The prevention and treatment of complicated grief: A meta-analysis

Effectiveness of Brief Contact Interventions for Bereavement: A Systematic Review

Brief contact interventions are an efficient and cost-effective way of providing support to individuals. Whether they are an effective bereavement intervention is not clear. This systematic review included articles from 2014 to 2021.711 studies were identified, with 15 meeting inclusion criteria. The brief contact interventions included informational and emotional supports. Narrative synthesis identified that participants valued brief contact interventions, however some did not find them helpful. Exposure to a brief contact intervention was typically associated with improvements in wellbeing. Studies with comparison groups typically found significant but modest improvements in grief, depression symptoms and wellbeing associated with the intervention. However, one intervention was associated with significant deterioration of depression symptoms. Existing brief contact interventions for bereavement appear feasible, generally acceptable to the target population and are associated with improvements in wellbeing. Further development and evaluation to account for why improvements occur, and to identify any unintended impacts, is required.

State of the Science: Psychotherapeutic Interventions for Prolonged Grief Disorder

Prolonged grief disorder (PGD) is a distinct diagnostic entity that has recently garnered considerable attention as it describes an intense, enduring, distressing and disabling bereavement reaction experienced by a small minority of community-based mourners. In recent decades, research has exploded to address how best to treat PGD with different psychotherapeutic interventions. In this state-of-the-science review, the strength of the evidence will be discussed regarding common psychotherapeutic interventions used to treat grief. Specifically, we focus on the most commonly used interventions, cognitive behavioral (CB)-based therapies, bereavement and support groups, and brief contact interventions (BCIs), in an effort to summarize the relevant clinical takeaways of the current available research. A discussion of the use of these therapies in specific clinical populations is also included, with a focus on those traumatically bereaved, pediatric populations, communities of color, and underserved communities. Important foci and directions for future research are also discussed.

A French-Language Web-Based Intervention Targeting Prolonged Grief Symptoms in People Who Are Bereaved and Separated: Randomized Controlled Trial

BACKGROUND

Losing a loved one, through death or separation, counts among the most stressful life events and is detrimental to health and well-being. About 15% of people show clinically significant difficulties coping with such an event. Web-based interventions (WBIs) are effective for a variety of mental health disorders, including prolonged grief. However, no validated WBI is available in French for treating prolonged grief symptoms.

OBJECTIVE

This study aimed to compare the efficacy and adherence rates of 2 WBIs for prolonged grief symptoms following the loss of a loved one through death or romantic separation.

METHODS

LIVIA 2.0 was developed relying on theoretical and empirical findings on bereavement processes and WBIs, and is compared with LIVIA 1, which has already demonstrated its efficacy. We conducted a randomized controlled trial and provided on-demand guidance to participants. Outcomes were assessed through web-based questionnaires before the intervention, after the intervention (12 weeks later), and at follow-up (24 weeks later). Primary outcomes were grief symptoms, depressive symptoms, and well-being. Secondary outcomes were anxiety symptoms, grief coping strategies, aspects related to self-identity, and program satisfaction.

RESULTS

In total, 62 participants were randomized (intent-to-treat [ITT] sample), 29 (47%) in LIVIA 2.0 (active arm) and 33 (53%) in LIVIA 1 (control arm). The dropout rate was 40% (37/62), and 10 participants were removed due to exclusion criteria, leading to a final per-protocol sample of 27 (44%) completers who differed from noncompleters only based on reporting fewer anxiety symptoms (t60=3.03; P=.004). Participants who are separated reported more grief symptoms (t60=2.22; P=.03) and attachment anxiety (t60=2.26; P=.03), compared to participants who are bereaved. There were pre-post within-group differences for both programs in the ITT sample, with significant reductions in grief (Cohen d=-0.90), depressive symptoms (Cohen d=-0.31), and centrality of the loss (Cohen d=-0.45). The same pattern was observed in the per-protocol sample, with the exception that anxiety symptoms also significantly diminished (Cohen d=-0.45). No difference was found in efficacy between the 2 programs (all P>.33). Participants (ITT sample) reported overall high levels of program satisfaction (mean 3.18, SD 0.54; over a maximum of 4). Effect stability was confirmed at the 6-month follow-up for all outcomes, with an improvement in self-concept clarity.

CONCLUSIONS

The 2 grief-related WBIs were effective in reducing grief, depressive and anxiety symptoms for participants who are bereaved or separated. The analyses did not reveal any pre-post between-group differences, suggesting that the innovations brought to LIVIA 2.0 did not significantly affect the outcome. However, caution is warranted with the interpretation of the results given the limited power of the sample, which only allows the detection of medium effect sizes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05219760; https://clinicaltrials.gov/study/NCT05219760.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/39026.

Nursing Interventions in Primary Care for the Management of Maladaptive Grief: A Scoping Review

Grief is a natural and self-limited adaptation process to a new reality that emerges after a significant loss (whether real or perceived), with a broad variety of manifestations that exert an impact on a grieving person's health. The study aim was to synthesize the evidence available about the interventions carried out by Primary Health Care nurses, by means of an individual approach to reduce maladaptive grief or maladaptive grief risk. A scoping review was conducted (November and December 2023) through searches in Medline, Cinahl, Web of Science, ProQuest and Scopus using MeSH terms combined with Booleans. Primary research of any design in adult people undergoing grief situations and receiving professional assistance by nurses in the primary, home and community care contexts published after 2009 in English, Spanish or Portuguese languages were included. Excluded publications were those conducted in in-hospital clinical settings and which did not correspond to research designs or the gray literature. The screening process was carried out by two reviewers using the appropriate JBI critical appraisal tools for each design and discrepancies were resolved by a third reviewer. A total of n = 10 studies were included (n = 4 qualitative, n = 2 RCTs, n = 1 quasi-experimental, n = 2 cross-sectional observational, and n = 2 mixed methods). The qualitative studies identified topics and subtopics of professionals' and families' experiences of grief. The observational studies analyzed symptoms and factors associated with the grieving process. Interventions consisted of cognitive-behavioral therapies delivered by psychological specialists who assessed the severity of grief in a range of cultural contexts using different instruments. The evidence retrieved from the studies that address the reduction in maladaptive grief or maladaptive grief risk is not conclusive. There is a need to increase both the number and the methodological quality of studies assessing the effectiveness of Nursing care in Primary Health Care for individuals experiencing maladaptive grief or maladaptive grief risk. Further research should focus on experimental studies, developing specific interventions conducted by nurses to address individual's grief and prevent maladaptive grief.

The Relationship Between Adult Attachment and Complicated Grief: A Systematic Review

Attachment insecurity, including attachment anxiety and attachment avoidance, is proposed as a key factor disrupting adaptive recovery following bereavement, resulting in complicated grief. However, findings are inconsistent across studies. This review aimed to synthesise existing research on attachment patterns in adults experiencing complicated grief to better understand this relationship. 22 cross-sectional and longitudinal studies (5149 participants), published between 2003 and 2020, met inclusion criteria. Higher levels of attachment anxiety were consistently associated with symptoms of complicated grief. Higher levels of attachment avoidance were associated with symptoms of complicated grief, although this relationship was less consistent. The review has implications for clinical practice as bereaved adults with insecure attachment histories may be particularly vulnerable to experiencing complicated grief. The research is limited by the reliance on mainly cross-sectional studies. Future research should focus on longitudinal studies, and studies that explore men's experiences, and of individuals living in non-Western countries.

A machine learning personalized treatment rule to optimize assignment to psychotherapies for grief among veterans

BACKGROUND

Complex grief patterns are associated with significant suffering, functional impairments, health and mental health problems, and increased healthcare use. This burden may be even more pronounced among veterans. Behavioral Activation and Therapeutic Exposure (BATE-G) and Cognitive Therapy for Grief (CT-G) are two evidence-based interventions for grief. The goal of this study was to use a precision medicine approach to develop a personalized treatment rule to optimize assignment among these psychotherapies.

METHODS

We analyzed data (N = 155) from a randomized clinical trial comparing BATE-G and CT-G. Outcome weighted learning was used to estimate an optimal personalized treatment rule. Baseline characteristics including demographics, social support, variables related to the death, and psychopathology dimensions were used as prescriptive factors of treatment assignment.

RESULTS

The estimated rule assigned 72 veterans to CT-G and 56 to BATE-G. Assigning participants according to this rule was estimated to lead to markedly lower mean grief level following 6 months from treatment compared to assigning everyone to either BATE-G (Vdopt - VBATE-G = -18.57 [95 % CI: -29.41, -7.72]) or CT-G (Vdopt - VBATE-G = -20.89 [95 % CI: -30.7, -11.07]) regardless of their characteristics.

LIMITATIONS

Participants were primarily male veterans, and identified with Black or White race. The estimated rule was not externally validated.

CONCLUSION

The estimated rule used relatively simple, easily accessible, client characteristics to personalize assignment to treatment using a precision medicine approach based on machine learning and causal inference. Upon further validation, such a rule can be easily implemented in clinical practice to prescriptively maximize treatment benefits.

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.

The meaning in loss protocol: A clinical trial of online grief therapy

For a minority of the bereaved, the loss of a significant other can trigger an overwhelming emotional reaction and impaired functioning across life domains, known as prolonged grief disorder (PGD). Hence, ongoing efforts have been made to refine existing treatments to increase their efficacy and to accommodate the idiosyncrasies of grief reactions. This study presents the results of an open clinical trial of the feasibility and effectiveness of the Meaning in Loss (MIL) protocol in an online format. The brief intervention of 12 to 16 sessions combines constructivist and narrative strategies to explore and work through impediments to meaning reconstruction in loss. The sample included 25 participants diagnosed with PGD who were treated by six therapists. Baseline and post-therapy comparisons showed a significant improvement in all clinical measures (grief symptomatology, depression and general distress) and an increase of meaning making regarding the loss. Meaning making was found to be a prospective mediator of symptomatic improvement in grief across the course of therapy. These findings suggest the effectiveness of the MIL protocol in decreasing grief specific and associated symptomatology and argue for the relevance of further controlled evaluations of its efficacy. Moreover, results confirm previous findings that meaning making is a relevant factor in the evolution of grief reactions, including in the context of psychotherapy.

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

BACKGROUND

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

METHOD

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

RESULTS

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

TRIAL REGISTRATION

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

LIMITATIONS

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

CONCLUSION

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

Prolonged Grief Disorder: Addressing Misconceptions With Evidence

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

Grief Coach: Feasibility and acceptability of a text message program for bereavement support among grievers in the United Kingdom

To address gaps in bereavement services in the UK, a national charity offered free access to Grief Coach, a 12-month text message-based grief support program. To assess the feasibility and acceptability of the approach, this study examined program reach, retention, and user satisfaction. Over 4000 grievers enrolled in the program over 13.5 months; 6- and 12-month retention rates were 87.8% and 83.2%. Among individuals responding to a satisfaction survey (response rate = 55.9%), 94.8% rated the program as moderately or very helpful and 95.4% said it contributed to their sense of being supported in their grief. Common themes emerging from a qualitative analysis of the written comments were how the program helped with coping with the pain of grief and user appreciation of the program. Grief Coach may be a promising component of high-quality grief support to meet the needs of grieving people in the UK.

The efficacy of psychosocial interventions for grief symptoms in bereaved children and adolescents: A systematic review and meta-analysis

BACKGROUND

The present meta-analysis investigates the efficacy of psychosocial interventions in bereaved children and adolescents.

METHOD

We conducted a systematic review searching PsycINFO, PsycARTICLES, PubMed, MEDLINE, PSYNDEX, Web of Science, CINAHL and ERIC. Random-effects meta-analyses examined the effect of interventions on symptoms of grief, posttraumatic stress disorder (PTSD) and depression in controlled and uncontrolled studies.

RESULTS

We included 39 studies (n = 5.578). Post-treatment, preventive interventions demonstrated a significant effect on grief (uncontrolled studies: g = 0.29, 95%CI [0.09;0.48]; controlled studies: g = 0.18, 95%CI [0.03;0.32]). For symptoms of PTSD and depression, only uncontrolled preventive studies yielded significant effects (PTSD: g = 0.24, 95%CI [0.11;0.36]; depression: g = 0.28, 95%CI [0.10;0.45]). Interventions targeting youth with increased grief-related distress demonstrated a significant effect in uncontrolled studies on grief (g = 1.25, 95%CI [0.94;1.57]), PTSD (g = 1.33, 95%CI [0.85;1.82]) and depression (g = 0.61, 95%CI [0.45;0.77]). A controlled effect size could only be calculated for PTSD symptoms (g = 0.71, 95%CI [0.15;1.27]).

LIMITATIONS

Interventions varied widely, contributing to high heterogeneity. Only a small number of studies with mostly limited quality could be analysed.

CONCLUSIONS

Psychosocial interventions may ameliorate grief symptoms in bereaved youth, especially when targeting youth with elevated grief distress. However, the effects observed in uncontrolled studies are substantially reduced when controlling for the natural course of bereavement. Given the increasing number of children worldwide bereaved through ongoing crises, research on interventions is surprisingly sparse.

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

BACKGROUND

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

Widowed Young: The Role of Stressors and Protective Factors for Resilience in Coping with Spousal Loss

While distressing, late life spousal loss is considered a normative life event and most demonstrate resilient recovery from grief. However, for 5-7% of the population spousal loss comes early, before the age of 50, and little is known about the factors that influence adjustment in this population. We used the DPM integrative framework to examine correlates and predictors of mental wellbeing and grief intensity in an international sample of 603 young widows and widowers. Contrary to existing bereavement research, loss-orientated stressors (e.g., expectedness and cause of death) did not predict bereavement outcomes. Employment and financial wellbeing were the only statistically significant restoration-orientated stressors associated with coping, mental wellbeing and grief intensity. We found no significant associations between parental status and coping or bereavement outcomes. Loss-orientated coping, followed by inter and intrapersonal protective factors for resilience and financial wellbeing were the greatest predictors of grief intensity. Loss-orientated coping was highest in early bereavement, the greatest predictor of grief intensity and associated with being unemployed, financial insecurity and decreased protective factors for resilience. Restoration-orientated coping was highest in later bereavement, was a weak predictor of grief intensity and associated with being employed, increased financial wellbeing and protective factors for resilience. Overall, we found the young-widowed population is at heightened risk of poor adjustment. Almost two-thirds reported decreased functioning, probable depression with high rates of psychological distress. Nearly half met diagnostic criteria for prolonged grief disorder. We discuss implications for research and clinical practice.

Latent trajectories of DSM-5-TR-based Prolonged Grief Disorder: findings from a data pooling project MARBLES

Background: With the release of the text revision of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5-TR), criteria for Prolonged Grief Disorder (PGD) were included. This necessitates studying grief trajectories based on these criteria.Objective: This is the first study examining latent trajectories of DSM-5-TR-based PGD symptom levels and testing whether specific risk factors (e.g. cause of death) predicted PGD trajectories.Method: We evaluated latent DSM-5-TR PGD trajectories using pooled existing data collected at 6-12, 13-24, and 25-60 months post-loss in Danish and Dutch bereaved adults (N = 398). Latent Growth Mixture Modelling (LGMM) was employed to determine the trajectories. Multinomial logistic regression analyses were used to examine which risk factors predicted class membership.Results: The four-class LGMM solution with a quadratic term was best-fitting the data. This solution represented four trajectories: High stable PGD (6%), High PGD quick recovery (10%), High PGD slow recovery (35%), and Low PGD symptoms (49%). Participants with a higher educational level were more likely to be assigned to the Low PGD symptoms trajectory compared to High stable PGD and High PGD slow recovery trajectories. Unnatural causes of death increased the likelihood of being in the High stable PGD and High PGD slow recovery trajectories compared to the Low PGD symptoms trajectory.Conclusions: Consistent with prior research, the Low PGD symptoms trajectory was the most common. A significant minority experienced high and stable levels of PGD within five years after the loss. About one-third of participants experienced high acute grief levels that decreased slowly; how slow decreasing symptoms relate to an individual's functioning requires further attention. This study demonstrates that a significant minority of bereaved people develop acute PGD symptomatology that does not diminish within five years post-loss, emphasizing the need for early screening for PGD to prevent long-lasting complaints.

Integrated immediate postmortem and acute bereavement care: Competency-based entrustable professional activities for nursing

BACKGROUND

Integrated immediate postmortem and acute bereavement care alleviates emotional distress due to losing a loved one; however, the provision of effective nursing care remains insufficient. Therefore, preparing nursing students with such skills is essential in end-of-life care education, and entrustable professional activities (EPAs) offer potential to address this gap.

OBJECTIVES

To establish EPAs concerning immediate postmortem and acute bereavement care with a seven-category description for EPAs, milestones, and assessment tools.

DESIGN

We used a modified Delphi method and four-step consensus-building approach to i) identifying the list of possible EPA items related to immediate postmortem and acute bereavement care based on a literature review and clinical experiences, ii) select an expert panel, iii) pool, review, and revise the EPAs, and iv) validate EPA quality using the Queen's EPA Quality rubric. Data analysis was performed via modes and quartile deviations.

RESULTS

The following four major EPA components were identified: i) cultural and religious ritual assessment; ii) death preparation; iii) postmortem care; and iv) acute bereavement care. Three essential competencies were identified as highly correlated: general clinical skills, communication and teamwork capabilities, and caring. Consensus was achieved after three survey rounds. A 100 % questionnaire response rate was obtained. In the third round, all items received 4 or 5 points from >95 % of the panel members and were found to meet the quartile deviation cutoff score of <0.6, indicating that a high consensus level was established. The average Queen's EPA Quality rubric score was 62.5, with an average item score of 4.46, which was higher than the cut-off score of 4.07. Three major parts of EPAs were developed: task descriptions, milestones, and the assessment tool.

CONCLUSION

The development of EPAs assessments concerning immediate postmortem and acute bereavement care may guide nursing curricula planning to bridge the gap between competencies and clinical practice.

Complicated Grief Following the Traumatic Loss of a Child: A Systematic Review

Complicated grief is a disabling condition that occurs when the natural grief process is disturbed or prolonged. Research demonstrates that complicated grief is more prevalent following the sudden or violent loss of a child. Despite the high incidence of accidental death worldwide, little research has focused on parental grief trajectories following this form of traumatic loss. A systematic review was conducted to explore parental bereavement outcomes following accidental death. Studies were included if they specifically examined complicated grief in parents bereaved by the accidental death of their child. A total of 767 articles were identified and seven studies met the eligibility criteria for review. Poorer outcomes were identified in relation to the mode of death, relationship type, time post-loss, perceived support, perceived justice and comorbidities. Results of the current study may be used to inform the development of clinical practice guidelines for the treatment of complicated grief.

Grief Coach, a Text-Based Grief Support Intervention: Acceptability Among Hospice Family Members

U.S. Medicare-certified hospices must provide bereavement care to family members for 13 months following a patient's death. This manuscript describes Grief Coach, a text message program that delivers expert grief support and can assist hospices in meeting the bereavement care mandate. It also describes the first 350 Grief Coach subscribers from hospice and the results of a survey of active subscribers (n = 154) to learn whether and how they found the program helpful. The 13-month program retention rate was 86%. Among survey respondents (n = 100, response rate = 65%), 73% rated the program as very helpful, and 74% rated it as contributing to their sense of being supported in their grief. Grievers aged 65+ and males gave the highest ratings. Respondents' comments identify key intervention content that they found helpful. These findings suggest that Grief Coach may be a promising component of hospice grief support programming to meet the needs of grieving family members.

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

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

A therapist-supported internet-based intervention for bereaved siblings: A randomized controlled trial

BACKGROUND

The loss of a sibling can have a long-term impact on the mental and physical health of the surviving sibling throughout adolescence and later adulthood. Even though bereaved siblings can be identified as a high-risk group, evidence-based interventions for this bereavement group are still missing.

AIM

To evaluate the treatment effects of an internet-based writing intervention for bereaved siblings aged 16-65 years.

DESIGN

A two-armed randomized controlled trial (DRKS00011514) compared the intervention to a waiting list control group. The 6-week intervention consisted of six structured writing assignments that were based on cognitive behavioral therapy, focusing on the specific situation of bereaved siblings.

SETTING/PARTICIPANTS

Eighty-six bereaved siblings (loss >1 month ago, no severe psychiatric symptoms) were randomly allocated to the intervention group (n = 47) or the waiting list control group (n = 39). Primary outcomes were symptoms of prolonged grief disorder and depression; secondary outcomes were posttraumatic stress symptoms and survivor guilt.

RESULTS

Symptoms of depression and prolonged grief disorder improved significantly in the intention-to-treat analyses from pre-to post-measurement compared with the control group (gDepression = -0.62, gGrief = 0.33). In the intervention group, all primary and secondary outcomes decreased significantly from baseline to 12-month follow-up (gs = -0.38 to -1.04). A significant clinical change could be found for depression (34%) compared to the waitlist control group (10%).

CONCLUSIONS

Bereaved siblings profited from this brief internet-based writing intervention in the short- and long-term. However, future research, such as dismantling studies, may help to further optimize the benefits of an intervention aimed at bereaved siblings.

The Effectiveness of Integrated Group Therapy on Prolonged Grief Disorder of Bereaved People from COVID-19 Randomized Controlled Trial

This study aimed to evaluate the integrated cognitive-behavioral group therapy and Gestalt empty chair technique on bereaved individuals with COVID-19-caused PGD (prolonged grief disease). Thirty-six patients with PGD resultant from COVID-19 were randomly assigned intervention and control groups. The intervention group underwent 16 90-minute integrated group therapy sessions twice a week. Both groups completed the BDI II depression, NAI anger, and GASP guilt scale before, after, and 2 months after the study's conclusion. The intervention and control groups significantly differed in the depression, anger, and guilt indices after the therapeutic intervention (p < .001). This difference remained in the follow-up phase. Integrated group therapy in treating could help with some of the symptoms of PGD resulting from the corona-caused loss of loved ones. This reduction in symptoms was also stable over time.

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

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

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.

A Narrative Review of Research on Adjustment to Spinal Cord Injury and Mental Health: Gaps, Future Directions, and Practice Recommendations

Spinal cord injury (SCI) results in autonomic, motor, and sensory impairments that can compromise mental health. Guidelines directing the management of mental health following SCI presently address clinical anxiety, depression, post-traumatic stress, substance use disorders, and suicide. However, evidence suggests that perhaps as many as 70% of individuals with SCI do not develop a clinically diagnosable mental health disorder. Therefore, the authors contend that understanding non-clinical cognitive and psychological aspects of adjustment post-SCI is paramount and that the application of this knowledge to the formulation of adjustment-enhancing interventions is crucial. To assist with this endeavour, we examine existing mental health guidelines targeting SCI, and present a narrative review of research on the under-represented topics of adjustment, coping, grief, and resilience. We include mild cognitive impairment, which reflects a common factor that can compromise adjustment. Loss and stress trigger processes of adjustment, coping, grief, and resilience. SCI involves loss and stress triggering these processes, arguably without exception. Our study applied a narrative review methodology searching Google Scholar and PsychInfo databases for terms adjustment, coping, grief, resilience, and cognitive impairment. Qualitative studies and quantitative studies were selected to capture bottom-up and top-down perspectives. Reference lists of retrieved papers were searched as appropriate. Reviewed literature suggested that existing guidelines concerning mental health following SCI neglect positive processes of adjustment and suggest this neglect contributes to a deficits-based view of mental health following SCI. Research into "positive" or adjustment-enhancing processes is mostly cross-sectional, heterogenous, and poorly positioned to inform future guideline-development. Researchers should achieve consensus over the operationalisation of essential processes and overcome a fixation with "outcomes" to better inform management of mental health after SCI.

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

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

Dramatic effects but fast adaptation: Changes in life satisfaction and different facets of affective well-being around the death of a partner and death of a child

Although everyone would agree that bereavement is extremely stressful, surprisingly little is known about changes in different facets of affective well-being in the years surrounding the death of a loved one. On the basis of the Socio-Economic Panel Study, we examined changes in cognitive well-being (life satisfaction) and different facets of affective well-being (happiness, sadness, anxiety, and anger) in the years around the death of a partner (N = 989) and child (N = 276). Data on the death of a partner and child as well as cognitive and affective well-being were assessed yearly since 2007. Multilevel analyses revealed that both events were associated with very large well-being impairments (>1 SD) that were most pronounced for sadness, happiness, and life satisfaction in the first year of bereavement. Afterwards, bereaved individuals managed to recover impressively well: Levels of life satisfaction, happiness, and sadness were on average similar 5 years after losing a partner or child compared with 5 years before the respective loss. Our findings suggest (a) that many individuals tend to be capable to even cope with highly stressful loss experiences and (b) that Set-Point Theory not only applies to life satisfaction but also different facets of affective well-being around the death of a loved one.

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.

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

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

Living with Loss: study protocol for a randomized controlled trial evaluating an internet-based perinatal bereavement program for parents following stillbirth and neonatal death

BACKGROUND

Stillbirth and neonatal death are devastating pregnancy outcomes with long-lasting psychosocial consequences for parents and families, and wide-ranging economic impacts on health systems and society. It is essential that parents and families have access to appropriate support, yet services are often limited. Internet-based programs may provide another option of psychosocial support for parents following the death of a baby. We aim to evaluate the efficacy and acceptability of a self-guided internet-based perinatal bereavement support program "Living with Loss" (LWL) in reducing psychological distress and improving the wellbeing of parents following stillbirth or neonatal death.

METHODS

This trial is a two-arm parallel group randomized controlled trial comparing the intervention arm (LWL) with a care as usual control arm (CAU). We anticipate recruiting 150 women and men across Australia who have experienced a stillbirth or neonatal death in the past 2 years. Participants randomized to the LWL group will receive the six-module internet-based program over 8 weeks including automated email notifications and reminders. Baseline, post-intervention, and 3-month follow-up assessments will be conducted to assess primary and secondary outcomes for both arms. The primary outcome will be the change in Kessler Psychological Distress Scale (K10) scores from baseline to 3-month follow-up. Secondary outcomes include perinatal grief, anxiety, depression, quality of life, program satisfaction and acceptability, and cost-effectiveness. Analysis will use intention-to-treat linear mixed models to examine psychological distress symptom scores at 3-month follow-up. Subgroup analyses by severity of symptoms at baseline will be undertaken.

DISCUSSION

The LWL program aims to provide an evidence-based accessible and flexible support option for bereaved parents following stillbirth or neonatal death. This may be particularly useful for parents and healthcare professionals residing in rural regions where services and supports are limited. This RCT seeks to provide evidence of the efficacy, acceptability, and cost-effectiveness of the LWL program and contribute to our understanding of the role digital services may play in addressing the gap in the availability of specific bereavement support resources for parents following the death of a baby, particularly for men.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12621000631808 . Registered prospectively on 27 May 2021.

Communication with bereaved family members after death in the ICU: the CATHARTIC randomised clinical trial

Objective: It is uncertain whether psychological distress in the family members of patients who die during an intensive care unit (ICU) admission may be improved by bereavement interventions. In this trial, relatives' symptoms of anxiety and depression after 6 months were measured when allocated to three commonly used bereavement follow-up strategies. Design: Single-centre, randomised, three parallel-group trial. Setting: A tertiary ICU in Australia. Participants: Relatives of patients who died in the ICU. Interventions: Relatives received bereavement follow-up 4 weeks after the death using a condolence letter, short telephone call or no contact. Main outcome measures: The primary outcome was the total Hospital Anxiety and Depression Scale (HADS-T) score. Secondary outcomes estimated anxiety, depression, complicated grief, post-traumatic stress, and satisfaction with ICU care. Results: Seventy-one relatives participated (24 had no contact, 19 were contacted by letter and 28 by telephone 4 weeks after the death). The mean HADS-T score for no contact was 16.1 (95% CI, 12.4-19.8). Receipt of a letter was associated with a mean HADS-T increase of 1.4 (4.0 decrease to 6.8 increase), and a condolence call was accompanied by a mean decrease of 1.6 (6.6 decrease to 3.4 increase; P > 0.5). Non-significant differences were observed for all secondary outcomes. Conclusions: Anxiety and depression at 6 months in the relatives of patients who died in the ICU was not meaningfully alleviated by receipt of either a condolence letter or telephone call. Trial registration: Australia New Zealand Clinical Trials Registry (ACTRN12619000917134).

Prolonged grief disorder in DSM-5-TR: Early predictors and longitudinal measurement invariance

OBJECTIVE

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision includes prolonged grief disorder as a novel disorder. Prolonged grief disorder can be diagnosed when acute grief stays distressing and disabling, beyond 12 months following bereavement. Evidence indicates that elevated prolonged grief disorder symptoms in the first year of bereavement predict pervasive grief later in time; targeting early elevated grief may potentially prevent symptoms getting chronic. There is limited knowledge about the characteristics of people in the first year of bereavement who have an elevated chance of developing full prolonged grief disorder beyond the 12-month time point. This study examined these characteristics.

METHODS

We used self-reported data from 306 adults who all completed questions on socio-demographic and loss-related characteristics plus a measure of prolonged grief disorder within the first year of bereavement (Wave 1; time since loss: M = 4.97, SD = 3.13 months) and again 1 year later (Wave 2; time since loss: M = 17.84, SD = 3.38 months). We examined the prevalence rates of probable prolonged grief disorder (Wave 2), measurement invariance of prolonged grief disorder symptoms between waves, and associations of socio-demographic and loss-related variables, and Wave 1 prolonged grief disorder with probable prolonged grief disorder at Wave 2.

RESULTS

Regarding prevalence, 10.1% (n = 31) met criteria for probable prolonged grief disorder (Wave 2). Multigroup confirmatory factor analysis supported longitudinal measurement invariance of prolonged grief disorder symptoms. People meeting criteria at Wave 1 (except the time criterion) had a significantly increased risk of meeting criteria at Wave 2. Variables best predicting probable prolonged grief disorder at Wave 2 were prolonged grief disorder at Wave 1, lower education, loss of a child and loss to unnatural/violent causes (sensitivity = 56.67%, specificity = 98.12%, 93.92% correct classifications).

CONCLUSION

People meeting criteria for prolonged grief disorder (except the time criterion) before the first anniversary of the death are at risk of full-blown prolonged grief disorder beyond this time point, particularly those who have lower education, confronted the death of a child and confronted unnatural/violent loss. Findings may inform advances in preventive bereavement care.

The Role of Emotion Regulation and Loss-Related Coping Self-efficacy in an Internet Intervention for Grief: Mediation Analysis

BACKGROUND

Internet interventions for mental disorders and psychological problems such as prolonged grief have established their efficacy. However, little is known about how internet interventions work and the mechanisms through which they are linked to the outcomes.

OBJECTIVE

As a first step in identifying mechanisms of change, this study aimed to examine emotion regulation and loss-related coping self-efficacy as putative mediators in a randomized controlled trial of a guided internet intervention for prolonged grief symptoms after spousal bereavement or separation or divorce.

METHODS

The sample comprised older adults who reported prolonged grief or adaptation problems after bereavement, separation, or divorce and sought help from a guided internet intervention. They were recruited mainly via newspaper articles. The outcome variables were grief symptoms assessed using the Texas Revised Inventory of Grief and psychopathology symptoms assessed using the Brief Symptom Inventory. A total of 6 module-related items assessed loss-focused emotion regulation and loss-related coping self-efficacy. In the first step, path models were used to examine emotion regulation and loss-related coping self-efficacy as single mediators for improvements in grief and psychopathology symptoms. Subsequently, exploratory path models with the simultaneous inclusion of emotion regulation and self-efficacy were used to investigate the specificity and relative strength of these variables as parallel mediators.

RESULTS

A total of 100 participants took part in the guided internet intervention. The average age was 51.11 (SD 13.60) years; 80% (80/100) were separated or divorced, 69% (69/100) were female, and 76% (76/100) were of Swiss origin. The internet intervention increased emotion regulation skills (β=.33; P=.001) and loss-related coping self-efficacy (β=.30; P=.002), both of which correlated with improvements in grief and psychopathology symptoms. Path models suggested that emotion regulation and loss-related coping self-efficacy were mediators for improvement in grief. Emotion regulation showed a significant indirect effect (β=.13; P=.009), whereas coping self-efficacy showed a trend (β=.07; P=.06). Both were confirmed as mediators for psychopathology (β=.12, P=.02; β=.10; P=.02, respectively). The path from the intervention to the improvement in grief remained significant when including the mediators (β=.26, P=.004; β=.32, P≤.001, respectively) in contrast to the path from the intervention to improvements in psychopathology (β=.15, P=.13; β=.16, P=.10, respectively).

CONCLUSIONS

Emotion regulation and loss-related coping self-efficacy are promising therapeutic targets for optimizing internet interventions for grief. Both should be further examined as transdiagnostic or disorder-specific putative mediators in internet interventions for other disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02900534; https://clinicaltrials.gov/ct2/show/NCT02900534.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-016-1759-5.

Supporting People having Lost a Close Person by Bereavement or Separation: Study Protocol of a Randomized Controlled Trial Comparing Two French-Language Internet Interventions (Preprint)

Background

Internet-based interventions (IBIs) are as efficient as face-to-face psychotherapy for a variety of mental health disorders, including complicated grief. Most evidence stems from guided IBIs. However, recent research indicates that the benefit of guidance is lower in more interactive IBIs. As such, providing guidance only to people requiring it (guidance on demand) appears a cost-effective solution. This is particularly important to develop given the recent rise in grief symptoms in the context of the COVID-19 pandemic. This paper presents the protocol of a randomized controlled trial comparing the efficacy and adherence rate of 2 IBIs for grief-related symptoms after the loss a close one following death or romantic separation, using a guidance on demand framework. LIVIA 2.0 was developed based on theoretical and empirical findings on grief processes and IBIs, and it will be compared to LIVIA 1 that has already demonstrated its efficacy.

Objective

Our main hypotheses are that LIVIA 1 (control condition) and LIVIA 2.0 (experimental condition) increase participants’ well-being and decrease their distress at posttest and at follow-up, that LIVIA 2.0 is more efficient than LIVIA 1 for all outcomes, and that LIVIA 2.0 has less dropouts than LIVIA 1.

Methods

Outcomes will be assessed at pretest, posttest (12 weeks later), and follow-up (24 weeks later). We will recruit 234 participants through a variety of means, including social media and contacts with the press. Primary outcomes are grief symptoms, depressive symptoms, and eudemonic well-being. Secondary outcomes are anxiety symptoms, grief coping strategies, aspects related to self-identity reorganization, and program satisfaction. LIVIA 2.0 participants will additionally undergo a weekly mood and grief symptom monitoring, allowing us to explore the short-term efficacy of the sessions.

Results

The creation and development of the content of LIVIA 2.0 was completed during the first phase of the project. Participant recruitment will begin in May 2022 and will last until January 2023.

Conclusions

This study will emphasize the relevance of the innovations included in LIVIA 2.0 regarding the efficacy and dropout rate of IBIs for grief symptoms and will allow investigations on how these changes impact the demand for guidance. In the current postpandemic times, developing and assessing IBIs targeting grief symptoms are particularly critical given the rise in grief-related symptoms.

Trial Registration

clinicaltrials.gov NCT05219760; https://tinyurl.com/3dzztjts

International Registered Report Identifier (IRRID)

PRR1-10.2196/39026

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.

Efficacy of an online-group intervention after suicide bereavement: A randomized controlled trial

Introduction

People bereaved by suicide are at high-risk for developing mental disorders and suicidal tendencies. Grief after suicide differs from grief after other types of death, and bereaved persons may require support tailored to their situation. In this study, we evaluate an online intervention for individuals bereaved by suicide and its effectiveness on mental health.

Methods

A total of 140 participants were included in the intervention and randomized to either the treatment or the waitlist control group. The intervention consisted of 12 weekly modules, based on cognitive-behavioral methods, and took place as a webinar in a group format. Primary outcomes were depression and suicidality; secondary outcomes were symptoms of prolonged grief, PTSD, posttraumatic cognitions, hopelessness, and grief-specific symptoms.

Results

Symptoms of posttraumatic avoidance improved significantly in the intention-to-treat analyses (d between = 0.43) and in treatment completers (d between = 0.56), posttraumatic intrusion improved in treatment completers (d between = 0.50) compared to the waitlist control group. In the intervention group, psychopathological symptoms decreased significantly from baseline to 6-month follow-up. Furthermore, factors such as higher scores of depression, grief, suicide ideation, and posttraumatic stress symptoms were identified at baseline, which impacted the effectiveness of the intervention.

Conclusions

The results of this study indicate that completing an online group intervention for the suicide bereaved could reduce trauma-related outcomes. However, the waiting control group also improved significantly from pre- to post-measurement in all other outcomes. Future studies with active control groups are needed to further examine the effectiveness.

Programa piloto de tratamiento psicológico grupal en duelo complicado

Objetivo: evaluar la efectividad de un programa piloto de tratamiento psicológico en duelo complicado. Método: se realizó una terapia grupal de duelo complicado en 20 sesiones, con frecuencia quincenal. Las participantes fueron 6 mujeres que recibían tratamiento psicológico en la Unidad de Gestión Clínica de Cuidados Paliativos. El grupo era homogéneo en cuanto a gravedad, tipo de proceso y tiempo del fallecimiento. Se las evalúo antes, durante y después de la intervención mediante escalas psicométricas: el Inventario de Duelo Complicado, la Escala de Ansiedad Depresión Hospitalaria y la Escala de Desesperanza de Beck. Resultados: se encontraron mejorías significativas en sintomatología de duelo y síntomas de depresión desde línea base al postratamiento de depresión, cuatro de los seis participantes estaban asintomáticos en postratamiento. Conclusiones: la intervención grupal puede ser eficaz para el duelo complicado.

[Before the diagnosis was established … A retrospective analysis of bereavement care in Germany]

INTRODUCTION

In Germany, many health care providers work in bereavement care. An epidemiological study of this field of work has not yet been conducted.

METHODS

In the initial survey of this three-phase trend study the situation of grief-specific health care in Germany in 2009/2010 is examined, i. e., at the time before the introduction of the new ICD-11 diagnosis of Prolonged Grief Disorder. For this purpose, bereavement care providers at different organizational levels participated in an online survey.

RESULTS

410 questionnaires were included in the study. Data analysis was descriptive. The most frequent reason for using grief-specific support services was the loss of a partner. In more than half of all cases of bereavement, people experienced a loss that was preceded by an illness and suffering. More than half of those providing bereavement care do not follow a concept of intervention.

DISCUSSION

There is considerable need for further development in German bereavement care, in particular with regard to qualification and the degree of professionalization, designation of the respective interventions, diagnostics, and intervention.

CONCLUSION

This three-phase trend study enables health care providers to derive bereavement care service standards that aim to treat people according to their needs. Whether the diagnosis of Prolonged Grief Disorder has led to changes in bereavement care is currently analyzed in the second survey phase of the study.

Reconnecting: Strategies for Supporting Isolated Older Adults during COVID-19 through Tele-palliative Care

The COVID-19 pandemic has resulted in unprecedented levels of social isolation which has negatively impacted older patients in particular on multiple levels. We present a case of an older patient with several complex psychosocial issues who was hospitalized and died from COVID-19. The social isolation required during the pandemic compounded patient and family stressors and diminished the patient's access to clinicians and to his usual support network and coping strategies. We describe how technology and tele-palliative care were utilized to reconnect the patient with clinicians and family and to provide clinical care that enhanced coping skills and support. Using telemedicine to restructure the approach to care was crucial in improving multiple domains of care and can be considered a resource for caring for older adults, especially during the challenging times brought on by the COVID-19 pandemic.

Stages of Grief Portrayed on the Internet: A Systematic Analysis and Critical Appraisal

Kübler-Ross's stage model of grief, while still extremely popular and frequently accepted, has also elicited significant criticisms against its adoption as a guideline for grieving. Inaccurate portrayal of the model may lead to bereaved individuals feeling that they are grieving incorrectly. This may also result in ineffectual support from loved ones and healthcare professionals. These harmful consequences make the presentation of the five stages model an important area of concern. The Internet provides ample resources for accessing information about grief, raising questions about portrayal of the stages model on digital resources. We therefore conducted a systematic narrative review using Google to examine how Kübler-Ross's five stages model is presented on the internet. We specifically examined the prominence of the model, whether warnings, limitations and criticisms are provided, and how positively the model is endorsed. A total of 72 websites were eligible for inclusion in the sample. Our analyses showed that 44 of these (61.1%) addressed the model, indicating its continued popularity. Evaluation scores were calculated to provide quantitative assessments of the extent to which the websites criticized and/or endorsed the model. Results indicated low criticalness of the model, with sites often neglecting evaluative commentary and including definitive statements of endorsement. We conclude that such presentation is misleading; a definitive and uncritical portrayal of the model may give the impression that experiencing the stages is the only way to grieve. This may have harmful consequences for bereaved persons. It may alienate those who do not relate to the model. Presentation of the model should be limited to acknowledging its historical significance, should include critical appraisal, and present contemporary alternative models which better-represent processes of grief and grieving.

Grief and bereavement beliefs among U. S. mental health professionals and the general public

The present study examined beliefs about grief and bereavement in a sample of mental health professionals and the general public in the United States. In part 1 of this study, we developed a 12-item questionnaire based on extant thanatology literature and expert review. In part 2, 210 participants rated their beliefs about grief and bereavement using this questionnaire. Participants rated most items accurately, and mental health professionals were more likely to answer items accurately compared to the general public. These findings provide support for increasing grief literacy in professional and public domains.

Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment

Losing a loved one is one of life's greatest stressors. Although most bereaved individuals navigate through a period of intense acute grief that lessens with time, approximately 10% will develop a prolonged grief condition. This review provides an overview of the course of grief and describes risk factors for developing prolonged grief disorder. The evolution of the prolonged grief disorder diagnosis, including the latest criteria sets for ICD-11 and DSM-5, as well as common comorbid conditions and differential diagnosis are discussed. Clinically useful self-report and clinician-rated measures for assessing symptom constructs and overall prolonged grief disorder severity, evidence-based psychotherapies (such as complicated grief treatment), as well as evidence about pharmacologic approaches are presented. Finally, the authors discuss important future directions, including a potential increase in prolonged grief disorder cases due to the COVID-19 pandemic.

Addressing the mental health impact of COVID-19 through population health

The COVID-19 pandemic has and will continue to result in negative mental health outcomes such as depression, anxiety and traumatic stress in people and populations throughout the world. A population mental health perspective informed by clinical psychology, psychiatry and dissemination and implementation science is ideally suited to address the broad, multi-faceted and long-lasting mental health impact of the pandemic. Informed by a systematic review of the burgeoning empirical research on the COVID-19 pandemic and research on prior coronavirus pandemics, we link pandemic risk factors, negative mental health outcomes and appropriate intervention strategies. We describe how social risk factors and pandemic stressors will contribute to negative mental health outcomes, especially among vulnerable populations. We evaluate the scalability of primary, secondary and tertiary interventions according to mental health target, population, modality, intensity and provider type to provide a unified strategy for meeting population mental health needs. Traditional models, in which evidence-based therapies delivered are delivered in-person, by a trained expert, at a specialty care location have proved difficult to scale. The use of non-traditional models, tailoring preventive interventions to populations based on their needs, and ongoing coordinated evaluation of intervention implementation and effectiveness will be critical to refining our efforts to increase reach.

Narrative reconstruction therapy for prolonged grief disorder - a pilot study

Background: Prolonged grief disorder (PGD) is a chronic and disabling condition that affects approximately 10% of non-traumatically bereaved people. Narrative reconstruction (NR), originally designed for the treatment of posttraumatic stress disorder (PTSD), is a time-limited integrative therapy consisting of exposure to the loss memory, detailed written reconstruction of the loss memory narrative, and an elaboration of the personal significance of that memory for the bereaved. Objective: This pilot study examined the efficacy of NR therapy in reducing symptoms in bereaved people diagnosed with PGD. Method: Ten PGD patients participated in the study and were treated with 16 weekly sessions of NR. PGD, PTSD, and depression symptoms, as well as levels of loss integration, were assessed at pre-treatment, post-treatment, and at a 3-month follow-up. Results: Following NR, participants showed significant reductions in PGD, depression, and PTSD symptoms, and elevated levels of trauma integration. Symptoms showed further improvement at the three-month follow-up. Conclusions: These findings provide preliminary evidence for the feasibility and efficacy of NR in treating PGD. Narrative reconstruction therapy requires further evaluation in randomized controlled trials.

[Bereavement care in Germany: Framework for a stepped care model]

The loss of a loved one can have serious health implications. In Germany, however, bereavement care services often provide support regardless of risk or need. A structural framework within which these services are provided systematically and which enables the establishment of qualitative standards throughout Germany has not yet been proposed. A British stepped care model for professionalized bereavement support is actually being discussed internationally. In this paper the British model is adapted to the German context in order to improve nationwide bereavement care services.