Effectiveness of an inpatient group therapy for comorbid complicated grief disorder

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.

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.

The associations of grief-related rumination with prolonged grief and posttraumatic stress symptoms: A longitudinal study of bereaved after the 2011 terror attack in Norway

After the sudden and violent death of a loved one, many bereaved experience symptoms of prolonged grief (PG) and posttraumatic stress (PTS). The present study investigated the cross-sectional and longitudinal associations of grief-related rumination with PG and PTS symptoms among bereaved parents and siblings after the Utøya terror attack in Norway on 22 July 2011 (N = 110, Mage  = 43.2 years, 59.1% female). Participants' responses on the Rumination Scale, the Inventory of Complicated Grief and the Impact of Event Scale-Revised 28, 40 and 102 months after the loss were analysed. Cross-sectionally and longitudinally, grief-related rumination was positively and strongly linked with PG and PTS symptoms. When controlling for the baseline levels of PG and PTS symptoms and demographics of the sample, grief-related rumination predicted PG symptoms after 12 months but not after 74 months. Further, grief-related rumination predicted significantly the PTS symptoms of avoidance after 12 and 74 months and hyperarousal after 74 months beyond sample demographics and baseline symptoms. The results suggest that grief-related rumination is an important factor in PG and PTS symptoms after traumatic bereavement.

Prolonged grief in refugees living in Germany confronted with ambiguous or confirmed loss

BACKGROUND AND OBJECTIVES

People often disappear in the context of displacement or armed conflicts. Although such an ambiguous loss is accompanied by persistent uncertainty about the whereabouts, the psychological consequences are not well understood. This study investigated the effects of ambiguous compared to a confirmed loss on prolonged grief disorder (PGD) and its correlates in refugees to Germany.

METHODS AND DESIGN

We investigated data on mental health outcomes of refugees from Syria, Iraq, Iran and Afghanistan who had applied for/were granted asylum in Germany. In a secondary analysis, we compared 87 refugees with disappeared (n = 33) and deceased relatives (n = 54) who had completed questionnaire-based interviews.

RESULTS

Participants with ambiguous loss displayed more severe symptoms of PGD than those with confirmed loss. However, we found no group differences in terms of probable disorder rates and the number of traumatic experiences. Even after controlling for several correlates of PGD, higher PGD symptom severity was associated with ambiguous loss, more PTSD symptoms and low perceived social support.

CONCLUSIONS

These results show a higher prolonged grief symptom severity after the loss of a significant other due to disappearance, indicating that this type of loss could be a specific risk factor for PGD severity.

A Scoping Review of Interventions for Spousal Bereavement in Older Adults

The loss of a spouse is a common and natural life event for older adults. Nearly one of four older bereaved spouses experience prolonged grief, impaired function or chronic depression. Mechanisms underlying these and other long-term health risks are not well understood. We conducted a scoping literature review to examine the interventions and outcomes that have been studied for late-life spousal bereavement to date. We identified 22 studies of group and individual-level interventions with most studies concerning grief processes within the first year. Nearly all studies evaluated emotional and psychological symptoms of loss and a small number evaluated the restoration of adaptive functioning. Four interventions addressed the treatment of complicated grief or grief with major depressive disorder. Qualitative studies explored themes of spirituality and mindfulness. There were 17 controlled studies, including 13 randomized controlled trials. Findings were eclectic, with evidence supporting mindfulness techniques in a group format for emotional and life satisfaction outcomes; an individual, function-based therapy addressing sleep to improve emotion and function; an individual, writing-based emotional expression therapy for short-term improvement in emotion and function; nortriptyline for the treatment of bereavement-related major depressive disorder; a group-based, complicated grief therapy for this condition; an internet-based CBT intervention for prolonged grief; and pharmacotherapy for cardiovascular changes during bereavement. These findings highlight the small literature of methodologically strong intervention studies addressing spousal bereavement in older adults and the need for greater exploration of relevant biological, social, cognitive and behavioral factors to improve short and long term health outcomes.

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.

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.

Effects of bereavement groups-a systematic review and meta-analysis

This review summarizes the evidence of bereavement groups for symptoms of grief and depression. The literature search using Web of Science, EBSCO, PubMed, CINAHL, and MEDLINE yielded 14 studies (N = 1519) meeting the inclusion criteria (i.e., randomized-controlled trials, bereaved adults, bereavement group, validated measures). Overall, bereavement groups were marginally more effective than control groups post-treatment (gG = 0.33, gD = 0.22) but not at follow-up. Although tertiary interventions yielded larger effect sizes than secondary interventions, the difference was not significant. The results imply that the evidence for bereavement groups is weak, although the large heterogeneity of concepts for intervention and control groups limits the generalizability.

Web-Based Bereavement Care: A Systematic Review and Meta-Analysis

BACKGROUND

Web-based interventions have been introduced as novel and effective treatments for mental disorders and, in recent years, specifically for the bereaved. However, a systematic summary of the effectiveness of online interventions for people experiencing bereavement is still missing.

OBJECTIVE

A systematic literature search was conducted by four reviewers who reviewed and meta-analytically summarized the evidence for web-based interventions for bereaved people.

METHODS

Systematic searches (PubMed, Web of Science, PsycInfo, PsycArticles, Medline, and CINAHL) resulted in seven randomized controlled trials (N = 1,257) that addressed adults having experienced bereavement using internet-based interventions. We used random effects models to summarize treatment effects for between-group comparisons (treatment vs. control at post) and stability over time (post vs. follow-up).

RESULTS

All web-based interventions were based on cognitive behavioral therapy (CBT). In comparison with control groups, the interventions showed moderate (g = .54) to large effects (g = .86) for symptoms of grief and posttraumatic stress disorder (PTSD), respectively. The effect for depression was small (g = .44). All effects were stable over time. A higher number of treatment sessions achieved higher effects for grief symptoms and more individual feedback increased effects for depression. Other moderators (i.e. dropout rate, time since loss, exposure) did not significantly reduce moderate degrees of heterogeneity between the studies.

LIMITATIONS

The number of includable studies was low in this review resulting to lower power for moderator analyses in particular.

CONCLUSIONS

Overall, the results of web-based bereavement interventions are promising, and its low-threshold approach might reduce barriers to bereavement care. Nonetheless, future research should further examine potential moderators and specific treatment components (e.g. exposure, feedback) and compare interventions with active controls.

Prolonged grief disorder: clinical utility of ICD-11 diagnostic guidelines

BACKGROUND

The World Health Organization (WHO) International Classification of Disease (ICD-11) is expected to include a new diagnosis for prolonged grief disorder (ICD-11PGD). This study examines the validity and clinical utility of the ICD-11PGD guideline by testing its performance in a well-characterized clinical sample and contrasting it with a very different criteria set with the same name (PGDPLOS).

METHODS

We examined data from 261 treatment-seeking participants in the National Institute of Mental Health (NIMH)-sponsored multicenter clinical trial to determine the rates of diagnosis using the ICD-11PGD guideline and compared these with diagnosis using PGDPLOS criteria.

RESULTS

The ICD-11PGD guideline identified 95.8% [95% confidence interval (CI) 93.3-98.2%] of a treatment-responsive cohort of patients with distressing and impairing grief. PGDPLOS criteria identified only 59.0% (95% CI 53.0-65.0%) and were more likely to omit those who lost someone other than a spouse, were currently married, bereaved by violent means, or not diagnosed with co-occurring depression. Those not diagnosed by PGDPLOS criteria showed the same rate of treatment response as those who were diagnosed.

CONCLUSIONS

The ICD-11PGD diagnostic guideline showed good performance characteristics in this sample, while PGDPLOS criteria did not. Limitations of the research sample used to derive PGDPLOS criteria may partly explain their poor performance in a more diverse clinical sample. Clinicians and researchers need to be aware of the important difference between these two identically named diagnostic methods.

A pilot randomised controlled trial of metacognitive therapy for prolonged grief

OBJECTIVES

Prolonged grief disorder is associated with significant distress and impairment and thus efforts to improve treatments are essential. The present pilot study tested the efficacy and feasibility of group Metacognitive Grief Therapy (MCGT) designed specifically for prolonged grief symptomatology to reduce the psychological distress and impaired function resulting from bereavement.

DESIGN/PARTICIPANTS

Twenty-two bereaved adult participants with prolonged grief symptomatology were randomised to a wait-list control (n=10) or an intervention condition (n=12) with a 3-month and 6-month follow-up. The wait-list control group was offered treatment after the post-test assessment.

INTERVENTION

Participants attended six group MCGT sessions that ran for 2 hours per week.

OUTCOME MEASURES

A primary outcome measure of prolonged grief symptomatology and secondary outcome measures of depression, anxiety, rumination, metacognitive beliefs and quality of life were taken pretreatment and post-treatment for both groups and at the 3-month and 6-month follow-up for the intervention group. A Generalised Linear Mixed Model was used to assess treatment efficacy.

RESULTS

Post-treatment intent-to-treat analyses showed MCGT reduced prolonged grief symptomatology (Cohen's d=1.7), depression (d=1.3), anxiety (d=0.8), stress (d=1.0), rumination (d=0.9) and increased quality of life (d=0.6), and these effects were maintained at the 3-month and 6-month follow-ups. No prepost between-group differences were found in metacognitive beliefs. However, a large significant effect was identified at the 3-month and 6-month follow-ups (d=1.0).

CONCLUSION

The results show promise for the utility of group MCGT for reducing psychological distress and promoting quality of life. Additionally, the results underscore the need for a full randomised controlled trial of group MCGT, which may be an important addition to the treatment armamentarium available to support people with prolonged grief.

TRIAL REGISTRATION NUMBER

ACTRN12613001270707; Results. ORIGINAL PROTOCOL: BMJ Open 2015;5:e007221. doi:10.1136/bmjopen-2014-007221.

The Impact on Informal Supporters of Domestic Violence Survivors: A Systematic Literature Review

Domestic violence (DV) is experienced by 1 in 4 women in the United Kingdom during their lifetime, and most survivors will seek informal support from the people around them, even if they choose not to access help from professionals. Support from these relatives, friends, neighbors, and colleagues can provide a buffer against effects on the survivor's physical health, mental health, and quality of life, and has been shown to be protective against future abuse. There has been an absence of research studying members of survivors' networks and, in particular, investigating how the impact of DV might diffuse to affect them. A systematic literature review of reported research (either in peer-reviewed journals or in gray literature) was undertaken to explore the impacts of DV on survivor networks. Of the articles found, 24 had data relating to the topic area, though no study addressed the question directly. Framework analysis and meta-ethnography generated the following themes: physical health impacts, negative impacts on psychological well-being, direct impacts from the perpetrator, and beneficial impacts on psychological well-being. The studies in this review indicated that informal supporters may be experiencing substantial impact, including vicarious trauma and the risk of physical harm. Currently, there is little support available which is directly aimed at informal supporters of DV survivors, thus these findings have practical and policy implications, in order to acknowledge and meet their needs.

Evaluating the Efficacy of EMDR With Grieving Individuals: A Randomized Control Trial

This study compared the effectiveness of eye movement desensitization and reprocessing (EMDR) with an integrated cognitive behavioral therapy (CBT) intervention for grief. Nineteen participants (12 females and 7 males) who identified themselves as struggling with grief were randomly allocated to treatment conditions. Each participant was wait-listed for 7 weeks and then received 7 weeks of therapy. There were no significant improvements on any measure in the wait-list period. In contrast, participants in both treatment groups improved on measures of grief (ηp2 = .47), trauma symptoms (ηp2 = .60), and distress (ηp2 = .34). There was no significant improvement in participants’ scores on a quality of life measure (ηp2 = .11). Neither treatment approach produced better outcomes than the other. For those who scored in the clinical range at intake, 72% achieved clinical and reliable change on the grief measure and 82% on the trauma measure. The study had several strengths, including randomization to treatment condition, multiple therapists, formal assessment of treatment fidelity, and the pretreatment and follow-up assessments were conducted by researchers blind to treatment assignment. Overall, the findings indicate that EMDR and CBT are efficacious in assisting those struggling with grief, and that those individuals reporting higher levels of distress and lower levels of functioning may benefit the most from an intervention.

Efficacy of an outpatient treatment for prolonged grief disorder: a randomized controlled clinical trial

BACKGROUND

Abnormal forms of grief, currently referred to as complicated grief or prolonged grief disorder, have been discussed extensively in recent years. While the diagnostic criteria are still debated, there is no doubt that prolonged grief is disabling and may require treatment. To date, few interventions have demonstrated efficacy.

METHODS

We investigated whether outpatients suffering from prolonged grief disorder (PGD) benefit from a newly developed integrative cognitive behavioural therapy for prolonged grief (PG-CBT). A total of 51 patients were randomized into two groups, stratified by the type of death and their relationship to the deceased; 24 patients composed the treatment group and 27 patients composed the wait list control group (WG). Treatment consisted of 20-25 sessions. Main outcome was change in grief severity; secondary outcomes were reductions in general psychological distress and in comorbidity.

RESULTS

Patients on average had 2.5 comorbid diagnoses in addition to PGD. Between group effect sizes were large for the improvement of grief symptoms in treatment completers (Cohen׳s d=1.61) and in the intent-to-treat analysis (d=1.32). Comorbid depressive symptoms also improved in PG-CBT compared to WG. The completion rate was 79% in PG-CBT and 89% in WG.

LIMITATIONS

The major limitations of this study were a small sample size and that PG-CBT took longer than the waiting time.

CONCLUSIONS

PG-CBT was found to be effective with an acceptable dropout rate. Given the number of bereaved people who suffer from PGD, the results are of high clinical relevance.

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.

Music therapy as grief therapy for adults with mental illness and complicated grief: a pilot study

This randomized, controlled, mixed-methods pilot study examined the effectiveness and experiences of grief-specific music therapy, in addition to standard care, with adults (N=10) who have complicated grief (CG) and mental illness, as compared to standard care alone. The study tested Worden's (2009) theories of grief therapy as well as a new grief-specific music therapy intervention, based on Shear, Frank, Houck, and Reynolds' (2005) imaginal dialogue intervention and Austin's (2008) method of vocal psychotherapy. Results demonstrated that participants in the experimental group had a greater decrease of grief symptoms, as measured by the ICG-R, as compared with the control group.

Positive and negative experiences from grief group participation: a qualitative study

This article presents qualitative interview data from the research project "Grief Support Groups in Norway" (2009-2011). The aim of this part of the study was to investigate grief group participant's experiences, benefits, and satisfaction with the grief group. Positive aspects were to meet with peers, share thoughts and feelings, normalization, exchange advice and information, and share hope. On the negative side were unfulfilled needs or expectations, additional personal stress, and unsatisfactory structure, organization, and leadership. Importantly, lack of screening caused bereaved with complicated grief to participate in groups that were non-therapeutic, leaving them with insufficient help. Also, group leaders were not always considered knowledgeable of group processes and impacts of different organizational and structural factors on groups. Conclusively, participants' needs and expectations should be considered when planning and organizing groups, in order to conduct helpful groups and increase the experience of a positive outcome.

Group work with bereaved individuals: the power of mutual aid

Group work has been underused as an intervention with grieving clients. This is despite the fact that group membership offers bereaved individuals a number of unique advantages. In this article, the use of group work with bereaved individuals is examined, based on current theory and research. The role and skills of the group worker are identified and illustrated through the use of case examples. Challenges associated with working with groups for bereaved individuals also are discussed.

Complicated grief therapy as a new treatment approach

Complicated grief therapy (CGT) is a relatively new psychotherapy model designed to address symptoms of complicated grief. Drawn from attachment theory and with roots in both interpersonal therapy (IPT) and cognitive-behavioral therapy, CGT includes techniques similar to prolonged exposure (repeatedly telling the story of the death and in vivo exposure activities). The treatment also involves focusing on personal goals and relationships. CGT has been demonstrated to be effective in a trial in which participants with complicated grief were randomly assigned to CGT or IPT; individuals receiving CGT responded more quickly and were more likely to respond overall (51% vs 28%). This article briefly summarizes the conceptual underpinnings of CGT, discusses the empirical evidence for its efficacy, describes its techniques, and presents a case example of a client treated in a 16-session manualized CGT protocol. The article concludes with a description of future research directions for CGT.

Erstvalidierung der deutschen Version des „Inventory of Complicated Grief” (ICG-D)

Theoretischer Hintergrund: Die Aufnahme der komplizierten Trauer (KT) in Diagnosesysteme wird derzeit diskutiert, es gibt jedoch kaum deutsche Erhebungsinstrumente. Fragestellung: Eines der meistverwendeten Testverfahren, das Inventory of complicated grief (ICG), wurde in deutscher Übersetzung (ICG-D) validiert. Methode: 117 psychosomatische Patienten mit KT bearbeiteten den ICG-D, das Beck Depressionsinventar und die Symptomcheckliste 90-R. Ergebnisse: Das ICG-D zeigte bei einer einfaktoriellen Struktur, guter interner Konsistenz und Retest-Reliabilität sowie Itemschwierigkeiten im mittleren bis sehr hohen Bereich gute Kennwerte. Erste Belege für die Konstruktvalidität werden berichtet. Schlussfolgerungen: Mit dem deutschen ICG-D liegt ein Instrument vor, mit dem KT reliabel und valide erfasst werden kann. Nachfolgende Untersuchungen sollten weitere Stichproben mit Trauerproblematik beinhalten und die Diagnostik der KT im klinischen Interview mit dem ICG-D vergleichen.

Participants with Prolonged Grief—How Do They Benefit from Grief Group Participation?

Data analyzed in this article is part of a study conducted to explore grief support groups in Norway. Participants that fulfilled the criteria of Prolonged Grief Disorder (PGD) were compared with participants that did not in order to explore whether they differed on satisfaction and experiences with participation. To allow for comparison, a subsample of 22 participants that fulfilled the criteria of PGD were drawn from the total of 262 participants. Demographic and loss-related variables were analyzed to explore factors associated with PGD. Fulfillment of PGD was then analyzed to explore the group's effect on life quality and overall satisfaction. The main finding is that participants who fulfill the criteria of prolonged grief are in general less satisfied with the groups and report less positive effect on life quality. We also found age- and gender-differences regarding fulfillment of PGD, with older bereaved women especially at risk of developing symptoms of PGD.

Recent trends in the treatment of prolonged grief

PURPOSE OF REVIEW

Treatment for prolonged grief has been controversial. However, recent studies have clarified several key issues, offering important guidance to clinicians. This review summarizes the most recent evidence on the efficacy of grief treatments, moderators of treatment response, and new treatment approaches.

RECENT FINDINGS

Recent research findings highlight that grief therapy is efficacious when targeted to adult and child grievers with persistent and elevated levels of distress. However, when grief therapy is applied as a universal intervention, it has minimal to no benefits, either for adults or for children. Earlier intervention for children is associated with greater efficacy. In recent studies, therapies employing cognitive-behavioral techniques, such as cognitive restructuring and exposure, have shown particularly robust effects in ameliorating grief symptoms. Other intervention approaches, including pharmacotherapy, internet-based, family-based, and preventive, have shown initial promise, but insufficient data exist to validate their efficacy to date.

SUMMARY

Prolonged grief, a pattern of persistent and elevated distress following a loss, is increasingly recognized as an independent form of psychopathology that is responsive to treatment. Therapies that employ cognitive-behavioral techniques are efficacious in ameliorating the symptoms of prolonged grief and should be more widely used. However, grief therapy should not be deployed as a blanket intervention for all grievers. Antidepressant medication may serve a useful adjunctive role in grief therapy completion and in reducing bereavement-related depression.

Treatment of complicated grief

Following the death of a loved one, a small group of grievers develop an abnormal grieving style, termed complicated or prolonged grief. In the effort to establish complicated grief as a disorder in DSM and ICD, several attempts have been made over the past two decades to establish symptom criteria for this form of grieving. Complicated grief is different from depression and PTSD yet often comorbid with other psychological disorders. Meta-analyses of grief interventions show small to medium effect sizes, with only few studies yielding large effect sizes. In this article, an integrative cognitive behavioral treatment manual for complicated grief disorder (CG-CBT) of 25 individual sessions is described. Three treatment phases, each entailing several treatment strategies, allow patients to stabilize, explore, and confront the most painful aspects of the loss, and finally to integrate and transform their grief. Core aspects are cognitive restructuring and confrontation. Special attention is given to practical exercises. This article includes the case report of a woman whose daughter committed suicide.