Getting straight about grief

Feeling Connected to Nature Attenuates the Association between Complicated Grief and Mental Health

Complicated grief (CG) predicts decreased mental health over time. Furthermore, feeling connected to nature (CN) is positively associated with beneficial mental health outcomes, such as psychological wellbeing and perceived psychological resilience. Thus, we hypothesized that CN moderates the association between general grief or CG and negative mental health for bereaved people. Further, we hypothesized that one's physical exposure to nature-that is, estimated time spent in nature and greenness (i.e., vegetation) surrounding one's residential area-might moderate the association between general grief or CG and negative mental health for bereaved people. To test these hypotheses, we conducted a cross-sectional study. We sampled 153 participants who experienced the death of a close other by COVID-19 infection. Participants reported CG, general grief, anxiety symptoms, depression symptoms, CN, estimated time spent in nature, and residential area postal code via a single online survey. We estimated greenness surrounding participants' residential areas using their self-reported five-digit U.S. postal code. Cross-sectional analyses indicated that, as predicted, CN attenuated the association between CG and depression, trended toward moderating the association between CG and anxiety, and did not moderate the associations between general grief and depression or anxiety. Other variables related to the experience of nature-the estimated time an individual spends in nature and the greenness surrounding one's residential area-did not moderate the association between general grief or CG and depression or anxiety. We thus conclude that a sense of feeling connected to nature-not simply spending more time in nature or being surrounded by nature-may serve an important role in the mental health status of people experiencing complicated grief, perhaps because CN replenishes general belonging when someone significant has passed away.

"I Have Accepted My Father's Death; I was not Sad but Relieved." Adaptive Grief Responses for Bereaved Dementia Family Caregivers: A Scoping Review

This scoping review explores findings from the psychological and medical literature on the adaptive grieving experiences of bereaved dementia family caregivers and integrates what healthcare professionals can do to support bereaved dementia family caregivers transition into a post-death role. Bereaved dementia family caregivers are particularly susceptible to prolonged grief disorder post-death due to the protracted caregiving demands and progressive course of the illness. The mention of caregiver grief while the person with dementia is living is quite common in the literature; however, limited research focuses on the bereaved dementia family caregiver and the methods they use to grieve adaptively. Three overarching adaptive grieving themes emerged from the review: 1) social health, 2) emotional and spiritual fitness, and 3) reclaiming activities. Given the growing prevalence of bereaved family dementia caregivers, understanding how they might most adaptively grieve and experience the greatest possible well-being should be a top focus for research.

The Role of Emotion Regulation Difficulties and Intrusive and Deliberate Rumination in the Association Between Insecure Attachment and Prolonged Grief

This study investigated the role of emotion regulation difficulties and intrusive/deliberate rumination in the relationship between insecure attachment and prolonged grief symptoms. A total sample of 342 bereaved participants was included in the study. Both anxious and avoidant attachment styles were found to be associated with prolonged grief symptoms, with an avoidant attachment showing a stronger effect. Emotion regulation difficulties and rumination mediated the relationships between attachment styles and prolonged grief symptoms, supporting the proposed mediation model. The study identified specific mediating pathways for anxious and avoidant attachment styles. Additionally, female gender, higher age, unexpected death, and closeness of the relationship with the deceased were significant predictors of prolonged grief symptoms.

Participatory Grieving: A Concept Analysis

Grief is a psychobiological response to loss as manifested by intense feeling of sadness, along with thoughts, mental images and memories of the deceased loved one. In order for the patient to attain successful grieving process, it is fundamental among nurses to recognize and understand the loss or impending loss experienced by the patient and/or its significant others. With the use of Walker and Avant's concept analysis, together with thorough literature review pertaining to bereavement and grieving, the defining attributes, antecedents and consequences of participatory grieving were determined. Furthermore, the results of this concept analysis provide a better view on the significant roles and responsibilities of nurses during the grieving process.

Resilient phenotypes among bereaved youth: a comparison of trajectory, relative, and cross-domain approaches

BACKGROUND

Bereavement is a common traumatic event associated with adverse health outcomes across the life course. Despite these risks, not all bereaved individuals experience these negative effects. Limited scientific consensus exists on how to define resilience in individuals who have experienced the death of a loved one.

METHODS

Using a sample of N = 3766 youth from the Avon Longitudinal Study of Parents and Children birth cohort, we identified bereavement of a family member between ages 7 and 8.5. We derived and compared three different approaches to assess resilience among bereaved youth. Trajectory-based psychological resilience identified sub-groups with similar psychological symptom profiles between ages 6 and 16 using latent growth mixture models. Relative psychological resilience at age 16 leveraged standardized residuals from a model regressing psychological symptoms on bereavement to determine better-than-expected psychological functioning relative to bereavement status. Relative cross-domain resilience around age 16 was a sum score of the residuals approach applied to eight unique domains of health. Predictive validity of each approach was assessed using depressive symptoms at age 17.5 RESULTS: Overall, N = 877 (23%) youth were bereaved of a family member between ages 7 and 8.5. Using latent growth mixture models, a three-class solution described 84% of bereaved youth with low and stable psychological symptoms over time, 8% with worsening symptoms, and 8% with improving yet elevated symptoms. Each relative resilience score was largely concordant with the trajectory-based approach in identifying individuals as resilient or not, though relative psychological resilience demonstrated a stronger degree of concordance than the cross-domain score. Relative psychological and cross-domain resilience exhibited moderate to low correlation, depending on the domains included (r = 0.14-0.43). For each approach, resilience significantly predicted lower depressive symptoms at age 17.5, highlighting predictive validity of these measures.

CONCLUSIONS

Psychological symptom trajectories among bereaved youth aligned with those previously identified among bereaved adults. The residual-based approach to defining resilience exhibited limited utility in the context of bereavement. When identifying risk and resilience after bereavement, researchers and clinicians must address the interplay across psychosocial and physical health domains, as bereaved youth considered resilient from a mental health perspective may benefit from intervention in other domains.

Community sadness: Clinical recommendations for working with grieving Arab American families

Grief is a universal emotion, both layered and multidimensional. Grief in Arab cultures center around three ideals: culture, family, and religion. This paper examines the multiple different factors that influence Arabs during their grief, broken down into how different religions process and view death, along with the impact of Westernized ideals and other relationships. We explore physiological responses of grief, gender differences in expressing emotions, self-care practice, and utilizing religion as a strength. The rules and traditions surrounding grief and loss in Arab communities need to be acknowledged by clinicians and incorporated into their practice. Recommendations and future directions for clinicians to support Arab grief within the three lenses of culture, family, and religion.

Job loss-related complicated grief symptoms: A cognitive-behavioral framework

In a significant minority of people, involuntarily job loss can result in symptoms of job loss-related complicated grief (JLCG). The present cognitive-behavioral framework is introduced to explain the underlying processes that may lead to the development and maintenance of JLCG symptoms. Three core processes play a central role, namely (1) negative cognitions related to the job loss and misinterpretation of one's grief reactions; (2) anxious and depressive avoidance strategies to cope with the job loss and its consequences; and (3) insufficient integration of the job loss into the autobiographical memory. These core processes are assumed to interact and reinforce each other, leading to JLCG symptoms. The three core processes can be influenced by certain risk factors, including circumstances surrounding the loss, personality traits, and characteristics of the social environment. JLCG symptoms can lead to additional psychological and practical problems, such as anxiety and depressive symptoms, lower employability, and reduced likelihood of re-employment. This paper explains and illustrates the three core processes with vignettes. Implications of the model for preventive measures and psychological interventions are introduced. It concludes with suggestions for future research on JLCG symptoms.

Simultaneous Individual Complicated Grief Treatment With a Couple

Persistent complex bereavement/complicated grief occurs when, after a period of 12 months following a death, there remains an ongoing intense yearning and sorrow for the deceased, preoccupation with the death and its circumstances, difficulty accepting its reality, and disruption in personal identity. This case study illustrates the successful application of Complicated Grief Treatment (CGT), a manualized research-supported intervention, with a husband and wife each receiving individual therapy simultaneously with separate clinicians. The core of CGT involves graded completion of imaginal and situational revisiting (i.e., exposure) exercises. To target maladaptive rumination and counterfactual thinking more explicitly, strategies from a research-based treatment for trauma, Cognitive Processing Therapy, were also incorporated for one member of the couple. To our knowledge, CGT has not been examined with couples receiving individual therapy delivered simultaneously. As such, practitioners have little information about how to proceed with cases where multiple members of the same family are experiencing complicated grief. We will detail the treatment provided, outlining the course of care for each member of the couple, highlighting unique adjustments made to tailor implementation to each individual and to deliver the intervention simultaneously. Quantitative and qualitative data show the effects of treatment on symptoms of complicated grief, depression, and relationship satisfaction.

Predictors of prolonged grief in an internet-based grief therapy for people bereaved by suicide

Internet-based cognitive-behavioural grief therapy (ICBGT) has proven to be effective for people bereaved by suicide, however the extent to which patients can benefit from therapy seems to differ. This study investigates predictors of initial grief as well as change in grief severity following treatment in an ICBGT for people bereaved by suicide. Data was gathered from a randomized control trial including 57 people participating in a 5-week intervention. Change in grief symptoms was calculated using absolute change scores of grief. In order to examine best overall combination of independent variables, best subset regressions were conducted. Higher levels of pre-test grief were associated with worse sleep quality (β = 0.32, p = .002), lower self-esteem (β = -0.37, p = .002), lower support seeking (β = -0.38, p = .006), and a higher need for social support (β = 0.28, p = .028). A greater reduction in grief severity was associated with higher self-efficacy (β = -0.49, p = .001), higher attachment anxiety (β = -0.31, p = .017) and higher pre-test grief symptoms (β = -0.39, p = .006). Attention should be paid to the intensity of grief, the attachment style and a positive self-image, as these variables seem to influence the extent, to which patients' symptoms of PGD subside following ICBGT. To specifically target factors of patients that require improvement, further studies are needed.

Psychosocial factors associated with complicated grief in caregivers during COVID-19: Results from a preliminary cross-sectional study

The COVID-19 pandemic has changed how end-of-life ceremonies are performed, affecting grief processing and bereavement experiences. In this study, caregivers of patients who died with COVID-19 during the first wave of the pandemic were asked to complete an online survey designed to detect psychosocial factors associated with the presence of complicated grief (CG). The results show CG present in 48.4% of caregivers. The marital and cohabitant status during lockdown, the perceived sense of guilt and depression levels were significantly associated with the presence of CG, whereas attendance at the funeral and social support were found to be significant protective factors.

The role of sense of coherence and emotion regulation difficulties in the relationship between early maladaptive schemas and grief

Few studies examine the relationship of grief with interrelated and broad concepts. In this study, the role of sense of coherence and emotion regulation difficulties in the relationship between early maladaptive schemas and grief was investigated with individuals (N = 254) who have lost a close person in the last 5 years. Mediation and moderated mediation analyses revealed that individuals with early maladaptive schemas may experience more complicated grief symptoms through the effect of early maladaptive schemas. For individuals with self-sacrifice schema, difficulties in the grief process were regulated by moderate to high levels of sense of coherence.

2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families

This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.

2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families

This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.

Mania Following Bereavement: State of the Art and Clinical Evidence

Bereavement is the state of loss, determined in most of the cases by the death of a close person. It is probably the greatest sorrow that can occur in an individual life. Grief is a normal, healthy response to loss, evolving through stages in the process of mourning. In some cases, bereavement may lead to the outburst of manic episode: despite literature data being scarce, reports have explored this important clinical entity, variously called as "funeral mania" or "bereavement mania". We systematically reviewed the literature exploring the possible relationships between bereavement and the onset of a manic episode, both first or recurrent pre-existing episode, besides describing a case report on a manic episode in the aftermath of a loss event, with an accurate evaluation of prior mild mood spectrum instability, supporting the role of loss-events as potential risk factor for bipolar illness progression. This article tries summarizing existing evidence on the debate whether clinicians should consider mania as a possible bereavement reaction.

If we knew then what we know now: The preparedness experience of pre-loss and post-loss dementia caregivers

We evaluated the relationship between grief preparedness and grief experience in 106 family caregivers anticipating or who had experienced the death of a family member with dementia. Using a phenomenological lens to discern a process of meaning-making in narratives, we found preparation that included positive construction of memories, death as the end of suffering, relationship resolution, and shared construction of meaning were associated with positive grief. Those caregivers who experienced the family member's decline as traumatic, caregiver role loss, unavailable support, and difficulties creating a new life reported inadequate death preparation, and difficulty making meaning of the illness and death.

Resilience in Bereaved Caregivers of Persons With Dementia

The purpose of the current study was to identify characteristics of resilience using surveys in 50 bereaved caregivers for persons with dementia who lost their care recipient in the past 6 months. Surveys were reviewed and sorted as demonstrating a resilient grieving process or a problematic grieving process. Resilience was defined as the ability to adapt in a positive direction, with adequate support resources in place despite destabilizing experiences. Following initial review and sorting, 19 resilient surveys were coded and grouped according to phrases. Using the qualitative descriptive analysis process, five themes of resilience were derived from these surveys. Themes of resilience included: Relationships, Spirituality, Formal Support, Honor, and Relief. The use of these themes was noted to be supportive of a positive grief experience. The information provided in the current study serves to inform clinical nurses on resilient attributes to support bereaved caregivers for persons with dementia to improve grief outcomes. [Journal of Gerontological Nursing, 46(1), 30-36.].

Prevalence and Predictors of Patient-Reported Long-term Mental and Physical Health After Donation in the Adult-to-Adult Living-Donor Liver Transplantation Cohort Study

BACKGROUND

Prospective and longitudinal studies have examined liver donors' medical outcomes beyond the first 1 to 2 years postdonation. There is no analogous longitudinal evidence on long-term psychosocial outcomes, including patient-reported clinically significant mental health problems and perceptions of physical well-being. We examined prevalence, descriptive characteristics, and predictors of diagnosable mental health conditions and self-reported physical health problems, including fatigue and pain, in the long-term years after liver donation.

METHODS

Donors from 9 centers who initially completed telephone interviews at 3 to 10 years postdonation (mean, 5.8 years; SD, 1.9) were reinterviewed annually for 2 years using validated measures. Outcomes were examined descriptively. Repeated-measures regression analyses evaluated potential predictors and correlates of outcomes.

RESULTS

Of 517 donors initially interviewed (66% of those eligible), 424 (82%) were reassessed at least once. Prevalence rates of major depression and clinically significant pain were similar to general population norms; average fatigue levels were better than norms. All prevalence rates showed little temporal change. Anxiety and alcohol use disorder rates exceeded normative rates at 1 or more assessments. Longer postdonation hospitalization, female sex, higher body mass index, concerns about donation-related health effects, and burdensome donation-related financial costs were associated with increased risk for most outcomes (P's < 0.05). Men were at higher risk for alcohol use disorder (P < 0.001).

CONCLUSIONS

Anxiety and alcohol use disorders were more common than would be expected; they may warrant increased research attention and clinical surveillance. Surveillance for long-term problems in the areas assessed may be optimized by targeting donors at higher risk based on identified predictors and correlates.

Five-factor model in bereaved adults with and without complicated grief

Knowledge about what psychological characteristics underlie complicated grief (CG) is limited. The current study examined the five-factor personality traits in 81 bereaved adults with (n = 51) and without (n = 30) CG. A trained doctoral-level clinician evaluated participants using a structured, diagnostic psychiatric interview, and they completed self-report measures of grief and personality. A multiple regression model indicated that higher levels of neuroticism were associated with greater CG symptom severity, implicating neuroticism in the development of CG. Future prospective studies confirming it as a risk factor for the development of CG are warranted.

Accommodating Grief on Twitter: An Analysis of Expressions of Grief Among Gang Involved Youth on Twitter Using Qualitative Analysis and Natural Language Processing

There is a dearth of research investigating youths' experience of grief and mourning after the death of close friends or family. Even less research has explored the question of how youth use social media sites to engage in the grieving process. This study employs qualitative analysis and natural language processing to examine tweets that follow 2 deaths. First, we conducted a close textual read on a sample of tweets by Gakirah Barnes, a gang-involved teenaged girl in Chicago, and members of her Twitter network, over a 19-day period in 2014 during which 2 significant deaths occurred: that of Raason "Lil B" Shaw and Gakirah's own death. We leverage the grief literature to understand the way Gakirah and her peers express thoughts, feelings, and behaviors at the time of these deaths. We also present and explain the rich and complex style of online communication among gang-involved youth, one that has been overlooked in prior research. Next, we overview the natural language processing output for expressions of loss and grief in our data set based on qualitative findings and present an error analysis on its output for grief. We conclude with a call for interdisciplinary research that analyzes online and offline behaviors to help understand physical and emotional violence and other problematic behaviors prevalent among marginalized communities.

Physical and psychosomatic health outcomes in people bereaved by suicide compared to people bereaved by other modes of death: a systematic review

Background

Little research has been conducted into the physical health implications of suicide bereavement compared to other causes of death. There is some evidence that suicide bereaved parents have higher morbidity, particularly in terms of chronic illness. This systematic review aims to examine the physical and psychosomatic morbidities of people bereaved by a family member’s suicide and compare them with family members bereaved by other modes of death.

Methods

MEDLINE, EMBASE, CINAHL, and PsycINFO were searched from 1985 to February 2016. The search was re-run in March 2017. Peer-reviewed English language articles comparing suicide-bereaved family members to non-suicide bereaved family members on measures of physical or psychosomatic health were eligible for inclusion. Cohort, cross-sectional, case-control and cohort-based register studies were eligible for inclusion. A modified version of the Newcastle Ottawa Scale was used for quality assessment. Results were synthesised using narrative synthesis.

Results

The literature search located 24 studies which met the inclusion criteria. Seven studies found statistically significant associations between physical health and suicide bereavement. Five of the studies found that suicide-bereaved family members were more likely to experience pain, more physical illnesses and poorer general health. They were also at increased risk of cardiovascular disease, hypertension, diabetes and chronic obstructive pulmonary disease. In contrast, another study in Denmark found that those bereaved by suicide had a lower risk of a number of physical health disorders, including cancers, diabetes, cardiovascular and chronic lower respiratory tract disorders compared to those bereaved by other causes of death. Additionally, a further study conducted in the United States found that suicide-bereaved children visited a GP less frequently than non-suicide bereaved children.

Conclusions

Review findings are relevant for clinicians working with people bereaved by suicide as they highlight that such clients are at increased risk of several adverse physical health outcomes. Future research should examine health risk behaviours of suicide-bereaved and non-suicide bereaved family members as they may confound the association between exposure and outcome.

Trial Registrations

The review protocol has been registered on PROSPERO, registration number CRD42016030007.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4930-3) contains supplementary material, which is available to authorized users.

The transformation of the meaning of death in complicated grief group therapy for survivors of suicide: A treatment process analysis using the meaning of loss codebook

We examined the therapeutic process of grief change in survivors of suicide participating in complicated grief group therapy (CGGT) using the meaning of loss codebook (MLC). Complicated grief group therapy is a multimodal group psychotherapy designed to restore normal grieving in persons with complicated grief. Using video data, we evaluated transition points in psychotherapy associated with meaning reconstruction: retelling the narrative of the death, having an imaginal conversation with the deceased, and memory integration. The MLC codes captured most of the voiced statements of participants, provided a valuable lens for articulating the therapeutic process, and affirmed that CGGT facilitated effective grief.

Examination of factor structure of the inventory of complicated grief (ICG) in a sample of bereaved military family members with persistent and elevated grief

Knowledge about the effect of a US service member's death on surviving family members is limited. In order to identify their grief-related health care needs, a first step is to identify the characteristics of persistent and elevated grief in a military family sample. The present study identified military family members (n = 232) bereaved more than six months who endorsed an elevated level of grief. A confirmatory factor analysis and test of measurement invariance of factor structure were used to compare the factor structure of their Inventory of Complicated Grief (ICG) responses to that of a bereaved non-military-related clinical research sample with similar grief levels. Results confirmed an equivalent five-factor structure of the ICG in both the military family sample and the clinical research sample. The similarity in factor structure was present despite differences in demographic characteristics and bereavement experiences between samples. Thus, the ICG reliably measures persistent and elevated grief in military family samples and provides grief symptom profiles that facilitates better understanding of their grief-related needs.

Health effects of parental deaths among adults in Norway: Purchases of prescription medicine before and after bereavement

We analyse effects of parental deaths on the health of women and men aged 18–59 in 2004–2008, indicated by purchases of prescription medicines. Register data covering the entire Norwegian population were used, and fixed-effects models were estimated to control for unobserved time-invariant individual factors. A parent's death seemed to have immediate adverse consequences in both main age groups considered (18–39, 40–59), although effects were lower in the older group. Some results suggested that this health disadvantage widened with increasing time since the parent's death. However, effects were weak: the annual number of different medicines purchased was only increased by 1–7% as a result of losing a parent. Death of a parent was associated with an immediate increase in purchases of medication for mental diseases, and there were indications of a physical response as well. As time since the parental death increased, there was a decline in the purchase of medication for mental diseases, but an opposite trend with respect to medication for other diseases. On the whole, maternal and paternal deaths had the same impact, and effects on daughters and sons were of the same magnitude.

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A parent’s death seemed to have immediate weakly adverse health consequences.

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Some results suggested that this health disadvantage widened with time since death.

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The effects on physical and mental health seemed to be different.

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Purchases of prescription medicine were used as indicators of health.

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Unobserved time-invariant individual factors were controlled for.

Measuring Maladaptive Cognitions in Complicated Grief: Introducing the Typical Beliefs Questionnaire

OBJECTIVES

Maladaptive cognitions related to loss are thought to contribute to development of complicated grief and are crucial to address in treatment, but tools available to assess them are limited. This paper introduces the Typical Beliefs Questionnaire (TBQ), a 25-item self-report instrument to assess cognitions that interfere with adaptation to loss.

DESIGN

Study participants completed an assessment battery during their initial evaluation and again after completing treatment at 20 weeks. Test-retest reliability was assessed on a subsample of the participants who did not show change in complicated grief severity after the first 4 weeks of treatment. To examine latent structure of the TBQ, an exploratory factor analysis (EFA) was performed.

SETTING

Academic medical centers in Boston, New York, Pittsburgh, and San Diego from 2010-2014.

PARTICIPANTS

394 bereaved adults who met criteria for complicated grief.

MEASUREMENTS

The TBQ along with assessments of complicated grief symptoms and related avoidance, depression symptoms, functional impairment, and perceived social support.

RESULTS

The TBQ exhibited good internal consistency (α = 0.82) and test-retest reliability (N = 105; intraclass correlation coefficient = 0.74). EFA indicated a five-factor structure: "Protesting the Death," "Negative Thoughts About the World," "Needing the Person," "Less Grief is Wrong" and "Grieving Too Much." The total score and all factors showed sensitivity to change with treatment.

CONCLUSIONS

This new tool allows a clinician to quickly and reliably ascertain presence of specific maladaptive cognitions related to complicated grief, and subsequently, to use the information to aid a diagnostic assessment, to structure the treatment, and to measure treatment outcomes.

Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial

IMPORTANCE

To our knowledge, this is the first placebo-controlled randomized clinical trial to evaluate the efficacy of antidepressant pharmacotherapy, with and without complicated grief psychotherapy, in the treatment of complicated grief.

OBJECTIVE

To confirm the efficacy of a targeted complicated grief treatment (CGT), determine whether citalopram (CIT) enhances CGT outcome, and examine CIT efficacy without CGT.

DESIGN, SETTING, AND PARTICIPANTS

Included in the study were 395 bereaved adults who met criteria for CG recruited from March 2010 to September 2014 from academic medical centers in Boston, Massachusetts; New York, New York; Pittsburgh, Pennsylvania; and San Diego, California. Co-occurring substance abuse, psychosis, mania, and cognitive impairment were exclusionary. Study participants were randomized using site-specific permuted blocks stratified by major depression into groups prescribed CIT (n = 101), placebo (PLA; n = 99), CGT with CIT (n = 99), and CGT with PLA (n = 96). Independent evaluators conducted monthly assessments for 20 weeks. Response rates were compared under the intention-to-treat principle, including all randomized participants in a logistic regression with inverse probability weighting.

INTERVENTIONS

All participants received protocolized pharmacotherapy optimized by flexible dosing, psychoeducation, grief monitoring, and encouragement to engage in activities. Half were also randomized to receive manualized CGT in 16 concurrent weekly sessions.

MAIN OUTCOMES AND MEASURES

Complicated grief-anchored Clinical Global Impression scale measurments every 4 weeks. Response was measured as a rating of "much improved" or "very much improved."

RESULTS

Of the 395 study participants, 308 (78.0%) were female and 325 (82.3%) were white. Participants' response to CGT with PLA vs PLA (82.5% vs 54.8%; relative risk [RR], 1.51; 95% CI, 1.16-1.95; P = .002; number needed to treat [NNT], 3.6) suggested the efficacy of CGT, and the addition of CIT did not significantly improve CGT outcome (CGT with CIT vs CGT with PLA: 83.7% vs 82.5%; RR, 1.01; 95% CI, 0.88-1.17; P = .84; NNT, 84). However, depressive symptoms decreased significantly more when CIT was added to treatment (CGT with CIT vs CGT with PLA: model-based adjusted mean [standard error] difference, -2.06 [1.00]; 95% CI, -4.02 to -0.11; P = .04). By contrast, adding CGT improved CIT outcome (CIT vs CGT with CIT: 69.3% vs 83.7%; RR, 1.21; 95% CI, 1.00-1.46; P = .05; NNT, 6.9). Last, participant response to CIT was not significantly different from PLA at week 12 (45.9% vs 37.9%; RR, 1.21; 95% CI, 0.82-1.81; P = .35; NNT, 12.4) or at week 20 (69.3% vs 54.8%; RR, 1.26; 95% CI, 0.95-1.68; P = .11; NNT, 6.9). Rates of suicidal ideation diminished to a substantially greater extent among participants receiving CGT than among those who did not.

CONCLUSIONS AND RELEVANCE

Complicated grief treatment is the treatment of choice for CG, and the addition of CIT optimizes the treatment of co-occurring depressive symptoms.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01179568.

Grief & depression at the end of life

People may experience grief and depression with serious illness at the end of life or as a loved one who survives. While grief is a normal reaction to loss, complicated grief and depression are not. Accurate diagnosis, treatment, and referral are essential clinical tools for practitioners managing this population.

Sudden-On-Chronic Death and Complicated Grief in Bereaved Dementia Caregivers: Two Case Studies of Complicated Grief Group Therapy

Caring for a person with Alzheimer's disease is challenging and often has negative health and mental health effects that, for 7-20% of caregivers, persist into bereavement in the form of complicated grief. Complicated grief is a state of prolonged and ineffective mourning. An under-recognized phenomenon in dementia care and bereavement is "sudden-on-chronic death." In these situations, the caregiver is preparing for a gradual dying process from dementia, but the care recipient dies instead from a sudden death. In this study, an application of complicated grief group therapy for bereaved dementia caregivers with complicated grief is presented, and the effect of therapy with two bereaved caregivers who experienced the sudden death of their spouses who had a diagnosis of dementia is described. The unique treatment elements of complicated grief group therapy facilitated resolution of the 'trauma-like" features of bereavement and progression to a healthy grief process.

The burden of loss: unexpected death of a loved one and psychiatric disorders across the life course in a national study

OBJECTIVE

Unexpected death of a loved one is common and associated with subsequent elevations in symptoms of multiple forms of psychopathology. Determining whether this experience predicts novel onset of psychiatric disorders and whether these associations vary across the life course has important clinical implications. The authors examined associations of a loved one's unexpected death with first onset of common anxiety, mood, and substance use disorders in a population-based sample.

METHOD

The relation between unexpected death of a loved one and first onset of lifetime DSM-IV disorders was estimated by using a structured interview of adults in the U.S. general population (analytic sample size=27,534). Models controlled for prior occurrence of any disorder, other traumatic experiences, and demographic variables.

RESULTS

Unexpected death of a loved one was the most common traumatic experience and most likely to be rated as the respondent's worst, regardless of other traumatic experiences. Increased incidence after unexpected death was observed at nearly every point across the life course for major depressive episode, panic disorder, and posttraumatic stress disorder. Increased incidence was clustered in later adult age groups for manic episode, phobias, alcohol use disorders, and generalized anxiety disorder.

CONCLUSIONS

The bereavement period is associated with elevated risk for the onset of multiple psychiatric disorders, consistently across the life course and coincident with the experience of the loved one's death. Novel associations between unexpected death and onset of several disorders, including mania, confirm multiple case reports and results of small studies and suggest an important emerging area for clinical research and practice.

Validation of the Italian version Inventory of Complicated Grief (ICG): a study comparing CG patients versus bipolar disorder, PTSD and healthy controls

BACKGROUND

A minority (9%-20%) of bereaved individuals experience symptoms of persistent intense grief associated with significant distress and impairment. This recently identified distinct post-loss syndrome has been variously named complicated grief, prolonged grief disorder, traumatic grief and persistent complex bereavement disorder. The Inventory of Complicated Grief (ICG) is a self-report instrument used to reliably identify this syndrome. We undertook a study to: 1) validate the Italian version of the ICG; 2) examine its performance in a clinical of bereaved individuals with complicated grief, post-traumatic stress disorder, bipolar disorder and healthy controls.

METHODS

Study participants included 171 bereaved individuals clinically diagnosed with complicated grief (n=64); post-traumatic stress disorder (n=72); bipolar disorder (n=35) and 58 bereaved healthy controls. Assessments included the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I/P) and the Italian version of the ICG.

RESULTS

The mean total ICG score was significantly different among the study groups [F(3.228)=94.19, p<.001]. Post-hoc Games-Howell comparisons indicated significantly higher scores in complicated grief patients with respect to the other three groups and significantly lower scores in healthy controls compared to all other participants. The scale demonstrated a high level of internal consistency: Cronbach's alpha value for the whole sample was 0.947. Factor analyses demonstrated a single-factor solution.

CONCLUSIONS

This study provides evidence of the validation of the Italian version of the ICG, tested in a large and well-characterized clinical help-seeking population. These data further support the existence of a unique grief-related syndrome different from bipolar and post-traumatic stress disorders.

Bereavement and behavioral changes as risk factors for cognitive decline in adults with Down syndrome

BACKGROUND

Cognitive decline and Alzheimer's disease often affect older adults with Down syndrome (DS) much earlier than those in the general population. There is also growing evidence of the effects of negative life events on the mental health and behavior of individuals with intellectual disability. However, to our knowledge, this is the first study investigating objective cognitive decline following bereavement in aging individuals with DS.

OBJECTIVE

The objective of this study was to determine whether cognitive decline correlates with bereavement following the recent loss of a caregiver or with behavioral changes in a sample of adult individuals with DS who do not meet the criteria for dementia or depression, using the longitudinal assessment of the Cambridge Cognitive Examination (CAMCOG), together with the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).

METHODS

We evaluated 18 subjects at baseline and over a follow-up period of 14-22 months, attempting to determine whether cognitive decline correlates with bereavement following the recent loss of the main caregiver or with behavioral changes (as assessed with the Neuropsychiatric Inventory).

RESULTS

The mean rate of change in CAMCOG was -1.83 (standard deviation 4.51). Behavioral changes had a significant direct influence on cognitive decline. When bereavement was accompanied by behavioral changes, the probability of cognitive decline was 87% (odds ratio 3.82).

CONCLUSION

The occurrence of behavioral changes attributed to bereavement following the loss of the primary caregiver significantly increases the probability of cognitive decline in individuals with DS. Longitudinal comparison of the CAMCOG and use of the IQCODE appear to enrich the analysis of cognitive decline in individuals with DS. Further studies involving larger samples are needed in order to corroborate and expand upon our findings, which can have implications for the clinical management of older adults with DS.

Complicated grief and manic comorbidity in the aftermath of the loss of a son

Based on the recommendations of the sub-workgroup on trauma and dissociative disorders, the American Psychiatric Association (APA) removed the "bereavement exclusion" from the criteria for major depression in DSM-5. In addition, proposed DSM-5 research criteria for persistent complex bereavement disorder (PCBD) were included in the new manual in a section for conditions and criteria needing further research. We describe a case that warranted such a diagnosis. The patient was a 52- year-old woman who was admitted to the inpatient unit of our clinic on the birthday of her son who had died 18 months earlier. She was diagnosed with a manic episode with psychotic symptoms according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria and was treated accordingly. Three months after discharge, she made a suicide attempt and was admitted and re-assessed. During this admission, she completed the Inventory of Complicated Grief (ICG), the Mood-Spectrum Rating Scale (MOODS-SR), and the Trauma and Loss Spectrum questionnaire (TALS-SR). She endorsed symptoms of intense yearning for her son, feelings of shock and disbelief, anger and bitterness related to his death, estrangement from others, auditory, tactile and visual hallucinations of the deceased, and intense emotional reactivity to memories of her son. These symptoms were sufficiently prolonged and severe to meet criteria for complicated grief. While complicated grief appeared to be the primary diagnosis for this patient, when she was diagnosed using only DSMIV-TR criteria, her treatment failed to address herprimary problem. This case draws attention to the occurrence of manic-like symptoms as well as depression-like manifestations following bereavement and highlights the importance of including the syndrome of complicated grief in the diagnostic nomenclature.

Treating complicated grief

IMPORTANCE

The death of a loved one is one of life's greatest, universal stressors to which most bereaved individuals successfully adapt without clinical intervention. For a minority of bereaved individuals, grief is complicated by superimposed problems and healing does not occur. The resulting syndrome of complicated grief causes substantial distress and functional impairment even years after a loss, yet knowing when and how to intervene can be a challenge.

OBJECTIVE

To discuss the differential diagnosis, risk factors for and management of complicated grief based on available evidence and clinical observations.

EVIDENCE REVIEW

MEDLINE was searched from January 1990 to October 2012. Additional citations were procured from references of select research and review articles. Available treatment studies targeting complicated grief were included.

RESULTS

A strong research literature led to inclusion of complicated grief in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (termed persistent complex bereavement disorder as a subtype of other specified trauma and stressor-related disorders), although it is a condition for which more research is formally recommended, and there is still ongoing discussion about the optimal name and diagnostic criteria for the disorder. Reliable screening instruments are available, and the estimated prevalence rate is 7% of bereaved people. Randomized controlled data support the efficacy of a targeted psychotherapy including elements that foster resolution of complicating problems and facilitate the natural healing process. Preliminary studies suggest antidepressant medications may be helpful.

CONCLUSION AND RELEVANCE

Individuals with complicated grief have greater risk of adverse health outcomes, should be diagnosed and assessed for suicide risk and comorbid conditions such as depression and posttraumatic stress disorder, and should be considered for treatment.