Bereavement and anxiety

From theory to reality: Unraveling the development of mature death concept

Death is commonly accepted as the irreversible ending of all biological functions that keep an organism alive. However, understanding death is more complicated than merely comprehending the biological elements of death. Beyond the biological elements of death, it is also critical to understand death's social, cognitive, and environmental aspects as they influence death awareness, death anxiety, grief and bereavement, and death education. This paper explores the development of mature death concept in children, from early childhood to adolescence. Drawing on a range of developmental and death awareness theoretical frameworks, the authors create a comprehensive model describing the development of mature death concept. The goal of this paper is to propose one theoretical perspective that connects traditional cognitive, socioemotional, and ecological developmental theories with current death awareness theories.

Exploring Resilience and Post-traumatic Growth Among Bereaved Adults in Kosovo

The study explores resilience and posttraumatic growth in adults in Kosovo who have experienced grief, using the Resilience Portfolio Model as a guiding framework. Twelve participants shared their experiences through semi-structured interviews, aiming to capture detailed personal narratives and insights into coping with loss. Thematic analysis of the data revealed three main themes: "Reaction to Loss," "Navigating through Loss and Embracing Adaptations," and "Resilience and Posttraumatic Growth." The findings highlight the transformative experiences contributing to personal development and resilience, emphasizing the significant role of cultural dimensions in shaping resilience and posttraumatic growth. The study underscores the importance of considering cultural context in therapeutic approaches to better support individuals in their recovery and growth from experiences of loss.

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.

Status Consumption as Coping With Fear of Death: The Mediating Role of Death Avoidance and the Moderating Role of Materialism

Individuals employ various coping mechanisms to deal with the fear of death. While materialism and status consumption are commonly recognized in the literature as such strategies, no study has yet empirically tested this premise. Accordingly, this study examined the mediating role of death avoidance in the link between the fear of death and death-related status consumption (DRSC). Data obtained from 346 participants were analyzed using structural equation modeling. The results showed that fear of death significantly and positively influences DRSC and that death avoidance partially and positively mediates this relationship. Results also revealed that materialism strengthens the relationship between fear of death and DRSC, while it does not significantly moderate the relationship between death avoidance and DRSC. These results support the conclusion that death-related status consumption may play a critical role as an avoidance mechanism in coping with the fear of death. This study, being among the few that investigate death-related consumer behaviors, enriches both terror management theory and the literature on consumer behavior in crises.

The relationship between perceived stress and prolonged grief disorder among Chinese Shidu parents: effects of anxiety and social support

BACKGROUND

Shidu parents refer to the couple who have lost their only child and have not given birth or adopted another child in China. The number of Shidu parents is increasing annually. The aim of this research was to examine the mediating role of anxiety and the moderating role of social support between perceived stress and prolonged grief disorder (PGD) among Chinese Shidu parents.

METHODS

A cross-sectional study was carried out with 505 participants who completed a questionnaire including the Prolonged Grief Questionnair-3 (PG-13), the Perceived Stress Scale-10 (PSS-10), the Self-Rating Anxiety Scale (SAS) and the Duke-UNC Functional Social Support Questionnaire (FSSQ). SPSS PROCESS macro was employed to examine the mediating role of anxiety and the moderating role of social support.

RESULTS

The mediation analysis showed anxiety partially mediated the link between perceived stress and PGD, and the proportion of mediation of anxiety was 39.22%. The moderated mediation analysis revealed the second stage of mediating effects of anxiety on the link between perceived stress and PGD was moderated by social support. Specifically, compared with Shidu parents with higher social support, the association between anxiety and PGD was closer for those with lower social support.

CONCLUSIONS

The moderated mediation model can broaden our understanding of how and when perceived stress, anxiety and social support work together to affect PGD. The interventions aimed at improving mental health of Chinese Shidu parents need to work on reducing stress and enhancing social support.

Symptoms and levels of ICD-11 Prolonged Grief Disorder in a representative community sample of UK adults

BACKGROUND

Prolonged Grief Disorder (PGD) is a new disorder included in ICD-11 (WHO, 2018). There is a growing body of literature surrounding the prevalence and correlates of ICD-11 PGD symptoms as assessed using various measures. This study was the first to assess levels of ICD-11 PGD symptoms as measured by the International Prolonged Grief Disorder Scale (IPGDS), a self-report scale directly aligned with the ICD-11 definition of PGD, among the United Kingdom adult general population, and identify correlates.

METHOD

Participants included 2025 adults who participated in Wave 5 of the COVID-19 Psychological Research Consortium Study (C19PRC-UK). Prevalence rates of PGD were estimated based on two commonly used algorithms defined as 'strict' and 'moderate'. Sociodemographic, loss-related, and mental health correlates (i.e., anxiety, depression, mental health treatment seeking, loneliness) of strict and moderate PGD were then examined using multinomial logistic regressions.

RESULTS

It was found that 2.4% (n = 43) of participants met probable caseness for PGD using the strict criteria while 7.9% (n = 140) met probable caseness for PGD using the moderate criteria. Multinomial logistic regression analysis results showed, as predicted, that income, time since bereavement, death of a child, religiosity, and depression were associated with both moderate and strict PGD. Correlates of moderate PGD included country of residence, urbanicity, younger age of bereaved, and loneliness.

CONCLUSIONS

This study highlights that some symptoms of PGD are commonly reported in the general population, although relatively few meet the criteria for clinical significance. The routine assessment for PGD following a bereavement is discussed and the development of appropriate interventions are recommended.

Assessing the validity and reliability of the International Anxiety Questionnaire and the International Depression Questionnaire in two bereaved national samples

The International Anxiety Questionnaire (IAQ) and International Depression Questionnaire (IDQ) are self-report measures of ICD-11 Generalized Anxiety Disorder (ICD-11 GAD) and ICD-11 Single Episode Depressive Disorder (ICD-11 DD). This study tested the psychometric properties of these scales in two samples of bereaved adults from the United Kingdom and the Republic of Ireland. Confirmatory factor analysis (CFA) was used to test the combined dimensionality and measurement invariance of the IAQ and IDQ across the United Kingdom (n = 1012) and Irish (n = 1011) samples. Differential item functioning (DIF) was tested using multiple indicator multiple cause (MIMIC) modelling while convergent validity was also assessed. CFA results supported a correlated two-factor model in both samples. The MIMIC model showed that the IDQ item "Had recurrent thoughts of death or suicide" showed DIF and the effect was small. Internal reliability of the scales were high and convergent validity was supported. The prevalence of ICD-11 GAD was 18.6% and 16.1% and ICD-11 DD was 13.8% and 10.5% in the United Kingdom and Irish samples, respectively. Findings of the study provide support for the validity, measurement invariance, and reliability of the IAQ and IDQ among two bereaved national samples.

Factors Associated With Symptoms of Prolonged Grief and Psychological Distress Among Bereaved Family Members of Persons Who Died From Sudden Cardiac Arrest

BACKGROUND

Death from sudden cardiac arrest implies a stressful and challenging situation for bereaved family members with an increased risk of prolonged grief disorder and psychological distress.

OBJECTIVES

The aims of this study were (1) to explore the associations between symptoms of prolonged grief and psychological distress and (2) to identify factors associated with symptoms of prolonged grief and psychological distress among bereaved family members of persons who died from sudden cardiac arrest.

METHODS

This cross-sectional survey included bereaved adult family members. Demographic data and measures of prolonged grief (Prolonged Grief Disorder-13), anxiety and depression (Hospital Anxiety and Depression Scale), posttraumatic stress (Posttraumatic Stress Disorder Checklist for DSM-5), and perceived social support (Multidimensional Scale of Perceived Social Support) were analyzed using Spearman's correlations ( r s ) as well as univariate and multiple linear regression analyses.

RESULTS

In total, 108 family members participated. Significant associations between symptoms of prolonged grief, anxiety, depression, and posttraumatic stress were identified ( r s = 0.69-0.79, P < .001). Offered, sought, and/or received professional support from healthcare, lower levels of perceived social support, being a spouse of the deceased, female sex, younger age, and family presence during resuscitation were significantly associated with higher symptom levels of prolonged grief, anxiety, depression, and/or posttraumatic stress.

CONCLUSIONS

The results indicate that family members with higher levels of symptoms were offered, sought, and/or received professional support. However, because a minority are offered professional support after deaths from cardiac arrest, future interventions need to proactively identify family members in need of support. Furthermore, perceived social support seems to be an important factor for family members of persons who died from cardiac arrest.

A cross-sectional examination of sudden-death bereavement in university students

ObjectivesThe objective of this research was to determine the unique contributions of sudden death bereavement to the mental health of university students compared to non-sudden death bereaved university students. Methods: We surveyed 1047 bereaved university students (retention rate 92%) and compared the non-sudden death bereaved university student population to the sudden death bereaved university population on outcomes including mental health symptomatology, and complicated grief using logistic regressions. Results: Sixty two percent of the sample reported sudden death bereavement. There were no differences on measures of PTSD, generalized anxiety disorder, depression, suicidal ideation, and at-risk drinking behavior across types of bereavement. However, sudden death bereavement compared to general bereavement was associated with increased likelihood of complicated grief. Conclusions: Sudden death bereavement in university students is associated with elevated risk of complicated grief. These findings confirm previous research and provide more insight into the unique needs of university student coping with sudden loss.

Self-Compassion for Caregivers of Children in Parentally Bereaved Families: A Theoretical Model and Intervention Example

Family-based bereavement interventions have shown promises to prevent problem outcomes and promote resilience in parentally bereaved children. Evidence of the broad range of mental and physical health problems following the death of a parent supports the need for a transdiagnostic approach that promotes adaptation and reduces multiple problem outcomes for parentally bereaved families. We discuss self-compassion as a promising framework for a transdiagnostic approach. We argue that three elements of self-compassion-mindfulness (vs. over-identification), self-kindness (vs. self-judgment), and common humanity (vs. isolation)-can facilitate loss-oriented coping, restoration-oriented coping, and the oscillation process between the two. This sets the foundation for individual and family processes that support bereavement adjustment. To explain how self-compassion promotes adjustment outcomes in parentally bereaved families, we review the extant literature with a focus on parental emotion regulation and effective parenting and propose a conceptual model with testable hypotheses to guide more research in this area. The model suggests that caregivers' self-compassion is a resilience resource for multiple adaptive outcomes for themselves and for their child through its positive impacts on emotion regulation and effective parenting. We illustrate the utility of the framework with an example of a family-based bereavement prevention program that integrated self-compassion training. Future directions for research are discussed.

Pandemic grief in El Salvador: factors that predict dysfunctional grief due to a COVID-19 death among Salvadoran adults

Thousands of people have died of COVID-19 in El Salvador. However, little is known about the mental health of those who are mourning the loss of a loved one to COVID-19. Therefore, the objective of this study was to examine the dysfunctional grief associated with COVID-19 death among Salvadoran adults. A sample of 435 Salvadorans (M = 29 years; SD = 8.75) who lost a family member or loved one to COVID-19 completed a digital survey using the Google Forms platform, during April 2 and 28, 2022. The results revealed that 35.1% reported clinically elevated symptoms of dysfunctional grief and among those mourners, and 25.1% also exhibited clinical levels of coronavirus anxiety. A binary logistic regression revealed that predictor variables such as COVID-19 anxiety (p = .003), depression (p = .021), and COVID-19 obsession (p = .032) were significant (χ² = 84.31; Nagelkerke R² = .242) and predict a 24.2% chance of dysfunctional bereavement.

Validation of the Persian Traumatic Grief Inventory- Self Report Plus (TGI-SR+) to Assess Prolonged Grief Severity

The Traumatic Grief Inventory-Self Report Plus (TGI-SR+) is a self-report measure to assess Prolonged Grief Disorder (PGD) in terms of ICD-11 and DSM-5-TR. Till now this measure has shown to yield good psychometric properties in Dutch and French speaking bereaved people. This study aimed to evaluate the psychometric properties of the Persian TGI-SR+. 461 individuals (280 women) fully completed the scales. The participants were recruited using convenience sampling. The Confirmatory factor analysis and concurrent validity, and reliability of the Persian version of the TGI-SR+ were evaluated. Confirmatory factor analysis results of a two-dimensional model support the construct validity of this version of the TGI-SR+, while concurrent validity was shown with significant correlations between the TGI-SR+ and measures of depression, anxiety, and ptsd. These results indicate satisfactory psychometric properties of the instrument, thus supporting the use of the TGI-SR + as a valid measure of PGD in bereaved Iranian adults.

Grief reactions in relation to professional and social support among family members of persons who died from sudden cardiac arrest: A longitudinal survey study

BACKGROUND

The loss of a close person from sudden cardiac arrest (CA) leaves family members at risk of developing grief reactions such as symptoms of prolonged grief, anxiety, depression, and posttraumatic stress. The aim was to describe longitudinal variations in grief reactions and its association with professional and social support among bereaved family members after a close person's death from sudden CA.

METHODS

This longitudinal multimethod survey included 69 bereaved family members who completed a questionnaire 6 and 12-months after the CA, including the Prolonged Grief Disorder-13, Hospital Anxiety and Depression Scale, PTSD Checklist for DSM-5, and Multidimensional Scale of Perceived Social Support. Qualitative data were collected by open-ended questions. Quantitative data was analyzed using Wilcoxon signed-rank test and linear regression analysis while written comments were analyzed using qualitative content analysis.

RESULTS

The median age was 62 years, 67 % were women, and 38 % had been present during the resuscitation attempts. Using the cut-off scores at the 6- and 12-month assessments respectively, 14 % and 17 % reported symptoms of prolonged grief, 32 % and 26 % symptoms of anxiety, 14 % and 9 % depression, and 4 % and 1 % posttraumatic stress. Professional and social support at the 6-month assessment were significantly associated with symptoms of prolonged grief, anxiety, depression, and/or posttraumatic stress at the 12-month assessments but could not predict any changes in the grief reactions.

CONCLUSIONS

Family members' grief reactions point to the importance of proactive and available support over time to meet family members' needs.

Predictors of prolonged grief disorder in Chinese elderly shidu parents: The role of perceived stigma and perceived stress

INTRODUCTION

Parents who have lost their only child and over the age of 60 are known as elderly shidu parents. This study aimed to investigate predictors of prolonged grief disorder (PGD) among Chinese elderly shidu parents.

METHODS

Two hundred and ninety-eight elderly shidu parents from Shenyang were included in this cross-sectional study. Participants completed a questionnaire including the Prolonged Grief questionnaire-13 (PG-13), the PTSD (post-traumatic stress disorder) Checklist for DSM-5 (PCL-5), the Center for Epidemiologic Studies Depression Scales (CES-D), the Self-Rating Anxiety Scale (SAS), and the Perceived Stress Scale-10 (PSS-10). Multiple linear regression was used to examine socio-demographic, bereavement-related and perceived stress associated with PGD symptoms.

RESULTS

The prevalence of PGD among Chinese elderly shidu parents was 13.8%. Among the 41 PGD patients, 29, 39, 36 patients had comorbidity of PTSD, depressive symptoms and anxiety, respectively. Perceived stress, higher educational level, lower annual household income, perceived stigma, violent death of the child, and being in debt were associated with severer PGD symptoms.

DISCUSSION

The present study revealed the prevalence of PGD and the important role of PGD in diagnosing other mental disorders in Chinese elderly shidu parents. Providing financial help, eliminating social stigma, and stress should be included in PGD prevention among Chinese elderly shidu parents.

Network analysis of PGD, PTSD and insomnia symptoms in Chinese shidu parents with PGD

Background

Chinese shidu parents (bereaved parents over the age of 49 who have lost their only child) are potentially at a high risk of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD) and insomnia.

Objective

The current study aimed to estimate three network models in 310 shidu parents who met the ICD-11 criteria for PGD: (1) a PGD network to identify central symptoms; (2) a comorbidity network to explore bridge symptoms between PGD and PTSD; (3) a comorbidity network to examine the associations between PGD and insomnia symptoms.

Methods

The R-packages bootnet, qgraph and networktools were used to investigate the structure of network models and centrality indices of symptoms. In addition, robustness and significance analyses for the edge weights and the order of centrality were performed.

Results

Emotional pain and numbness emerged as the most central symptoms in the PGD network. In the PGD-PTSD comorbidity network, the highest bridge strength symptoms were inability to trust others (PGD) and feeling upset (PTSD). Inability to trust others (PGD), avoidance (PGD), and impairment of life quality (insomnia) were possible bridge symptoms connecting PGD and insomnia.

Conclusions

Reducing emotional pain and numbness may be a viable target in PGD interventions for shidu parents. Additionally, findings suggest that future studies could examine the role of inability to trust others and avoidance in PGD comorbidities.

HIGHLIGHTS

• Emotional pain and numbness were the most influential symptoms in shidu parents with PGD. The role of PGD symptoms of inability to trust others and avoidance in the comorbidities of PGD with PTSD and insomnia might be worthy of further study.

Prevalence of Anxiety Symptoms and Associated Clinical and Sociodemographic Factors in Mexican Adults Seeking Psychological Support for Grief During the COVID-19 Pandemic: A Cross-Sectional Study

The COVID-19 pandemic is one of the greatest challenges in modern history, with more than four million confirmed deaths worldwide. To date, evidence regarding the psychological impact of the COVID-19 pandemic on grievers is scarce for developing countries such as Mexico. This study aimed to assess the levels of anxiety and associated concerns in a sample of Mexican adults bereaved during the COVID-19 outbreak. A cross-sectional study was conducted through the Duelo COVID (COVID Grief) platform, which is a self-guided online treatment. A total of 5,224 participants reported their anxiety, depression, sleep quality, avoidance, and arousal, prolonged grief symptoms, and medication consumption. Independent sample Mann-Whitney U-tests, chi-square tests, and Kruskal-Wallis tests, as well as multinomial logistic regression, were conducted. Results indicated that 90.4% of the participants reported clinical levels of anxiety, depression, and sleep affectations. The people who lost someone during the last 5 months scored higher in normal grief symptoms compared to the people whose loss was 6 months ago or more, and 9.8% of individuals reported the use of prescription medication, with anxiolytics and antidepressants being the most common. Females, younger respondents, unemployed people with a lower educational level, and participants who disclosed a recent suicide attempt were among those who reported medication consumption. Sleep problems were more frequent in older participants.

BEREAVEMENT AND COVID-19: PREVALENCE, COMORBIDITY, AND ASSOCIATED FEATURES AMONG UKRAINIAN SAMPLE

OBJECTIVE

The aim: To examine the features of experiences of bereavement reactions and the severity of comorbid mental health problems in persons who lost loved ones during the pandemic.

PATIENTS AND METHODS

Materials and methods: 191 volunteers aged 18-60 years participated in this study. All participants were tested during 2018-2020. To assess the mental health problems was used International Neuropsychiatric Interview (MINI) and a set of IAPT scales; to the psycho-emotional distress severity associated with loss of loved ones - Inventory of Complicated Grief, with verification of symptoms of complicated grief based on an independent assessment of two experts; and the quality of life satisfaction was assessed by the Quality of Life Enjoyment and Satisfaction Questionnaire, Short Form.

RESULTS

Results: The results show an association between the severity of symptoms of depression, general anxiety, social avoidance, and loss during the pandemic. The level of psycho-emotional distress was associated with the experience of bereavement as a traumatic event for a group of participants who experienced loss during the pandemic and, at the same time, before the pandemic was associated with the severity of depression. Regardless of the time of loss, people who demonstrated signs of complicated grief have a more pronounced comorbid psychopathology, a higher level of psycho-emotional distress, and a lower level of satisfaction with life quality.

CONCLUSION

Conclusions: It has been established that a person's ability to experience loss as a traumatic experience and grieve during the pandemic is modified with the context of the life situation and reflects those challenges that impose quarantine restrictions.

Incidence of Anxiety in Latest Life and Risk Factors. Results of the AgeCoDe/AgeQualiDe Study

Research on anxiety in oldest-old individuals is scarce. Specifically, incidence studies based on large community samples are lacking. The objective of this study is to assess age- and gender-specific incidence rates in a large sample of oldest-old individuals and to identify potential risk factors. The study included data from N = 702 adults aged 81 to 97 years. Anxiety symptoms were identified using the short form of the Geriatric Anxiety Inventory (GAI-SF). Associations of potential risk factors with anxiety incidence were analyzed using Cox proportional hazard models. Out of the N = 702 older adults, N = 77 individuals developed anxiety symptoms during the follow-up period. The incidence rate was 51.3 (95% CI: 41.2-64.1) per 1000 person-years in the overall sample, compared to 58.5 (95% CI: 43.2-72.4) in women and 37.3 (95% CI: 23.6-58.3) in men. Multivariable analysis showed an association of subjective memory complaints (HR: 2.03, 95% CI: 1.16-3.57) and depressive symptoms (HR: 3.20, 95% CI: 1.46-7.01) with incident anxiety in the follow-up. Incident anxiety is highly common in late life. Depressive symptoms and subjective memory complaints are major risk factors of new episodes. Incident anxiety appears to be a response to subjective memory complaints independent of depressive symptoms.

It's not who you lose, it's who you are: Identity and symptom trajectory in prolonged grief

The death of a loved one has been associated with a range of emotional and cognitive impacts, with up to 10% of the bereaved population experiencing a prolonged grief reaction. Direct investigation of the role of self-identity in the maintenance of grief symptoms is limited and has not discriminated between relationship type. This longitudinal study investigated the differences in grief symptoms over time depending on relationship to the deceased person (partner or adult child), as well as the association between long-term grief symptoms and identity, attachment, and cognitive interdependence. Data from bereaved partners and adult children in The Aarhus Bereavement Study at two- and 18-months post-bereavement were included in this study. They completed questionnaires measuring their grief symptoms at both time points, a measure of attachment at Time 1, and measures of the interdependence of their pre- and post-loss identity with the deceased, their cognitive interdependence, and everyday memory retrieval failures at Time 4. Compared with adult children, bereaved partners experienced more intense grief symptoms at both time points. Regression analysis identified that over and above immediate grief symptoms, key predictors of prolonged grief symptoms were a merged post-bereavement identity with the deceased, younger age, and everyday memory retrieval difficulties. Relationship type and pre-bereavement identity contributed to initial but not prolonged grief symptoms. We discuss these findings in terms of the role of interdependence in prolonged grief.

Psychopathology in a treatment-seeking sample of homicidally bereaved individuals: Latent class analysis

BACKGROUND

Violently bereaved individuals are at increased risk of developing severe and comorbid disorders. Comorbidity may increase psychiatric symptom severity and suicide risk and decrease psychosocial functioning compared with having one disorder. We aimed to identify subgroups of individuals with similar symptom patterns, describe prevalence rates and overall levels of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD) per class, and explore associations between class membership and personal and homicide related variables.

METHODS

We investigated the comorbidity of symptoms of PGD, PTSD, MDD, and GAD in a sample of 923 treatment-seeking homicidally bereaved individuals by deploying latent class analysis.

RESULTS

Three subgroups were identified: (i) a moderate distress, low depression class (12.4%), (ii) a high distress, moderate depression class (42.7%), and (iii) a high distress and high depression class (45.0%). Prevalence rates and total scores of the questionnaires followed the pattern of iii ≥ ii ≥ i (ps ≤ .001). Being female and having experienced prior life stress distinguished between all classes (ps ≤ .05).

LIMITATIONS

The data-driven analytic approach and reliance on self-reported routine outcome monitoring data limit the generalizability and validity of the study. Strengths include the large sample size and the inclusion of four measures in a treatment-seeking, violently bereaved sample.

CONCLUSIONS

Classes were most clearly distinguishable based on symptom severity, indicating high comorbidity following bereavement by homicide. This argues for an integrated treatment that targets different complaints simultaneously rather than successively.

Assessment of Dysfunctional Grief due to Death from COVID-19 in Peru: Adaptation and Validation of a Spanish Version of the Pandemic Grief Scale

This study evaluated the psychometric properties of the Pandemic Grief Scale (PGS), using Classical Test Theory (CTT) and Item Response Theory (IRT) methods, in a sample of 458 people who have suffered the loss of a loved one due to the COVID-19 pandemic. The Pandemic Grief Scale, Patient Health Questionnaire-2 (PHQ-2), the two-item Generalized Anxiety Disorder Scale (GAD-2), and a single item on suicidal ideation were used. The unidimensional model had good fit and reliability; furthermore, convergent validity was demonstrated based on the relationships between dysfunctional grief, anxiety symptoms, depression, and suicidal ideation. Additionally, a higher presence of dysfunctional grief is required to answer using the higher response categories. The evidence of validity and reliability of the PGS in its Spanish version, using traditional and modern methods, is confirmed in Peru.

Impacts of the COVID-19 Pandemic on the Bereaved: A Study of Bereaved Weibo Users

The global COVID-19 pandemic may significantly affect the experiences of death and bereavement. This study aimed to learn from recent outbreaks of infectious diseases and further understand their impacts on bereavement. We obtained psychological status scores for 32 individuals bereaved due to COVID-19 and 127 individuals bereaved due to non-COVID-19 causes using the online ecological recognition (OER) approach. Next, a sentiment analysis and independent sample t-test were performed to examine the differences between these two groups. The results indicated that the individuals bereaved due to COVID-19 were more insecure and more preoccupied with the grief of the moment than those bereaved due to non-COVID-19 reasons, while the latter group had higher depression scores than the former group. This study can guide policy-makers and clinical practitioners to provide more targeted and sustainable post-bereavement support for both bereaved groups during the COVID-19 period.

Symptoms of Prolonged Grief and Self-Reported Health Among Bereaved Family Members of Persons Who Died From Sudden Cardiac Arrest

Sudden cardiac arrest is common and is one of the leading causes of death in the western world, and the sudden loss following cardiac arrest may have a significant impact on bereaved family members' health. Therefore, the aim of this study was to describe symptoms of prolonged grief and self-reported health among bereaved family members of persons who died from sudden cardiac arrest, with comparisons between spouses and non-spouses. This was a cross-sectional observation study with 108 adult family members who completed a questionnaire. A fifth of the family members reported prolonged grief, and problems with self-reported health were common, especially regarding anxiety. Spouses reported more problems with prolonged grief and self-reported health compared with non-spouses. The risk of these family members developing prolonged grief and health problems should be recognized, and professional support should be offered.

Complicated Grief, Depression and Post-Traumatic Stress Symptoms Among Bereaved Parents following their Child's Death in the Pediatric Intensive Care Unit: A Follow-Up Study

BACKGROUND

Parents often suffer reduced mental health after their child's death; however, the trajectory and risk factors are not well described.

OBJECTIVE

Describe the change in complicated grief, depression, and post-traumatic stress symptoms among parents between 6 and 13 months after their child's death in a pediatric intensive care unit (PICU), and factors associated with 13-month symptoms.

METHODS

Parents whose children died in 1 of 8 PICUs affiliated with the Collaborative Pediatric Critical Care Research Network completed surveys 6 and 13 months after their child's death. Surveys included the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-8 (PHQ-8) for depression, and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT). Parents provided sociodemographics. Charts were reviewed for child characteristics.

RESULTS

One-hundred and fifty seven parents of 104 deceased children completed surveys at both time points. Mental health symptoms declined over time (mean (SD)): ICG (33.8 (15.4) vs. 30.5 (15.2), p < 0.001), PHQ-8 (9.0 (6.4) vs. 7.3 (5.8), p < 0.001), and SPRINT (14.1 (8.3) vs. 12.0 (8.2), p < 0.001). After controlling for 6-month scores, higher 13-month ICG was independently associated with sudden unexpected death; higher PHQ-8 with Black race, insecure attachment style, and sudden unexpected death; and higher SPRINT with having a high school level of education (compared to college degree or higher).

CONCLUSION

Mental health symptoms improve among parents during the first 13 months after their child's death; however, symptoms persist for many. Black parents and those whose children die suddenly may be high risk for poor adjustment during bereavement.

The role of post-loss anxiety in the development of depressive symptoms and complicated grief symptoms: a longitudinal SEM study

BACKGROUND

Though grief, anxiety, and depression often co-occur, existing evidence mostly focus on any two of them at a time. Our study examined the relationships among the three clusters of symptoms.

METHODS

A Chinese community sample of 101 bereaved individuals participated at T1. We utilized Bayesian Structural Equation Modelling (BSEM) to conduct cross-lagged analyses on three-wave panel data (T1 at one-month post-loss, T2 at four-months, and T3 at seven-months).

RESULTS

BSEM findings confirmed the presence of distinctive developmental paths for complicated grief (CG), anxiety, and depressive symptoms. Three simplex models showed that anxiety, CG symptoms, and depressive symptoms maintained high consistency. In cross-lagged models, anxiety at T1 was a significant predictor of depressive symptoms (standardized estimate B=0.386*) and CG symptoms (standardized estimate B=0.300*) at T2. The remaining positive directions (0.338*, 0.256*) in the final model suggest the important role of anxiety at early bereavement, while at a later stage, T2 CG contributed to depressive symptoms at T3 (0.356*).

LIMITATIONS

In addition to attrition, the overall sample size was limited. Data were based on self-report. Future research with repeated measures and Bayesian informative priors would be more useful to establish relational patterns of symptoms.

CONCLUSIONS

In our models, the reduction in anxiety symptoms contributed to the development of depressive and CG symptoms, and these results should be replicated. Theories of mechanisms underlying post-loss anxiety can be explored as a potential means of reducing later symptoms.

Depression, Anxiety and Post-traumatic Growth Among Bereaved Adults: A Latent Class Analysis

Background

The death of a loved one can trigger a range of responses, including painful thoughts and emotions, as well as positive changes, such as post-traumatic growth (PTG). To understand more about the relationship between these outcomes this study explored the co-occurrence of depression, anxiety and PTG among a group of bereaved Chinese adults.

Methods

Data were collected from 194 participants, who had lost a first-degree relative. Latent class analysis was used to analyze the data to identify subgroups of participants with shared symptom profiles.

Results

Three classes were identified: a Growth class, a Depression/Anxiety/Growth class and a Depression/Anxiety class. Marital status, social support, close relationship with the deceased and witnessing the suffering of the deceased were identified as differential predictors of class membership.

Conclusion

The findings contribute to our understanding of the potentially wide ranging impacts of bereavement and highlight the important role of stressor characteristics and support and in influencing impairment and positive outcomes.

Poor Psychosocial Well-Being in the First Year-and-a-Half After Losing a Parent to Cancer - A Longitudinal Study Among Young Adults Participating in Support Groups

The purpose of this study was to investigate variations in psychosocial well-being over time among young adults who participated in a support group after the death of a parent from cancer. Fifty-five young adults, aged 16-28 years, completed questionnaires that measured self-esteem, anxiety, depression, and life satisfaction at three time-points during the first year-and-one-half after the loss. Results indicated overall poor psychosocial well-being with few increases in psychological health over the study period, despite access to support and social networks. However, these resources may help to prevent major impairments in the participants' future lives.

Impact of earthquake exposure, family adversity and peer problems on anxiety-related emotional disorders in adolescent survivors three years after the Ya'an earthquake

BACKGROUND

Traumatic experiences often give rise to an increased risk of anxiety problems in adolescents. This study investigated the anxiety prevalence in adolescent earthquake survivors and the effect of secondary stressors such as bullying, poverty, or being "left behind" by parents working in the cities.

METHODS

This cross-sectional study was conducted three years after the 2013 Ya'an (China) earthquake on 6,132 adolescents aged 9 to 18 years from 11 public schools in three severely earthquake affected counties. The participants completed self-report questionnaires that assessed anxiety, earthquake exposure, poverty level, left-behind duration and bullying.

RESULTS

Separation anxiety (38.7%) and panic symptoms (32.2%) were found to be the primary contributors to anxiety in this adolescent sample. The regression and structural equation modeling indicated that adolescents who had suffered from high earthquake exposure, peer bullying, being left-behind, or poverty were more likely to report problems in all anxiety subcategories, with females reporting more anxiety symptoms than males. The likelihood of all anxiety disorders except separation anxiety was found to increase with age.

CONCLUSIONS

This study highlighted the need for post-disaster interventions aimed at minimizing post-earthquake adversity such as peer bullying and specialized psychological services that target subgroups that might be more susceptible to anxiety-related emotional problems. The results could be used to identify possible markers for anxiety problems in children who had not experienced any major traumas.

[Recommendations for the support of suffering, severely ill, dying or grieving persons in the corona pandemic from a palliative care perspective : Recommendations of the German Society for Palliative Medicine (DGP), the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI), the Federal Association for Grief Counseling (BVT), the Working Group for Psycho-oncology in the German Cancer Society, the German Association for Social Work in the Healthcare System (DVSG) and the German Association for Systemic Therapy, Counseling and Family Therapy (DGSF)]

The corona pandemic has led to a number of restrictions and prohibitions, which in turn place large psychosocial or spiritual burdens on patients with COVID-19, their families and relatives and the treating personnel in the healthcare system. Patients with COVID-19 are not allowed to receive visitors and many hospitals and nursing homes have completely banned visitors. Many support services have been reduced or stopped completely. Necessary treatment interventions for other patients with critical and life-limiting diseases have been delayed or suspended in order to free resources for the expected COVID-19 patients; however, these people need to feel social connectedness with their relatives. Palliative care patients should be exempted from any ban on visitors. Families should be able to visit dying patients even on intensive care units or isolation wards, using adequate protective equipment. Alternative options, such as video telephone calls or via social media should be explored for patients in isolation. Families should also be enabled to say goodbye to the deceased with adequate protective equipment or should be offered alternative real or virtual options for remembrance and commemoration. Health care professionals coping with the exceptional stress should be continuously supported. This requires clear communication and leadership structures, communication training, psychosocial support, but most of all optimal framework conditions for the clinical work.

Suicidal Ideation in Bereavement: A Systematic Review

Background: Bereavement is associated with impaired mental health, increases in adverse health behaviors, and heightened risk of suicidal ideation, attempts, and death by suicide. The purpose of this literature review was to explore associations between cause of death and suicidal thoughts among bereaved individuals. Our aim was to compare incidence of suicidal ideation by cause of death and identify gaps in this literature to guide future research and clinical intervention. Methods: PRISMA-P guidelines were used to structure an electronic literature search in the PsycINFO, MEDLINE, and Web of Science databases. The search focused on English language studies that were published before February 2019 and sought to compare rates of suicidal ideation among bereaved people who lost a loved one to suicide, accidental overdose, cancer, dementia, cardiovascular disease, and HIV/AIDs. Results: Ten articles were identified with suicide as cause of death, zero articles for accidental overdose, zero articles for cardiovascular disease, eight articles for cancer, one article for dementia, and one article for HIV/AIDs. Given the limited number of articles generated by our search, a formal meta-analysis was not appropriate. However, a comparison of results did suggest that suicide bereavement was associated with the highest rates of suicide ideation (14.1% to 49%). Stigma, isolation, avoidance behaviors, and psychological distress were associated with suicidal thoughts among bereaved individuals, regardless of the deceased's cause of death. Conclusions: Findings of this literature search revealed significant gaps in the literature, especially regarding thoughts of suicide in bereaved survivors of accidental overdose and cardiovascular disease. Results suggest that multiple causes of death are associated with suicidal ideation in bereavement, but that suicide bereavement may be the cause of death associated with the highest risk of suicidal ideation. More research is needed to understand the ways in which cause of death influences prevalence, risk, and protective factors associated with suicidal thoughts among bereaved individuals.

Variations in grief, anxiety, depression, and health among family caregivers before and after the death of a close person in the context of palliative home care

This article investigates longitudinal variations in grief, self-rated health, and symptoms of anxiety and depression among family caregivers in palliative care. Data were taken from a randomized psycho-educational intervention trial and were collected at four time-points; at baseline, upon completion, 2 months later, and 6 months after the patient's death. In total, 117 family caregivers completed all questionnaires. The participants' grief was stable across the measurements, while anxiety, depression, and health varied significantly (p < 0.05). No significant differences were found between the intervention or control group. In conclusion, grief emerged as a constant phenomenon, distinct from symptoms of anxiety and depression.

Bereavement stressors and psychosocial well-being of young adults following the loss of a parent - A cross-sectional survey

PURPOSE

The knowledge about young adults who have lost a parent to cancer is limited, and to reach a broader understanding about this group, this study used the Dual Process Model of Coping with Bereavement (Stroebe and Schut, 1999) as a theoretical framework. The purpose of this study was to describe loss- and restoration-oriented bereavement stressors and psychosocial wellbeing of young adults following the loss of a parent to cancer.

METHOD

This survey used baseline data from a longitudinal study. Young adults, aged 16-28 years, who lost a parent to cancer more than two months earlier and agreed to participate in support groups held at three palliative care services in Sweden, responded to a comprehensive theory-based study-specific questionnaire.

RESULTS

Altogether, 77 young adults (64 women and 13 men) answered the questionnaire an average of five-to-eight months after the loss. Twenty percent (n = 15) had not been aware of their parent's impending death at all or only knew a few hours before the death, and 65% (n = 50) did not expect the death when it occurred. The young adults reported low self-esteem (n = 58, 76%), mild to severe anxiety (n = 55, 74%), mild to severe depression (n = 23, 31%) and low life satisfaction.

CONCLUSION

Young adults reported overall poor psychosocial wellbeing following bereavement. The unexpectedness and unawareness of the parent's imminent death, i.e., loss-oriented bereavement stressors, might influence psychosocial wellbeing. Despite these reports, restoration-oriented stressors, such as support from family and friends, helped them to cope with the loss.

Depression, Hopelessness, and Complicated Grief in Survivors of Suicide

Suicide often has a severe impact on the surviving family and friends. There is a need to better understand the psychological and psychopathological consequences of losing a significant other by suicide. The aim of the present study was to assess hopelessness, depression, suicide risk, complicated grief, intrusive memories, and avoidance in a sample of suicide survivors. In this observational study, 35 bereaved individuals were recruited at the Suicide Prevention Centre of Sant’Andrea Hospital in Rome. Individuals were administered a series of validated instruments: the Beck Depression Inventory II (BDI), the Beck Hopelessness Scale (BHS), the Inventory of Complicated Grief (ICG), the Impact of Event Scale (IES), the Subjective Happiness Scale (SHS), and the Satisfaction With Life Scale (SWLS). Most survivors (62.8%) obtained high scores on measures of complicated grief. Scores on the measure of complicated grief were associated with intrusiveness of thoughts and memories, attempts to prevent the thoughts and emotions related to the event, depressive symptoms and hopelessness, and lower scores for feelings of happiness and satisfaction with life. A subgroup of suicide survivors may be at risk of severe psychological distress and suicidal behavior. Identification of these survivors is a necessary step for providing appropriate counseling and psychotherapy.

Initial Validation of a Comprehensive Assessment Instrument for Bereavement-Related Grief Symptoms and Risk of Complications: The Indicator of Bereavement Adaptation-Cruse Scotland (IBACS)

Objective

This study assessed the validity of the Indicator of Bereavement Adaptation Cruse Scotland (IBACS). Designed for use in clinical and non-clinical settings, the IBACS measures severity of grief symptoms and risk of developing complications.

Method

N = 196 (44 male, 152 female) help-seeking, bereaved Scottish adults participated at two timepoints: T1 (baseline) and T2 (after 18 months). Four validated assessment instruments were administered: CORE-R, ICG-R, IES-R, SCL-90-R. Discriminative ability was assessed using ROC curve analysis. Concurrent validity was tested through correlation analysis at T1. Predictive validity was assessed using correlation analyses and ROC curve analysis. Optimal IBACS cutoff values were obtained by calculating a maximal Youden index J in ROC curve analysis. Clinical implications were compared across instruments.

Results

ROC curve analysis results (AUC = .84, p < .01, 95% CI between .77 and .90) indicated the IBACS is a good diagnostic instrument for assessing complicated grief. Positive correlations (p < .01, 2-tailed) with all four instruments at T1 demonstrated the IBACS' concurrent validity, strongest with complicated grief measures (r = .82). Predictive validity was shown to be fair in T2 ROC curve analysis results (n = 67, AUC = .78, 95% CI between .65 and .92; p < .01). Predictive validity was also supported by stable positive correlations between IBACS and other instruments at T2. Clinical indications were found not to differ across instruments.

Conclusions

The IBACS offers effective grief symptom and risk assessment for use by non-clinicians. Indications are sufficient to support intake assessment for a stepped model of bereavement intervention.

Grief and loss for patients before and after heart transplant

OBJECTIVES

The purpose of the study was to examine the loss and grief experiences of patients waiting for and living with new hearts.

BACKGROUND

There is much scholarship on loss and grief. Less attention has been paid to these issues in clinical transplantation, and even less on the patient experience.

METHODS

Part of a qualitative inquiry oriented to the work of Merleau-Ponty, a secondary analysis was carried out on audiovisual data from interviews with thirty participants.

RESULTS

Patients experience loss and three forms of grief. Pre-transplant patients waiting for transplant experience loss and anticipatory grief related to their own death and the future death of their donor. Transplanted patients experience long-lasting complicated grief with respect to the donor and disenfranchised grief which may not be sanctioned.

CONCLUSIONS

Loss as well as anticipatory, complicated and disenfranchised grief may have been inadvertently disregarded or downplayed. More research and attention is needed.

Prevalence of psychiatric disorders and functional impairment after loss of a family member: a longitudinal study after the 2004 Tsunami

BACKGROUND

Bereavement following disasters is a devastating experience for family members. The aim of this study was to examine the long-term mental health effects of losing a loved one in a natural disaster.

METHODS

Ninety-four Norwegians aged 18-80 years who lost close family members in the 2004 Southeast Asian tsunami were evaluated 2 and 6 years after the disaster. The participants were either staying in an affected area at the time of the disaster (i.e., directly exposed) or not (i.e., not directly exposed). The prevalence of psychiatric disorders was assessed by the MINI International Neuropsychiatric Interview (M.I.N.I). Prolonged grief disorder (PGD) was self-reported using the Inventory of Complicated Grief (ICG), and functional impairment was self-reported using the Work and Social Adjustment Scale (WSAS).

RESULTS

We did not identify a significant decrease in the prevalence of PGD, posttraumatic stress disorder (PTSD), or major depressive disorder (MDD) from 2 to 6 years. Approximately, one-third of the bereaved (36%) had a psychiatric disorder 6 years after the tsunami. The most common disorder was PGD (12%) followed by general anxiety disorder (GAD, 11%), agoraphobia (11%), and MDD (10%). The prevalence of PTSD and MDD was higher among family members who were directly exposed to the disaster compared to those who were not (21 vs. 0%, and 25 vs. 3%). PGD was associated with functional impairment independent of other disorders.

CONCLUSIONS

Loss of a close family member in a natural disaster can have a substantial adverse long-term effect on mental health and everyday functioning.

Bereavement: course, consequences, and care

This paper discusses each of several potential consequences of bereavement. First, we describe ordinary grief, followed by a discussion of grief gone awry, or complicated grief (CG). Then, we cover other potential adverse outcomes of bereavement, each of which may contribute to, but are not identical with, CG: general medical comorbidity, mood disorders, post-traumatic stress disorder, anxiety, and substance use.

Bereavement and common mental disorders in middle-aged adults: results from the Brazilian longitudinal study of adult health (ELSA-Brasil)

BACKGROUND

Although bereavement is accompanied with depression and anxiety symptoms, it is usually not associated with increased rates of mental disorders in North American and European samples. Data from low- and middle-income countries are, however, scarce. We therefore explored the prevalence of mental disorders after bereavement in Brazil.

METHODS

The Clinical Interview Schedule-Revised (CIS-R) was used for psychiatric assessment of 15,105 participants from the Brazilian Health Longitudinal Study (ELSA-Brasil). We asked whether the participant suffered loss of a first-degree relative/spouse within 6 and 12 months prior to the interview.

RESULTS

The prevalence within 6 and 12 months after bereavement for major depressive disorder (MDD, 4.3% for 6 and 12 months) and anxiety disorders (17.4% and 15.9%, respectively) did not differ compared to non-bereaved participants, except for panic disorder. Sociodemographic and clinical data were also similar. Conversely, we found increased 12-month prevalence of bereaved-related (vs. non-related) mixed anxiety and depressive disorder (15.7% vs. 12.5%, respectively) and common mental disorder (30.7% vs. 26.2%); diagnoses that are solely based on the number and severity of depression and anxiety symptoms.

LIMITATIONS

Although this was a cross-sectional study, the sample size was large.

CONCLUSIONS

Bereavement was associated with greater psychopathological burden but not with increased prevalence of MDD and anxiety disorder diagnoses, therefore highlighting the need of carefully monitoring subjects whom recently experienced bereavement. Our findings also support and provide a "cultural validator" for excluding bereavement as an exclusionary criterion for MDD diagnosis.

Complicated grief symptoms in anxiety disorders: prevalence and associated impairment

BACKGROUND

Previous research has identified high rates of comorbid anxiety disorders among individuals presenting with primary CG. In the present study, we examined the prevalence of comorbid CG in bereaved primary anxiety disorder (AD) patients compared to bereaved healthy controls. We also examined the impairment associated with comorbid CG in AD.

METHODS

Participants were 242 bereaved adults (mean (SD) age = 41.5 (13.1), 44.2% women) with a primary AD diagnosis, including generalized anxiety disorder (GAD; n = 57), panic disorder (PD; n = 49), posttraumatic stress disorder (PTSD; n = 29), and generalized social anxiety disorder (GSAD; n = 107), as well as 155 bereaved healthy controls with no current DSM-IV Axis I diagnosis (mean (SD) age = 43.0 (13.6), 51.0% women). CG symptoms were measured using the 19-item inventory of complicated grief (ICG), with threshold CG defined as an ICG score of ≥30. Quality of life and functional impairment were assessed with the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Range of Impaired Functioning Tool (LIFE-RIFT), respectively.

RESULTS

Participants with primary ADs had significantly higher rates of threshold CG symptoms than bereaved controls (12.0% vs. 0.65%; Fisher's Exact P < 0.001). Rates of threshold CG were significantly elevated for each AD when compared to bereaved controls. After adjustment for age, sex, education, and comorbid major depressive disorder, threshold CG was associated with lower quality of life (β = -0.140, P = 0.023) and greater impairment (β = 0.141, P = 0.035) among individuals with AD.

CONCLUSIONS

Our findings suggest that threshold CG is of clinical relevance in bereaved individuals with a primary anxiety disorder. Screening for CG in patients with ADs may be warranted.

Panic-agoraphobic spectrum symptoms in complicated grief

Little is known about the presence and role of subclinical anxiety symptoms and traits in complicated grief (CG). Data from adults with CG (n=28) suggest that they experience more panic-spectrum symptoms (PSS) than bereaved controls (n=44), and that the presence of greater PSS is independently associated with poorer quality of life.

The wrap-up: a unique forum to support pediatric residents when faced with the death of a child

OBJECTIVE

The project intended to describe the format of the Wrap-up, a unique multidisciplinary guided debriefing following a child's death. Specific feedback from pediatric residents was sought to assess the model.

METHODS

The Wrap-ups were timely (within 48 hours of a death), consistent (conducted after each pediatric intensive care unit (PICU) death), multidisciplinary (all care providers were invited), and specifically conducted by someone trained in postdeath facilitation. The role of the conductor was focused on being inclusive, navigating the discussion, diffusing areas of conflict or angst, and managing the tone of the meeting. Resident feedback was obtained by a one-time (May 2010) anonymous internet-based survey, with both open-ended free-text questions and five-point Likert scale queries. Surveyed were all residents rotating though the PICU between 2007 and 2010. Open-ended free-text responses were analyzed using content analysis methods by combining recurrent themes and organizing by main components of the Wrap-up. Quantitative responses, via a five-point Likert scale, were averaged.

RESULTS

Between 2007 and 2010, there were 36 PICU deaths. The average age was nine years old. All deaths had an accompanying conductor-led Wrap-up occurring, on average, two days after the death. Sixty percent (27/45) of pediatric residents completed the survey. Their qualitative responses showed that the key components (timely, multidisciplinary, and specifically conducted) of the Wrap-ups were valuable. Quantitatively, they agreed or strongly agreed that the consistent Wrap-ups improved end-of-life care, teamwork, stress surrounding the death, and the ability to care for others.

CONCLUSION

The Wrap-up, a unique forum for debriefing after a pediatric death, was well-received by residents and assisted them with processing, understanding, and resolving their experience regarding the pediatric death. The Wrap-up was a valuable addition to residents' experience and education in pediatric critical care medicine and can be replicated in other institutions.

Getting straight about grief

Acute grief is emotionally intense, cognitively preoccupying, and disruptive, but grief is not an illness; major depression and anxiety disorders are. Grief and mourning have a purpose. They provide an intense, focused opportunity to reregulate emotion and to engage in a learning process that is aimed at reconfiguring life without the deceased—both the internal life of the mind, and ongoing life in the world. A bereaved person needs to figure out how to find meaning, purpose, joy, and satisfaction in life without someone who has previously been central to these feelings. This reconfiguration is a very natural process that tends to occur in fits and starts as bereaved people move forward and deal with everyday life. Nevertheless, a knowledgeable, empathic and supportive clinician can foster good adjustment. Successful mourning is, however, not a given. For some people, the mourning process is derailed and acute grief is inordinately painful and prolonged. For others, the stress of bereavement triggers the onset or worsening of symptoms of MDD, an anxiety disorder or another psychiatric or medical condition, suicidality or negative health behaviors. Clinicians need to be alert to all of these problematic responses to loss. In the wake of bereavement, we need to both facilitate effective mourning and diagnose and treat co-occurring conditions.