Efficacy of an integrative CBT for prolonged grief disorder: A long-term follow-up

On the concept, taxonomy, and transculturality of disordered grief

The enduring question of whether grief can ever be pathological (and, if so, when) has been shrouding mental health and psychiatric care over the last few years. While this discussion extends beyond the confines of psychiatry to encompass contributions from diverse disciplines such as Anthropology, Sociology, and Philosophy, scrutiny has been mainly directed toward psychiatry for its purported inclination to pathologize grief-an unavoidable facet of the human experience. This critique has gained particular salience considering the formal inclusion of prolonged grief disorder (PGD) in the 11th edition of the International Classification of Diseases (ICD-11) and the subsequent Text Revision 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This study contends that the inclusion of prolonged grief disorder as a diagnostic entity may be excessively rooted in Western cultural perspectives and empirical data, neglecting the nuanced variations in the expression and interpretation of grief across different cultural contexts. The formalization of this disorder not only raises questions about its universality and validity but also poses challenges to transcultural psychiatry, due to poor representation in empirical research and increased risk of misdiagnosis. Additionally, it exacerbates the ongoing concerns related to normativism and the lack of genuine cultural relativism within the DSM. Furthermore, the passionate discussion surrounding the existence, or not, of disordered forms of grief may actually impede effective care for individuals genuinely grappling with pathological forms of grief. In light of these considerations, this study proposes that prolonged grief disorder should be approached as a diagnostic category with potential Western cultural bias until comprehensive cross-cultural studies, conducted in diverse settings, can either substantiate or refute its broader applicability. This recalibration is imperative for advancing a more inclusive and culturally sensitive understanding of grief within the field of psychiatry.

Factors associated with grief in informal carers of people living with Motor Neuron Disease: A mixed methods systematic review

The purpose of this mixed methods systematic review was to identify factors associated with anticipatory grief, post-death grief, and prolonged grief in informal carers of people living with Motor Neuron Disease (MND) to inform future research and practice. Six electronic databases were searched and two quantitative and eight qualitative studies were identified. Five overarching themes were generated through thematic synthesis. The findings suggest that there are factors that may affect different grieving processes. It might be particularly important to target some factors prior and after the death of the person living with MND such as the knowledge about the progression of the disease, changes in relationships, anxiety and depressive symptoms of carers, and planning for death of the care recipient. Factors that may affect all three grieving processes were also identified such as negative experiences of caregiving, experiences of losses, end of life and psychological support, and emotional avoidance coping.

Long-term efficacy of brief psychological treatments for common mental disorders in Myanmar refugees in Malaysia: 12-month follow-up of a randomized, active-controlled trial of integrative adapt therapy v. cognitive behavioral therapy

BACKGROUND

Long-term efficacy of brief psychotherapies for refugees in low-resource settings is insufficiently understood. Integrative adapt therapy (IAT) is a scalable treatment addressing refugee-specific psychosocial challenges.

METHODS

We report 12-month post-treatment data from a single-blind, active-controlled trial (October 2017-August 2019) where 327 Myanmar refugees in Malaysia were assigned to either six sessions of IAT (n = 164) or cognitive behavioral treatment (CBT) (n = 163). Primary outcomes were posttraumatic stress disorder (PTSD), depression, anxiety, and persistent complex bereavement disorder (PCBD) symptom scores at treatment end and 12-month post-treatment. Secondary outcome was functional impairment.

RESULTS

282 (86.2%) participants were retained at 12-month follow-up. For both groups, large treatment effects for common mental disorders (CMD) symptoms were maintained at 12-month post-treatment compared to baseline (d = 0.75-1.13). Although participants in IAT had greater symptom reductions and larger effect sizes than CBT participants for all CMDs at treatment end, there were no significant differences between treatment arms at 12-month post-treatment for PTSD [mean difference: -0.9, 95% CI (-2.5 to 0.6), p = 0.25], depression [mean difference: 0.1, 95% CI (-0.6 to 0.7), p = 0.89), anxiety [mean difference: -0.4, 95% CI (-1.4 to 0.6), p = 0.46], and PCBD [mean difference: -0.6, 95% CI (-3.1 to 1.9), p = 0.65]. CBT participants showed greater improvement in functioning than IAT participants at 12-month post-treatment [mean difference: -2.5, 95% CI (-4.7 to -0.3], p = 0.03]. No adverse effects were recorded for either therapy.

CONCLUSIONS

Both IAT and CBT showed sustained treatment gains for CMD symptoms amongst refugees over the 12-month period.

Complicated grief knowledge and practice: a qualitative study of general practitioners in Ireland

OBJECTIVE

Complicated grief is a debilitating condition that individuals may experience after losing a loved one. General practitioners (GPs) are well positioned to provide patients with support for grief-related issues. Traditionally, Irish GPs play an important role in providing patients with emotional support regarding bereavement. However, GPs have commonly reported not being aptly trained to respond to bereavement-related issues. This study explores GPs' current knowledge of and practice regarding complicated grief.

METHODS

A qualitative study adopting a phenomenological approach to explore the experiences of GPs on this issue. Semi-structured interviews were carried out with a purposive sample of nine GPs (five men and four women) in Ireland. Potential participants were contacted via email and phone. Interviews were audio-recorded, transcribed and analysed using Braun & Clarke's () model of thematic analysis.

RESULTS

GPs had limited awareness of the concept of complicated grief and were unfamiliar with relevant research. They also reported that their training was either non-existent or outdated. GPs formed their own knowledge of grief-related issues based on their intuition and experiences. For these reasons, there was not one agreed method of how to respond to grief-related issues reported by patients, though participants recognised the need for intervention, onward referral and review.

CONCLUSIONS

The research highlighted that GPs felt they required training in complicated grief so that they would be better able to identify and respond to complicated grief.

Self-guided online treatment of disturbed grief, posttraumatic stress, and depression in adults bereaved during the COVID-19 pandemic: A randomized controlled trial

OBJECTIVE

This randomized-waitlist controlled trial is the first study examining short-term effects of a self-guided online grief-specific cognitive behavioral therapy (CBT) in reducing early persistent complex bereavement disorder (PCBD), posttraumatic stress disorder (PTSD), and depression symptoms in adults bereaved during the COVID-19 pandemic.

METHOD

Sixty-five Dutch adults, bereaved at least three months earlier during the pandemic, with clinically-relevant PCBD, PTSD, and/or depression symptoms, were allocated to a treatment (n = 32) or waitlist condition (n = 33). Telephone interviews were conducted to assess PCBD, PTSD, and depression symptoms (using validated instruments) at baseline, post-treatment, and post-waiting period. Participants received an eight-week self-guided online grief-specific CBT including exposure, cognitive restructuring, and behavioral activation assignments. Analyses of covariance were performed.

RESULTS

Intention-to-treat analyses indicated that people in the intervention condition showed significantly lower PCBD (d = 0.90), PTSD (d = 0.71), and depression (d = 0.57) symptom-levels post-treatment relative to waitlist controls post-waiting, while taking baseline symptom-levels and use of professional psychological co-intervention into account.

CONCLUSIONS

The online CBT proved to be an effective intervention, reducing PCBD, PTSD, and depression symptoms. Pending replication of these findings, early online interventions may be widely implemented in practice to improve treatments for distressed bereaved people.

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

INTRODUCTION

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

OBJECTIVES

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

METHODS

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

RESULTS

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

SIGNIFICANCE OF RESULTS

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

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.

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.

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.

Introduction and evaluation of a therapeutic adherence and competence scale for grief-focused cognitive behavioural therapy

BACKGROUND

There is no therapeutic competence and adherence scale for grief-focused cognitive behavioural therapy (grief-focused CBT). However, given the growing body of evidence for the efficacy of grief-focused CBT, such a scale is needed both to ensure the internal validity of clinical trials and to facilitate psychotherapy process research.

OBJECTIVE

To develop and undertake a psychometric evaluation of a therapeutic adherence and competence scale for grief-focused CBT.

METHOD

The scale was developed in two steps. (I) Five experts on the treatment of prolonged grief disorder provided feedback on the relevance and appropriateness of the items. The scale was revised to reflect their feedback. The final therapeutic adherence and competence scale for grief (TACs-G) consisted of 15 adherence and 16 competence items. (II) Psychometric evaluation of the TACs-G was based on the rating of 48 randomly selected PG-CBT sessions by two independent raters. The videos were recorded in the context of a randomized controlled trial (RCT; DRKS00012317.) ICC was used to calculate inter-rater reliability and TACs-G stability over time (re-evaluation of 10 sessions after 12 months).

RESULTS

The five experts confirmed the relevance and appropriateness of the items. Interrater reliability was found to be high for the total adherence and competence scores (ICC = 0.889 and 0.782, respectively) and moderate to excellent for individual items (ICC = 0.509-1.00). The TACs-G stability over time was found to be strong for both adherence (ICC = 0.970) and competence total scores (ICC = 0.965).

CONCLUSIONS

The TACs-G for CBT is a reliable instrument that can be used not only to ensure internal validity but is also suited for psychotherapy process studies. Additionally, it provides a valuable database for targeted feedback in training settings.

HIGHLIGHTS

This is the first study to report on the development and psychometrical evaluation of a grief-focused adherence and competence scale.Although an increasing number of clinical trials do report the efficacy of grief-focused cognitive-behavioural therapy, none of these studies used a standardized adherence and competence scale to control internal validity.In the present study, we introduced a therapeutic adherence and competence scale for grief (TACs-G) that can be applied efficiently across different research settings (e.g. manipulation check, dissemination), and report results of good to excellent psychometric properties.The scale itself could prove useful beyond the research setting as it could possibly serve as a basis for feedback in training settings.

Inclusion of the other in the self as a potential risk factor for prolonged grief disorder: A comparison of patients with matched bereaved healthy controls

Pathological grief has received increasing attention in recent years, as about 10% of the bereaved suffer from one kind of it. Pathological grief in the form of prolonged grief disorder (PGD) is a relatively new diagnostic category which will be included into the upcoming ICD-11. To date, various risk and protective factors, as well as treatment options for pathological grief, have been proposed. Nevertheless, empirical evidence in that area is still scarce. Our aim was to identify the association of interpersonal closeness with the deceased and bereavement outcome. Interpersonal closeness with the deceased in 54 participants (27 patients suffering from PGD and 27 bereaved healthy controls) was assessed as the overlap of pictured identities via the inclusion of the other in the self scale (IOS scale). In addition to that, data on PGD symptomatology, general mental distress and depression were collected. Patients suffering from PGD reported higher inclusion of the deceased in the self. By contrast, they reported feeling less close towards another living close person. Results of the IOS scale were associated with PGD severity, general mental distress and depression. Inclusion of the deceased in the self is a significant statistical predictor for PGD caseness.

Grief and loss in old age: Exploration of the association between grief and depression

BACKGROUND

The proportion of older adults is increasing due to demographic changes. Depression belongs to the most common mental disorders in late life. The loss of an emotionally significant person is a risk factor for the development of depression. The aim of this study is to analyze the association between depression and grief burden resulting from loss. Based on prior evidence, we examined loneliness as a possible mediator and social support as possible moderator of this association.

METHODS

The cross-sectional analyses are based on a sample (N = 863) of study participants aged 75+ (M = 81.4 years, SD = 4.4, 62.2% female) with loss experience deriving from the multicenter prospective German cohort study AgeMooDe. Regression analyses (moderated mediation) were performed.

RESULTS

With increasing age (β = 0.10, p = .005) and grief burden (β = 0.33, p <. 001) depression severity increased. There was an indirect mediating effect of loneliness on the correlation of grief burden and depression (b = 0.04, CI [0.03, 0.05]), but no moderating effect of social support on the correlation of grief burden and loneliness. People living alone had a significantly higher risk of depression, increased loneliness and lack of social support.

LIMITATIONS

Assessments were based on self-reporting and recorded dimensionally. The cross-sectional design limits conclusions about directions and causality of associations. Sampling bias cannot be completely excluded.

CONCLUSION

The study provides empirical evidence and a better understanding of the association between grief and depression among the very old and the mediating role of loneliness.

Behavioral Activation and Therapeutic Exposure vs. Cognitive Therapy for Grief Among Combat Veterans: A Randomized Clinical Trial of Bereavement Interventions

Approximately two-thirds of Operations Enduring Freedom, Iraqi Freedom, and New Veterans reported knowing someone who was killed or seriously injured, lost someone in their immediate unit, or personally saw dead or seriously injured Americans (Hoge et al., 2004; Thomas et al., 2010; Toblin et al., 2012). Thus, it is not surprising that prevalence of Persistent Complex Bereavement Disorder (PCBD) is high in these groups. Importantly, PCBD impact appears to be independent of both Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (Bonnano, 2007), 2 disorders that are also highly prevalent in these groups, thus tailored treatments for grief are indicated. The Department of Veterans Affairs suggests Cognitive Therapy for Grief as a first line psychotherapy, however treatments relatively more focused on behavior change and exposure to grief cues also may be useful for this population. To address this question, the present study used a randomized controlled trial to compare a 7-session program of Behavioral Activation and Therapeutic Exposure for Grief vs. Cognitive Therapy for Grief among 155 OIF/OEF/OND veterans. Both treatments produced significant treatment gains over baseline, and these improvements were maintained over 6-month followup; however no differences were observed between groups. Given equal efficacy, implications for matching treatment to patient characteristics are discussed.

Feasibility of Present-Centered Therapy for Prolonged Grief Disorder: Results of a Pilot Study

Present-centered therapy (PCT) was originally developed as a strong comparator for the non-specific effects of psychotherapy in the treatment of posttraumatic stress disorder. PCT qualifies as a not strictly supportive treatment as it is structured and homework is assigned between sessions. It does not focus on cognitive restructuring or exposure. A growing body of literature supports its beneficial effects. For example, it demonstrated only slightly inferior effect sizes and lower dropout rates compared to that of trauma-focused cognitive behavioral therapy in several trials with patients suffering from posttraumatic stress disorder. The current study is the first to evaluate the feasibility and the treatment effects of PCT in adults with prolonged grief disorder (PGD). Meta-analyses on psychotherapy for PGD have yielded moderate effect sizes. N = 20 individuals suffering from PGD were treated with PCT by novice therapists as part of a preparation phase for an upcoming RCT in an outpatient setting. Treatment consisted of 20-24 sessions á 50 min. All outcomes were assessed before treatment, at post-treatment, and at the 3-month follow-up. The primary outcome, PGD symptom severity, was assessed using the Interview for Prolonged Grief-13. Secondary outcomes were self-reported PGD severity, depression, general psychological distress, and somatic symptom severity. Furthermore, therapists evaluated their experiences with their first PCT patient and the treatment manual. In intent-to-treat analyses of all patients we found a significant decrease in interview-based PGD symptom severity at post-treatment (d = 1.26). Decreases were maintained up to the 3-month follow-up assessment (d = 1.25). There were also significant decreases in self-reported PGD symptoms, depression, and general psychological distress. No changes were observed for somatic symptoms. The completion rate was 85%. Therapists deemed PCT to be a learnable treatment program that can be adapted to the patient's individual needs. The preliminary results of PCT as a treatment for PGD demonstrate large effects and indicate good feasibility in outpatient settings. The treatment effects were larger than those reported in meta-analyses. Thus, PCT is a promising treatment for PGD. Possible future research directions are discussed.

Online treatment of persistent complex bereavement disorder, posttraumatic stress disorder, and depression symptoms in people who lost loved ones during the COVID-19 pandemic: study protocol for a randomized controlled trial and a controlled trial

BACKGROUND

Losing a loved one during the COVID-19 pandemic is a potentially traumatic loss that may result in symptoms of persistent complex bereavement disorder (PCBD), posttraumatic stress disorder (PTSD), and depression. To date, grief-specific cognitive-behavioural therapy (CBT) has mostly been delivered through individual face-to-face formats, while studies have shown that online treatment also yields promising results. Offering treatment online is now more than ever relevant during the pan demic and may offer important benefits compared with face-to-face CBT, such as lower costs and higher accessibility. Our expectation is that grief-specific online CBT is effective in reducing PCBD, PTSD, and depression symptoms.

OBJECTIVE

Our aim is to evaluate the short-term and long-term effectiveness of grief-specific online CBT in reducing PCBD, PTSD, and depression symptom-levels for adults who lost a loved one during the COVID-19 pandemic.

METHOD

This study consists of two parts. In part 1, a two-armed (unguided online CBT versus waitlist controls) randomized controlled trial will be conducted. In part 2, a two-armed (guided online CBT versus unguided online CBT) controlled trial will be conducted. Symptoms of PCBD, PTSD, and depression will be assessed via telephone interviews at pre-treatment/pre-waiting period, post-treatment/post-waiting period, and six months post-treatment. Potential participants are people who lost a loved one at least three months earlier during the COVID-19 pandemic with clinically relevant levels of PCBD, PTSD, and/or depression. Analysis of covariance and multilevel modelling will be performed.

DISCUSSION

This is one of the first studies examining the effectiveness of online grief-specific CBT. More research is needed before implementing online grief-specific CBT into clinical practice.

Prolonged Grief Disorder Among Refugees in Psychological Treatment-Association With Self-Efficacy and Emotion Regulation

BACKGROUND

While Prolonged Grief Disorder (PGD) among refugees has recently started to attract scientific attention, knowledge regarding associated psychological factors remains limited. Given the multifactorial context of persecution, trauma, displacement, and exile-related difficulties, obtaining a better understanding of PGD in refugees is crucial because PGD may affect psychological well-being, level of functioning, and social integration.

METHODS

In a sample of refugees receiving psychological treatment in Switzerland (N = 88), we examined the relationship between severity of PGD and potentially associated factors such as emotion regulation, perceived self-efficacy, as well as potentially traumatic events and post-migration living difficulties.

RESULTS

In a regression analysis, difficulties in emotion regulation and lower perceived self-efficacy were associated with greater severity of PGD, while post-migration living difficulties and potentially traumatic events did not emerge as significant factors.

CONCLUSION

These findings suggest that emotion regulation and perceived self-efficacy are associated with PGD in refugees in psychological treatment and are thus potential targets for treatment interventions.

Grief Before and After Bereavement in the Elderly: An Approach to Care

Grief is the natural response to the death of a loved one and is encountered frequently in clinical practice with the elderly; it can also precede the death. Knowledge about four distinct forms of grief can aid clinicians with the conceptualization of grief, and the assessment and care of grievers. First, predeath grief is experienced by many caregivers of terminally ill patients. Second, acute grief arises immediately after the death of a loved one; and third, this normally evolves to a permanent state of integrated grief after a process of adaptation. Finally, failure of adaptation results in Prolonged Grief Disorder (PGD) which has been recently included in ICD-11. The hallmark feature of PGD is intense longing for the deceased or persistent preoccupation with the deceased that lasts longer than 6 months after the death. Validated instruments are available to assist practitioners with assessment of predeath grief and screening for PGD, thereby enabling identification of patients in need of additional support. Increased risks of morbidity and mortality following bereavement are important health issues for clinicians to be aware of. All grievers can benefit from support focused on understanding their grief, managing emotional pain, thinking about the future, strengthening their relationships, telling the story of the death, learning to live with reminders of the deceased, and connecting with memories. A short-term evidence-based intervention for PGD is based upon these seven themes and is efficacious in the elderly. Caregivers of the terminally ill benefit from psychological support that validates and normalizes their grief experiences and helps them recognize and accept their losses.

Deepening the understanding of complicated grief among Chinese older adults: A network approach

Instead of understanding symptoms in a way where a latent cause exists and symptoms serve as its indicators, the network approach enables an innovative comprehension on psychological disorders that focuses on causal interactions. There is need to update the knowledge in this direction in Chinese context. This study strives to apply network approach to deepening the understanding of complicated grief (CG) among older adults in rural China. A sample of older participants (N = 352) who experienced spousal bereavement living in Zhejiang Province of China were administrated with face-to-face interviews. Networks analysis was conducted to realize the object of this study. The 19-item ICG network revealed that symptoms were both positively and negatively connected within the network. The most three central symptoms were "feeling longing for the person who died" and "memories of the dead", and feeling lonely". Edge-weights accuracy and centrality stability were tested in order to remind carefulness when interpreting the results. This study demonstrates the utility of a network approach in deepening the understanding of the structure of CG symptoms among Chinese older people. Strengths and limitations, as well as implications for informing the assessment and treatment of this disorder, were discussed.

Prolonged grief disorder in Chinese Shidu parents who have lost their only child

Background: China has the largest population of '"loss-of-only-child' parents, that are also known as Shidu parents in Chinese society; however, little is known about their unresolved grief. Objective: This is the first study to examine the grief symptoms, prevalence, comorbidity and potential predictors of prolonged grief disorder (PGD) in such parents, taking into consideration that the new PGD diagnostic criteria ICD-11 will soon be implemented in China. Methods: 149 Shidu parents completed assessments of PGD (PG-13), PTSD (PCL-C), depression (CES-D) and general psychiatric morbidity (GHQ-12) via in-person interviews. Results: Of the 149 Shidu parents, 22.2% met the PGD criteria, with a mean of 7.59 years post-loss, and 62.4% experienced daily longing or yearning. Regression analysis indicated that fewer years since loss, subjective perception of poor economic situation, female gender and more hospital visits were prominent risk factors for the development of PGD. Older age of the parents at the time of child loss was also associated with PGD. Parents with PGD had higher comorbidity of PTSD or depression compared with those without PGD. Conclusions: There is a high prevalence of PGD and a high rate of comorbidity between PGD and PTSD or depression in Shidu parents in China, which highlights the need of timely developing effective assessments and interventions to prevent PGD in this population, particularly in female, recently bereaved, low-income and aged parents who lost their only child.

Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies

An update of the chapter on Mental, Behavioral and Neurodevelopmental Disorders in the International Classification of Diseases and Related Health Problems (ICD) is of great interest around the world. The recent approval of the 11th Revision of the ICD (ICD-11) by the World Health Organization (WHO) raises broad questions about the status of nosology of mental disorders as a whole as well as more focused questions regarding changes to the diagnostic guidelines for specific conditions and the implications of these changes for practice and research. This Forum brings together a broad range of experts to reflect on key changes and controversies in the ICD-11 classification of mental disorders. Taken together, there is consensus that the WHO's focus on global applicability and clinical utility in developing the diagnostic guidelines for this chapter will maximize the likelihood that it will be adopted by mental health professionals and administrators. This focus is also expected to enhance the application of the guidelines in non-specialist settings and their usefulness for scaling up evidence-based interventions. The new mental disorders classification in ICD-11 and its accompanying diagnostic guidelines therefore represent an important, albeit iterative, advance for the field.

Commentary on evidence in support of a grief-related condition as a DSM diagnosis

The death of a loved one is one of life's greatest stressors. Most bereaved individuals experience a period of acute grief that diminishes in intensity as they adapt to the changes brought about by their loss. Over the past four decades, a growing body of research has focused on a form of prolonged grief that is painful and impairing. There is a substantial and growing evidence base that supports the validity and significance of a grief-related disorder, including the clinical value of being able to diagnose it and provide effective targeted treatment. ICD-11 will include a new diagnosis of prolonged grief disorder (PGD). DSM-5 called this condition persistent complex bereavement disorder (PCBD) and included it in Section III, signaling agreement that a diagnosis is warranted while further research is needed to determine the optimal criteria. Given the remaining uncertainties, reading this literature can be confusing. There is inconsistency in naming the condition (including complicated grief as well as PGD and PCBD) and lack of uniformity in identifying it, with respect to the optimal threshold and timeframe for distinguishing it from normal grief. As an introductory commentary for this Depression and Anxiety special edition on this form of grief, the authors discuss the history, commonalities, and key areas of variability in identifying this condition. We review the state of diagnostic criteria for DSM-5 and the current ICD-11 diagnostic guideline, highlighting the clinical relevance of making this diagnosis.

Ritual in Therapy for Prolonged Grief: A Scoping Review of Ritual Elements in Evidence-Informed Grief Interventions

The aim of this article of to analyze ritual in evidence-informed treatments for prolonged and traumatic grief. A scoping review is conducted in order to give an overview of existing literature on ritual and symbolic interventions in grief therapies for prolonged grief and the type of evidence supporting these interventions. The 22 studies reported in this review reveal a variety of ritual elements ranging from symbolic expression and interaction, writing assignments, dialogue with the deceased or an imaginary person, to farewell ceremonies at the end of the treatment. The interventions are studied within different populations (e.g., bereaved spouses, perinatal loss, grief after violent death, and genocide). Almost all studies show significant effects of the grief treatment, trauma and related symptoms. However, the effects are mostly measured for the entire treatment and not separately for the ritual intervention. In the discussion we focus on the role of ritual and culture in prolonged grief treatment.

The prevalence of complicated grief among Chinese people at high risk: A systematic review and meta-analysis

OBJECTIVE

This unprecedented systematic review aims to unearth the rate of CG among Chinese people.

METHODS

Data sources were from PsycINFO, ProQuest Databases, Web of Science, PsycARTICLES, China National Knowledge Infrastructure (CNKI), WanFang, Taiwan Periodical Literature System (TPLS), HKInChiP from the inception to June 2019. The eligibility criteria for inclusion were (a) including or useful to calculate the prevalence of CG in Chinese settings, (b) published in journals, (c) containing information on sample size, (d) full texts either written in English or in Chinese are available. Thirteen studies were engaged in meta-analytic evaluation after the systematic review. They were appraised by the risk of bias (RoB) for publication-quality and synthesized through meta-analysis for identifying the prevalence of CG among Chinese people.

RESULTS

Meta-analysis revealed a pooled estimate of CG of 22.0% (95% CI: 0.111-0.391). The studies identified in this review were of methodological heterogeneousness and focused on the population at high risk of CG. They were a moderate or high risk of bias.

CONCLUSION

Results warrant the need to conduct a population-based and quality study to investigate the prevalence of CG in Chinese people. Many suggestions on treatment for Chines people with CG were provided.

Psychological interventions for grief in adults: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The present meta-analysis evaluates the efficacy of psychological interventions for grief in bereaved adults and explores the possible moderating influence of various study characteristics.

METHODS

A systematic literature search was conducted by two reviewers who independently searched electronic databases, reviewed and selected eligible studies, and evaluated their methodological quality.

RESULTS

A total of 31 randomized controlled trials (RCTs) were included in the meta-analysis. Statistically significant pooled effects of psychological intervention on grief symptoms were found for both post-intervention (Hedges's g = 0.41, p > .001, K = 31) and follow-up (g = 0.45, p > .001, K = 18). While generally robust, the effect was smaller at post-intervention when adjusting for possible publication bias (g = 0.31). Compared with the remaining studies, larger post-intervention effect sizes were found for studies with (1) individually delivered interventions (Beta = 0.49, p < .001), (2) the ICG-(R)/PG-13 questionnaire as the grief instrument (Beta = 0.46, p < .001), (3) participants who were ≥6 months post-loss (Beta = 0.58, p < .001), (4) participants included based on high baseline symptom levels (Beta = 0.40, p = .002) and (5) higher study quality (Beta = 0.06, p = .013).

LIMITATIONS

The included studies were methodologically heterogeneous and their methodological quality varied considerably. Moreover, there were some indications of publication bias.

CONCLUSIONS

Given the recent introduction of Prolonged Grief Disorder in the ICD-11, the results of the present meta-analysis are timely and of clinical relevance. Based on our results, psychological intervention appears efficacious for alleviating grief symptoms in bereaved adults, with several study characteristics as possible moderators of the effect. The interpretability of the results, however, is challenged by some limitations of the available research, including possible publication bias.

[Prolonged grief disorder]

Grief is a natural response to the loss of a loved one and its intensity usually lessens over time. Approximately 10% of bereaved persons, however, experience persistent symptoms resulting in the development of a prolonged grief disorder (PGD). A PGD shows a distinct symptom cluster and is considered for inclusion as a diagnosis in the upcoming revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). It is distinct from other mental disorders but symptoms overlap, especially with major depression and posttraumatic stress disorder. In addition to diagnostic criteria and differential diagnosis, the following article also describes prevalence rates, comorbidities, risk factors as well as treatment options for PGD.

Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability

A new mental health disorder, prolonged grief disorder (PGD), will be included in the 11th edition of the International Classification of Diseases (ICD-11). We provide a brief overview of the historical conceptualizations of disordered grief and the previous research efforts to assess and define this condition. We describe the new ICD-11 PGD symptom criteria and how they are conceptualized in terms of the World Health Organization's call for improved clinical utility. Finally, we review the research evidence for the clinical utility of the new ICD-11 PGD symptom structure and usability in the international arena.

Treating prolonged grief disorder with prolonged grief-specific cognitive behavioral therapy: study protocol for a randomized controlled trial

BACKGROUND

Prolonged grief disorder (PGD) has emerged as a well-defined and relatively common mental disorder that will be included in the upcoming revision of the International Classification of Diseases. Recent trials with grief-specific, mostly cognitive behavioral interventions for patients with a clinically relevant diagnosis of PGD showed large effect sizes. However, a small trial suggested that non-specific behavioral activation might suffice to improve PGD. So, more evidence for the relative efficacy of grief-specific treatments is needed, as is more research on the predictors of treatment success. The purpose of the proposed trial is to evaluate a newly developed and successfully pilot-tested, prolonged grief-specific, integrative cognitive behavioral therapy (PG-CBT) compared to an active yet unspecific treatment, present-centered therapy (PCT).

METHODS

In a multicenter, randomized controlled trial with 204 adults with a primary diagnosis of PGD, PG-CBT is compared to PCT, assuming the superiority of PG-CBT. Both treatments consist of 20 to 24 individual sessions, with an overall treatment length of about 6 months. The primary outcome, grief symptom severity, is assessed by blinded interviewers 12 months after randomization. Secondary outcomes are grief symptom severity at post treatment, in addition to self-reported overall mental health symptoms, depressive and somatoform symptoms at post treatment and 12 months post randomization. Possible moderators and mediators of treatment success are also explored.

DISCUSSION

The trial is designed to avoid bias as much as possible (stratified randomization performed independently, blinded outcome assessment, intention-to-treat-analysis, balanced treatment dose, continuous supervision, control for allegiance effects) thereby enhancing internal validity. At the same time, some aspects of the trial will ensure clinical relevance (recruiting at outpatient clinics that are part of routine health care and keeping exclusion criteria to a minimum). Since the trial is powered adequately for the primary outcome, all secondary analyses including moderator analyses are exploratory by nature. The results will extend the knowledge on efficacious treatment of PGD and its predictors.

TRIAL REGISTRATION

German Clinical Trials Register, ID: DRKS00012317 . Registered on 6 September 2017.

Does prolonged grief treatment foster posttraumatic growth? Secondary results from a treatment study with long-term follow-up and mediation analysis

OBJECTIVES

Prolonged grief disorder (PGD) is a persistent and disabling kind of grief reaction that can be treated effectively with psychotherapeutic interventions. There has been limited investigation of whether these interventions can also enhance positive outcomes of bereavement, such as posttraumatic growth or benefit finding.

DESIGN

As part of secondary analyses in a randomized controlled trial evaluating integrative cognitive-behavioural therapy for PGD (PG-CBT), the posttraumatic growth trajectories in 51 outpatients with clinically relevant prolonged grief symptoms were followed up from baseline up to 1.5 years.

METHODS

Immediate treatment effects on posttraumatic growth in comparison with a waiting list control group were evaluated with univariate ANCOVA. Using mediation analysis, we examined the relation between symptom reduction and the short-term treatment effect on posttraumatic growth. For evaluating long-term outcome stability, the immediately treated group and the delayed treatment group were pooled.

RESULTS

PG-CBT significantly fostered growth in patients suffering from PGD, with a controlled medium effect size of Cohen's d = 0.60 (completer analysis). This effect remained stable up to the 1.5-year follow-up. Grief symptom reduction mediated short-term treatment effects on posttraumatic growth. However, growth also partially mediated treatment effects on prolonged grief symptoms.

CONCLUSIONS

Taken together, PG-CBT was effective in enhancing the participants' perception of posttraumatic growth, but the definite interaction between symptom reduction and posttraumatic growth remains unclear, as both seemed to influence each other's trajectory in the course of treatment.

PRACTITIONER POINTS

Integrative CBT for prolonged grief disorder also fostered posttraumatic growth. Post-treatment and 1.5-year follow-up effect sizes for posttraumatic growth were moderate. Whether growth-enhancing techniques are useful in grief treatment needs further research.

Cognitive therapy and eye movement desensitization and reprocessing for reducing psychopathology among disaster-bereaved individuals: study protocol for a randomized controlled trial

Background: Confrontation with a traumatic (e.g. disaster-related) loss is a risk factor for the development of psychopathology, including symptoms of prolonged grief (PG), posttraumatic stress (PTS), and depression. Although interventions have been developed for reducing post-loss psychopathology, more research into the effectiveness of treatment is needed to improve care for bereaved persons. Cognitive therapy (CT) and eye movement desensitization and reprocessing (EMDR) have been shown to be effective in trauma-exposed populations. We hypothesize that CT and EMDR are also effective in reducing symptoms among people exposed to traumatic loss. Objective: In this article we describe the rationale of a randomized controlled trial (RCT) to examine (1) treatment effects of CT and EMDR for reducing PG, PTS, and depression among traumatically bereaved people, and (2) the associations between improvements in PG, PTS, and depression symptoms on the one hand and tentative mechanisms of change, including a sense of unrealness, negative cognitions, avoidance behaviour, and intrusive memories, on the other hand. Method: A two-armed (intervention versus waiting list controls) RCT will be conducted. Participants will be asked to fill in questionnaires prior to treatment, during treatment, and one, 12, and 24 weeks post-treatment. Potential participants are people who have lost one or multiple significant other(s) in the Ukrainian plane disaster in 2014 with clinically significant levels of self-rated PG, PTS, and/or depression. Multiple regression, including analysis of covariance, and multilevel regression analyses will be used. Discussion: There is a need for treatment for psychopathology following traumatic loss. Strengths of this study are the development of a treatment that targets grief and trauma-related complaints and the examination of potential mechanisms of change in CT and EMDR. Bereaved people, clinicians, and researchers could benefit from the results of this study.

Effectiveness of bereavement counselling through a community-based organization: A naturalistic, controlled trial

This controlled, longitudinal investigation tested the effectiveness of a bereavement counselling model for adults on reducing complicated grief (CG) symptoms. Participants (N = 344; 79% female; mean age: 49.3 years) were adult residents of Scotland who were bereaved of a close relation or partner, experiencing elevated levels of CG, and/or risks of developing CG. It was hypothesized that participants who received intervention would experience a greater decline in CG levels immediately following the intervention compared to the control participants, but the difference would diminish at follow‐up (due to relapse). Data were collected via postal questionnaire at 3 time points: baseline (T), post‐intervention (T + 12 months), and follow‐up (T + 18 months). CG, post‐traumatic stress, and general psychological distress were assessed at all time points. Multilevel analyses controlling for relevant covariates were conducted to examine group differences in symptom levels over time. A stepwise, serial gatekeeping procedure was used to correct for multiple hypothesis testing. A main finding was that, contrary to expectations, counselling intervention and control group participants experienced a similar reduction in CG symptoms at postmeasure. However, intervention participants demonstrated a greater reduction in symptom levels at follow‐up (M = 53.64; d = .33) compared to the control group (M = 62.00). Results suggest community‐based bereavement counselling may have long‐term beneficial effects. Further longitudinal treatment effect investigations with extensive study intervals are needed.

Effects of Mental Health Support on the Grief of Bereaved People Caused by Sewol Ferry Accident

Few studies have assessed the overall effects of multi-centered, complicated mental health support on the grief process. This study investigated the broader influence of mental health support provided practically to the bereaved family on the severity of complicated grief. Ninety-three bereaved family members of the Sewol ferry accident were recruited. Severity of complicated grief, post-traumatic stress disorder (PTSD) and depressive disorder was assessed through self-reporting questionnaire, inventory of complicated grief (ICG), PTSD Check List-5 (PCL-5) and Patient Health Questionnaire-9 (PHQ-9). We also included demographic, socioeconomic, health-related variables, and Functional Social Support Questionnaire (FSSQ), which affect the ICG score. Participants were divided into 4 groups based on the experience of psychotherapy or psychiatry clinic service before the accident and mental health support after the disaster. In univariate analysis, these 4 groups showed a significant difference in the mean ICG score (P = 0.020). Participants who received mental health support only after the Sewol ferry accident (group 2) showed a lower mean ICG score than those who received neither psychotherapy or psychiatry clinic service before the disaster nor mental health support after the accident (group 4). There was no significant correlation between the ICG score and other variables except for subjective health status measured 1 month after the disaster (P = 0.005). There was no significant difference in PCL-5 (P = 0.140) and PHQ-9 scores (P = 0.603) among groups, respectively. In conclusion, mental health support significantly reduced the severity of grief only in those participants who had not received any psychotherapy or psychiatry clinic service before the accident.

Grief interventions for people bereaved by suicide: A systematic review

BACKGROUND

Adaption to the loss of a loved one due to suicide can be complicated by feelings of guilt, shame, responsibility, rejection, and stigmatization. Therefore people bereaved by suicide have an increased risk for developing complicated grief which is related to negative physical and mental disorders and an increased risk for suicidal behavior. Grief interventions are needed for this vulnerable population. The aim of this systematic review was to provide an overview of the current state of evidence concerning the effectiveness of interventions that focus on grief for people bereaved by suicide.

METHODS

We conducted a systematic literature search using PubMed, Web of Science, and PsycINFO for articles published up until November 2016. Relevant papers were identified and methodological quality was assessed by independent raters. A narrative synthesis was conducted.

RESULTS

Seven intervention studies met the inclusion criteria. Two interventions were based on cognitive-behavioral approaches, four consisted of bereavement groups, and one utilized writing therapy. As five of the seven interventions were effective in reducing grief intensity on at least one outcome measure, there is some evidence that they are beneficial. Bereavement groups tend to be effective in lowering the intensity of uncomplicated grief, as are writing interventions in lowering suicide-specific aspects of grief. Cognitive-behavioral programs were helpful for a subpopulation of people who had high levels of suicidal ideation.

LIMITATION

On average, methodological quality was low so the evidence for benefits is not robust. The stability of treatment effects could not be determined as follow-up assessments are rare. Generalizability is limited due to homogeneous enrollments of mainly female, white, middle-aged individuals.

CONCLUSIONS

People bereaved by suicide are especially vulnerable to developing complicated grief. Therefore, grief therapies should be adapted to and evaluated in this population. Prevention of complicated grief may be successful in populations of high risk individuals.

The body of knowledge in thanatology: An outline

The Association for Death Education and Counseling has updated its articulation of the body of knowledge in the field of thanatology. In doing so it has relinquished the use of a matrix format in favor of a more serviceable outline containing three major sections: Arenas of Thanatology, Practice Considerations for Professionals in the Field, and Contextual and Theoretical Considerations. Accompanying the outline is a new commentary on the state of the field itself, along with an annotated bibliography of recent relevant publications.

Predictors of treatment response for cognitive behaviour therapy for prolonged grief disorder

Background: Prolonged grief disorder (PGD) causes significant impairment in approximately 7% of bereaved people. Although cognitive behaviour therapy (CBT) has been shown to effectively treat PGD, there is a need to identify predictors of treatment non-response. Methods: PGD patients (N = 80) were randomly allocated to receive 10 weekly two-hour group CBT sessions and (a) four individual sessions of exposure therapy or (b) CBT without exposure. PGD was assessed by self-report measures at baseline, post-treatment (N = 61), and six-months (N = 56) after treatment. Results: Post-treatment assessments indicated that greater reduction in grief severity relative to pretreatment levels was associated with being in the CBT/Exposure condition, and lower baseline levels of self-blame and avoidance. At follow-up, greater grief symptom reduction was associated with being in the CBT/Exposure condition and lower levels of avoidance. Conclusions: These patterns suggest that strategies that target excessive self-blame and avoidance during treatment may enhance response to grief-focused cognitive behaviour therapy.

Treatment for complicated grief: state of the science and ways forward

PURPOSE OF REVIEW

There is increasing recognition that a minority of bereaved persons experiences persistent and disabling grief symptoms, also termed complicated grief. We review currently proposed criteria for complicated grief in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) and the International Statistical Classification of Diseases and Related Health Problems (ICD-11), highlight controversies with regard to establishing complicated grief as a psychiatric disorder, summarize recent complicated grief treatment research within a cognitive behavioral treatment framework, and establish a novel and systematic research agenda for complicated grief treatment.

RECENT FINDINGS

Clinicians should be wary of overdiagnosis and misdiagnosis of complicated grief. Recent changes to definitions of complicated grief may threaten generalizability and clinical application of research findings. Universal treatment, treatment for at-risk groups and preventive complicated grief treatment appear ineffective. Although medication is often prescribed to bereaved persons, evidence for its effectiveness is equivocal. Face-to-face and internet-based cognitive behavioral therapy techniques appear most effective in targeting complicated grief. However, little is known about what, how, and for whom treatment works best.

SUMMARY

In light of these findings, we recommend systematic investigation of: what works best in complicated grief treatment, by conducting well designed, stepped effectiveness trials and treatment component dismantling studies; how it works, by conducting investigations on therapeutic theories and examining mediators of therapeutic change; and for whom it works, by examining potential moderators of treatment effects.

Cognitive behavioural therapy for psychopathology in relatives of missing persons: study protocol for a pilot randomised controlled trial

BACKGROUND

It is hypothesized that the grieving process of relatives of missing persons is complicated by having to deal with uncertainty about the fate of their loved one. We developed a cognitive behavioural therapy (CBT) with mindfulness that focuses on dealing with this uncertainty. In this article, we elucidate the rationale of a pilot randomised controlled trial (RCT) for testing the feasibility and potential effectiveness of this CBT for reducing symptoms of psychopathology in relatives of missing persons.

METHODS

A pilot RCT comparing participants of the CBT condition (n = 15) with waiting list controls (n = 15) will be executed. Individuals suffering from psychopathology related to the long-term disappearance of a loved one are eligible to participate. The treatment consists of eight individual sessions. Questionnaires tapping psychological constructs will be administered before, during, and after the treatment. The feasibility of the treatment will be evaluated using descriptive statistics (e.g., attrition rate). The primary analysis consists of a within-group analysis of changes in mean scores of persistent complex bereavement disorder from baseline to immediately post-treatment and follow-up (12 and 24 weeks post-treatment).

DISCUSSION

A significant number of people experience the disappearance of a loved one. Surprisingly, an RCT to evaluate a treatment for psychopathology among relatives of missing persons has never been conducted. Knowledge about treatment effects is needed to improve treatment options for those in need of help. The strengths of this study are the development of a tailored treatment for relatives of missing persons and the use of a pilot design before exposing a large sample to a treatment that has yet to be evaluated. Future research could benefit from the results of this study.

TRIAL REGISTRATION

NTR4732 (The Netherlands National Trial Register (NTR)).

Prolonged grief: setting the research agenda

BACKGROUND

Prolonged grief disorder is proposed for the International Classification of Diseases (ICD-11), though it was rejected as a diagnosis for DSM-5.

OBJECTIVE

This review outlines findings and defines important areas for future research viewed from a lifespan perspective.

RESULTS

The development and psychometric evaluation of measures for the new diagnosis is paramount, specifically for children and adolescents. Treatments need to be adapted for specific subgroups and research findings have to be disseminated into various professional settings.