Satomi Nakajima

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.

Prevalence and determinants of complicated grief in general population

BACKGROUND Few epidemiological studies have examined complicated grief in the general population, especially in Asian countries. Therefore, this study aimed to explore the prevalence and predictors of complicated grief among community dwelling individuals in Japan. METHODS A questionnaire survey regarding grief and related issues was conducted on community dwelling individuals aged 40-79 who were randomly sampled from census tracts. Complicated grief was assessed using the Brief Grief Questionnaire. Stepwise logistic regression analysis was conducted in order to identify predictors of complicated grief. RESULTS Data from 969 responses (response rate, 39.9%) were subjected to analysis. The analysis revealed 22 (2.4%) respondents with complicated grief and 272 (22.7%) with subthreshold complicated grief. Respondents who were found to be at a higher risk for developing complicated grief had lost their spouse, lost a loved one unexpectedly, lost a loved one due to stroke or cardiac disease, lost a loved one at a hospice, care facility or at home, or spent time with the deceased everyday in the last week of life. LIMITATIONS Limitations of this study include the small sample size, the use of self-administered questionnaire, and the fact that the diagnoses of complicated grief were not based on robust diagnostic criteria. CONCLUSIONS The point prevalence of complicated grief within 10years of bereavement was 2.4%. Complicated grief was maintained without significant decrease up to 10years after bereavement. When subthreshold complicated grief is included, the prevalence of complicated grief boosts up to a quarter of the sample, therefore, routine screening for complicated grief among the bereaved is desired. Clinicians should pay particular attention to the bereaved families with abovementioned risk factors in order to identify people at risk for future development of complicated grief.

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.

Incidence and prediction of psychiatric morbidity after a motor vehicle accident in Japan: the Tachikawa Cohort of Motor Vehicle Accident Study.

Objectives:To assess both the incidence of new-onset psychiatric illness after involvement in a motor vehicle accident in Japan for comparison with Western data and the predictors of psychiatric morbidity and posttraumatic stress disorder (PTSD) evaluated immediately after the accident. Design:Prospective cohort study of injured patients assessed immediately and 4–6 wks after involvement in a motor vehicle accident. Setting:Intensive care unit in a teaching hospital in Tokyo, Japan. Patients:Total of 100 consecutive patients with motor vehicle accident–related injuries (mean Injury Severity Score, 11.2; mean Glasgow Coma Scale, 14.5; age, 18–69 yrs) admitted to the intensive care unit. Patients with traumatic brain injury, suicidality, current psychiatric or neurologic illness, or cognitive impairment were excluded. Measurements:An extensive clinical interview and evaluation of vital signs, sociodemographic variables, previous traumatic events, family history of psychopathology, Impact of Event Scale–Revised, Hospital Anxiety and Depression Scale, Clinician-Administered PTSD Scale, and Mini-International Neuropsychiatric Interview. Results:A total of 31 patients showed some form of new-onset psychiatric illness at the 4- to 6-wk follow-up. The majority of illnesses consisted of depression (major depression, n = 16; minor depression, n = 7) and PTSD (full PTSD, n = 8; partial PTSD, n = 16). Other illnesses included alcohol dependence (n = 3), obsessive–compulsive disorder (n = 2), agoraphobia (n = 2), and social phobia (n = 1). Both psychiatric morbidity and PTSD were predicted by a sense of life threat (odds ratio, 4.2 and 6.2, respectively), elevated heart rate (odds ratio, 1.6 and 1.7), and higher Impact of Event Scale–Revised intrusion subscale score (odds ratio, 1.1 and 1.1). Conclusion:This study showed that psychopathology and PTSD after a motor vehicle accident in Japan is common and that the incidence is within the range of that in Western countries. A combination of a sense of life threat, heart rate, and Impact of Event Scale–Revised intrusion subscale allowed for significant prediction of psychiatric morbidity and PTSD.

Incidence and prediction of post-traumatic stress disorder at 6 months after motor vehicle accidents in Japan

BACKGROUND Incidence proportion of post-traumatic stress disorder (PTSD) after motor vehicle accidents (MVA) vary considerably across countries, and whether heart rate (HR) and respiratory rate (RR) immediately after MVA predict subsequent PTSD remains controversial. This study examined the incidence proportion of PTSD at 6 months after MVA in Japan, and the predictors of PTSD in MVA survivors. METHOD Patients with MVA-related injuries consecutively admitted to the intensive care unit of a teaching hospital in Tokyo were recruited. Six months after MVA, PTSD was diagnosed using the Clinician Administered Post-traumatic Stress Disorder Scale (CAPS). RESULTS Of the 300 participants, 106 completed the assessments at 6 months after MVA and PTSD was diagnosed in 7.5% of the patients. Eight of the 300 participants (2.7%) were regarded as having PTSD after imputing their CAPS score at follow-up assessment for participants who dropped out. In multivariate regression analysis, no variables were shown to be independent predictors for PTSD. HR and RR did not predict PTSD in the analysis. DISCUSSION The results suggested that the incidence proportion of PTSD following MVA in Japan was lower than that in most developed countries, and HR and RR might not be accurate screening tools despite their importance in a fear-conditioning model of the genesis of PTSD.

Are patients after severe injury who drop out of a longitudinal study at high risk of mental disorder

In longitudinal studies of traumatic stress, it is particularly important to examine the data for any differences between those who drop out and those who continue to participate, because reluctance to participate might reflect symptoms of avoidance frequently seen in posttraumatic stress disorder (PTSD). However, whether those who drop out are at high risk of PTSD remains unclear. Over a 25-month period, 188 consecutive patients with motor vehicle accident (MVA)-related injuries admitted emergently were enrolled and followed for 4 to 6 weeks. Baseline characteristics were compared between subjects who did and did not participate in the follow-up study. At 4 to 6 weeks, 66 (35.1%) of the participants had dropped out. Bivariate analyses revealed that those who dropped out were likely to be men, alcohol drinkers, smokers, and unconscious just after MVA and to have fewer years of education, less severe injuries, less posttraumatic symptoms, and lower cooperativeness as assessed by the Temperament and Character Inventory. Logistic regression analysis revealed that male sex, unconsciousness during MVA, low cooperativeness, and less severe injuries were significant predictors of dropout. The literature says that male sex and unconsciousness just after MVA might be protective factors against MVA-related PTSD, whereas low cooperativeness is a risk factor for general mental problems. To summarize, it is expected that those who drop from the follow-up are unlikely to have MVA-related PTSD, but might have mental problems independent of injury.

Development of disaster mental health guidelines through the Delphi process in Japan

BackgroundThe mental health community in Japan had started reviewing the country’s disaster mental health guidelines before the Great East Japan Earthquake, aiming to revise them based on evidence and experience accumulated in the last decade. Given the wealth of experience and knowledge acquired in the field by many Japanese mental health professionals, we decided to develop the guidelines through systematic consensus building and selected the Delphi method.MethodsAfter a thorough literature review and focus group interviews, 96 items regarding disaster mental health were included in Delphi Round 1. Of 100 mental health professionals experienced in disaster response who were invited to participate, 97 agreed. The appropriateness of each statement was assessed by the participants using a Likert scale (1: extremely inappropriate, 9: very appropriate) and providing free comments in three rounds. Consensus by experts was defined as an average score of ≥7 for which ≥70% of participants assigned this score, and items reaching consensus were included in the final guidelines.ResultsOverall, of the 96 items (89 initially asked and 7 added items), 77 items were agreed on (46 items in Round 1, and 19 positive and 12 negative agreed on items in Round 2). In Round 2, three statements with which participants agreed most strongly were: 1) A protocol for emergency work structure and information flow should be prepared in normal times; 2) The mental health team should attend regular meetings on health and medicine to exchange information; and 3) Generally, it is recommended not to ask disaster survivors about psychological problems at the initial response but ask about their present worries and physical condition. Three statements with which the participants disagreed most strongly in this round were: 1) Individuals should be encouraged to provide detailed accounts of their experiences; 2) Individuals should be provided with education if they are interested in receiving it; and 3) Bad news should be withheld from distressed individuals for fear of causing more upset.ConclusionsMost items which achieved agreement in Round 1 were statements described in previous guidelines or publications, or statements regarding the basic attitude of human service providers. The revised guidelines were thus developed based on the collective wisdom drawn from Japanese practitioners’ experience while also considering the similarities and differences from the international standards.

Towards an Explanation of Inconsistent Rates of Posttraumatic Stress Disorder across Different Countries: Infant Mortality Rate as a Marker of Social Circumstances and Basic Population Health

One hundred and six (35.3%) of the 300 patients completed a face-to-face follow-up interview at 6 months. All patients met the stressor criterion A1. Six patients (5.7%, 95% confidence interval = 1.3–10.1) met all other criteria for accident-related PTSD including A2, and the mean ( 8 SD) CAPS total score of these 6 patients was 57.8 8 16.1. However, in the present report, we adopted the manner of omitting item 8 (psychogenic amnesia in criterion C) when making the diagnosis of PTSD [15] , because we were often unable to differentiate organic from psychogenic amnesia. For reference purposes, 8 (7.5%) patients met criteria for PTSD when item 8 was included in making the diagnosis of PTSD. We examined the cross-country relationship between infant mortality rate and prevalence of PTSD. Methodologies which included the consecutive recruitment of accidentally injured patients in emergency departments or intensive care units, prospective design, and assessment according to internationally accepted diagnostic criteria suggest the validity and comparability of these data. Studies were excluded if they included help-seeking patients, patients recruited from police records, or all patients with traumatic brain injury. The data from seven studies undertaken in six developed countries (UK, US, Israel, Australia, Switzerland and Japan) [2–8] as well as our current data were used. We used data for the prevalence of chronic PTSD (4–12 months after the accident) because spontaneous remission is relatively common within 3 months of a traumatic event. Although self-reported questionnaires are likely to result in elevated PTSD estimates, we used large-scale data from the US and the UK [2, 3] for comparison. The infant mortality rates in each country for the year when each study was conducted or submitted to the journal were used [16] . The relation between infant mortality rate and prevalence of accident-related PTSD was nonlinear ( fig. 1 ). On the basis of model fit, the best fitting was obtained with the quadratic model (R 2 = 0.82, p = 0.01), though a linear model was acceptable (R 2 = 0.60, p = 0.02). Infant mortality rate is well known to be associated with levels of basic health care, well-developed technology, and medical advances. These rates are also commonly included as part of standard of living evaluations in economics. There are many cultural differences among the six countries such as population density, ethnic background, founding history, dietary habit, and residential setting. The present study showed a plausible explanation for the observed discrepancy in the prevalence of PTSD following injury. These observations may provide clues regarding the estimated prevalence of accident-related PTSD and ways to reduce the number of patients that do develop PTSD. The present Japanese study has methodological strengths, including consecutive sampling and standardized assessment. However, we also consider important limitations related to representativeness, such as sampling from only one hospital and a relatively high dropout rate. Furthermore, a higher prevalence of Not only has accidental injury been shown to account for a significant health burden on all populations, regardless of age, sex and geographic region [1] , it is also an important risk factor for posttraumatic stress disorder (PTSD). Recent epidemiological studies using consecutive patients have reported inconsistent findings in the prevalence of accident-related PTSD in developed countries. For instance, PTSD prevalence at 4–12 months after accident was in the range of 17–32% in the UK [2] , US [3] and Israel [4] , but at considerably lower rates of 10.4% in Australia [5] , 8.5% in Japan [6] , and 1.9–3.1% in Switzerland [7, 8] . In a recent study by Schnyder et al. [8] published in Psychotherapy and Psychosomatics , the authors discussed that intercultural differences play an important role in the development of PTSD. We agree with their suggestion that local environmental factors, such as socioeconomic and cultural components, and health care systems are also important. In this context, Babones [9] showed an unambiguously positive correlation between income inequality and population health including infant mortality (an indicator of social circumstances and basic population health) at country level. The aim of the present study was to reveal the prevalence of PTSD at 6 months’ follow-up in our prospective study [10] and to examine the relation between infant mortality rate and prevalence of PTSD in the reliable cross-country data available. A total of 300 patients consecutively admitted to the intensive care unit (ICU) of a teaching hospital in Tokyo due to accidentrelated injury were enrolled in the study and were assessed shortly after admission and 6 months after their accident. The main outcome measure was the Clinician-Administered PTSD Scale [11, 12] . The method and sociodemographic and clinical information have been presented in an earlier publication [10] . Briefly, the majority of participants were men (77.7%), the average ( 8 SD) age was 36.5 8 15.0 years, the average ( 8 SD) Injury Severity Score [13] was 9.1 8 7.9, and the median Glasgow Coma Scale score [14] was 15.0 (range 3–15). Published online: November 18, 2009

The relationships between complicated grief, depression, and alexithymia according to the seriousness of complicated grief in the Japanese general population

BACKGROUND The present research investigated whether the relationship between alexithymia and complicated grief was different from the relationship between alexithymia and general depressive symptom according to the seriousness of complicated grief in the Japanese general population. METHODS In the Japanese general population sample, 948 participants between 40 and 79 years old (effective response rate, 48.0%) completed a cross-sectional anonymous questionnaire about alexithymia, depression, and complicated grief. To compare the high risk (n=243) and low risk (n=705) of complicated grief groups, simultaneous analysis of two groups with standard maximum likelihood estimation was performed and six hypothesized models were verified. RESULTS The model (RMSEA=0.047, AIC=71.520) that showed that the path coefficients of the latent variable of alexithymia to the observed variables were equal and that the path coefficient of alexithymia to psychological distress was equal was adopted. The contribution ratios from alexithymia to complicated grief were apparently smaller (2-4%) than those to depression (37-38%). CONCLUSIONS Our findings showed that alexithymia scarcely contributed to complicated grief compared to depression and that the contribution ratio in the high risk group was lower than that in the low risk group. The contribution of the latent variable of psychological distress to complicated grief and depression was lower in the high risk group than in the low risk group. The lack of a correlation between alexithymia and complicated grief might indicate that there are different mechanisms underlying the symptoms of alexithymia and complicated grief.

Impact of psychiatric morbidity on quality of life after motor vehicle accident at 1-month follow up

The aim of the present study was to investigate the development of, prediction of, protection against, and the course of psychological distress and well‐being in a sample of patients with motor vehicle accident‐related injuries, in a cohort study. In a secondary analysis, the question of whether psychiatric morbidity was associated with quality of life in 95 injured patients after motor vehicle accident at 1‐month follow up, was investigated. Results indicated that psychiatric morbidity has an adverse effect on quality of life.