Angela Ghesquiere

Complicated grief and related bereavement issues for DSM‐5

Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally, grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence, some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over‐and under‐diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over‐diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This article focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders. Depression and Anxiety, 2011.

Major ingredients of fidelity: A review and scientific guide to improving quality of intervention research implementation

Despite the critical role of fidelity and the proliferation of intervention manuals and related measures, no comprehensive, structured guide exists, resulting in definitional confusion, varying interpretations of what constitutes core components, and inconsistent application of methods to ensure fidelity. To improve integration of fidelity criteria into intervention research, this review paper focuses on three aims: 1) to identify, define, and operationalize the key ingredients and components of intervention fidelity; 2) to identify consistency and uniformity in terms of core characteristics of fidelity; and, 3) to provide a comprehensive fidelity tool that assesses the core ingredients of fidelity that can be used by researchers to measure the degree of fidelity. Twenty-four (n=24) meta-analyses and review articles focusing on fidelity were identified in a systematic literature search over the past 30 years. A comprehensive review and fidelity guide outlining four required components of intervention research (design, training, monitoring of intervention delivery, and intervention receipt) was developed, with special consideration given to threats and measurement. Fidelity is imperative in all stages and phases of intervention research. This review and guide can be used by practitioners and researchers in their scientific process of designing and implementing community-based psychological, social, and behavioral intervention research.

Treatment of complicated grief in elderly persons: a randomized clinical trial.

IMPORTANCE Complicated grief (CG) is a debilitating condition, most prevalent in elderly persons. However, to our knowledge, no full-scale randomized clinical trial has studied CG in this population. OBJECTIVE To determine whether complicated grief treatment (CGT) produces greater improvement in CG and depressive symptoms than grief-focused interpersonal psychotherapy (IPT). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial enrolling 151 individuals 50 years or older (mean [SD] age, 66.1 [8.9] years) scoring at least 30 on the Inventory of Complicated Grief (ICG). Participants were recruited from the New York metropolitan area from August 20, 2008, through January 7, 2013, and randomized to receive CGT or IPT. The main outcome was assessed at 20 weeks after baseline, with interim measures collected at 8, 12, and 16 weeks after baseline. INTERVENTIONS Sixteen sessions of CGT (n = 74) or IPT (n = 77) delivered approximately weekly. MAIN OUTCOMES AND MEASURES Rate of treatment response, defined as a rating from an independent evaluator of much or very much improved on the Improvement subscale of the Clinical Global Impression Scale. RESULTS Both treatments produced improvement in CG symptoms. Response rate for CGT (52 individuals [70.5%]) was more than twice that for IPT (24 [32.0%]) (relative risk, 2.20 [95% CI, 1.51-3.22]; P < .001), with the number needed to treat at 2.56. Secondary analyses of CG severity and CG symptom and impairment questionnaire measures confirmed that CGT conferred a significantly greater change in illness severity (22 individuals [35.2%] in the CGT group vs 41 [64.1%] in the IPT group were still at least moderately ill [P = .001]), rate of CG symptom reduction (1.05 ICG points per week for CGT vs 0.75 points per week for IPT [t633 = 3.85; P < .001]), and the rate of improvement in CG impairment (0.63 work and Social Adjustment Scale points per week with CGT and 0.39 points per week with IPT [t503 = 2.87; P = .004]). Results were not moderated by participant age. CONCLUSIONS AND RELEVANCE Complicated grief treatment produced clinically and statistically significantly greater response rates for CG symptoms than a proven efficacious treatment for depression (IPT). Results strongly support the need for physicians and other health care providers to distinguish CG from depression. Given the growing elderly population, the high prevalence of bereavement in aging individuals, and the marked physical and psychological impact of CG, clinicians need to know how to treat CG in older adults. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01244295.

Brief measure for screening complicated grief: reliability and discriminant validity.

Background Complicated grief, which is often under-recognized and under-treated, can lead to substantial impairment in functioning. The Brief Grief Questionnaire (BGQ) is a 5-item self-report or interview instrument for screening complicated grief. Although investigations with help-seeking samples suggest that the BGQ is valid and reliable, it has not been validated in a broader population. Methodology/Principal Findings A questionnaire was mailed to a randomly selected sample (n = 5000) residing in one of 4 areas of Japan. The BCQ was examined for responders who were bereaved more than 6 months and less than 10 years (n = 915). Non-specific psychological distress was assessed with the K6 screening scale. Multiple group confirmatory factor analysis supported a uni-dimensional factor structure and the invariance of parameters across gender and age. Cronbachs alpha was sufficiently high (alpha = .75) to confirm internal consistency. Average Variance Extracted (0.39) was higher than the shared covariance (0.14) between BGQ and K6, suggesting discriminant validity. Conclusions The results of this study support the reliability and validity of the BGQ in the Japanese population. Future studies should examine predictive validity by using structured interviews or more detailed scales for complicated grief.

COMPLICATED GRIEF ASSOCIATED WITH HURRICANE KATRINA

Background: Although losses are important consequences of disasters, few epidemiological studies of disasters have assessed complicated grief (CG) and none assessed CG associated with losses other than death of loved one. Methods: Data come from the baseline survey of the Hurricane Katrina Community Advisory Group, a representative sample of 3,088 residents of the areas directly affected by Hurricane Katrina. A brief screen for CG was included containing four items consistent with the proposed DSM‐V criteria for a diagnosis of bereavement‐related adjustment disorder. Results: Fifty‐eight and half percent of respondents reported a significant hurricane‐related loss: Most‐severe losses were 29.0% tangible, 9.5% interpersonal, 8.1% intangible, 4.2% work/financial, and 3.7% death of loved one. Twenty‐six point one percent respondents with significant loss had possible CG and 7.0% moderate‐to‐severe CG. Death of loved one was associated with the highest conditional probability of moderate‐to‐severe CG (18.5%, compared to 1.1–10.5% conditional probabilities for other losses), but accounted for only 16.5% of moderate‐to‐severe CG due to its comparatively low prevalence. Most moderate‐to‐severe CG was due to tangible (52.9%) or interpersonal (24.0%) losses. Significant predictors of CG were mostly unique to either bereavement (racial–ethnic minority status, social support) or other losses (prehurricane history of psychopathology, social competence.). Conclusions: Nonbereavement losses accounted for the vast majority of hurricane‐related possible CG despite risk of CG being much higher in response to bereavement than to other losses. This result argues for expansion of research on CG beyond bereavement and alerts clinicians to the need to address postdisaster grief associated with a wide range of losses. Depression and Anxiety, 2011.

Complicated grief among individuals with major depression: prevalence, comorbidity, and associated features.

BACKGROUND Growing data suggest that complicated grief (CG) may be common in clinical care settings, but there are few prior reports about CG in outpatients presenting with primary mood disorders. METHODS The present study examined rates of bereavement and threshold CG symptoms (defined as a score ≥ 25 on the Inventory of Complicated Grief scale) in 111 outpatients with major depressive disorder (MDD) and 142 healthy controls participating in a study of stress and depression. Clinical and demographic characteristics were also compared for bereaved individuals with CG (MDD+CG) to those without (MDD-CG). Participants completed structured diagnostic interviews as well as measures of CG, depression, anxiety, exposure to traumatic events, and perceived social support. RESULTS Lifetime history of a significant loss did not differ for the MDD and control groups (79.3% vs. 76.1%), but bereaved participants with MDD had higher rates of threshold CG (25.0% vs. 2.8%). Among those with MDD, CG was associated with a higher prevalence of lifetime alcohol dependence, greater exposure to traumatic events, and lower perceived social support. Depressed women, but not men, with CG also had higher rates of panic disorder, social anxiety disorder, and posttraumatic stress disorder. LIMITATIONS Our findings are limited by the lack of a clinician confirmatory assessment of CG diagnosis, absence of complete information about the nature and timing of the loss, and relatively narrow generalizability. CONCLUSIONS We found high rates of CG in a group of psychiatric outpatients with chronic MDD, suggesting that patients with depression should be routinely screened for CG.

The Structured Clinical Interview for Complicated Grief: Reliability, Validity, and Exploratory Factor Analysis

Complicated grief (CG) has been recently included in the DSM‐5, under the term “persistent complex bereavement disorder,” as a condition requiring further study. To our knowledge, no psychometric data on any structured clinical interview for CG (SCI‐CG) is available to date. In this manuscript, we introduce the SCI‐CG, a 31‐item “SCID‐like” clinician‐administered instrument to assess the presence of CG symptoms.

Risks for Complicated Grief in Family Caregivers

Complicated Grief (CG) is a recently recognized disorder experienced by the bereaved and characterized by intense distress that interferes with functioning. Estimates indicate that about 20 % of bereaved individuals may develop CG. Family caregivers of those who are chronically ill may face unique risks for CG, such as pre-death stressors associated with caregiving. In this article, existing literature on CG in family caregivers is reviewed to identify pre-bereavement risk factors for the disorder. Implications for practice are also discussed, including both preventive interventions that could be instituted before the ill persons death and therapeutic techniques for treating CG after the death.

Outcomes of Bereavement Care Among Widowed Older Adults With Complicated Grief and Depression

Bereavement is common among older adults and may result in major depression or complicated grief (CG). Little is known about the effectiveness of physician care for these conditions. We examined whether, among older adults with CG and/or major depression, using physician support was associated with reductions in grief, depression, or anxiety severity. Outcomes were compared to group and religious support. We analyzed data from the Changing Lives of Older Couples (CLOC) Study, a prospective cohort study of married couples in the Detroit area. Spousal death was tracked over 5 years, and follow-up interviews conducted with widowed participants at 6 months (wave 1) and 18 months (wave 2) post loss. Analyses were limited to those with CG or depression with support-seeking data (weighted n = 89). Yes/no items asked whether participants had seen each provider for help with grief up until wave 1. A 19-item grief severity measure was developed by CLOC researchers. The 20-item Center for Epidemiologic Studies Depression scale measured depression severity. The Symptom Checklist 90–Revised assessed anxiety severity. Regressions indicated that seeking support from a family doctor at wave 1 was not associated with changes in anxiety, depression, or grief severity at wave 2 (P > .05). However, support group use was associated with reductions in grief severity (β = −8.46, P < .05), and religious leader support-seeking associated with reductions in depression severity (β = −10.12, P < .01). Findings imply that physician care for grief may not be effective, and support group referral may be helpful. Physicians may benefit from training in recognizing and appropriate referring for bereavement-related distress.

Performance characteristics and clinical utility of diagnostic criteria proposals in bereaved treatment-seeking patients

BACKGROUND Persistent complex bereavement disorder (PCBD) is a protracted form of grief included in DSM Section 3 indicating a need for more research. Two other criteria sets [prolonged grief disorder (PGD) and complicated grief (CG) disorder] are also currently in use by researchers. This study evaluates rates of diagnosis of each proposed criteria set in a clinical sample of bereaved individuals participating in clinical research. METHOD Two groups in which persistent grief was judged to be present or absent completed an assessment instrument that included items needed to diagnose PCBD as well as PGD and CG. One group included grief treatment-seeking participants in our multicenter National Institute of Mental Health (NIMH)-sponsored study who scored ⩾30 on the Inventory of Complicated Grief (ICG) and the other comprised bereaved adults enrolled in clinical research studies who scored <20 on the ICG. Rates of diagnosis were determined for proposed PCBD, PGD and CG criteria. RESULTS PCBD criteria diagnosed 70 [95% confidence interval (CI) 64.2-75.8] % of the grief treatment-seeking group, PGD criteria identified 59.6 (95% CI 53.4-65.8) % of these individuals and CG criteria identified 99.6 (95% CI 98.8-100.0) %. None of the three proposed criteria identified any cases in the bereaved comparison group. CONCLUSIONS Both proposed DSM-5 criteria for PCBD and criteria for PGD appear to be too restrictive as they failed to identify substantial numbers of treatment-seeking individuals with clinically significant levels of grief-related distress and impairment. Use of CG criteria or a similar algorithm appears to be warranted.