help resources, general practitioners, psychologists, and internet/online community groups. Notably, each was nominated as most helpful and most unhelpful by participants. Two-thirds (66%) reported specific unmet support needs. Those with unmet needs scored lower on mental health measures. Correlates of unmet needs included being of younger age, being a spouse or parent to the deceased; reporting more impacts from public health measures, and not reporting family and friends as supports. The most frequent unmet need was for social support after the death and during lockdown.

CONCLUSIONS

This study demonstrates the complexity of bereavement support needs during a pandemic. Specialised grief therapy needs to be more readily available to the minority of grievers who would benefit from it. A clear recommendation for a bereavement support action plan is to bolster the ability of social networks to provide support in times of loss. The fostering of social support in the wake of bereavement is a major gap that needs to be addressed in practice, policy, and research.

Psychosocial Intervention on the Dual-Process Model for a Group of COVID-19 Bereaved Individuals in Wuhan: A Pilot Study

Wuhan was the first large city where the initial breakout of COVID-19 took numerous lives. A group of social workers and mental health specialists coordinated the "Be Together Program" (BTP), a psychosocial grief intervention program to help a group of Wuhan COVID-19 bereaved people. Under the Dual-process model framework, BTP used the internet and social media as the main tools, combined with group and individual intervention. Additionally, it employed a "Supermarket Mode" with abundant intervention themes and approaches for BTP participants to choose according to their special needs. Additionally, Chinese cultural elements are integrated into the program. At the end of the program, the grief scores of participants in the qualified sample reduced significantly, and the prevalence of the potential Prolonged Grief Disorder diagnosis reduced from 75% to 12%. The study also found that the BTP was especially effective for those who had high levels of grief reaction.

A case report to understand the use of an evidence-based approach of prolonged grief therapy in Chinese culture

Prolonged grief disorder (PGD) is a new diagnosis that may cause significant functional impairment. Prolonged grief therapy (PGT) is a manualized 16-session intervention, whose efficacy has been demonstrated in studies primarily from Western cultures. The current report aimed to present a case to illustrate the use of PGT in Chinese culture. The client was a bereaved adult suffering from PGD after the death of her mother ten years ago. Additionally, she lost her father three months ago. Questionnaires were completed before and after treatment. In-depth interview was conducted at a 3-month follow-up. The client's scores for grief, functional impairment, grief-related beliefs and avoidance, depression and insomnia all decreased substantially after treatment. The follow-up feedbacks indicated that the beneficial effects of PGT persisted in the client's life. This case report provides preliminary evidence that bereaved people in China could benefit greatly from PGT, with minimal cultural adaptation.

Prolonged grief disorder in an inpatient psychiatric sample: psychometric properties of a new clinical interview and preliminary prevalence

BACKGROUND

Prolonged Grief Disorder (PGD) was newly included in the ICD-11 and DSM-5-TR. It is not yet part of the standard assessments in many healthcare systems, including psychiatric wards. Because disordered grief is associated with suicidality, sleep problems and substance use disorders, an investigation into PGD in psychiatric inpatients is warranted.

METHOD

We interviewed N = 101 psychiatric inpatients who were admitted to the open psychiatric wards and the day hospital of a German psychiatric hospital and who had lost a person close to them. Assessments comprised clinical interviews and self-report instruments covering PGD and other mental disorders. We specifically developed the International Interview for Prolonged Grief Disorder according to ICD-11 (I-PGD-11) for the study and examined its psychometric properties.

RESULTS

The prevalence rate of PGD among bereaved patients according to ICD-11 was 16.83% and according to DSM-5-TR 10.89%. The I-PGD-11 showed good psychometric properties (Mc Donald's ω = 0.89, ICC = 0.985). Being female, having lost a child or spouse, and unnatural or surprising circumstances of the death were associated with higher PGD scores.

TRIAL REGISTRATION

Approval was obtained by the ethics committee of the of the Goethe University Frankfurt (2021-62, 2023-17) and the Chamber of Hessian Physicians (2021-2730-evBO). The study was preregistered ( https://doi.org/10.17605/OSF.IO/K98MF ).

LIMITATIONS

We only assessed inpatients of one psychiatric clinic in Germany, limiting the generalizability of our findings.

CONCLUSION

The present study underlines the importance of exploring loss and grief in psychiatric inpatients and including PGD in the assessments. Given that a significant minority of psychiatric inpatients has prolonged grief symptoms, more research into inpatient treatment programs is needed.

Prolonged Grief Disorder: Addressing Misconceptions With Evidence

There are many misconceptions about Prolonged Grief Disorder (PGD). We show with data that PGD is a diagnosis that applies to a rare few of mourners who are at risk of significant distress and dysfunction. Those mourners who meet criteria for PGD have been shown to benefit from specialized, targeted treatment for it. The case against PGD is empirically unsubstantiated, and the need for scientific examination of effective treatments is warranted.

Prairie voles as a model for adaptive reward remodeling following loss of a bonded partner

Loss of a loved one is a painful event that substantially elevates the risk for physical and mental illness and impaired daily function. Socially monogamous prairie voles are laboratory-amenable rodents that form life-long pair bonds and exhibit distress upon partner separation, mirroring phenotypes seen in humans. These attributes make voles an excellent model for studying the biology of loss. In this review, we highlight parallels between humans and prairie voles, focusing on reward system engagement during pair bonding and loss. As yearning is a unique feature that differentiates loss from other negative mental states, we posit a model in which the homeostatic reward mechanisms that help to maintain bonds are disrupted upon loss, resulting in yearning and other negative impacts. Finally, we synthesize studies in humans and voles that delineate the remodeling of reward systems during loss adaptation. The stalling of these processes likely contributes to prolonged grief disorder, a diagnosis recently added to the Diagnostic and Statistical Manual for Psychiatry.

The mental health of Australians bereaved during the first two years of the COVID-19 pandemic: a latent class analysis

BACKGROUND

The COVID-19 pandemic disrupted many areas of life, including culturally accepted practices at end-of-life care, funeral rites, and access to social, community, and professional support. This survey investigated the mental health outcomes of Australians bereaved during this time to determine how these factors might have impacted bereavement outcomes.

METHODS

An online survey indexing pandemic and bereavement experiences, levels of grief, depression, anxiety, and health, work, and social impairment. Latent class analysis (LCA) was used to identify groups of individuals who shared similar symptom patterns. Multinomial regressions identified pandemic-related, loss-related, and sociodemographic correlates of class membership.

RESULTS

1911 Australian adults completed the survey. The LCA identified four classes: low symptoms (46.8%), grief (17.3%), depression/anxiety (17.7%), and grief/depression/anxiety (18.2%). The latter group reported the highest levels of health, work, and social impairment. The death of a child or partner and an inability to care for the deceased due to COVID-19 public health measures were correlated with grief symptoms (with or without depression and anxiety). Preparedness for the person's death and levels of pandemic-related loneliness and social isolation differentiated all four classes. Unemployment was associated with depression/anxiety (with or without grief).

CONCLUSIONS

COVID-19 had profound impacts for the way we lived and died, with effects that are likely to ricochet through society into the foreseeable future. These lessons learned must inform policymakers and healthcare professionals to improve bereavement care and ensure preparedness during and following future predicted pandemics to prevent negative impacts.

Eye Movement Desensitisation and Reprocessing (EMDR) therapy for prolonged grief: theory, research, and practice

Prolonged Grief Disorder occurs within 7-10% of the bereaved population and is a more complicated and persistent form of grief which has been associated with suicidality, mental health disorders, sleep disturbance, poor health behaviors, and work and social impairment. EMDR is a fitting treatment option for those with Prolonged Grief, focusing on processing past memories, blocks, current triggers, future fears, and preparing the person for living life beyond the loss in line with the Adaptive Information Processing Model and grief frameworks. This paper discusses the theory, research regarding the application of EMDR with prolonged grief, and gives insight and guidance to clinicians working in this area including a case example.

Feasibility and Acceptability of a Mobile App for Prolonged Grief Disorder Symptoms

Background

Mobile apps provide a unique platform for mental health assessment and monitoring. They can provide real time, accessible data on symptoms of mental disorders that may yield rich data for detailed clinical assessment and help individuals gain insight into their current mental state. We developed one of the first apps for tracking symptoms of prolonged grief disorder.

Method

In this pilot feasibility study, we assess the feasibility and acceptability of a new mobile app mGAGE for use once a day for 3 weeks. 27 participants completed mental health assessments at t1 and t2.

Results

Adherence to the app protocol was very high with 100% for the first two weeks of use. A surprising finding was the improvement of grief symptoms at t2. Debriefing interviews revealed general qualitative categories including positive feedback, negative feedback and specific recommendations. Overall, the app was found to be feasible for use for the first two weeks and acceptable for bereaved individuals.

Conclusions

This app could provide valuable data for in depth clinical assessment, may support individuals to gain greater insight into their symptoms and may have a therapeutic effect in terms of improved grief symptoms. Implications for future studies including use in larger intervention studies are discussed.

Somatic symptoms and insomnia among bereaved parents and siblings eight years after the Utøya terror attack

Background: Levels of prolonged grief symptoms (PGS) and post-traumatic stress symptoms (PTSS) can be high, many years following bereavement after terror, but knowledge concerning somatic health is scarce. Terrorism is a serious public health challenge, and increased knowledge about long-term somatic symptoms and insomnia is essential for establishing follow-up interventions after terrorism bereavement.Objective: To study the prevalence of somatic symptoms and insomnia and their association with PGS, PTSS, and functional impairment among terrorism-bereaved parents and siblings.Methods: A cross-sectional quantitative study included 122 bereaved individuals from the Utøya terror attack in Norway in 2011. The sample comprised 88 parents and 34 siblings aged 19 years and above (Mage = 49.7 years, SDage = 13.8 years, 59.8% females). The participants completed questionnaires 8 years after the attack assessing somatic symptoms (Children's Somatic Symptoms Inventory) and insomnia (Bergen Insomnia Scale) along with measures of PGS (Inventory of Complicated Grief), PTSS (Impact of Event Scale-Revised), and functional impairment (Work and Social Adjustment Scale).Results: Fatigue was the most frequently reported somatic symptom (88% of females and 65% of males). Females reported statistically significantly more somatic symptoms than males. In total, 68% of the bereaved individuals scored above the cut-off for insomnia. There were no statistically significant gender differences for insomnia. Female gender, intrusion, and arousal were associated with somatic symptoms. Intrusion and somatic symptoms were associated with insomnia. Somatic symptoms, avoidance, and hyperarousal were associated with functional impairment.Conclusion: Many bereaved parents and siblings report somatic symptoms and insomnia eight years after the terror attack. Somatic symptoms are associated with functional impairment. Long-term follow-up and support after traumatic bereavement should focus on somatic symptoms and insomnia.

Half a Century of Research on Posttraumatic Stress Disorder: A Scientometric Analysis

We conducted a scientometric analysis to outline clinical research on posttraumatic stress disorder (PTSD). Our primary objective was to perform a broad-ranging scientometric analysis to evaluate key themes and trends over the past decades. Our secondary objective was to measure research network performance. We conducted a systematic search in the Web of Science Core Collection up to 15 August 2022 for publications on PTSD. We identified 42,170 publications published between 1945 and 2022. We used CiteSpace to retrieve the co-cited reference network (1978-2022) that presented significant modularity and mean silhouette scores, indicating highly credible clusters (Q = 0.915, S = 0.795). Four major trends of research were identified: 'war veterans and refugees', 'treatment of PTSD/neuroimaging', 'evidence syntheses', and 'somatic symptoms of PTSD'. The largest cluster of research concerned evidence synthesis for genetic predisposition and environmental exposures leading to PTSD occurrence. Research on war-related trauma has shifted from battlefield-related in-person exposure trauma to drone operator trauma and is being out published by civilian-related trauma research, such as the 'COVID-19' pandemic impact, 'postpartum', and 'grief disorder'. The focus on the most recent trends in the research revealed a burst in the 'treatment of PTSD' with the development of Mhealth, virtual reality, and psychedelic drugs. The collaboration networks reveal a central place for the USA research network, and although relatively isolated, a recent surge of publications from China was found. Compared to other psychiatric disorders, we found a lack of high-quality randomized controlled trials for pharmacological and nonpharmacological treatments. These results can inform funding agencies and future research.

A quasi-experimental trial of narrative reconstruction for prolonged grief disorder: Symptomatic improvement and enhanced memory integration

BACKGROUND

Prolonged grief disorder (PGD) was recently approved as a formal diagnosis in the DSM-5-TR. The implementation of bereavement interventions is frequently requested, but their effectiveness has been controversial. Narrative reconstruction (NR) is a time-limited integrative therapy, originally developed for the treatment of post-traumatic stress disorder (PTSD) and adapted for the treatment of PGD. NR consists of exposure to the loss memory, a detailed written reconstruction of the loss memory narrative, and an elaboration of the personal significance of that memory for the bereaved.

OBJECTIVES

In this study we evaluated the efficacy of NR for PGD.

METHOD

In this study, 33 participants with PGD were quasi-randomized-that is, assigned to an immediate (n = 20) or delayed (n = 13) 16-session NR intervention. PGD, intrusion, avoidance and depression symptoms, as well as levels of the loss memory integration, were assessed at pretreatment, post-treatment, and at a 3-month follow-up.

RESULTS

Mixed linear models showed significant intervention effects for PGD and intrusive symptomatology. Results also showed an increase in integration of the loss memory, and improvements remained stable for all outcomes at follow-up.

CONCLUSION

In this study we established NR as an effective intervention for PGD and call for further validation in future studies. Integrating this intervention into the routine care of people with PGD seems important and beneficial.

Measuring Grief in the Context of Traumatic Loss: A Systematic Review of Assessment Instruments

Following traumatic loss, defined as the death of a loved one due to unexpected or violent circumstances, adults may experience a myriad of grief-related problems. Given the addition of Prolonged Grief Disorders into the Diagnostic and Statistical Manual for Mental Disorders Fifth Edition, Text-Revision and influx of unexpected deaths due to the global Coronavirus pandemic, there is heightened interest in the measurement of grief-related processes. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify measures of grief used in studies of adults who experienced traumatic loss. Searches yielded 164 studies that used 31 unique measures of grief-related constructs. The most commonly used instrument was the Inventory of Complicated Grief-Revised. Half of the measures assessed constructs beyond diagnosable pathological grief responses. Given the wide variation and adaptations of measures reviewed, we recommend greater testing and uniformity of measurement across the field. Future research is needed to adapt and/or design measures to evaluate new criteria for Prolonged Grief Disorder.

Responding to Suicide in School Communities: An Examination of Postvention Guidance from Expert Recommendations and Empirical Studies

PURPOSE OF REVIEW

We review the published literature on a school's response after a student dies by suicide ("postvention"). We examine published recommendations based on expert guidance and empirical studies that have evaluated postvention measures.

RECENT FINDINGS

Experts recommend careful communication with family, staff, and students that adheres to published suicide reporting guidelines. Experts also emphasize the importance of identifying and supporting high-risk students. Few robust, controlled studies have identified effective postvention measures. Effective measures tended to occur in group settings (e.g., group therapy), focus on improving grief symptoms, and involve mental health professionals. Postvention has not been robustly studied in the school context. Expert recommendations and a few evidence-backed studies provide the frame for a coherent, school-based postvention response. Further research is needed to strengthen and expand our collective understanding of effective postvention measures in the school context as youth suicide attempts continue to rise.

Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies

Prolonged grief disorder has recently been added to the International Classification of Diseases, 11th edition and the Diagnostic and Statistical Manual of Mental Disorders 5, Text Revision. This historical development is often presented as a linear process culminating in the inclusion of valid, clinically relevant prolonged grief disorder criteria in diagnostic handbooks. The present contribution provides an overview of work contradicting this dominant narrative. First, I show that the developmental history of prolonged grief disorder has been nonlinear and that this yields questions on generalizability and problems with measurement of the newest criteria sets. Second, I highlight an important gap in the validity evidence: the distinction of prolonged grief disorder from normal grief. Third, I discuss concerns relating to the societal effects of the inclusion of prolonged grief disorder in diagnostic handbooks, including the medicalization of grief, development and adverse effects of pharmacotherapy and stigmatization. A more realistic, balanced view on the history, validity and societal impact of prolonged grief disorder appears appropriate. I recommend stringent validation of assessment instruments for prolonged grief disorder, convergence of criteria-sets, closing gaps in validity evidence and developing strategies to mitigate the negative effects of grief diagnoses.

Prolonged Grief Disorder: Recognition and Provision of Care Along the Bereavement Journey

ABSTRACT

Prolonged grief disorder (PGD), sometimes called complicated grief, can impair a person's ability to function in daily life and elevate the risk for physical and mental decompensation. In 2022, PGD was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), increasing the potential for treatment with interpersonal therapy and medication. Nurses with knowledge of the signs and risk factors of PGD can identify people experiencing extended, unresolving grief and can offer care and referrals for therapy and support.

Bereavement issues and prolonged grief disorder: A global perspective

The death of a loved one - bereavement - is a universal experience that marks the human mental health condition. Grief - the cognitive, emotional, and behavioral responses to bereavement - is thus experienced by virtually everyone at some point in life, while mourning is a process through which grievers come to terms with the loss envisioning life without the deceased. Although distress subsides over time among most bereaved individuals, a minority will develop a condition recently identified as prolonged grief disorder (PGD). The present review provides a global perspective on bereavement, grief reactions, and PGD. Although the loss of a loved one and grief reactions are in general experienced consistently across different cultures, differences and variations in their expression may exist across cultures. Especially within specific populations that may be more at risk for PGD, possibly due to risk factors associated with the mechanisms of loss (e.g., refugees, migrants, and conflict survivors). The diagnostic criteria for PGD are mostly based on Western grieving populations, and cultural adaptations of PGD treatments are limited. Therefore, cross-cultural development and validation of PGD screening/assessment is critical to support future research on grief reactions and PGD, especially in non-Western contexts, and concerning the potential future global changes and challenges that appear to have a major impact on PGD. More transcultural research on PGD is needed to contextualize and will lead to culture-bound symptom identification of PGD, and the adaptation of current treatment protocols, which may ultimately improve health at the individual level, and health-care systems.

Competitive Neurocognitive Processes Following Bereavement

Bereavement is a common human experience that often involves significant impacts on psychological, emotional and even cognitive functioning. Though various psychological theories have been proposed to conceptualize the grief process, our current understanding of the underlying neurocognitive mechanisms of grief is limited. The present paper proposes a neurocognitive model to understand phenomena in typical grief, which links loss-related reactions to underlying learning and executive processes. We posit that the competitive relationship between the basal ganglia (BG) and circuitry involving the medial temporal lobe (MTL) underlies common cognitive experiences in grief such as a sense of "brain fog." Due to the intense stressor of bereavement, we suggest that these two systems' usually flexible interactive relationship become imbalanced. The resulting temporary dominance of either the BG or the MTL system is then manifested in perceived cognitive changes. Understanding the underlying neurocognitive mechanism in grief could inform ways to best support bereaved individuals.

Prolonged Grief Disorder and the DSM: A History

ABSTRACT

In the early 1990s, a research group that included Holly Prigerson and Charles Reynolds established that disordered grief overlaps with depression and anxiety but is not the same. They also developed a research inventory for studying disordered grief. Subsequently, Prigerson focused on measuring disordered grief using advanced psychometric techniques. Because treatment for grief-related depression reduced symptoms of depression but not grief, Katherine Shear was recruited to develop a more effective therapy. Prigerson came to conceptualize disordered grief as prolonged grief that is associated with negative outcomes. Shear came to conceptualize disordered grief as intense grief that is complicated by features that interfere with adaption to the loss. In 2013 a hybrid disorder composed of criteria from both groups was placed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) appendix. Under the leadership of the DSM Steering Committee, a summit meeting in 2019 helped break an impasse, and a revised prolonged grief disorder became an official DSM diagnosis.

An exploration of gender and prolonged grief symptoms using network analysis

BACKGROUND

Gender has been proposed as a potentially important predictor of bereavement outcomes. The majority of research in the field has explored this issue by examining gender differences in global grief severity. Findings have been mixed. In this study, we explore potential gender differences in grief using network analysis. This approach examines how individual symptoms relate to and reinforce each other, and so offers potential to shed light on novel aspects of grief expression across genders.

METHOD

Graphical lasso networks were constructed using self-report data from 839 spousally bereaved older participants (584 female, 255 male) collected at 2- and 11- months post-bereavement. Edge strength, node strength and global network strength were compared to identify similarities and differences between gender networks across time.

RESULTS

At both time points, the strongest connection for both genders was from yearning to pangs of grief. Yearning, pangs of grief, acceptance, bitterness and shock were prominent nodes at time 1. Numbness and meaninglessness emerged as prominent nodes at time 2. Males and females differed in the relative importance of shock at time 1, and the female network had greater overall strength than the male network at time 2.

CONCLUSIONS

This study identified many similarities and few differences in the relationships between prolonged grief symptoms for males and females. Findings suggest that future studies should examine alternate sources of variation in grief outcomes. Limitations are discussed.

A Web-Based Therapist Training Tutorial on Prolonged Grief Disorder Therapy: Pre-Post Assessment Study

BACKGROUND

Prolonged grief disorder (PGD) is a newly recognized mental disorder characterized by pervasive intense grief that persists longer than cultural or social expectations and interferes with functioning. The COVID-19 epidemic has resulted in increased rates of PGD, and few clinicians feel confident in treating this condition. PGD therapy (PGDT) is a simple, short-term, and evidence-based treatment developed in tandem with the validation of the PGD diagnosis. To facilitate the dissemination of PGDT training, we developed a web-based therapist tutorial that includes didactic training on PGDT concepts and principles as well as web-based multimedia patient scenarios and examples of clinical implementation of PGDT.

OBJECTIVE

We aimed to evaluate user satisfaction with the tutorial and whether the tutorial increased trainees' knowledge of PGDT principles and procedures. Moreover, we included a small number of pilot questions to evaluate the PGDT-related clinical skills.

METHODS

This study evaluated tutorial learning using a pre- and poststudy design. Participants were recruited from professional organization mailing lists, announcements to graduates of the Columbia School of Social Work, and through word of mouth. After signing consent, participants completed a brief demographic survey, a 55-item multiple-choice prestudy test on the concepts and principles of PGD and PGDT covered in the tutorial, and a 4-item pilot web-based prestudy test to gauge PGD clinical implementation skills. The link to the course content was then activated, and participants were given 8 weeks to complete the 11-module tutorial containing information, web-based exercises, simulated patient and video examples, and self-tests.

RESULTS

Overall, 406 clinicians signed consent, and 236 (58.1%) started the tutorial. Of these, 83.1% (196/236) completed all 11 modules. Trainee scores on our PDGT assessment improved substantially from pretraining to the postmodule assessment, with the total number of correct answers increasing from a mean of 29 (SD 5.5; 52.7% correct) to 36.7 (SD 5.2; 66.7% correct; t₁₉₅=18.93; P<.001). In addition, the trainee's implementation scores on 4 clinical vignettes increased from 2.6 (SD 0.7) correct out of 4 to 3.1 (SD 0.4) out of 4 (t₁₈₈=7.02; P<.001). Effect sizes (Cohen d) were 1.44 (95% CI 1.23-1.65) for PDGT assessment and 1.06 (95% CI 0.84-1.29) for implementation. Trainees found the tutorial interesting, enjoyable, clearly presented, and useful for professional development. They endorsed a mean score of 3.7 (SD 0.47) on a 1 to 4 scale of agreement with recommending the course to others and feeling satisfied with the tutorial, and a mean of 3.3 (SD 0.57) with feeling able to apply the skills with clients.

CONCLUSIONS

This pilot study provides support for the usefulness of this web-based training for teaching clinicians how to administer PGDT. The addition of patient scenarios for clinical implementation strategies holds promise for increasing the effectiveness of PGDT training and other evidence-based treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05121792; https://www.clinicaltrials.gov/ct2/show/NCT05121792.

From Mourning and Melancholia to Neurobiology in an Era of Global Warming, Pandemic Disease, and Social Chasms: Grief as a Requisite for Change

We find ourselves in a unique time in history with the confluence of a pandemic, global warming, and social chasms felt throughout the world. In this article, it is suggested that the grieving process is necessary for progress. The article addresses grief from a psychodynamic lens and progresses through the neurobiological changes that occur in the grieving process. The article discusses grief as both a result of and a necessary response to COVID-19, global warming, and social unrest. It is argued that grief is a vital process in order to fully change as a society and move forward. The role of psychiatry, and specifically psychodynamic psychiatry, is integral in paving the way to this new understanding and a new future.

Effectiveness of a cognitive-behavioral group therapy for complicated grief in relatives of patients with cancer: A randomized clinical trial

INTRODUCTION

Complicated grief can affect a large number of individuals who have lost a relative due to cancer.

OBJECTIVES

To assess the efficacy of a cognitive-behavioral grief therapy (CBGT) group for complicated grief (CG) in those who have lost a relative due to cancer in comparison with a psychoeducational and emotional expression intervention group (PSDEEI).

METHODS

A randomized clinical trial was used, in which 249 relatives of deceased cancer patients with CG were randomly assigned to CBGT or PSDEEI. Complicated grief (Inventory of Complicated Grief [ICG]), depression (Beck Depression Inventory [BDI-II]), hopelessness (Beck Hopelessness Scale [BHS]), anxiety (Beck Anxiety Inventory [BAI]) symptoms, and general health (Goldberg's General Health Questionnaire [GHQ28]) were assessed at pretreatment, posttreatment, and follow-up at 6 and 12 months.

RESULTS

The CBGT group improved significantly (p < 0.001), with the scores in ICG, BDI-II, BAI, BHS, and GHQ28 (p < 0.001) being higher than those for the PSDEEI group in each of the assessed moments, with high effect sizes: ICG (η2 = 0.16), BDI (η2 = 0.10), BAI (η2 = 0.06), BHS (η2 = 0.21), and GHQ28 (η2 = 0.21). At the 12-month follow-up, the number of cases of CG decreased by 81.1% for the CBGT group vs. 31.7% in the PSDEEI group.

SIGNIFICANCE OF RESULTS

The CBGT treatment was effective for CG, depression, anxiety, and hopelessness symptoms and for mental health and was superior to the PSDEEI treatment.

Cognitive reappraisal, emotional expression and mindfulness in adaptation to bereavement: a longitudinal study

BACKGROUND AND OBJECTIVES

Maladaptive emotion regulation strategies increase prolonged grief and depressive symptoms following bereavement. However, less is known about the role of adaptive emotion regulation strategies in adaptation to loss. Therefore, we examined the concurrent and longitudinal associations of three putative adaptive emotion regulation strategies (cognitive reappraisal, emotional expression, and mindfulness) with prolonged grief and depression symptoms.

DESIGN

A two-wave longitudinal survey.

METHODS

A sample of 397 bereaved Dutch adults (89% female, mean age 54 years) completed validated questionnaires to assess trait cognitive reappraisal, emotional expression, mindfulness and prolonged grief and depression symptoms at baseline (T1) and 344 participants completed symptom measures again six months later (T2).

RESULTS

Zero-order correlations demonstrated that mindfulness, cognitive reappraisal and emotional expression relate negatively to T1 and T2 prolonged grief and depression symptoms. In multiple regression analyses, controlling for relevant background variables, all emotion regulation strategies related negatively to T1 prolonged grief and depression symptoms. In multiple regression analyses, controlling for T1 symptoms and background variables, mindfulness predicted lower T2 depression symptoms.

CONCLUSIONS

Adaptive emotion regulation strategies relate negatively to post-loss psychopathology symptoms, yet only mindfulness longitudinally predicts lower depression symptoms. Dispositional mindfulness may be a protective factor in psychological adaptation to bereavement.

Narrative reconstruction therapy for prolonged grief disorder: Basic interventions and mechanisms of change

Narrative reconstruction is a time-limited integrative therapy, originally developed in the context of post-traumatic stress disorder and adjusted for the treatment of prolonged grief disorder (PGD). It consists of exposure to the loss memory and narrating a detailed written reconstruction of it. In this paper, we describe narrative reconstruction interventions and modifications for the treatment of PGD as well as the underlying mechanisms of change including integration of the loss episode into the life narrative. A case demonstration of narrative reconstruction with a patient with PGD presented for illustration and the integrative nature of narrative reconstruction for PGD is discussed.

Psychotropic medication among children who experience parental death to cancer

The psychological consequences of losing a parent to cancer are unclear. We investigated whether experiencing parental death to cancer before 18 years of age increases the risk of psychotropic medication. We used register data of all children born in Denmark between 1 January 1987 and 31 December 2016 (N = 1,488,846). We assessed rate ratios (RRs) with 95% confidence intervals (CIs) for first redeemed prescription of antidepressants, anxiolytics and hypnotics according to parental death status using Poisson multi-state models. We further examined whether the associations differed according to the gender of the deceased parent, child's age at the time of death or the parental length of illness. Cancer-bereaved children had a significantly increased risk of first prescription of psychotropic medication (rate ratio, RR 1.22, 95% confidence interval, CI 1.10-1.34 for males; RR 1.18, 95% CI 1.09-1.28 for females). Associations were strongest if the parent had the same sex as the child and if the parent died within one year of diagnosis. The risk was highest during the first six months after the loss (RR 2.35, 95% confidence interval, CI 1.48-3.73 for males; RR 1.81, 95% CI 1.17-2.80 for females). Children who lose a parent to cancer, particularly in cases when the disease progressed quickly, may need extra psychological support, especially during the first six months after the death.

Ventral striatal subregional dysfunction in late-life grief: Relationships with yearning and depressive symptoms

Bereaved older adults experiencing high grief in the first year after an attachment loss is at increased risk for prolonged grief disorder (PGD) via unknown mechanisms. Yearning, a core grief symptom, is linked to the ventral striatal (VS) brain function, but the role of this neuronal system in late-life grief is poorly understood. As a first step, we examined the VS subregional abnormalities associated with multidimensional symptoms in bereaved elders during the first year post-loss. Sixty-five bereaved elders completed clinical assessments within 13 months post-loss. Ventral caudate (VCau) and nucleus accumbens (NAcc) functional connectivity (FC) was assessed using seed-based resting-state functional MRI. VCau and NAcc FC differences between high (inventory of complicated grief [ICG] score≥30; n = 35) and low (ICG score<30; n = 30) grief, and the relationships between ventral striatal subregional FC and clinical measures (yearning and depressive symptoms) were assessed after covariate adjustments (α < 0.05; 3dClustSim corrected). Relative to low grief participants, those with high grief showed higher FC between VCau and the medial prefrontal, orbitofrontal, and subgenual cingulate cortices. VCau FC abnormalities positively correlated with yearning (r2 = 0.24, p < 0.001). In contrast, FC between VCau and temporoparietal junction negatively correlated with depressive symptoms, a commonly co-occurring symptom (r2 = 0.37, p < 0.001). The FC between NAcc and insula/striatum positively correlated with yearning (r2 = 0.35, p < 0.001); no other NAcc FC findings were seen in the full sample. In women, higher FC between the NAcc and bilateral posterior cingulate, precuneus, and visual areas were found in those with high, relative to low grief symptoms. Distinct VS subregional abnormalities associate with yearning and depressive symptoms in bereaved elders. Whether ventral striatal dysfunction correlates with PGD development and/or worsening depression remains to be elucidated.

Prolonged grief, post-traumatic stress, and functional impairment in parents and siblings 8 years after the 2011 Utøya terror attack

Background: Research on bereavement after terrorism is limited and primarily aiming on short-term consequences.Objective: To better understand the long-term health consequences of terrorism, we studied bereaved parents and siblings eight years after the Utøya terrorist attack in Norway. We examined the participants' symptom levels of prolonged grief (PG) and post-traumatic stress (PTS), as well as their psychosocial functioning and employment status.Method: Bereaved parents (n = 88) and siblings (n = 34) aged 19 and above (mean age  = 49.7 years, SD = 13.8 years, 59.8% female) completed the Inventory of Complicated Grief (ICG), the Impact of Event Scale-Revised (IES-R), and the Work and Social Adjustment Scale (WSAS) to assess PG, PTS, and functional impairment, respectively. In addition, information about employment status was obtained. The proportion of participants scoring above recommended thresholds on the ICG, IES-R, and WSAS was calculated. Differences between parents and siblings and gender differences on these measures were examined.Results: In total, 62.3% of the participants had scores on the ICG indicating a risk for prolonged grief, while 45.9% scored over cutoff on the IES. There was a high overlap between symptoms of PG and PTS. Females had significantly higher scores on both the ICG and the IES compared to males. There were no differences between parents and siblings regarding PG and PTS symptoms. One out of three showed severe functional impairment on the WSAS. Approximately 30% of all the bereaved were outside the labour force, and one third of the parents had become unable to work after the terrorist attack.Conclusion: Many bereaved parents and siblings, following the Utøya terror attack, report long-lasting health consequences with symptoms of PG and PTS and functional impairment. The results suggest a need for follow up of bereaved after a terror attack and identify family members in need of health services.

The social health domain of people bereaved by a drug-related death and associations with professional help: A cross-sectional study

People bereaved by traumatic deaths are vulnerable to long-lasting impairments in social health, including the quality of social relationships and the capacity to manage their social lives. In this Norwegian study involving 255 participants bereaved by a drug-related death, we aimed to investigate their social health and associations with professional help. The results of a cross-sectional survey showed that participants on average rated their social health as poor, though with large variations within the group. Participants who reported high satisfaction with professional help reported significantly higher scores on most social health-related variables. More research is needed on professional help focusing on the social health of traumatically bereaved people.

Exploring the role of expectancy in older US participants' response to an accelerated resolution therapy intervention for prolonged grief disorder

Accelerated resolution therapy (ART) is a psychotherapy for the treatment of prolonged grief disorder (PGD) defined as severe, enduring longing for the lost person. Currently, ART lacks examination of intrapersonal processes, like expectancy, as behavioural mechanisms for action. Therefore, the purpose of this paper was to present the findings on participants' treatment expectations of ART for PGD and then discuss potential hypotheses for future testing. This study was a primary qualitative descriptive analysis of prospectively collected interview data (collected 2017-2019) accrued as part of a randomised, wait-list controlled clinical trial in bereaved hospice family caregivers in the United States. The sample included 29 former informal caregivers who were at least 1-year post death of their care recipient. They were primarily female, older (67.4 ± 7.1 years), and a little over half (n = 18) had been married to their care recipient. Thematic analysis resulted in three distinct themes with six sub-themes: The role of knowledge in expectations (sub-themes uncertainty, prior knowledge); The role of personality in expectations (sub-themes openness, positive affect); and Expecting a process (sub-themes cognitive processes, affective processes) which described the interaction of person and process in shaping expectations of our intervention. An across theme analysis of the specificity of the participants' expectations uncovered that knowledge and personality inform expectations of ART and that individuals who verbalise a process for recovery tend to be very specific in their expectations. Three hypotheses for testing are put forward and implications for practice, research and policy discussed.

Perspectives on the success rate of current antidepressant pharmacotherapy

INTRODUCTION

There has been growing debate about the effectiveness of traditional antidepressants for the treatment of depression, and whether the clinical trials literature overstates the value of existing agents. Antidepressant efficacy is limited by suboptimal remission rates, lack of robust efficacy across diverse depressed subgroups, slow onset, and challenges managing tolerability. Clinicians can better navigate uncertainties in this area by recognizing patient-specific clinical and prognostic factors that influence the likelihood of antidepressant drug response.

AREAS COVERED

The author summarizes pertinent literature regarding drug-placebo differences in antidepressant outcome as well as patient-specific factors that influence antidepressant drug responsivity across subtypes of depressive disorders.

EXPERT OPINION

Standardized effect sizes for most monoaminergic antidepressants are relatively modest. At least one-third of treatment response derives from nonspecific (yet substantial) placebo effects, limiting the ability to compare antidepressant medication effects to that of "no treatment." Patients with high baseline depressive symptom severity are less likely to respond to placebo but may be more responsive to antidepressant pharmacotherapy than is the case in mild forms of depression. Patient satisfaction with antidepressant response must take into consideration not only efficacy for reducing symptoms but also drug tolerability/acceptability and tangible improvement in functional outcome and quality of life.

Mental health care for older adults: recent advances and new directions in clinical practice and research

The world's population is aging, bringing about an ever-greater burden of mental disorders in older adults. Given multimorbidities, the mental health care of these people and their family caregivers is labor-intensive. At the same time, ageism is a big problem for older people, with and without mental disorders. Positive elements of aging, such as resilience, wisdom and prosocial behaviors, need to be highlighted and promoted, both to combat stigma and to help protect and improve mental health in older adults. The positive psychiatry of aging is not an oxymoron, but a scientific construct strongly informed by research evidence. We champion a broader concept of geriatric psychiatry - one that encompasses health as well as illness. In the present paper, we address these issues in the context of four disorders that are the greatest source of years lived with disability: neurocognitive disorders, major depression, schizophrenia, and substance use disorders. We emphasize the need for implementation of multidisciplinary team care, with comprehensive assessment, clinical management, intensive outreach, and coordination of mental, physical and social health services. We also underscore the need for further research into moderators and mediators of treatment response variability. Because optimal care of older adults with mental disorders is both patient-focused and family-centered, we call for further research into enhancing the well-being of family caregivers. To optimize both the safety and efficacy of pharmacotherapy, further attention to metabolic, cardiovascular and neurological tolerability is much needed, together with further development and testing of medications that reduce the risk for suicide. At the same time, we also address positive aging and normal cognitive aging, both as an antidote to ageism and as a catalyst for change in the way we think about aging per se and late-life mental disorders more specifically. It is in this context that we provide directions for future clinical care and research.

Group-based compassion-focused therapy for prolonged grief symptoms in adults - Results from a randomized controlled trial

Prolonged grief disorder is a debilitating condition, which affects approximately one out of ten who lose a loved one. While existing meta-analyses have synthesized evidence regarding the overall effect of psychological interventions for pathological grief across different types of psychotherapy, it remains clinically relevant to explore whether specific types of psychological interventions are efficacious in the treatment of grief. The present study investigated the efficacy of group-based Compassion-Focused Therapy (CFT) for adults who had lost a spouse or a parent, and who reported clinically relevant levels of prolonged grief symptoms (PGS) at 11 months post-loss. A total of 82 participants were randomized to the CFT group (n = 42) or the waitlist control (n = 40). Time × group interactions showed no statistically significant effects of the intervention on the primary outcome PGS at post-intervention or 6-month follow-up. Likewise, no statistically significant effects were found for any of the secondary outcomes or process variables, with the exception of posttraumatic stress symptoms and self-reassurance. Taken together, in the present study group-based CFT did not emerge as an efficacious treatment for PGS. Possible explanations include that CFT may not target core maintaining processes in PGS and that the group-based, 8-week operationalization of CFT may be less than optimal.

An Internet-delivered Cognitive-Behavioral Therapy (iCBT) for Prolonged Grief Disorder (PGD) in adults: A multiple-baseline single-case experimental design study

The death of a loved one has physical, psychological, and social consequences. Between 9.8 and 21.5 % of people who lose a loved one develop Prolonged Grief Disorder (PGD). Internet- and computer-based interventions (i.e., Internet-delivered Cognitive-Behavioral Therapy, iCBT) are cost-effective and scalable alternatives that make it possible to reach more people with PGD. The main goal of the present investigation was to examine the effect and feasibility (usability and satisfaction) of an iCBT (GROw program) for adults with PGD. A secondary objective was to detect adherence to the app (Emotional Monitor) used to measure daily grief symptoms. The study had a single-case multiple-baseline AB design with six participants. The GROw program is organized sequentially in eight modules, and it is based on the dual-process model of coping with bereavement. Evaluations included a pre-to-post treatment assessment of depression, grief symptoms, and typical grief beliefs, along with daily measures of symptom frequency and intensity on the Emotional Monitor App. Treatment opinions and adherence to the App were also collected. Efficacy data were calculated using a Nonoverlap of All Pairs (NAP) analysis and Reliable Change Index (RCI). The mean age of the sample was 29.5 years (SD = 8.19). Two participants dropped out of the study. Adherence to the App varied across patients (4.8 % -77.8 %). Most participants (75 %) showed a clinically significant change (recovered) in depression, and 50 % obtained a clinically significant improvement (recovered) in symptoms of loss and typical beliefs in complicated grief. The participants reported high usability and satisfaction with the treatment content and format. In sum, the GROw program was very well accepted and generally feasible, and it has strong potential for treating PGD. The results support scaling up the treatment by using more complex designs with larger samples (i.e., randomized controlled trials comparing GROw with active conditions).

Characteristics of Survivors of Suicide Seeking Counseling From an NGO in Denmark: Analyses of a National Database

OBJECTIVE

The loss of a friend or family member to suicide, i.e., surviving suicide, can be devastating. Yet, little is known regarding the support received by survivors of suicide. We aimed to examine the characteristics of survivors of suicide who sought counseling from a Danish volunteer organization.

METHOD

Data on all users of the Danish Network for those Affected by Suicidal Behavior (NASB) were obtained during 2012-2018. Information on age, sex, relation, time of loss, municipality was analyzed, and geographical driving distances calculated.

RESULTS

Altogether, 1,268 survivors of suicide (mean age 43.3; 29.8% of all suicides) received counseling from NASB. In all, 81.8% of service users had lost a partner or first-degree relative; those being spouses/partners (15.3%), parents (28.5%), children (19.0%), and siblings (15.4%). Female service users (71.1%) outnumbered males (28.7%). A third of users sought counseling within 6-months of the death. A help-seeking rate of 6 users per 10 suicide deaths was found within close proximity to a counseling venue; equivalent of 5.5 (95% CI: 5.0-6.0) users per 100,000 inhabitants. Each additional 10 km of driving distance was associated with a 15% lower rate of use (b: -0.015; 95% CI: 0.027 to 0.003; p = 0.013).

CONCLUSION

Geographical proximity to help centers was important and could suggest that support might be lacking in some parts of the country. It seems likely that more than 0.6 persons per suicide might seek counseling from volunteer organizations if services were available within short driving distance.HIGHLIGHTSMore than one out of three who sought support after a suicide death were partners or first-degree relatives and only a third of users who sought counseling did so within 6-months of the death. Also, female sought counseling more frequently than males.Approximately 5.5 people per 100,000 inhabitants sought help after a suicide in areas where a counseling venue was within short driving distance.Based on the region with most counseling venues, 6 survivors would seek support per 10 suicide deaths.

Development and initial test of the self-report grief and bereavement assessment

Implementing evidence-based and cost-effective bereavement care is a challenge. A self-report measure could assist to identify caregivers at-risk of prolonged grief. We developed a new measure via five steps: identification of risk and protective factors for prolonged grief, item generation, consultation with an expert panel (n = 8), review by the academic team and expert panel, and a pilot test with family caregivers (n = 19) from three palliative care services. The Grief and Bereavement Assessment is a brief self-report measure that is theoretically and empirically grounded, acceptable to caregivers, feasible for use in palliative care, and requires psychometric validation.

Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder

Among the important changes in the ICD-11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD-11 implementation. This paper focuses on four disorders: complex post-traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD-11 represents a different decision than was made for the DSM-5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD-11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD-11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD-11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.