Gender Differences in Traumatic Grief Symptom Severity after the Loss of a Spouse

Gender differences in bereavement outcome have received much attention in bereavement research in the past decades. While many studies have focused on depressive symptomatology and/or normal grief reactions, little attention has been paid to gender differences in symptoms of pathological or traumatic grief (TG). In addition, few studies have investigated gender differences beyond the acute grieving period. In the present study, cross-sectional data were used to explore gender differences in the temporal course of TG symptomatology. Data were derived from 270 spousally bereaved individuals who filled in the Inventory of Traumatic Grief on the Internet. Analyses of variance were conducted to explore differences in TG symptoms over time and between widows and widowers. No differences were found between men and women on the TG symptoms or the TG summary score, on any of the observational time points. With regard to the temporal course of TG symptomatology, indications were found that symptoms of separation distress are likely to subside over the passage of time, while symptoms of traumatic distress are unlikely to do so.

Internet-Based Exposure and Behavioral Activation for Complicated Grief and Rumination: A Randomized Controlled Trial

This study examined the effectiveness and feasibility of therapist-guided Internet-delivered exposure (EX) and behavioral activation (BA) for complicated grief and rumination. Forty-seven bereaved individuals with elevated levels of complicated grief and grief rumination were randomly assigned to three conditions: EX (N=18), BA (N=17), or a waiting-list (N=12). Treatment groups received 6 homework assignments over 6 to 8weeks. Intention-to-treat analyses showed that EX reduced complicated grief, posttraumatic stress, depression, grief rumination, and brooding levels relative to the control group at posttreatment (d=0.7-1.2). BA lowered complicated grief, posttraumatic stress, and grief rumination levels at posttreatment (d=0.8-0.9). At 3-month follow-up, effects of EX were maintained on complicated grief and grief rumination (d=0.6-1.2), and for BA on complicated grief, posttraumatic stress, and grief rumination (d=0.8-0.9). EX reduced depression more strongly than BA (d=0.6). Completers analyses corroborated results for EX, and partially those for BA, but no group differences were detected. BA suffered from high dropout (59%), relative to EX (33%) and the waiting-list (17%). Feasibility appeared higher for EX than BA. Results supported potential applicability of online exposure but not behavioral activation to decrease complicated grief and rumination.

Imagery rehearsal therapy in addition to treatment as usual for patients with diverse psychiatric diagnoses suffering from nightmares: a randomized controlled trial

OBJECTIVE

Nightmares are associated with psychopathology and daily distress. They are highly prevalent in a psychiatric population (30%). Currently, imagery rehearsal therapy (IRT) is the treatment of choice for nightmares. With IRT, the script of the nightmare is changed into a new dream, which is imagined during the day. However, the effects of IRT in a psychiatric population remain unknown. The aim of this study was to determine the effectiveness of IRT in a heterogeneous psychiatric population.

METHOD

Between January 2006 and July 2010, 90 patients with psychiatric disorders (DSM-IV-TR) were randomized to IRT or treatment-as-usual conditions. IRT consisted of 6 individual sessions added to the treatment as usual. Nightmare frequency was assessed using daily nightmare logs and the Nightmare Frequency Questionnaire. Nightmare distress was assessed using the Nightmare Distress Questionnaire and the Nightmare Effects Survey. General psychiatric symptoms were assessed using the Symptom Checklist-90 and a PTSD symptom questionnaire. Assessments were administered at the start of the trial, after the IRT and at follow-up 3 months later.

RESULTS

IRT showed a moderate effect (Cohen d = 0.5-0.7, P < .05) on nightmare frequency, nightmare distress, and psychopathology measures compared with treatment as usual. These effects were largely sustained at the 3-month follow-up (Cohen d = 0.4-0.6, P < .10).

CONCLUSIONS

IRT is an effective treatment for nightmares among patients with comorbid psychiatric disorders and can be employed in addition to the on-going treatment.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00291031.

Rumination and implicit avoidance following bereavement: an approach avoidance task investigation

BACKGROUND AND OBJECTIVES

Rumination, a risk factor in adjustment to bereavement, has often been considered a confrontation process. However, building on research on worry in generalized anxiety disorder (GAD) and rumination in post-traumatic stress disorder (PTSD), researchers recently developed the Rumination as Avoidance Hypothesis (RAH), which states that rumination after bereavement serves to avoid the reality of the loss. In the present study, RAH was tested by investigating if rumination is associated with implicit loss avoidance.

METHODS

An Approach Avoidance Task (AAT) was used to assess automatic behavior tendencies. Using a joystick, 71 persons who recently lost a first-degree relative (90.1% women), pulled stimuli toward themselves or pushed them away from themselves. Stimuli represented the loss (picture deceased + loss word), were loss-related but ambiguous (picture deceased + neutral word; picture stranger + loss word), or were non-loss-related (picture stranger + neutral word; puzzle picture + X's).

RESULTS

Participants who ruminated more were relatively faster in pushing loss stimuli away from themselves and slower in pulling loss stimuli towards themselves, implying more rumination was associated with stronger implicit loss avoidance. Effects were maintained after controlling for depressive or post-traumatic stress symptom levels, but not when controlling for prolonged grief symptom levels.

LIMITATIONS

Conjugally bereaved women were overrepresented in the sample, which limits generalizability of results. The study was correlational, precluding causal inferences.

CONCLUSIONS

In line with RAH, rumination was positively associated with loss avoidance. This may indicate that the application of exposure-based techniques can reduce rumination and loss-related psychopathology.

Avoidance processes mediate the relationship between rumination and symptoms of complicated grief and depression following loss

Ruminative coping has been associated with negative outcomes in bereavement. Rather than assuming it to be a problematic confrontation process, researchers have recently suggested rumination to be maladaptive through its links with avoidance processes. The main aim of this study was to examine, for the first time, whether the relationship between ruminative coping and symptoms of complicated grief and depression is mediated by avoidance processes (suppression, memory/experiential avoidance, behavioral avoidance, loss-reality avoidance). A sample of 282 adults (88% female, 12% male), bereaved on average 18 months previously, filled out three questionnaires at 6-month intervals. We assessed symptom levels, grief rumination, and trait rumination at baseline; avoidance processes after 6 months; and symptom levels after 12 months. When controlling for initial symptom levels, experiential avoidance mediated the link between grief rumination and complicated grief, and experiential avoidance and behavioral avoidance mediated the link between grief rumination and depression. Post hoc analyses showed suppression may also mediate the link between grief rumination and symptoms of complicated grief, but not depression. Loss-reality avoidance was no significant mediator of these relationships. This study provides initial evidence that rumination during bereavement increases and perpetuates symptoms of psychopathology, because it is linked with specific avoidance processes. Bereaved individuals with problematic grief and (chronic) rumination may benefit from therapy focused on countering avoidance tendencies.

The effect of support on internet-delivered treatment for insomnia: does baseline depression severity matter?

Internet-delivered cognitive-behavioral treatment is effective for insomnia. However, little is known about the beneficial effects of support. Recently we demonstrated that motivational support moderately improved the effects of Internet-delivered treatment for insomnia. In the present study, we tested whether depressive symptoms at baseline moderate the effect of support on Internet-delivered treatment for insomnia. We performed a multilevel intention-to-treat analysis on 262 participants in a randomized controlled trial. We found that baseline depressive symptoms moderated the effect of support on sleep efficiency, total sleep time, and sleep onset latency (but not on wake after sleep onset, number of nightly awakenings, or the Insomnia Severity Index). This means that for these variables, people with high levels of depressive symptoms benefit from support, whereas people with low levels of depressive symptoms improve regardless of support. The data show that baseline depression severity plays an important role in the way Internet treatments need to be delivered. These findings open up opportunities to personalize the support offered in Internet-delivered treatments.

The effectiveness of Grief-Help, a cognitive behavioural treatment for prolonged grief in children: study protocol for a randomised controlled trial

Background

There is growing recognition of a syndrome of disturbed grief referred to as prolonged grief disorder (PGD). PGD is mostly studied in adults, but clinically significant PGD symptoms have also been observed in children and adolescents. Yet, to date no effective treatment for childhood PGD exists. The aims of this study are: (1) to investigate the effectiveness of Grief-Help, a nine-session cognitive-behavioural treatment for childhood PGD, combined with five sessions of parental counselling, immediately after the treatment and at three, six and twelve months follow-up; (2) to examine tentative mediators of the effects of Grief-Help, (i.e., maladaptive cognitions and behaviours and positive parenting), and (3) to determine whether demographic variables, child personality, as well as symptoms of PGD, anxiety, and depression in parents moderate the treatment effectiveness.

Methods/Design

We will conduct a Randomised Controlled Trial (RCT) in which 160 children and adolescents aged 8–18 years are randomly allocated to cognitive behavioural Grief-Help or to a supportive counselling intervention; both treatments are combined with five sessions of parental counselling. We will recruit participants from clinics for mental health in the Netherlands. The primary outcome measure will be the severity of Prolonged Grief Disorder symptoms according to the Inventory of Prolonged Grief for Children (IPG-C). Secondary outcomes will include PTSD, depression and parent-rated internalizing and externalizing problems. Mediators like positive parenting and maladaptive cognitions and behaviours will be identified. We will also examine possible moderators including demographic variables (e.g. time since loss, cause of death), psychopathology symptoms in parents (PGD, anxiety and depression) and child personality. Assessments will take place in both groups at baseline, after the treatment-phase and three, six and twelve months after the post-treatment assessment.

Discussion

We aim to contribute to the improvement of mental health care for children and adolescents suffering from loss. By comparing Grief-Help with supportive counselling, and by investigating mediators and moderators of its effectiveness we hope to provide new insights in the effects of interventions for bereaved children, and their mechanisms of change.

Trial registration

Netherlands Trial Register NTR3854

Partner-Oriented Self-Regulation Among Bereaved Parents

Bereavement research has focused on individual rather than interdependent processes in coping with loss. Yet bereavement takes place in a social context, and relationship partners are likely to influence each other’s grieving process. We examined the impact of a dynamic, interpersonal phenomenon, partner-oriented self-regulation (POSR): the avoidance of talking about loss and remaining strong in the partner’s presence to protect the partner. Two hundred nineteen couples who had lost a child participated 6, 13, and 20 months after their loss. Consistent with predictions, results showed that one partner’s POSR was associated not only with an increase in his or her own grief, but also with an increase in the other partner’s grief. These relationships persisted over time: Self-reported and partner-reported POSR predicted later grief. These results are paradoxical: Although parents try to protect their partners through POSR, this effort has the opposite of the desired outcome. These findings underline the importance of further investigating interpersonal dynamics of coping with bereavement.

Baseline depression levels do not affect efficacy of cognitive-behavioral self-help treatment for insomnia

BACKGROUND

Cognitive-behavioral therapy can effectively treat insomnia (CBT-I). Randomized controlled trials have shown efficacy of self-help CBT-I, but unclear is whether excluding depressive patients boosted treatment effects.

METHOD

We administered unsupported self-help CBT-I to insomnia patients with low and high depression levels. Based on the validated Centre of Epidemiological Studies-Depression (CES-D) scale, the internet-recruited sample (N = 479) was divided into three groups: low depression scores (n = 198), mild depression scores (n = 182), and high depression scores (n = 99). Follow-ups were 4 and 18 weeks after completion of the treatment.

RESULTS

At 4-week follow-up, all groups had a similar amelioration on the primary sleep measures (d = 0.1-0.7; P < 0.05) and the secondary insomnia ratings (d = 1.2; P < 0.001). The only difference was that the high/mild depression groups had a steeper reduction in depression (d = 1.0-1.1; P < 0.001) and anxiety scores (d = 0.7-0.8; P < 0.001) than the low depression group (depression and anxiety: d = 0.3; P < 0.01), possibly due to floor effects in the latter group. The observed effects were sustained at the 18-week follow-up.

CONCLUSIONS

This study showed that CBT-I is effective regardless of baseline depression levels. Treating the combination of insomnia and depression is an extra challenge since it is associated with increased sleep problems. These data may help us understand the relationship between insomnia and depression and indicate that self-help CBT-I may be a promising addition to regular depression treatment.

Internet-delivered or mailed self-help treatment for insomnia?: a randomized waiting-list controlled trial

Cognitive Behavioral Therapy (CBT) is effective in reducing insomnia complaints, but the effects of self-help CBT have been inconsistent. The aim of this study was to determine the effectiveness of self-help for insomnia delivered in either electronic or paper-and-pencil format compared to a waiting-list. Participants kept a diary and filled out questionnaires before they were randomized into electronic (n = 216), paper-and-pencil (n = 205), or waiting-list (n = 202) groups. The intervention consisted of 6 weeks of unsupported self-help CBT, and post-tests were 4, 18, and 48 weeks after intervention. At 4-week follow-up, electronic and paper-and-pencil conditions were superior (p < .01) compared to the waiting-list condition on most daily sleep measures (Δd = 0.29-0.64), global insomnia symptoms (Δd = 0.90-1.00), depression (Δd = 0.36-0.41), and anxiety symptoms (Δd = 0.33-0.40). The electronic and paper-and-pencil groups demonstrated equal effectiveness 4 weeks after treatment (Δd = 0.00-0.22; p > .05). Effects were sustained at 48-week follow-up. This large-scale unsupported self-help study shows moderate to large effects on sleep measures that were still present after 48 weeks. Unsupported self-help CBT for insomnia therefore appears to be a promising first option in a stepped care approach.

Cognitive-behavioral self-help treatment for nightmares: a randomized controlled trial

BACKGROUND

Several cognitive-behavioral techniques are effective in reducing nightmare frequency, but the therapeutic factor (e.g. cognitive restructuring, systematic desensitization) remains unclear. The aim of this study was to compare the nightmare treatments imagery rehearsal therapy (IRT), exposure, and recording (keeping a diary)--in a self-help format--with a waiting list.

METHODS

Participants were recruited through a Dutch nightmare website. After completion of the baseline questionnaires, 399 participants were randomly assigned to a condition, received a 6-week self-help treatment (or were placed on the waiting list), and filled out the post-treatment measurements 11 weeks after baseline.

RESULTS

Compared to the waiting list, IRT and exposure were effective in ameliorating nightmare frequency and distress, subjective sleep quality, anxiety (after imagery rehearsal), and depression (after exposure; Δd = 0.25-0.56). Compared to recording, IRT reduced nightmare frequency while exposure reduced nightmare distress (Δd = 0.20-0.30; p < 0.05). The recording condition was more effective compared to the waiting list in ameliorating nightmare frequency, nightmare distress, and subjective sleep quality (Δd = 0.19-0.28; p < 0.05). IRT had a more rapid reduction on the diary compared to exposure and recording.

CONCLUSIONS

IRT and exposure appear equally effective in ameliorating nightmare complaints. Exposure to nightmare imagery may function as the crucial therapeutic factor; however, cognitive restructuring may be a useful addition to increase immediate effects.

Item Bias Analysis of the Young Schema-Questionnaire for Psychopathology, Gender, and Educational Level

This study examines the construct validity of the Young Schema-Questionnaire at the item level in a Dutch population. Possible bias of items in relation to the presence or absence of psychopathology, gender, and educational level was analyzed, using a cross-validation design. None of the items of the YSQ exhibited differential item functioning (DIF) for gender, and only one item showed DIF for educational level. Furthermore, item bias analysis did not identify DIF for the presence or absence of psychopathology in as much as 195 of the 205 items comprising the YSQ. Ten items, however, spread over the questionnaire, were found to yield relatively inconsistent response patterns for patients and nonclinical participants.

Parents grieving the loss of their child: Interdependence in coping

OBJECTIVES

A longitudinal study was conducted among bereaved parents, to examine the relationship between parents' own and their partners' ways of coping in terms of the constructs loss-orientation and restoration-orientation (coping strategies based on the bereavement-specific Dual Process Model (Stroebe & Schut, 1999)), and psychological adjustment following the death of their child.

METHOD

219 couples participated at 6, 13 and 20 months post-loss. Use of the Actor Partner Interdependence Model within multi-level regression analyses enabled assessment of both actor as well as partner effects, and permitted differentiating these effects according to the gender of the parent.

RESULTS

Loss-orientation was predictive of negative psychological adjustment, while restoration-orientation was related to better adjustment. Furthermore, high levels of restoration-oriented coping buffered the negative effect of high levels of loss-orientation on depression. In the interpersonal context, results indicated that for men, having a female partner high in restoration-oriented coping was related to positive adjustment.

CONCLUSION

In coping with the loss of their child, intra-personal as well as interpersonal processes are relevant for the adjustment process of parents after the loss of their child.

Effects of a visiting service for older widowed individuals: a randomized clinical trial

The loss of the partner is an important risk factor for developing serious psychological problems. In this study the authors examined the effect of the visiting service on the mental health and quality of life of older widowed individuals. They conducted a pragmatic randomized trial. All respondents were randomly assigned to a visiting service (n = 110) or a control condition (n = 106) and were interviewed at baseline, at 6 months, and at 12 months after baseline. The visiting service was not more effective than the control condition in the overall sample. However, socially lonely, physically ill, or low-educated respondents improved more in the experimental group than in the control group.

Mediating processes in bereavement: the role of rumination, threatening grief interpretations, and deliberate grief avoidance

Limited research so far has examined coping processes that mediate between risk factors and bereavement outcome. Knowledge of these pathways is important, since it helps establish why some bereaved persons are more vulnerable than others and suggests possibilities for intervention. In this international longitudinal study, three potentially critical mediators, namely rumination, threatening grief interpretations and deliberate grief avoidance, were examined in relationship to previously established risk factors (e.g., expectedness of the death, attachment style) and four major outcome variables (grief, depressive symptoms, emotional loneliness and positive mood). Individuals who were recently bereaved (maximum 3 years) filled in questionnaires at three points in time. Results showed that rumination and--to a somewhat lesser extent--threatening grief interpretations played an important role in mediating the effects of various risk factors on outcomes. However, the contribution of these two mediators was dependent on the specific risk factor and outcome measure under consideration. For example, whereas the effect of neuroticism on grief was mediated by both processes (to the extent of 73%), the effect of neuroticism on positive mood was only mediated by rumination and to a smaller extent (23%). A few risk factors, such as current financial situation and spirituality, were not mediated by either coping strategy. Implications of these findings are discussed.

Risk factors for bereavement outcome: a multivariate approach

Bereavement increases the risk of ill health, but only a minority of bereaved suffers lasting health impairment. Because only this group is likely to profit from bereavement intervention, early identification is important. Previous research is limited, because of cross sectional designs, small numbers of risk factors, and use of a single measure of bereavement outcome. Our longitudinal study avoids these pitfalls by examining the impact of a large set of potential risk factors on grief depressive symptoms, emotional loneliness, and positive mood following recent bereavement (3 years maximum). Participants provided information 3 times over 6 months. A multivariate approach was chosen to avoid reporting spurious results due to confounding. As expected, risk factors were differentially related to different outcome measures. For example, being high in anxious attachment and having lost a partner were related to more intense feelings of emotional loneliness, whereas these variables did not predict any of the other outcome variables. By contrast, social support did not influence emotional loneliness but did predict grief depressive symptoms and positive mood. Implications of these findings are discussed.

Development and evaluation of a guideline for nursing care of suicidal patients with schizophrenia

PURPOSE

The purpose of this study was to develop and test an evidence-based guideline that would support nursing care for suicidal patients with schizophrenia.

DESIGN AND METHODS

Systematic review of the literature and consultation of experts preceded completion of the guideline. Twenty-one nurses from two mental health institutions tested the guideline for feasibility in nursing practice.

FINDINGS

The guideline was found to support discussing suicidality with patients and assessing suicide risk. Participants endorsed implementation of the guideline in mental health care.

PRACTICE IMPLICATIONS

Nurses who care for patients with schizophrenia are advised to use this guideline as a foundation for their care.

Distress in couples approached for genetic counseling and BRCA1/2 testing during adjuvant radiotherapy

OBJECTIVE

Breast cancer patients mostly rely on their partners for support in dealing with their cancer diagnosis and treatment. Genetic counseling and BRCA1/2 testing during primary treatment may add to demands made on their partners. This study aimed to gain insight into the extent of psychological distress in partners of recently diagnosed patients and to find factors to help identify couples vulnerable to high psychological distress after an active approach for genetic counseling.

METHODS

Breast cancer patients and their partners (n=110) completed psychological distress measures (HADS and IES) prior to the approach for counseling (T0), after the approach (T1), and after leaving the genetic counseling protocol (T2). Couples not approached for counseling (n=85) completed similar questionnaires.

RESULTS

Partners reported an equal or lower level of distress than patients, with a positive correlation between the two, although partners and patients differed in the course of their distress. Couples approached for genetic counseling did not differ in the level or course of either distress measure from not approached couples. A high baseline distress best predicts long-term high distress in patients and their partners. Younger patients were found to be particularly vulnerable.

CONCLUSIONS

The approach for genetic counseling during adjuvant radiotherapy was not associated with extra psychological distress in partners or patients in the first year following the breast cancer diagnosis. A partner's long-term level of distress was significantly associated with that of the patient. Highly distressed patients with highly distressed partners were most likely to experience high distress in the long term.

Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months

OBJECTIVE

We studied psychological outcomes and predictors for adverse outcome in 147 women 4, 8, and 16 months after termination of pregnancy for fetal anomaly.

STUDY DESIGN

We conducted a longitudinal study with validated self-completed questionnaires.

RESULTS

Four months after termination 46% of women showed pathological levels of posttraumatic stress symptoms, decreasing to 20.5% after 16 months. As to depression, these figures were 28% and 13%, respectively. Late onset of problematic adaptation did not occur frequently. Outcome at 4 months was the most important predictor of persistent impaired psychological outcome. Other predictors were low self-efficacy, high level of doubt during decision making, lack of partner support, being religious, and advanced gestational age. Strong feelings of regret for the decision were mentioned by 2.7% of women.

CONCLUSION

Termination of pregnancy for fetal anomaly has significant psychological consequences for 20% of women up to > 1 year. Only few women mention feelings of regret.

The factor structure of Posttraumatic Stress Disorder symptoms among bereaved individuals: a confirmatory factor analysis study

Posttraumatic Stress Disorder (PTSD) is defined in DSM-IV as an anxiety disorder that encompasses symptom-clusters of reexperiencing, avoidance, and hyperarousal. Several studies have examined the factor structure of PTSD symptoms. To our knowledge, no studies have yet examined the factor structure of loss-related PTSD symptoms in samples exclusively comprised of bereaved individuals. Such an examination is important because it can advance our understanding of the stability of the structure of PTSD symptoms across groups confronted with different aversive life-events and of processes underlying the occurrence of PTSD symptoms after loss. In this study, five alternative models of the factor structure of PTSD symptoms were examined in a sample of 347 mourners. Results showed that, in this group, PTSD symptoms are best conceptualized as forming four factors: reexperiencing, avoidance, dysphoria, and hyperarousal. Patterns of correlations with depression and complicated grief supported the validity of the model.

A systematic review of cognitive-behavioral treatment for nightmares: toward a well-established treatment

The aim of this review is to evaluate the effectiveness of cognitive behavioral therapy (CBT) on nightmare frequency and to determine which kind of CBT is the most effective treatment. A systematic literature search was carried out in PsychInfo and PubMed articles published on or before May 1, 2008. The inclusion criteria were: nightmare treatment study, use of nonpharmacological treatment, not a qualitative case study, randomized-controlled trial (RCT). After selection, 12 peer-reviewed studies about 9 RCTs remained (2 follow-up studies and one displaying preliminary results). Several interventions have been reviewed including, recording one's nightmares, relaxation, exposure, and techniques of cognitive restructuring. The 12 evaluated articles varied in quality, and none fulfilled CONSORT guidelines. All articles used nightmare frequency as the primary dependent variable, and all found significant in-group differences (pre vs. post) for intervention or placebo (range d = 0.7-2.9). Five studies were able to find a significant group effect for the intervention compared to a waiting list control group. Only one study found significant differences between 2 intervention groups. Nightmare-focused CBT (exposure and imagery rehearsal therapy [IRT]) revealed better treatment outcomes than indirect CBT (relaxation, recording). IRT and exposure showed no meaningful differences, but only one RCT directly compared both techniques. Three different research groups demonstrated the effects of exposure, but only one group showed the effect of IRT. Thus, RCTs that compare IRT with exposure by independent research groups are much needed.

Cost-utility of a visiting service for older widowed individuals: randomised trial

BACKGROUND

Despite a growing understanding of the effectiveness of bereavement interventions and the groups that benefit most from them, we know little about the cost-effectiveness of bereavement interventions.

METHODS

We conducted a cost-utility analysis alongside a randomized clinical trial on a visiting service for older widowed individuals (n=110) versus care as usual (CAU; n=106). The visiting service is a selective bereavement intervention that offers social support to lonely widows and widowers by a trained volunteer. Participants were contacted 6-9 months post-loss. Eleven percent of all contacted persons responded and eight percent participated in the trial. The primary outcome measure was quality adjusted life years (QALYs) gained (assessed with the EQ-5D), which is a generic measure of health status. Costs were calculated from a societal perspective excluding costs arising from productivity losses. Using the bootstrap method, we obtained the incremental cost utility ratio (ICUR), projected these on a cost-utility plane and presented as an acceptability curve.

RESULTS

Overall, the experimental group demonstrated slightly better results against slightly higher costs. Whether the visiting service is acceptable depends on the willingness to pay: at a willingness to pay equal to zero per QALY gained, the visiting service has a probability of 31% of being acceptable; beyond euro20,000, the visiting service has a probability of 70% of being more acceptable than CAU.

CONCLUSION

Selective bereavement interventions like the visiting service will not produce large benefits from the health economic point of view, when targeted towards the entire population of all widowed individuals. We recommend that in depth analyses are conducted to identify who benefits most from this kind of interventions, and in what subgroups the incremental cost-utility is best. In the future bereavement interventions are then best directed to these groups.

TRIAL REGISTRATION

Controlled trials ISRCTN17508307.

Complicated grief and uncomplicated grief are distinguishable constructs

With data from 242 mourners who received help post-loss and were at least 6 months removed from their loss, it was found that symptoms proposed as denoting complicated grief (CG) are distinguishable from reactions representing uncomplicated grief (UG). With data from a subgroup of 130 mourners, CG but not UG was found to relate to concurrent distress and disability.

Ruminative coping as avoidance: a reinterpretation of its function in adjustment to bereavement

The paper argues for a reconceptualization of ruminative coping with the death of a loved one as an avoidant rather than a confrontational strategy. Ruminative coping has been characterized within the bereavement field as persistent, repetitive and passive focus on negative emotions and symptoms. It has been theoretically described and empirically shown to be a maladaptive process, being conceptually related to complicated/chronic/prolonged grief. Furthermore, it has been contrasted with denial and suppression processes--which, too, have been understood to be maladaptive and associated with major complications following bereavement. Here evidence is reviewed and the case made that rumination is not an opposite form of coping from suppression or denial, but that it is a similar phenomenon to these, and different from the types of confrontation that take place in so-called "grief work". Implications with respect to intervention for complicated grief are discussed.

BRCA1/2 mutation testing in breast cancer patients: a prospective study of the long-term psychological impact of approach during adjuvant radiotherapy

This study assessed psychological distress during the first year after diagnosis in breast cancer patients approached for genetic counseling at the start of adjuvant radiotherapy and identified those vulnerable to long-term high distress. Of the approached patients some chose to receive a DNA test result (n = 58), some were approached but did not fulfill criteria for referral (n = 118) and some declined counseling and/or testing (n = 44). The comparative group consisted of patients not eligible for genetic counseling (n = 182) and was therefore not approached. Patients actively approached for genetic counseling showed no more long-term distress than patients not eligible for such counseling. There were no differences between the subgroups of approached patients. Predictors for long-term high distress or an increase in distress over time were pre-existing high distress and a low quality of life, having children, and having no family members with breast cancer. It is concluded that breast cancer patients can be systematically screened and approached for genetic counseling during adjuvant radiotherapy without imposing extra psychological burden. Patients vulnerable to long-term high distress already displayed high distress shortly after diagnosis with no influence of their medical treatment on their level of distress at long-term.

Patterns of Attachment and Parents' Adjustment to the Death of Their Child

The impact of adult attachment on psychological adjustment among bereaved parents and the mediating effect of relationship satisfaction were examined among a sample of 219 couples of parents. Data collection took place 6, 13, and 20 months after loss. Use of the actor partner interdependence model in multilevel regression analysis enabled exploration of both individual as well as partner attachment as predictors of grief and depression. Results indicated that the more insecurely attached parents were (on both avoidance and anxiety attachment), the higher the symptoms of grief and depression. Neither the attachment pattern of the partner nor similarity of attachment within the couple had any influence on psychological adjustment of the parent. Marital satisfaction partially mediated the association of anxious attachment with symptomatology. Contrary to previous research findings, avoidant attachment was associated with high grief intensity. These findings challenge the notion that the avoidantly attached are resilient.

Maternal decision to terminate pregnancy in case of Down syndrome

OBJECTIVE

This study explores decisional processes regarding termination of pregnancy because of Down syndrome and aims to identify possibilities for improving counseling.

STUDY DESIGN

Seventy-one women completed questionnaires 4 months after termination of pregnancy for Down syndrome, including motivations for the decision, reasons for doubt, perceived influence and/or pressure at decision-making, and satisfaction with the received health care.

RESULTS

Child-related motivations to the termination were the most frequently mentioned, but almost all women indicated also motives of self-interest. Twenty-one percent of women reported much doubt. Perceived influence of the medical staff was substantial, but most women felt that they had not been put under pressure. Satisfaction with the caregivers was high.

CONCLUSION

Women acknowledge that self-interested motives play an important role. Medical caregivers are among the most important persons for women who decide to terminate pregnancy because of Down syndrome.

Lucid dreaming treatment for nightmares: a pilot study

BACKGROUND

The goal of this pilot study was to evaluate the effects of the cognitive-restructuring technique 'lucid dreaming treatment' (LDT) on chronic nightmares. Becoming lucid (realizing that one is dreaming) during a nightmare allows one to alter the nightmare storyline during the nightmare itself.

METHODS

After having filled out a sleep and a posttraumatic stress disorder questionnaire, 23 nightmare sufferers were randomly divided into 3 groups; 8 participants received one 2-hour individual LDT session, 8 participants received one 2-hour group LDT session, and 7 participants were placed on the waiting list. LDT consisted of exposure, mastery, and lucidity exercises. Participants filled out the same questionnaires 12 weeks after the intervention (follow-up).

RESULTS

At follow-up the nightmare frequency of both treatment groups had decreased. There were no significant changes in sleep quality and posttraumatic stress disorder symptom severity. Lucidity was not necessary for a reduction in nightmare frequency.

CONCLUSIONS

LDT seems effective in reducing nightmare frequency, although the primary therapeutic component (i.e. exposure, mastery, or lucidity) remains unclear.

Treatment of complicated grief: A comparison between cognitive-behavioral therapy and supportive counseling

Few studies have examined treatments for complicated grief--a debilitating condition that can develop after the loss of a loved one. This study compared the effectiveness of cognitive-behavioral therapy with a nonspecific treatment with supportive counseling (SC). Using a minimization method, 54 mourners with clinically significant levels of complicated grief were allocated to 1 of 3 treatment conditions: (a) a condition of 6 sessions of cognitive restructuring (CR) and 6 sessions of exposure therapy (ET; CR + ET), (b) a condition in which these interventions were applied in reversed order (ET + CR), and (c) 12 sessions of SC. Outcomes showed that the 2 cognitive-behavioral therapy conditions produced more improvement in complicated grief and general psychopathology than SC in the completers and intention-to-treat groups. Comparison of the cognitive-behavioral conditions showed that "pure" exposure was more effective than "pure" cognitive restructuring, that adding ET to CR led to more additional improvement than adding CR to ET, and that ET + CR was more efficacious than CR + ET. Effect sizes of ET + CR were encouraging and compare favorably with those found in earlier bereavement intervention studies.

Negative cognitions and avoidance in emotional problems after bereavement: A prospective study

Cognitive behavioural conceptualisations of grief propose that negative cognitions and avoidance strategies play a key role in emotional problems after bereavement. In the current study, this assumption was examined. Ninety-seven individuals who had lost a relative less than 5 months ago completed questionnaires tapping background and loss-related variables, negative cognitions (about the self, life, the future, and one's own grief reactions), avoidance, and symptoms of complicated grief (CG) and depression. Of these mourners, 70 people (72%) completed symptom measures again 6 months later at T2 (7-10 months after the loss), and 60 (62%) completed symptoms measures still 9 months later at T3 (16-19 months after the loss). Among other things, results showed that all four cognitive variables and the avoidance variable were strongly associated with concurrent and prospective symptom levels, even when the influence of relevant background/loss-related variables was controlled. In addition, independent of initial symptom levels, most of the cognitive variables predicted later CG and depression. The avoidance variable only predicted additional variance in depression at T3 beyond T1 symptom levels. Findings indicate that negative cognitions are important in emotional problems after bereavement and that the role of avoidance in the development of these problems needs further scrutiny.

Short term psychological distress in patients actively approached for genetic counselling after diagnosis of breast cancer

This prospective study assessed anxiety, depression and breast cancer-specific distress in recently diagnosed breast cancer patients before and after an active approach for genetic counselling at the beginning of adjuvant radiotherapy (mean: 52 days after surgery). Patients completed the hospital anxiety and depression scale (HADS) and the impact of event scale (IES). Psychological distress did not increase after the approach. High anxiety decreased in the comparison group (n=182), whereas breast cancer specific distress decreased in the approached group (n=220). It is concluded that breast cancer patients can be approached for genetic counselling shortly after surgery without additional short-term psychological burden. Patients who are young, single with little social support, less optimistic, use an avoiding coping style, experience a lower quality of life or who are highly distressed prior to approach for genetic counselling, need extra attention. Medical history did not prove to be relevant.

Initial validation of the SLEEP-50 questionnaire

Initial psychometric properties of the SLEEP-50 questionnaire, designed to detect sleep disorders as listed in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision), were examined. The sample consisted of 377 college students, 246 sleep patients, 32 nightmare sufferers, and 44 healthy volunteers. The internal consistency was high (Cronbach's alpha = .85); test-retest correlations fell between .65 and .89. Principal component analysis with a direct oblimin rotation revealed a factor structure that closely matched the designed structure. Sensitivity and specificity scores were promising for all sleep disorders; the agreement between all clinical diagnoses and SLEEP-50-classifications was substantial (kappa = .77). These initial findings indicate that the SLEEP-50 seems able to detect a variety of sleep disorders. The SLEEP-50 can aid in screening for common sleep disorders in the general population.

Nightmares: from anxiety symptom to sleep disorder

The DSM-IV-TR definition of nightmares-extremely frightening dreams from which the person wakes up directly-is unnecessarily narrow. Other emotions (anger, grief) have also been reported in nightmares, and direct awakening from a bad dream seems to be unrelated to increased distress. In addition, assessment of nightmares is problematic. Polysomnographic recordings have an ameliorating effect on nightmare frequency, retrospective measurements tend to underestimate nightmare frequency, and persons with frequent nightmares may feel reluctant to fill out (daily) prospective measurements. For studying nightmares, it is necessary to distinguish idiopathic nightmares from posttraumatic nightmares, which are part of a posttraumatic stress reaction or disorder that may result from experiencing a traumatic event. Both types of nightmares have been associated with an elevated level of periodic limb movements, although only posttraumatic nightmares seem to be related to more and longer nocturnal awakenings. Nightmares have also been repeatedly associated with the general level of psychopathology, or the so-called personality factor neuroticism. Nightmare distress, the impact on daily functioning caused by nightmares, may function as a mediating variable. Several studies in the last decades have shown that nightmares can be treated with several cognitive-behavioral techniques. The cognitive-restructuring technique imagery rehearsal therapy is the treatment of choice for nightmares, although a randomized controlled trial with an attention control-group has not yet been carried out. Nightmares are more than a symptom of a larger (anxiety) syndrome and need to be viewed from a sleep medicine perspective: nightmares are a highly prevalent and separate sleep disorder that can and should receive specific treatment.

Couples at risk following the death of their child: predictors of grief versus depression

This longitudinal study examined the relative impact of major variables for predicting adjustment (in terms of both grief and depression) among bereaved parents following the death of their child. Couples (N = 219) participated 6, 13, and 20 months postloss. Use of multilevel regression analyses enabled assessment of the impact of several predictors and facilitated analysis of factors that were either shared by parents or individual. Grief was predicted mainly by shared parent factors: child's age, cause and unexpectedness of death, and number of remaining children. By contrast, depression was predicted by individual parent factors: gender, religious affiliation, and professional help seeking. Theoretical implications of these findings are discussed.

Complicated grief, depression, and anxiety as distinct postloss syndromes: a confirmatory factor analysis study

OBJECTIVE

The authors used confirmatory factor analysis to replicate earlier findings that complicated grief, depression, and anxiety are distinct syndromes.

METHOD

Data were derived from 1,321 bereaved individuals. Complicated grief was measured with the Inventory of Traumatic Grief. Depression and anxiety were measured with the SCL-90.

RESULTS

A model in which symptoms of complicated grief, depression, and anxiety loaded on separate factors was superior to a one-factor model, revealed good model fit, and was invariant across subgroups.

CONCLUSIONS

Previous findings of a distinction among complicated grief, depression, and anxiety were confirmed.

Depression and anxiety complaints; relations with sleep disturbances

Objectives were to assess the relations of various sleep complaints with depressive and anxiety complaints in a non-clinical population. Four-hundred-and-two randomly approached adults received three questionnaires. Results showed a high interrelatedness between sleep and depressive/anxiety complaints. Both assessment and treatment of depressive and anxiety complaints should address sleep problems.

Euthanasia and Depression: A Prospective Cohort Study Among Terminally Ill Cancer Patients

Purpose

To study the association between depression and the incidence of explicit requests for euthanasia in terminally ill cancer patients.

Patients and Methods

A prospective cohort study was conducted on 138 consecutive cancer patients with an estimated life expectancy of 3 months or less, in the period between September 1999 and August 2003. At inclusion, participants completed the Hospital Anxiety and Depression Scale. To identify “depressed mood” we used a cutoff score of 20. Kaplan-Meier curves and Cox regression analyses were used to assess the association between depressed mood and the risk of a request for euthanasia.

Results

Of 138 patients, 32 patients had depressed mood at inclusion. Thirty patients (22%) made an explicit request for euthanasia. The risk to request euthanasia for patients with depressed mood was 4.1 times higher than that of patients without depressed mood at inclusion (95% CI, 2.0 to 8.5).

Conclusion

Depression in cancer patients with an estimated life expectancy of less than 3 months is associated with a higher likelihood to request for euthanasia. The question of whether depressed mood can adequately be treated in this terminally ill population, and if so, whether it would lower the incidence of requests for euthanasia needs further investigation.

Stability and discriminative power of the Young Schema-Questionnaire in a Dutch clinical versus non-clinical population

In this study the temporal stability and general discriminative and classifying ability of the Young Schema-Questionnaire (YSQ) was examined in a clinical and non-clinical sample. To be able to cross-validate on the variables, two parallel subtests, drawn from the YSQ item pool, were utilized. Results suggest adequate rank order stability. However, mean scores tended to drop systematically over time, most likely caused by transient error. Therefore, to assess progress in therapy, the alternate utilization of the parallel parts is advised. Findings from discriminant analysis suggest high sensitivity of the YSQ and its subscales in predicting the presence or absence of psychopathology.

Psychological consequences of termination of pregnancy for fetal anomaly: similarities and differences between partners

OBJECTIVE

We examined the psychological responses to termination of pregnancy (TOP) for fetal anomaly from both men and women. The aim was to find risk factors for poor psychological outcome both for the individuals and for the couple.

METHODS

A cross-sectional study was performed in 151 couples 2-7 years after TOP. We used standardized and validated questionnaires to investigate grief, symptoms of posttraumatic stress, somatic complaints, anxiety, and depression.

RESULTS

Most couples adapted well to their loss, although several patients had pathological scores on posttraumatic stress symptoms and depression. Differences between men and women were slight. Higher education, good partner support, earlier gestational age, and life-incompatibility of the disorder positively influenced the outcomes, more for women than for men. Men and women with pathological scores rarely had such scores simultaneously.

CONCLUSION

We emphasize the importance of equally involving both parents in the counselling because the outcomes of grief and posttraumatic stress symptoms between men and women only moderately differ and post-TOP psychopathology occurs in men as well. Good adjustment to TOP in women seems dependent on the level of support that they perceive from their partners. The intracouple results of the study suggest a mutual influence in the process of grieving between the partners.