Mai-Britt Guldin

A confirmatory factor analysis of combined models of the Harvard Trauma Questionnaire and the Inventory of Complicated Grief-Revised: Are we measuring complicated grief or posttraumatic stress?

The aim of this study was to assess the factorial structure of complicated grief (CG) and investigate the relationship between CG and posttraumatic stress disorder (PTSD) through the assessment of models combining both constructs. The questionnaire was completed by elderly, married respondents with a history of at least one significant, interpersonal loss (145 males and 147 females, 60-81 years). Confirmatory factor analysis (CFA) supported a two-factor model of separation and traumatic distress in CG. To investigate the relationship between CG and PTSD three combined models were specified and estimated using CFA. A model where all five factors, the two factors of CG and the three factors of PTSD, as defined by the DSM-IV, were allowed to correlate provided the best fit. The results indicated a considerable overlap between the dimensions of CG and PTSD, and complicated grief is construct that appears to be largely accounted for by especially the intrusive component of PTSD.

Incidence of Suicide Among Persons Who Had a Parent Who Died During Their Childhood A Population-Based Cohort Study

IMPORTANCE Parental death from suicide is associated with increased risk of suicide in the bereaved child, but little is known about the long-term risks of suicide after parental death from other causes. A better understanding of this association may improve suicide prevention efforts. OBJECTIVE To examine the long-term risks of suicide after parental death and how the risk trajectories differed by cause of parental death while accounting for major potential confounding variables. DESIGN, SETTING, AND PARTICIPANTS A population-based matched cohort study was performed using information from nationwide registers (data from 1968 to 2008) in 3 Scandinavian countries (for a total of 7,302,033 persons). We identified 189,094 children (2.6%) who had a parent who died before the child reached 18 years of age (ie, the bereaved cohort). Each bereaved child was matched by sex and age to 10 children who did not have a parent who died before they reached 18 years of age (for a total of 1,890,940 children) (ie, the reference cohort). Both cohorts were followed for up to 40 years. Poisson regression was used to calculate the incidence rate ratio (IRR), while accounting for age at parental death, sex, time since bereavement, maternal/paternal death, birth order, family history of psychiatric illness, and socioeconomic status. Data analyses were finalized June 24, 2015. EXPOSURE The main exposure was death of a parent within the first 18 years of life. MAIN OUTCOMES AND MEASURES Incidence of suicide among persons who had a parent who died during their childhood. RESULTS During follow-up, 265 bereaved persons (0.14%) and 1342 nonbereaved persons (0.07%) died of suicide (IRR = 2.02 [95% CI, 1.75-2.34]); IRR = 3.44 (95% CI, 2.61-4.52) for children who had a parent who died of suicide, and IRR = 1.76 (95% CI, 1.49-2.09) for children who had a parent who died of other causes. The IRR tended to be higher for children who had a parent who died before they reached 6 years of age, and the IRR remained high for at least 25 years. During 25 years of follow-up, the absolute risk of suicide was 4 in 1000 persons for boys who experienced parental death and 2 in 1000 persons for girls who experienced parental death. CONCLUSIONS AND RELEVANCE Parental death in childhood is, irrespective of cause, associated with an increased long-term risk of suicide. The consequences of parental death in childhood are far-reaching, and suicide risk trajectories may be influenced by early-life conditions. Future public health efforts should consider helping highly distressed children to cope with bereavement.

Preloss grief in family caregivers during end-of-life cancer care: A nationwide population-based cohort study

Severe grief symptoms in family caregivers during end‐of‐life cancer trajectories are associated with complicated grief and depression after the loss. Nevertheless, severe grief symptoms during end‐of‐life caregiving in caregivers to cancer patients have been scarcely studied. We aimed to explore associations between severe preloss grief symptoms in caregivers and modifiable factors such as depressive symptoms, caregiver burden, preparedness for death, and end‐of‐life communication.

Risk of suicide, deliberate self-harm and psychiatric illness after the loss of a close relative: A nationwide cohort study

The loss of a close relative is a common event, yet it is associated with increased risk of serious mental health conditions. No large‐scale study has explored up to now the importance of the bereaved persons relation to the deceased while accounting for gender and age. We performed a nationwide Danish cohort study using register information from 1995 through 2013 on four sub‐cohorts including all persons aged ≥18 years exposed to the loss of a child, spouse, sibling or parent. We identified 1,445,378 bereaved persons, and each was matched by gender, age and family composition to five non‐bereaved persons. Cumulative incidence proportions were calculated to estimate absolute differences in suicide, deliberate self‐harm and psychiatric illness. Cox proportional hazard regression was used to calculate hazard ratios while adjusting for potential confounders. Results revealed that the risk of suicide, deliberate self‐harm and psychiatric illness was increased in the bereaved cohorts for at least 10 years after the loss, particularly during the first year. During that year, the risk difference was 18.9 events in 1,000 persons after loss of a child (95% CI: 17.6‐20.1) and 16.0 events in 1,000 persons after loss of the spouse (95% CI: 15.4‐16.6). Hazard ratios were generally highest after loss of a child, in younger persons, and after sudden loss by suicide, homicide or accident. One in three persons with a previous psychiatric diagnosis experienced suicide, deliberate self‐harm or psychiatric illness within the first year of bereavement. In conclusion, this study shows that the risk of suicide, deliberate self‐harm and psychiatric illness is high after the loss of a close relative, especially in susceptible subgroups. This suggests the need for early identification of high‐risk persons displaying adjustment problems after loss of a close family member, in order to reduce the risk of serious mental health outcomes.

Increased utilisation of primary healthcare in persons exposed to severe stress in prenatal life: a national population-based study in Denmark

Objective Recent studies have suggested that stress in a pregnant mother may affect the future health of the unborn child negatively. An excellent proxy for health problems is the use of healthcare resources. Using nationwide data, we examined whether persons born to mothers who lost a close relative during pregnancy have more contacts to general practice. Design Population-based cohort study. Setting Denmark. Participants We included all children born in Denmark from 1973 to 2002 (N=2 032 528). Exposure of prenatal stress was defined as maternal bereavement by the death of a close relative during the antenatal period. The outcome of interest was contact with general practice between 2003 and 2009 when the participants were between 1 and 35 years of age. Poisson regression was used to assess the association between exposure and outcome. Outcome measures Contacts to general practitioner. Results Overall, persons exposed to prenatal stress had 2% more GP contacts than those not exposed, primarily due to increased utilisation of healthcare services during late adolescence and early adulthood. The exposed persons born to mothers who had lost a spouse had a higher risk (relative risk (RR) 1.12, 95% CI 1.10 to 1.14) and so did those born to mothers who had lost a close relative due to unexpected death (RR 1.06, 95% CI 1.05 to 1.06). Exposed persons had more contacts to general practice in daytime and more psychometric tests, talk therapies and C reactive protein tests than unexposed persons. Conclusions Prenatal stress following maternal bereavement was associated with a slightly increased utilisation of primary healthcare, mainly due to increased healthcare needs related to mental health and infections. Understanding how stress during pregnancy influences the future health of the child is an important aspect of prenatal care.

A process evaluation of systematic risk and needs assessment for caregivers in specialised palliative care

BackgroundCaregiving is strenuous and it may be associated with adverse psychological outcomes. During the palliative care trajectory, there are unique opportunities for providing support and preventing poor bereavement outcome. However, the tasks of palliative care staff in relation to caregivers are often unclear in the daily practice. Assessment is recommended to establish risk and needs and standards for caregiver support are available. Still, the feasibility of applying these standards among caregivers in everyday clinical practice has not been tested so far.MethodsThis study tested the feasibility of an intervention based on key elements of the “Bereavement support standards for specialist palliative care services” in a Danish specialised palliative home care team. We followed the UK Medical Research Council’s guidelines for the process evaluation of complex interventions. The intervention consisted of: 1. Systematic risk and needs assessment for caregivers at care entry; 2. Interdisciplinary conference to prepare a support plan; 3. Targeted support; 4. The establishment of an electronic medical record for caregivers to document targeted support. Outcomes included the reach, fidelity and acceptability of the intervention as well as the assessment of contextual factors.ResultsThe intervention reached 76 of 164 caregivers (46%). The interdisciplinary risk assessment and documentation of a support plan was conducted in 57 (75%) of the enrolled caregivers. Finally, a separate medical record was established according to the intervention blueprint for 62% of caregivers receiving targeted support. After managing initial challenges, palliative care staff reported that the intervention was useful and acceptable.ConclusionThe intervention proved feasible and useful. Still, we identified barriers to the implementation which should be taken into consideration when planning implementation of a systematic risk and needs assessment and in the establishment of medical records for caregivers.

Complicated grief – a challenge in bereavement support in palliative care: An update of the field

Abstract The philosophy of palliative care recognizes that end-of-life care impacts the whole family. Consequently, palliative care involves support for the family during illness and after the patients death. Until recently, no clinical guidelines on bereavement support existed in palliative care. Little is known about the extent of bereavement follow-up provided by specialist services. A few surveys show that bereavement programmes may be common, but need to work with best-practice models to ensure optimal allocation of support. An increasing amount of research shows complicated grief as a clinical phenomenon and a distinct diagnostic entity. The fundamental issue is mapping universally valid norms of reactions, including the prevalence of complications, and lately also the pursuit of a diagnostic entity of complicated grief. In the recently released fifth edition of the American Diagnostic and Statistical Manual of Mental Disorders all proposals for diagnostic criteria for complicated grief were rejected. Instead, the committee chose to remove the ‘bereavement exclusion’ of the DSM-IV, which excluded individuals from a diagnosis of major depressive disorder right after a loss. This paper addresses issues related to complicated grief as a bereavement-related disorder, and current implications and challenges in palliative care bereavement support will be discussed. The academic society seems to support a public health framework based on a systematic and evidence-based approach, which builds on needs and risks, to inform the organization of bereavement services. Until a distinctive and clearly defined concept of complicated grief exists and validated assessment tools are applicable, attention to new effective interventions is of vital importance in the provision of bereavement care. Bereavement counsellors in palliative care need to work to provide a clearer platform for evidence-based treatments for complicated grief within the remit of palliative care, or the lack of focus on complicated grief in palliative care is a complicating factor for the bereaved caregivers.

Early treatment with talk therapy or antidepressants in severely bereaved people and risk of suicidal behavior and psychiatric illness: an instrumental variable analysis

Purpose Losing a loved one to death is a common and natural life-course experience. Still, bereavement has been associated with an increased risk of suicidal behavior and psychiatric hospitalization and little is known of how to counter these adverse events. We aimed to study the effect of early treatment in primary care with talk therapy (TT) or antidepressants (AD) in severely bereaved people. Methods We conducted a population-based cohort study including 207,435 adult Danes who experienced a severe loss in 1996–2013. We compared treatment and no treatment with either of the two treatment regimens within 6 months after the loss. The main outcome was a serious mental health condition (defined as suicide, deliberate self-harm, or psychiatric hospitalization) occurring >6 months after bereavement. Adjusted risk differences (RDs) 2 years after bereavement were calculated using both standard regression analysis and instrumental variable analysis (IVA) in which estimated physician preferences for treatment served as instruments. Results The standard adjusted regression analysis showed a higher risk of developing a serious mental health condition associated with both TT (RD, 7.1; 95% CI, 5.0 to 9.1 per 1000 people) and AD (RD, 30.1; 95% CI, 25.7 to 34.6 per 1000 people). The IVA, which was used to control for unmeasured confounding, showed that TT was associated with a lower risk of a serious mental health condition (RD, −17.1; 95% CI, −30.7 to −3.5 per 1000 people), whereas the results were inconclusive for AD (RD, −8.6; 95% CI, −62.6 to 45.4 per 1000 people). Conclusion This study suggests that early treatment with TT is associated with reduced long-term risk of serious mental health conditions in severely bereaved people. No clear benefit or harm of treatment with AD after bereavement was ascertained since the statistical precision was low.