Complicated grief (CG) poses significant physical, psychological, and economic risks to bereaved family caregivers. An integrative review of the literature published 2009-2018 on CG associated with caregiving was performed using PubMed, PsychINFO, and Web of Science. The search returned 1428 articles, of which 32 were included in the review. Sixteen studies described risk and protective factors and 16 described interventions for CG. Caregiver-related risk factors included fewer years of education, depression, anxiety, poor physical health, and maladaptive dependency and attachment traits. Additional risk factors included lower perceived social support, family conflict at end-of-life, and family having difficulty accepting death. Care recipient-related risk factors are younger age, fear of death, and place of death. Protective factors included hospice utilization in reducing fear of death, high pre-bereavement spiritualty, and satisfaction with palliative care. Complicated grief treatment was the most widely-studied intervention. Social Workers and other clinicians can use this information to identify family caregivers at increased risk for CG and refer or implement an early intervention to lessen its impact.
The current article focused on examining the potential benefits of the End-of-Life (EoL) informal caregiving, communication, and ritualistic behaviors in adaptation to the conjugal bereavement across two different cultural-background contexts: France and Togo, West Africa. The investigation adopted a transnational approach including a total of 235 bereaved spouses. Despite the variation in the length of time since death, no significant difference was found between the Togolese and French bereaved with respect to the level of complicated grief symptoms. However, the Togolese bereaved perceived a significant postloss growth, fostered by EoL communication with the dying and the performance of ritualistic behaviors. In the French sample, bereaved individuals who had experienced more intimate communication with their dying spouse reported a high level of postloss growth. Moreover, findings showed that EoL caregiving without ritualistic support or communication is associated with poor postbereavement outcomes. These findings suggest a clinical need to promote informal caregiving to the dying, communication with the dying, and ritualistic support during the process of dying as entangled components of EoL care.
The current study examined Posttraumatic Growth (PTG) experienced by bereaved pet owners in the United States, French-Canada, Japan, and Hong Kong following the death of their pet. Using qualitative methodology, we analyzed responses of participants who answered “yes” to a question about experiencing PTG and explored to what extent the cross-cultural responses mapped onto the five factors of the Posttraumatic Growth Inventory (PTGI). For the U.S. sample, 58% of responses mapped onto the PTGI. For French-Canada, 72% of responses mapped onto the PTGI. For Japan, 50% of responses mapped onto the PTGI and for Hong Kong, 39% of responses mapped onto the PTGI. We also explored emergent categories related to PTG for individuals who have lost a pet and discerned the unique aspects for PTG across cultures.
The present study examines how meaning and belief in God or god(s) is related to bereavement outcomes. Data from 299 participants residing in the United States indicated that the variables of search for meaning, presence of meaning, and belief in God or god(s) were significantly related to posttraumatic growth, complicated grief, and psychological distress. Results from this study can be used to identify appropriate clinical strategies for mental health practitioners working with bereaved clients and will expand the breadth of literature on bereavement with atheist populations in the United States.
Knowledge about what psychological characteristics underlie complicated grief (CG) is limited. The current study examined the five-factor personality traits in 81 bereaved adults with (n = 51) and without (n = 30) CG. A trained doctoral-level clinician evaluated participants using a structured, diagnostic psychiatric interview, and they completed self-report measures of grief and personality. A multiple regression model indicated that higher levels of neuroticism were associated with greater CG symptom severity, implicating neuroticism in the development of CG. Future prospective studies confirming it as a risk factor for the development of CG are warranted.
The impact of traumatic workplace death on bereaved families, including their mental health and well-being, has rarely been systematically examined. This study aimed to document the rates and key correlates of probable posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and prolonged grief disorder (PGD) in family members following a workplace injury fatality. The hidden nature of the target population necessitated outreach recruitment techniques, including the use of social media, newspaper articles, radio interviews, and contact with major family support organizations. Data were collected using a cross-sectional design and international online survey. The PCL-C (PTSD), the PHQ-8 (MDD), and PG-13 (PGD) were used to measure mental health disorders. All are well-established self-report measures with strong psychometric qualities. Participants were from Australia (62%), Canada (17%), the USA (16%), and the UK (5%). The majority were females (89.9%), reflecting the gender distribution of traumatic workplace deaths (over 90% of fatalities are male). Most were partners/spouses (38.5%) or parents (35%) and over half (64%) were next of kin to the deceased worker. Most deaths occurred in the industries that regularly account for more than 70 percent of all industrial deaths-construction, manufacturing, transport, and agriculture forestry and fishing. At a mean of 6.40 years (SD = 5.78) post-death, 61 percent of participants had probable PTSD, 44 percent had probable MDD, and 43 percent had probable PGD. Logistic regressions indicated that a longer time since the death reduced the risk of having each disorder. Being next of kin and having a self-reported mental health history increased the risk of having MDD. Of the related information and support variables, having satisfactory support from family, support from a person to help navigate the post-death formalities, and satisfactory information about the death were associated with a decreased risk of probable PTSD, MDD, and PGD, respectively. The findings highlight the potential magnitude of the problem and the need for satisfactory information and support for bereaved families.
Purpose: Prior latent class analyses (LCA) have focused on people who were bereaved more than 6 months earlier. Research has yet to examine patterns and correlates of emotional responses in the first few months of bereavement. We examined whether subgroups could be identified among very recently (= 6 months) bereaved adults, based on their endorsement of symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. Associations of class membership with overall disturbed grief, PTSD, and depression—assessed concurrently and at 6 months follow-up—were examined. Furthermore, we examined differences between classes regarding socio-demographics, loss-related, and cognitive behavioural variables.
Methods: PGD, PTSD, and depression self-report data from 322 Dutch individuals bereaved = 6 months earlier were subjected to LCA; N = 159 completed the follow-up assessment. Correlates of class membership were examined.
Results: Three classes were identified: a low symptom class (N = 114; 35.4%), a predominantly PGD class (N = 96; 29.8%), and a high symptom class (N = 112; 34.8%). PGD, PTSD, and depression scores (assessed concurrently and at 6 months follow-up) differed significantly between classes, such that low symptom class < predominantly PGD class < high symptom class. Being a woman, younger, more recently bereaved, experiencing deaths of a partner/child and unnatural losses, plus maladaptive cognitions and avoidance behaviours were associated with membership of the pervasive symptom classes.
Conclusion: In the first 6 months of bereavement, meaningful subgroups of bereaved people can be distinguished, which highlights the relevance of early detection of people with elevated bereavement-related distress and offering them preventive interventions that foster adaptation to loss.
OBJECTIVE: Bereavement can result in unresolved and prolonged grief, often termed prolonged grief disorder (PGD). The impact of PGD on cognitive functioning is poorly understood. The aim of the study was to compare the cognitive decline, assessed by repeated measures of different cognition domains, between persons with normal and PGD and a non-grieving reference population in a 7-year follow-up study.
METHODS: The study sample comprised 3126 non-demented persons, mean age: 64 years, of the Rotterdam Study. Participants were classified into three groups: no grief (reference group, N = 2,582), normal grief (N = 418), and prolonged grief disorder (N = 126). Participants were assessed with the Complicated Grief Inventory and underwent cognitive testing (Mini-Mental State Examination [MMSE], Letter-Digit Substitution test, Stroop test, Word fluency task, Word learning test). Analyses were adjusted for baseline cognition and depressive symptoms; persons with major depressive disorders were excluded.
RESULTS: Compared with the reference group, participants with PGD showed a decrease in global cognitive function, MMSE scores, and World learning test (immediate and delayed) over time. Participants with normal grief did not show a stronger cognitive decline in any of cognitive tests than the reference group.
CONCLUSIONS: Participants with PGD showed a stronger cognitive decline than the reference group during 7 years of follow-up. This suggests that PGD is a risk factor for cognitive decline, but this study cannot detect the psychobiological mechanism underlying this longitudinal association.
Complicated grief (CG) is a debilitating syndrome characterized by persisting and intense distress and impairment after the death of a loved one. The biological mechanisms associated with this syndrome remain unclear but may involve neurobiological pathways implicated in the stress response and attachment systems. The neuropeptide oxytocin has been implicated in attachment and social behaviour, and loss of social bonds has been associated with disruptions in oxytocin signalling. Furthermore, prior research has reported associations between circulating oxytocin and other mental illnesses, including depression. The present pilot study aimed to examine plasma levels of oxytocin in bereaved adults with primary CG (n = 47) compared to age- and sex-matched bereaved individuals with primary Major Depressive Disorder (MDD) (n = 46), and bereaved individuals without any mental disorder (n = 46). In unadjusted analyses comparing groups according to primary diagnosis, oxytocin levels were significantly higher for primary CG compared to primary MDD (p = 0.013), but not compared to bereaved controls (p = 0.069). In adjusted regression models, having a primary or probable (Inventory of Complicated Grief = 30) diagnosis of CG was associated with significantly higher oxytocin levels (p = 0.001). While additional research is needed, findings from our pilot study provide preliminary support for recent conceptualizations of CG implicating a role for oxytocin and the attachment system. Importantly, these findings contribute to the limited current knowledge about possible biological correlates of CG.
Persistent complex bereavement (PCBD) was entered to DSM-5. No studies have yet examined the nature, prevalence, prognostic validity, and underlying mechanisms of PCBD symptom patterns in recently bereaved people. Knowledge on these issues could improve the early identification and treatment of disturbed grief. Latent class analysis was used to identify subgroups characterized by different PCBD symptom patterns among recently (=6 months) bereaved adults (n = 476). In a subgroup (n = 251), we assessed associations of class membership with PCBD severity and functional impairment assessed 3 years later. Associations between class membership and sociodemographic and cognitive-behavioral variables were also examined. We identified a resilient (50.0%), separation distress (36.1%), and high PCBD symptoms (13.9%) class. Class membership had prognostic value as evidenced by associations with PCBD severity and functional impairment assessed 3 years later. Deaths of partners/children, unexpectedness of the loss, and maladaptive cognitions and avoidance behaviors were also associated with membership of the pervasive symptom classes.
Witnessing end-of-life suffering of loved ones is an underappreciated stressor that may affect caregiver bereavement. We interviewed 61 spousal caregivers of hospice patients who died within the past 6–18 months. Higher rumination about suffering and lower feelings of relief was related to poorer well-being. Rumination by caregivers about end-of-life suffering was an important predictor of depression and complicated grief. Most caregivers viewed the death as at least in part a relief. One important focus of grief support may be to help caregivers find productive ways to avoid rumination and use other forms of coping and to acknowledge feelings of relief.
The majority of epilepsy deaths are sudden, unexpected, and most prevalent among young adults. The number of people affected by a death can be high, as extended family and social networks survive. Those bereaved are at risk of developing traumatic and complex grief reactions and need access to specialist bereavement support as soon as possible after a death. It helps bereaved families to know how the death happened. They want lessons to be learnt and deaths to be prevented in future. The process of investigation into the death - which can contribute to these aims - may alienate families if not handled well and cause further trauma. Loss of participation by those bereaved can lead to suboptimal investigation and missed opportunities for learning and prevention. With integrated specialist emotional and practical support, tailored to the individual, families can be empowered to participate as they choose, with those working to understand and prevent epilepsy deaths. SUDEP Action (formerly Epilepsy Bereaved) is a charity which provides specialist services for people bereaved by epilepsy. It is the only organization which delivers these services globally. It was set up by the bereaved for the bereaved and has developed its model through more than twenty years' experience of supporting bereaved people. If the bereaved are signposted to specialist support of the sort SUDEP Action provides as soon as possible after a death, that early intervention can help to alleviate the effects of traumatic bereavement and restore an element of control and choice as they navigate what is to come. Early intervention by signposting to skilled experienced epilepsy death-related bereavement services could be vital.
This cross-sectional survey compares the risk of mental health problems like poor well-being, complicated and prolonged grief, and mental disorders between young adults experiencing a divorced or non-divorced parent’s death. 190 participants were recruited from Facebook via the Danish National Center for Grief. Well-being was measured using WHO-5, prolonged grief using PG-13 and complicated grief using BGQ, and common mental disorders using CMDQ. Findings confirmed deleterious effects on mental health in young adults experiencing parental death, but higher risk, when losing a divorced parent compared to a non-divorced parent, was associated to prolonged grief, complicated grief, bodily distress syndrome, and alcohol misuse.
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.
BACKGROUND: The objective of this study was to determine whether severity and severity change of coexisting psychiatric symptoms might affect change of complicated grief (CG) regarding the Sewol ferry disaster.
METHODS: Data from a cross-sectional survey were obtained 18 months (Time 1) and 30 months (Time 2) after the disaster. We ascertained sociodemographic variables and variables obtained from self-reporting questionnaires (i.e., CG, depression, anxiety, post-traumatic stress disorder [PTSD], insomnia, embitterment, and suicidal risk) among 56 bereaved family members.
RESULTS: Severity of other psychiatric symptoms at Time 1 had no effect on change of CG at Time 2. However, changes in severity of PTSD over a year affected change of CG.
CONCLUSION: It is important to evaluate changes in severity of PTSD and its treatment during management of CG, especially when it involves bereaved families experiencing a traumatic accident.
BACKGROUND: Empirical evidence suggests that individuals who have experienced the death of a parent early in life endorse interpersonal difficulties in adulthood. However, little is known about the underlying experiences that may lead to such distress. The current study examined whether individuals who experienced early parental death would endorse greater levels of alexithymia than individuals raised in intact families, and whether early parental death and interpersonal distress were linked through alexithymia and grief.
METHODS: A total of 160 participants in a parental death group and 183 in a comparison group completed self-report measures online. Statistical analyses were conducted using ANCOVA, mediation analysis, and regression.
RESULTS: We observed that the parental death group reported greater levels of alexithymia than the comparison group. Second, alexithymia mediated the relationship between early parent death and global interpersonal distress. Third, greater levels of complicated grief were related to greater levels of alexithymic traits in the parental death group.
CONCLUSION: Results suggest that early parental death results in higher levels of alexithymic traits. Furthermore, alexithymia indirectly leads to interpersonal distress in this population. Finally, the link discovered between grief and alexithymia has important clinical implications.
Spirituality has long served as a source of solace for many grievers following a loss. For other mourners, whose bereavement experience has been significantly challenged by struggles in their relationship with God and/or their faith community, the opposite is true. Complicated spiritual grief (CSG) is a spiritual crisis following the loss of a loved one. To assess CSG in samples of bereaved adults, a simple-to-use, multidimensional measure of spiritual crisis following loss called the Inventory of Complicated Spiritual Grief (ICSG) was previously developed and validated. However, subsequent research providing greater clarity about the construct of CSG supported the need to revise and update the ICSG. The goal of the present study was to establish the psychometric validity of a revised measure of CSG, called the Inventory of Complicated Spiritual Grief 2.0 (ICSG 2.0), with a large, diverse cohort of bereaved Christian adults (N = 440). Analyses of the bifurcated sample supported a three-factor model measuring insecurity with God, estrangement from the spiritual community, and disruption in religious practices. Further analyses supported the convergent and incremental validity of a 28-item scale relative to other theoretically similar instruments and measures of poor bereavement outcome, indicating the instrument’s research and clinical usefulness.
This aims of this longitudinal study were to identify the risk factors of and depressive mood in caregivers who received hospice care 6 months after their patients’ death, and the cutoff pint of the bereavement risk index, as well as, the prevalence of persistent complex bereavement disorder (PCBD). There were 30.28 and 4.59% of caregivers with depressive mood and PCBD, respectively. The risk factors included resistance to the reality of patients’ death, anger, self-blame and guilt, support networks, and coping. The cutoff points of total bereavement risk index and five-item short form were 10/11 and 9/10, respectively.
Complicated grief is a prolonged, bereavement-specific disorder with significant psychological and physical consequences. Although complicated grief represents a risk to individuals with substance misuse, this relationship is poorly understood. Consequently, this systematic literature review examined empirical findings regarding the relationship between substance misuse and complicated grief. We searched 11 databases to identify pertinent quantitative studies published in English. Our search yielded 12 peer-reviewed journal articles (N = 1749) published between 1997 and 2017. Included studies evaluated the prevalence, assessment, etiology, correlates, risk factors, and treatment of complicated grief and substance misuse among individuals with one or both conditions. Our review found evidence of a positive relationship between complicated grief and substance misuse. Individuals with substance misuse were at increased risk for subsequent development of complicated grief, particularly when increases in substance consumption preceded bereavement. Conversely, complicated grief predicted increases in smoking and alcohol dependence. Multiple risk factors for individuals with complicated grief and substance misuse were identified and discussed. An existing complicated grief assessment performed well among individuals with substance misuse, and grief interventions were effective in reducing symptoms of complicated grief and substance misuse simultaneously. Given the severity of consequences associated with both conditions, more research is needed to understand this relationship, identify effective assessment tools, and evaluate intervention strategies to improve outcomes.
Research on the association between complicated grief (CG), hope, and posttraumatic growth (PTG) among bereaved youth is limited. Measures of CG, depression, hope, and PTG were completed by 85 youth (aged 7–18 years). Results indicated a strong positive relationship between CG and depressive symptoms, an inverse relationship between hope and depressive symptoms, and a moderate positive relationship between hope and PTG. There was no significant association between CG and hope or between CG and PTG. Higher levels of CG and lower levels of hope independently predicted greater depressive symptoms, but PTG did not. Results have implications for assessing positive outcomes in bereaved youth.