Traumatic grief among adolescents exposed to a peer's suicide

OBJECTIVE: The phenomenology of grief among children and adolescents is not well studied. A syndrome of traumatic grief, distinct from depression and anxiety, has been described among bereaved adults. The purpose of this study was to describe the symptoms and course of traumatic grief among adolescents exposed to a peer's suicide and to examine the relationship between traumatic grief and depression and posttraumatic stress disorder (PTSD) in this population. METHOD: A total of 146 friends and acquaintances of 26 suicide victims were included in this study. Subjects were interviewed at 6, 12-18, and 36 months after the peer's suicide. A subgroup was also interviewed 6 years afterward. The Texas Revised Inventory of Grief was administered at 6, 12-18, and 36 months; the Inventory of Complicated Grief was administered at the 6-year assessment. RESULTS: Principal component analysis of the Texas Revised Inventory of Grief resulted in two factors: one assessing a traumatic grief reaction and another assessing a milder or even normal grief reaction. The occurrence of traumatic grief was found to be independent from that of depression and PTSD. Traumatic grief at 6 months predicted the onset or course of depression and PTSD at subsequent assessments. CONCLUSIONS: Similar to adults, adolescents experience a traumatic grief reaction after exposure to a peer's suicide. Clinicians should be alerted to the occurrence of traumatic grief reactions among adolescents and the need to assess these reactions and address them in their treatment approaches.     

Bereavement of spouse caregivers of cancer patients

This study assessed bereavement aspects among 69 widowed spouses (mean age = 61.1; 36.2% men) of deceased cancer patients. They completed questionnaires related to psychological distress as measured by the Brief Symptom Inventory (L. R. Derogatis, 1975a), psychosocial adjustment as measured by the Psychosocial Adjustment to Illness Scale (L. R. Derogatis, 1975b), grief as measured by the Texas Revised Inventory of Grief (T. Faschingbauer, S. Zisook, & R. Devaul, 1987), and communication with spouse (D. H. Olson, D. G. Fournier, & T. M. Druckman, 1982). The findings indicated that women, older people, and past grief were variables that contributed to levels of current distress and grief. The widowed sample as a group showed high levels of distress, suggesting marked vulnerability and the need for planned intervention.     

A preliminary study of unresolved grief in families of seriously mentally ill patients

Investigations of the grief reactions experienced by families when a relative develops a serious mental illness have been hampered by the lack of an appropriate instrument to measure such reactions. The authors devised the Mental Illness Version of the Texas Inventory of Grief, adapted from the Texas Revised Inventory of Grief, to assess family members' initial and present feelings about their relative's loss of mental health. A test of the instrument with 58 family members of patients with schizophrenia or bipolar disorder revealed a surprisingly low level of initial grief but higher levels of present grief.     

Self-reported mental health difficulties and subsequent risk for schizophrenia in females: a 5-year follow-up cohort study

BACKGROUND: Patients with schizophrenia often report a history of premorbid mild to severe psychological distress. We investigated the association between self-reported mental health difficulties and later psychiatric hospitalization for schizophrenia. METHODS: 13,357 females aged 17, mandatory assessed by the Israeli Draft Board were followed up over 5 years for psychiatric hospitalization by means of the Israeli National Psychiatric Hospitalization Case Registry. Seventeen females, judged healthy at Draft Board assessment, were hospitalized for schizophrenia or schizoaffective disorder over the follow-up period. RESULTS: There was a significant monotonic association between increasing self-reported mental health difficulties (psychological distress and increasing need for psychological counseling) and prevalence of schizophrenia [odds ratios over four levels: 1.56; 95% CI:1.04 to 2.34; chi2 (1) = 4.62, p = 0.03], after controlling for low IQ, immigration, SES, and presence of psychiatric disorders at age 17. Increasing severity of self-reported mental health difficulties was related to earlier age of first hospitalization [r = -0.48, p = 0.05]. CONCLUSIONS: Increased undifferentiated self-reported mental health difficulties are associated with increased risk of later hospitalization for schizophrenia prior to age 23 in females. This may reflect the prodromal phase of the illness.     

Bereavement and mental health after sudden and violent losses: a review

This paper reviews the literature on the psychological consequences of sudden and violent losses, including disaster and military losses. It also reviews risk and resilience factors for grief and mental health and describes the effects and possible benefit of psychosocial interventions. The review shows gaps in the literature on grief and bereavement after sudden and violent deaths. Still, some preliminary conclusions can be made. Several studies show that a sudden and violent loss of a loved one can adversely affect mental health and grief in a substantial number of the bereaved. The prevalence of mental disorders such as post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and prolonged grief disorder (PGD, also termed complicated grief) varies widely, however, from study to study. Also, mental health disorders are more elevated after sudden and violent losses than losses following natural deaths, and the trajectory of recovery seems to be slower. Several factors related to the circumstances of the loss may put the bereaved at heightened risk for mental distress. These factors may be differentially related to different outcomes; some increase the risk for PTSD, others for PGD. Given the special circumstances, bereavement following sudden and violent death may require different interventions than for loss from natural death. Recommendations for future research and clinical implications are discussed.     

Grief experiences of parents whose children suffer from mental illness

OBJECTIVE: To examine the grief experience of parents of adult children with a mental illness and its relationship to parental health and well-being and parent child attachment and affective relationship. METHODS: Participants were recruited from a variety of organizations throughout Australia that provide support services for sufferers of mental illness and/or for their families. Seventy-one participants (62 mothers and nine fathers) all of whom had a child diagnosed with mental illness volunteered to take part in the study. All completed measures of grief, health status and parent-child relationship. RESULTS: Parents reported experiencing grief in relation to their child's illness as evidenced by intrusive thoughts and feelings and avoidance of behaviour as well as difficulties adapting to and distress associated with reminders of the illness. Parental grief appears to reduce over time, but only in some aspects of grief and after an extended period. Increased parental grief was related to lowered psychological well-being and health status and associated with an anxious/ambivalent and a negative affective parent-child relationship. CONCLUSION: The study provides important insights into the grief experiences of parents following their child's diagnosis with mental illness. The significant relationship between parental grief and parental psychological well-being and health status as well as to parent-child relationship has important implications for health professionals. Foremost amongst these are the need to validate the distress and grief of parents and to better understand how to provide interventions that promote grief work and family bonds while reducing emotional distress and life disruption.     

Examination of factor structure of the inventory of complicated grief (ICG) in a sample of bereaved military family members with persistent and elevated grief

Knowledge about the effect of a US service member's death on surviving family members is limited. In order to identify their grief‐related health care needs, a first step is to identify the characteristics of persistent and elevated grief in a military family sample. The present study identified military family members (n = 232) bereaved more than six months who endorsed an elevated level of grief. A confirmatory factor analysis and test of measurement invariance of factor structure were used to compare the factor structure of their Inventory of Complicated Grief (ICG) responses to that of a bereaved non‐military‐related clinical research sample with similar grief levels. Results confirmed an equivalent five‐factor structure of the ICG in both the military family sample and the clinical research sample. The similarity in factor structure was present despite differences in demographic characteristics and bereavement experiences between samples. Thus, the ICG reliably measures persistent and elevated grief in military family samples and provides grief symptom profiles that facilitates better understanding of their grief‐related needs.     

Psychodiagnosis,Old and New: Commentary on Weinstein and Seidman et al.

Abstract

This paper reviews the literature on the psychological consequences of sudden and violent losses, including disaster and military losses. It also reviews risk and resilience factors for grief and mental health and describes the effects and possible benefit of psychosocial interventions. The review shows gaps in the literature on grief and bereavement after sudden and violent deaths. Still, some preliminary conclusions can be made. Several studies show that a sudden and violent loss of a loved one can adversely affect mental health and grief in a substantial number of the bereaved. The prevalence of mental disorders such as post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and prolonged grief disorder (PGD, also termed complicated grief) varies widely, however, from study to study. Also, mental health disorders are more elevated after sudden and violent losses than losses following natural deaths, and the trajectory of recovery seems to be slower. Several factors related to the circumstances of the loss may put the bereaved at heightened risk for mental distress. These factors may be differentially related to different outcomes; some increase the risk for PTSD, others for PGD. Given the special circumstances, bereavement following sudden and violent death may require different interventions than for loss from natural death. Recommendations for future research and clinical implications are discussed.     

Trajectories of mental health problems in children of parents with mental health problems: results of the BELLA study

Children of parents with mental health problems (CPM) have an increased risk for behavioral and psychological problems. This study investigated the age- and gender-specific course as well as predictors of mental health problems in CPM using the longitudinal data (baseline 1- and 2-year follow-ups) of a German general population sample from the BELLA study. Children and adolescents aged 11–17 years (at baseline) who had a parent with mental health problems (n = 325) were analyzed. The mental health problems of the children were assessed by the self-reported version of the strengths and difficulties questionnaire (SDQ). We used individual growth modeling to investigate the age- and gender-specific course, and the effects of risk as well as personal, familial and social protective factors on self-reported mental health problems in CPM. Additionally, data were examined differentiating internalizing and externalizing mental health problems in CPM. Results indicated that female compared to male CPM showed increasing mental health problems with increasing age. Mental health problems in CPM were associated with lower self-efficacy, worse family climate and less social competence over time. Internalizing problems were associated with lower self-efficacy, less social competence and more severe parental mental health problems. Externalizing problems were associated with lower self-efficacy, worse family climate and lower social competence. The main limitations of the study are the short time period (2 years) covered and the report of mental health problems by only one parent. Our findings should be considered in the development of treatment and prevention programs for mental health problems in CPM.     

Family focused grief therapy: a randomized, controlled trial in palliative care and bereavement

OBJECTIVE: The aim of family focused grief therapy is to reduce the morbid effects of grief among families at risk of poor psychosocial outcome. It commences during palliative care of terminally ill patients and continues into bereavement. The authors report a randomized, controlled trial. METHOD: Using the Family Relationships Index, the authors screened 257 families of patients dying from cancer: 183 (71%) were at risk, and 81 of those (44%) participated in the trial. They were randomly assigned (in a 2:1 ratio) to family focused grief therapy (53 families, 233 individuals) or a control condition (28 families, 130 individuals). Assessments occurred at baseline and 6 and 13 months after the patient's death. The primary outcome measures were the Brief Symptom Inventory, Beck Depression Inventory, and Social Adjustment Scale. The Family Assessment Device was a secondary outcome measure. Analyses allowed for correlated family data and employed generalized estimating equations based on intention to treat and controlling for site. RESULTS: The overall impact of family focused grief therapy was modest, with a reduction in distress at 13 months. Significant improvements in distress and depression occurred among individuals with high baseline scores on the Brief Symptom Inventory and Beck Depression Inventory. Global family functioning did not change. Sullen families and those with intermediate functioning tended to improve overall, whereas depression was unchanged in hostile families. CONCLUSIONS: Family focused grief therapy has the potential to prevent pathological grief. Benefit is clear for intermediate and sullen families. Care is needed to avoid increasing conflict in hostile families.     

Traumatic grief treatment: case histories of 4 patients

BACKGROUND: Traumatic grief treatment is a newly developed intervention for a debilitating bereavement-related condition. Traumatic grief treatment uses imaginal and in vivo exposure techniques to target emotional distress and behavioral avoidance hypothesized to be core features of the syndrome, along with interpersonal psychotherapy techniques to engage patients and maintain rapport. The present report describes 4 case histories of patients treated in this way. METHOD: Each patient met our criterion for traumatic grief, defined as a score of at least 25 on the Inventory of Complicated Grief. Additionally, all 4 patients met DSM-IV criteria for a current episode of major depression and 1 patient for bipolar II disorder. The treatment course followed a direct replication design and ranged from 14 to 18 weekly 60- to 90-minute sessions. RESULTS: These 4 cases illustrate reduction in distress during exposure to painful emotional memories and avoided situations that was associated with decreased scores on measures of traumatic grief, depression, and anxiety and increased participation in and enjoyment of daily-life activities. CONCLUSION: Case histories of traumatic grief treatment suggest it is a promising treatment for individuals suffering from traumatic grief. It appears that imaginal relieving and in vivo exposure are effective in reducing grief intensity and lead to reduction in symptoms.     

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

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

Complicated grief therapy for clinicians: An evidence‐based protocol for mental health practice

In the United States alone, about 10 million persons are newly bereaved each year. Most do not require professional intervention or treatment, but many can benefit from targeted support. However, a significant minority of bereaved persons experience intense, prolonged and disabling grief symptoms associated with considerable morbidity and mortality (aka, “Complicated Grief”). Individuals with Complicated Grief require more formal interventions. In this article, we describe a compassionate and evidence‐based approach to bereavement‐care that can be provided in varied mental health settings. For individuals struggling with acute grief, clinicians can help by providing recognition and acceptance of the grief, eliciting and compassionately listening to their narratives of their relationship with the deceased and the death, and regularly “checking in” regarding their grief experiences. For bereaved persons who are experiencing Complicated Grief, we recommend an evidence‐based approach to bereavement‐care, complicated grief therapy (CGT), that involves helping the individual accept and cope with the loss while simultaneously assisting them with adaptation to life without the deceased. We describe ways of implementing CGT's seven core themes: (1) understanding and accepting grief, (2) managing painful emotions, (3) planning for a meaningful future, (4) strengthening ongoing relationships, (5) telling the story of the death, (6) learning to live with reminders, and (7) establishing an enduring connection with memories of the person who died. This work can be done in a variety of settings, taking into consideration the needs of the patient, the limitations of the setting, and the skills and experiences of each clinician.     

Bupropion sustained release for bereavement: results of an open trial

OBJECTIVE: The present study was conducted to assess whether DSM-IV-defined bereavement responds to bupropion sustained release (SR). METHOD: Twenty-two subjects who had lost their spouses within the previous 6 to 8 weeks and who met DSM-IV symptomatic/functional criteria for a major depressive episode were evaluated. Subjects completed the Hamilton Rating Scale for Depression (HAM-D), the Clinical Global Impressions scale, the Texas Revised Inventory of Grief, and the Inventory of Complicated Grief at baseline and follow-up. Subjects were treated with bupropion SR, 150 to 300 mg/day, for 8 weeks. RESULTS: Improvement was noted in both depression and grief intensity. For the intent-to-treat group. 59% experienced a reduction of > or = 50% on HAM-D scores. The correlations between changes in the HAM-D scores and the grief scale scores were high, ranging from 0.61 (p = .006) to 0.44 (p = .054). CONCLUSION: Major depressive symptoms occurring shortly after the loss of a loved one (i.e., bereavement) appear to respond to bupropion SR. Treatment of these symptoms does not intensify grief; rather, improvement in depression is associated with decreases in grief intensity. The results of this study challenge prevailing clinical wisdom that DSM-IV-defined bereavement should not be treated. Larger, placebo-controlled studies are indicated.     

Grief in widowhood and divorce

This article describes the development of scales to assess grief and anger in widowhood and divorce. Widows have significantly higher grief scores than do divorcees, but the two groups do not differ in the degree of anger they report. Grief and anger scores are higher for widows and divorcees with social and psychological vulnerabilities and demographic characteristics that have been hypothesized as making them at greater risk for difficulties in adjustment. The data are from age, race, and census tract of residence-matched samples of widows and divorcees interviewed approximately 3 months after the death of or filing for divorce from their spouses.     

Religious beliefs and practices are associated with better mental health in family caregivers of patients with dementia: findings from the REACH study.

OBJECTIVE: Providing care to a loved one with dementia and the death of that loved one are generally considered two of the most stressful human experiences. Each puts family caregivers at risk of psychologic morbidity. Although research has suggested that religious beliefs and practices are associated with better mental health, little is known about whether religion is associated with better mental health in family caregivers. Our objective, then, is to explore the relationship between religion and mental health in active and bereaved dementia caregivers. METHODS: A total of 1,229 caregivers of persons with moderate to severe dementia were recruited from six geographically diverse sites in the United States and followed prospectively for up to 18 months. Three measures of religion: 1) the frequency of attendance at religious services, meetings, and/or activities; 2) the frequency of prayer or meditation; and 3) the importance of religious faith/spirituality were collected. Mental health outcomes were caregiver depression (Center for Epidemiological Studies-Depression [CES-D] scale) and complicated grief (Inventory of Complicated Grief [ICG]). RESULTS: Religious beliefs and practices were important to the majority of caregivers. After controlling for significant covariates, the three measures of religion were associated with less depressive symptoms in current caregivers. Frequent attendance was also associated with less depression and complicated grief in the bereaved. CONCLUSIONS: Religious beliefs and practices, and religious attendance in particular, are associated with better mental health in family caregivers of persons with dementia.     

Informal caregivers in early psychosis: evaluation of need for psychosocial intervention and unresolved grief

Aim: Relatives of service users involved with Early Intervention in Psychosis services often experience substantial distress and need associated with their role as caregivers. This study adapted versions of the Relatives Cardinal Needs Schedule and the Texas Inventory of Grief and tested their utility for use among relatives of service users experiencing a first episode of psychosis. Methods: Staff, service users and relatives were consulted and a pilot took place which facilitated the creation of the Relatives' Urgent Needs Schedule – Early Intervention version (RUNS‐EI) and the Texas Inventory of Grief – Early Intervention version (TIG‐EI). Thirty service user‐caregiver dyads were recruited for the evaluation of reliability and validity. Results: The level of ‘urgent need’ identified by the RUNS‐EI demonstrated good concurrent validity with measures of service user social and global functioning as well as measures assessing relatives' distress, expressed emotion and grief. The measure demonstrated acceptable interrater and test–retest reliability. The profile of need is reported. The TIG‐EI demonstrated ‘excellent’ internal consistency. It also demonstrated good concurrent validity with increased TIG‐EI scores correlated with reduced service user social and global functioning as well as increased scores on measures assessing relatives' distress, expressed emotion and caregiving needs. Conclusions: Results appear to support these assessments' utility as measures of need for psychosocial intervention and grief among relatives supporting service users experiencing a first episode of psychosis.     

The Perinatal Grief Scale: development and initial validation

The theoretical strategy underlying development of the Perinatal Grief Scale is described. The instrument was completed by 194 subjects as part of a longitudinal study of factors affecting the resolution of grief following spontaneous abortion, fetal or neonatal death, or ectopic pregnancy. Variables found to be significant predictors of grief, as measured by this scale, were: overall physical health of mother, gestational age at time of loss, quality of the marital relationship, and pre-loss mental health symptomatology.     

Closely spaced stressful life events precede the onset of benign essential blepharospasm and hemifacial spasm.

BACKGROUND: The purpose of this study was to assess the possible role of major stressful life events, complicated grief, and depression in the pathogenesis of benign essential blepharospasm (BEB) and hemifacial spasm (HFS). METHODS: This was a case-control study involving 23 participants with BEB/HFS and 23 control subjects, comparing the frequency of major stressful life events, depression on the Beck Depression Inventory-II, and complicated grief on the Inventory of Complicated Grief. RESULTS: There was no difference in the rate of depression or complicated grief between participants with BEB/HFS (57%) and control subjects (48%). Participants with BEB/HFS experienced a significantly (P = 0.0048) shorter time interval between two major stressful life events (median, 0.3 year) than did the control group (median, 3.0 years). The proportion of participants who had suffered two major stressful lifetime events separated by 1 year or less was significantly greater for participants with BEB/HFS than for control subjects (P = 0.0007). CONCLUSIONS: The onset of BEB and HFS was often preceded by a major lifetime stressor. The development of these conditions was significantly related to the number of stressful life events occurring within the preceding year rather than to the total number of stressful life events. Subjects who sustain closely spaced stressful life events may be at increased risk of developing BEB and HFS.