Grief Symptoms Research Articles

Complicated grief following the perinatal loss: a systematic review

BackgroundPerinatal loss is a severe stressor that usually triggers distressing symptoms of acute grief. Moreover, acute grief can worsen with time and become a chronic debilitating state known as complicated grief. However, there is a lack of comprehensive reviews on this topic. This systematic review aims to synthesize the existing literature on complicated grief following the perinatal loss.MethodsWe systematically searched PubMed, Embase, Cochrane Library, CINAHL, ProQuest, and Web of Science to identify articles on complicated grief symptoms and influencing factors following perinatal loss. We performed a comprehensive, structured evaluation in full compliance with PRISMA guidelines.ResultsA systematic search produced 1163 results. Of these, 38 articles met the full-text screening criteria, and 10 pieces of literature met the inclusion criteria. Individuals may experience complicated grief following perinatal loss, manifesting in symptoms such as emotional reactions, physical responses, and social impairments. Furthermore, based on existing evidence, influencing factors include demographic characteristics, reproductive characteristics, marital relationships, social support, and coping strategies.ConclusionsComplicated grief following perinatal loss is easily overlooked and has not been adequately studied. Further empirical research is needed to explore the symptoms and factors influencing this condition. A better understanding of complicated grief will help develop and optimize care strategies, informing future clinical practice and improving psychological support for individuals affected by perinatal loss.Trial registrationPROSPERO registration number: CRD42023473510.

My grief app for prolonged grief in bereaved parents: a randomised waitlist-controlled trial

ABSTRACT A minority of bereaved adults experiences prolonged grief disorder, depression, and/or posttraumatic stress disorder, with heightened risks observed among bereaved parents. Cognitive-behavioural therapies, both face-to-face and online, have demonstrated efficacy in treating post-loss mental health problems. Mobile phone applications potentially offer an efficient and cost-effective way to deliver self-help to bereaved adults, yet controlled effectiveness studies are lacking. Therefore, we examined the short-term efficacy of the My Grief app, based on cognitive-behavioural therapy, in 248 bereaved parents, in a randomised controlled trial (Clinicaltrials.gov, identifier: NCT04552717). Participants were randomly allocated to access to the My Grief app (n = 126) or a waitlist (n = 122). At baseline and post-assessment, symptoms of prolonged grief, posttraumatic stress, and depression, negative grief cognitions, rumination, and avoidance were assessed. Reductions in prolonged grief and posttraumatic stress symptoms and negative cognitions in the intervention group were larger than in the control group, albeit with small effect sizes. Fifteen app users reported negative experiences with the app; for example, some mentioned that it elicited painful memories and emotions related to their loss. My Grief appears to achieve modest improvements in mental health in bereaved parents. Given that it is accessible and low-cost, it is an important addition to the suite of prolonged grief interventions.

Predictors of ICU Surrogates' States of Concurrent Prolonged Grief, Post-Traumatic Stress, and Depression Symptoms*

Predictors of ICU Surrogates' States of Concurrent Prolonged Grief, Post-Traumatic Stress, and Depression Symptoms*

Grief-Specific Cognitive Behavioral Therapy vs Present-Centered Therapy

Prolonged grief disorder (PGD) is included as a new diagnosis in international classification systems. Treatments following a cognitive behavioral model are most effective, but comparisons with active control treatments are scarce. To examine whether integrative cognitive behavioral therapy for prolonged grief (PG-CBT) is superior to present-centered therapy (PCT). This was a rater-blinded, multicenter, randomized clinical trial (stratified by center and relationship to the deceased) with enrollment from April 2017 to May 2022. The setting included 4 university outpatient clinics in Germany. Eligible participants were aged 18 to 75 years and had PGD based on the Prolonged Grief Disorder 13 (PG-13) interview. Participants were randomized 1:1 to PG-CBT and PCT. PG-CBT focused on the exposure to the worst moment of the loss and cognitive restructuring of grief-related cognitions in combination with solution-focused and experiential methods (eg, walk to the grave exercise). PCT was adapted in session length and number to PG-CBT and focused on a supportive relationship and coping with daily problems that may have arisen from the loss or grief symptoms. All outcomes were assessed at baseline, after treatment, and 12 months after randomization at follow-up. The primary outcome was a blinded assessment of the PG-13 severity score at follow-up. Secondary outcomes were self-reported depressive, somatic, and overall psychopathological symptoms. Of 544 treatment-seeking individuals experiencing bereavement, 212 eligible participants (mean [SD] age, 51.8 [13.3] years; 173 female [82%]) with PGD based on the PG-13 interview were randomized to PG-CBT and PCT (n = 106 in each condition). In the intention-to-treat analysis, both treatments yielded high reductions in PGD severity at follow-up (PG-CBT: Cohen d = 1.64; 95% CI, 1.31-1.97; PCT: Cohen d = 1.38; 95% CI, 1.09-1.66). After treatment, participants receiving PG-CBT demonstrated significantly greater reductions in PGD severity than those receiving PCT (Cohen d = 0.31; 95% CI, 0.03-0.57). At follow-up, this effect was only visible on a trend level (Cohen d = 0.28; 95% CI, -0.02 to 0.57), whereas participants in the PG-CBT group had significantly less depressive and general psychopathological symptoms. Twenty-three participants (20%) discontinued PG-CBT treatment, and 17 participants (16%) discontinued PCT. This randomized clinical trial demonstrates that PG-CBT was superior to PCT after treatment and at follow-up with regard to comorbid symptoms. Both treatments were shown to be effective and acceptable, showing the potential for dissemination and increasing patient choice. German Clinical Trials Register (DRKS) identifier: DRKS00012317.

Patterns and relationships of prolonged grief, post-traumatic stress, and depressive symptoms in Chinese shidu parents: Latent profile and network analyses

Parents who experience the trauma of losing an only child are called “shidu” parents in China. There are individual differences in post-loss outcomes.1,061 Chinese shidu parents were asked to complete questionnaires assessing prolonged grief, post-traumatic stress, and depressive symptoms. The mean age of the sample was 59.68 (SD = 7.52), with the average time since the loss was 9.46 years (SD = 7.05). Most participants were female (62.3%). The main cause of the loss was an unnatural case (52.7%). Latent profile analysis was used to identify similar symptom patterns. Network analysis was used to explore the relationships among symptoms within different subgroups. A two-profile model based on symptom severity identified a “low symptom severity” subgroup (n = 419) and a “high symptom severity” subgroup (n = 642). In the low symptom severity subgroup network, the most central symptoms were loss of interest, feeling numb, and meaninglessness. In the high symptom severity subgroup network, the most central symptoms were physiological cue reactivity, emotional pain, and feeling easily startled. Individual differences in the post-loss outcomes of Chinese shidu parents are reflected not only in symptom patterns but also in the relationships among symptoms.

Psychosocial Needs of People Living With Pleural Mesothelioma and Family Carers: A Mixed Methods Study.

Mesothelioma is a cancer of growing global incidence, especially in developing countries, with unique complex psychosocial impacts on patients and their carers. To provide a comprehensive understanding of the psychosocial needs of people living with pleural mesothelioma and family carers. A mixed methods design with 61 semi-structured interviews and psychometrically validated questionnaires to assess pleural mesothelioma patients' (n=36) quality of life and frailty and carers' (n=25) caregiving experiences, quality of life, and pre-loss prolonged grief symptoms. People with mesothelioma (29 men, 7 women, aged 46-89years) indicated moderate quality of life; 18 (50%) met criteria for frailty. Current carers (21 women, 4 men; aged 41-79years) generally reported positive caregiving experiences and high quality of life; 5 (20%) scored in the range indicative of risk for prolonged grief disorder. Four themes were generated: a desire for tailored information with bespoke detail, assistance to coordinate tasks of treatment, improved social and peer support, and effective psychological services. Needs varied, with main concerns being about breaking the news to spouses/children, the impact of the disease and death on family, loss of personal future, managing psychological symptoms, and avoiding burden. These specific and unmet psychosocial needs provide a strong basis for individualised care pathways to address these needs via the integration of psychology into the multidisciplinary care team and the development and evaluation of mental health and wellbeing interventions for mesothelioma patients and carers. Doing so will reduce psychosocial distress and improve residual vitality.

Healing grief: Insights from relatives of cancer patients with prolonged grief. The FamiLife multicenter qualitative study.

Prolonged grief is a chronic and debilitating condition that affects millions of persons worldwide. The aim of this study was to use a qualitative approach to better understand how relatives with prolonged grief disorder perceive what does or not help them and whether they were able to make recommendations. Participants were all relatives of deceased patients admitted to 26 palliative care units involved in the FamiLife study; relatives were included if diagnosed with prolonged grief symptoms (i.e., Inventory Complicated Grief (ICG) questionnaire with a cut-off >25), and volunteered to participate. Semi-directed telephone interviews were conducted by psychologists between 6 and 12 months after the patient's death. The interviews were open-ended, without a pre-established grid, then transcribed and analyzed using a thematic approach. Overall, 199/608 (32.7%) relatives were diagnosed with prolonged grief symptoms, i.e., with an ICG score >25, and 39/199 (20%) agreed to be interviewed. The analysis yielded 4 themes: (1) the experience of mourning: intense sadness and guilt (reported by 35/39 participants, 90%); (2) aggravating factors (38/39, 97%): feeling unprepared for death and loneliness, presence of interpersonal barriers to adjustment, external elements hindering the mourning progress; (3) facilitating factors (39/39, 100%): having inner strength or forcing oneself to get better, availability of social and emotional support; and (4) the suggestions grieving relatives had to alleviate the grief burden (36/39, 92%). The analysis enabled to identify 5 suggestions for relieving the grief burden: improving communication, developing education about death and grief, maintaining contact, offering psychological support, and choosing the right time for the palliative care team to contact the relatives. This study revealed how bereaved relatives experienced the help provided by the healthcare teams, their representations, and what could be improved. These findings could be used to design intervention studies.

Perinatal loss: attachment, grief symptoms and women’s quality of life

ABSTRACT Aims/Background Perinatal loss may cause intense distress even psychiatric issues, affecting the woman’s quality of life. Attachment may provide a useful perspective in understanding the outcomes of the mourning process. Thus, the objectives of the present study were to evaluate perinatal grief symptoms and the psychological and general quality of life among 137 Italian women (mean age 36,9. ± 6,88 years old) in relation to attachment, specifically measured through parental care and control. Design/Methods About 79.6% of the participants had miscarriages and 20.4% had stillbirths. About 45.3% were childless. The women completed the Parental Bonding Instrument, the Perinatal Grief Scale and the Psychosocial General Well-Being Index online most frequently between 3 and 6 months (56.2%) after the perinatal loss. Results All the study participants showed intense grief and severe grief reactions to loss. Moreover, women experiencing optimal bonding towards their own mothers had a more positive effect on perinatal grief and psychological and general quality of life. Conclusions Attachment-based, tailored interventions for women who have experienced perinatal loss should improve their psychological and overall quality of life.

Navigating grief in unprecedented times: risk factors in the wake of pandemic loss and end-of-life care

ABSTRACT Coronavirus is an infectious disease that has left tens of millions of deaths around the world, and which has had social, economic, emotional, and psychological consequences. To mitigate the spread of the virus, several countries have adopted restrictive measures that impacted the way people experienced the end-of-life and the death of their loved one. This study aimed to identify the variables associated with prolonged grief symptoms in the context of both pandemic-related losses and the unique challenges related to end-of-life care. An anonymous online survey was disseminated widely through various channels including local press, social media, professional networks and hospitals. Socio-demographic information was collected, as well as information related to loss (cause of death, place of end-of-life care and death) and bereavement, and on the impact of the restrictions imposed by the pandemic. The participants were 163 bereaved who lost a loved one who received end-of-life care during the pandemic in Portugal. Most participants were female, married, professionally active and had lost their grandparents. A hierarchical multiple regression was performed to determine the factors associated with prolonged grief symptoms. The results showed that more prolonged grief symptoms were associated with less social support, worsening of the financial situation, greater psychological impact of restrictions on communicating with the deceased, and the deceas having received end-of-life care in a hospital. The early identification based on these factors of individuals at higher risk for more prolonged grief symptoms could allow for targeted interventions and support services. This study unveils crucial factors contributing to heightened grief amid pandemic-related losses and challenges in end-of-life care, which provide practical insights for healthcare practitioners. Highlight the importance of personalized interventions to fortify social connections, address financial challenges, and offer compassionate alternatives to hospital-centric care. Policymakers can leverage this information to optmise grief management during public health crises.

A French-Language Web-Based Intervention Targeting Prolonged Grief Symptoms in People Who Are Bereaved and Separated: Randomized Controlled Trial.

Losing a loved one, through death or separation, counts among the most stressful life events and is detrimental to health and well-being. About 15% of people show clinically significant difficulties coping with such an event. Web-based interventions (WBIs) are effective for a variety of mental health disorders, including prolonged grief. However, no validated WBI is available in French for treating prolonged grief symptoms. This study aimed to compare the efficacy and adherence rates of 2 WBIs for prolonged grief symptoms following the loss of a loved one through death or romantic separation. LIVIA 2.0 was developed relying on theoretical and empirical findings on bereavement processes and WBIs, and is compared with LIVIA 1, which has already demonstrated its efficacy. We conducted a randomized controlled trial and provided on-demand guidance to participants. Outcomes were assessed through web-based questionnaires before the intervention, after the intervention (12 weeks later), and at follow-up (24 weeks later). Primary outcomes were grief symptoms, depressive symptoms, and well-being. Secondary outcomes were anxiety symptoms, grief coping strategies, aspects related to self-identity, and program satisfaction. In total, 62 participants were randomized (intent-to-treat [ITT] sample), 29 (47%) in LIVIA 2.0 (active arm) and 33 (53%) in LIVIA 1 (control arm). The dropout rate was 40% (37/62), and 10 participants were removed due to exclusion criteria, leading to a final per-protocol sample of 27 (44%) completers who differed from noncompleters only based on reporting fewer anxiety symptoms (t60=3.03; P=.004). Participants who are separated reported more grief symptoms (t60=2.22; P=.03) and attachment anxiety (t60=2.26; P=.03), compared to participants who are bereaved. There were pre-post within-group differences for both programs in the ITT sample, with significant reductions in grief (Cohen d=-0.90), depressive symptoms (Cohen d=-0.31), and centrality of the loss (Cohen d=-0.45). The same pattern was observed in the per-protocol sample, with the exception that anxiety symptoms also significantly diminished (Cohen d=-0.45). No difference was found in efficacy between the 2 programs (all P>.33). Participants (ITT sample) reported overall high levels of program satisfaction (mean 3.18, SD 0.54; over a maximum of 4). Effect stability was confirmed at the 6-month follow-up for all outcomes, with an improvement in self-concept clarity. The 2 grief-related WBIs were effective in reducing grief, depressive and anxiety symptoms for participants who are bereaved or separated. The analyses did not reveal any pre-post between-group differences, suggesting that the innovations brought to LIVIA 2.0 did not significantly affect the outcome. However, caution is warranted with the interpretation of the results given the limited power of the sample, which only allows the detection of medium effect sizes. ClinicalTrials.gov NCT05219760; https://clinicaltrials.gov/study/NCT05219760. RR2-10.2196/39026.

Does Meaning-Making Mediate COVID-19 Restrictions' Impact on Grief and Psychological Symptoms?

The COVID-19 pandemic imposed substantial restrictions on funeral ceremonies, profoundly affecting grief experiences. This study investigated the mediating role of meaning-making in the relationship between these restrictions and prolonged grief disorder (PGD) symptoms, anxiety, depression, and trauma. A longitudinal study involving 141 bereaved individuals was conducted, with assessments at two time points: 3-6months (T1) and 9-12months (T2) post-loss. Structural equation modeling revealed that the psychological impact of restrictions on death and funeral ceremonies had indirect effects on anxiety and prolonged grief symptoms through meaning-making, particularly the footing in the world subscale. These findings underscore the importance of understanding the complex interplay between pandemic-related restrictions and grief experiences, emphasizing the pivotal role of meaning-making in adapting to loss during those challenging times.

The effectiveness of acceptance and commitment therapy in reducing the symptoms of complicated grief, corona disease anxiety, and improving the quality of life in the survivors of the deceased due to COVID-19

BACKGROUND: COVID-19 is an infectious disease that has threatened the physical and mental health of people and in many cases leads to death. The present study investigated the effectiveness of acceptance and commitment therapy (ACT) in reducing the symptoms of complicated grief, and corona disease anxiety, and improving the quality of life in the survivors of the deceased due to COVID-19. MATERIALS AND METHODS: The research method was an experimental design with pre-test, post-test, and follow-up with a control group and random assignment to the intervention and the control groups. Thirty-eight people who met the study criteria were selected as a sample and assigned to the two intervention and control groups using a simple randomization method (19 people in each group). Measures included the complex grief scale, the coronavirus anxiety scale, and the short form of the World Health Organization quality of life scale. Then, mixed analysis of variance was used to compare the average variables between the two groups. Also, the independent t-test was used to compare the mean quantitative outcomes between the two groups. RESULTS: The results showed that there were significant changes over time between the experimental and control groups (with a small effect coefficient) in complicated grief symptoms (P < 0.05), corona disease anxiety (P = 0.001), and quality of life (P = 0.001). Also, the results of all three variables showed that there were significant differences between pre-test and post-test (P < 0.05) and between pre-test and follow-up (P value < 0.05), but the difference between post-test and follow-up was insignificant. CONCLUSIONS: ACT has significant effects on reducing the symptoms of complicated grief and corona disease anxiety as well as on improving the quality of life in the survivors of the deceased due to COVID-19.

A time/space bubble: Expectant parents’ experience of birth after termination of pregnancy due to fetal anomaly in a midwifery-led, obstetric unit for prenatal loss

Termination of pregnancy due to a fetal anomaly is a challenging and mentally stressful experience, associated with trauma-related stress, depression and symptoms of complicated grief. It differs from other types of pregnancy loss because of the role of active decision-making. Expectant parents depend on caring and experienced staff to guide them during a time full of ambiguity and contrasting emotions.This study examines how expectant parents experience the process of birth with termination of pregnancy due to fetal anomaly at a specialised unit for prenatal loss.Data was generated from semi-structured interviews with 11 women and 9 male partners, one to five months after termination of pregnancy.Three themes were identified 1) Suspended time/space bubble; the unit for prenatal loss was described as a time-space bubble, that promoted a sense of meaning, a feeling of togetherness and an awareness of parallel worlds, 2) The midwife matters; participants emphasised midwives’ 'invisible', chronological and individualised practice, making it possible to be present and in the process, and 3) Meeting and spending time with the fetus/baby; participants’ responses and relation to the fetus were very different, with most of them embracing the fetus as a baby, grateful for the opportunity to have time together.The findings from this study suggest a need for specialised midwives dedicated to prenatal loss, in units designed as private and protected spaces to accommodate the requirements of parents undergoing termination of pregnancy due to fetal anomaly.

Is COVID-19 loss more associated with prolonged grief disorder than other losses?

The COVID-19 pandemic raised fears about a rise in prolonged grief rates. To determine if these fears are justified, we examined an online sample of 329 Turkish adults for their level of prolonged grief symptoms (as well as probable Prolonged Grief Disorder-PGD) and associated factors in relation to losses during the pandemic. Respondents completed measures of prolonged grief, post-traumatic stress disorder, and depression. Overall, 10% of participants reported symptoms indicating a probable PGD diagnosis. Surprisingly, loss due to COVID-19 or disruption of the natural mourning process did not relate to higher levels of prolonged grief. Our findings suggest that although levels of prolonged grief (and rates of PGD) may have increased during the pandemic, prolonged grief (or PGD) during this time is likely not linked to losses due to COVID-19 or to disruptions in the normal grieving process.

Grief on pain and quality of life in combat veterans with PTSD

ABSTRACT Background: Persistent Complex Bereavement Disorder (PCBD) comprises a set of grief symptoms that are often linked to other psychological conditions such as PTSD and depression, may be prevalent in Veterans with combat experience, and may also impact general health. Objective: This study investigated the association between grief and sleep, pain, PTSD, and depression, among Veterans participating in a clinical trial for PCBD treatment. Method: Data from 155 Veterans receiving treatments for PCBD were analysed to explore the association between PCBD and symptoms of sleep pain, PTSD, and depression. Veterans experiencing grief reported symptoms related to physical health, emotional problems, energy, and fatigue, emotional well-being, social functioning, presence of pain, and general health. PCBD appeared to have a specific association with pain and physical functioning, independent of other variables. Conclusions: This study examined the potential independent association of PCBD on physical and mental health in Veterans with PTSD. PCBD appeared to have a very specific and significant association with pain and physical functioning. In other words, the pain of grief was related to ratings of physical pain. Future research on PCBD should address the potentially bidirectional association with bodily pain, particularly chronic pain, in relation to loss, with specific attention to potential mechanisms underlying this relationship.

Prolonged Grief, Posttraumatic Stress and Depression Symptoms Before and After COVID-19 in Brazil.

This study aims to explore the differences in prolonged grief (PDG), posttraumatic stress (PTSD), and depression symptoms (MDD) following the loss of a loved one before and after the COVID-19 pandemic. Using a cross-sectional design, 888 bereaved individuals were classified on different groups according to the cause of death. Results indicate that participants who experienced a loss during the pandemic, regardless of the cause, presented higher levels of prolonged grief, posttraumatic stress and depression when compared to those who lost a loved one before the pandemic. This study sheds light on the environmental influences (ex: the COVID-19 pandemic) on the grieving process, emphasizing the need to take the context into account when tailoring interventions in bereavement and mental health care.

Predictors of ICU Surrogates' States of Concurrent Prolonged Grief, Post-Traumatic Stress, and Depression Symptoms.

Scarce research explores factors of concurrent psychologic distress (prolonged grief disorder [PGD], post-traumatic stress disorder [PTSD], and depression). This study models surrogates' longitudinal, heterogenous grief-related reactions and multidimensional risk factors drawing from the integrative framework of predictors for bereavement outcomes (intrapersonal, interpersonal, bereavement-related, and death-circumstance factors), emphasizing clinical modifiability. Prospective cohort study. Medical ICUs of two Taiwanese medical centers. Two hundred eighty-eight family surrogates. None. Factors associated with four previously identified PGD-PTSD-depressive-symptom states (resilient, subthreshold depression-dominant, PGD-dominant, and PGD-PTSD-depression concurrent) were examined by multinomial logistic regression modeling (resilient state as reference). Intrapersonal: Prior use of mood medications correlated with the subthreshold depression-dominant state. Financial hardship and emergency department visits correlated with the PGD-PTSD-depression concurrent state. Higher anxiety symptoms correlated with the three more profound psychologic-distress states (adjusted odds ratio [95% CI] = 1.781 [1.562-2.031] to 2.768 [2.288-3.347]). Interpersonal: Better perceived social support was associated with the subthreshold depression-dominant state. Bereavement-related: Spousal loss correlated with the PGD-dominant state. Death circumstances: Provision of palliative care (8.750 [1.603-47.768]) was associated with the PGD-PTSD-depression concurrent state. Surrogate-perceived quality of patient dying and death as poor-to-uncertain (4.063 [1.531-10.784]) correlated with the subthreshold depression-dominant state, poor-to-uncertain (12.833 [1.231-133.775]), and worst (12.820 [1.806-91.013]) correlated with the PGD-PTSD-depression concurrent state. Modifiable social-worker involvement (0.004 [0.001-0.097]) and a do-not-resuscitate order issued before death (0.177 [0.032-0.978]) were negatively associated with the PGD-PTSD-depression concurrent and the subthreshold depression-dominant state, respectively. Apparent unmodifiable buffering factors included surrogates' higher educational attainment, married status, and longer time since loss. Surrogates' concurrent bereavement distress was positively associated with clinically modifiable factors: poor quality dying and death, higher surrogate anxiety, and palliative care-commonly provided late in the terminal-illness trajectory worldwide. Social-worker involvement and a do-not-resuscitate order appeared to mitigate risk.

Prolonged grief and career adaptability of university students through meaning making and coping styles

AbstractIn this study, the relationship between prolonged grief and career adaptability was examined. Specifically, it was predicted that the relationship would be mediated by meaning making and coping styles. The total sample consisted of 120 university students who have experienced at least one death of significant others that happened more than 6 months ago. Results showed that the direct paths between prolonged grief and career adaptability were insignificant, but through meaning making’s mediation, the indirect paths were all significant. The findings indicate that prolonged grief can affect career development. Therefore, there is a need for counselors to promote meaning making and the use of problem-focused coping to support the career development of individuals with prolonged grief symptoms.

Strategies for Coping With Complicated Grief in Relatives of Patients Who Are Critically Ill: An Observational Single-Center Cohort Study

Relatives of deceased critically ill patients are at high risk for symptoms of complicated grief (CG) with potential individual and social burdens. The prevalence and predictors of CG, and in particular the involvement of individual facets of relatives' coping strategies, are not well understood. How high is the prevalence and what are the predictors of CG, and how are coping strategies associated with CG symptoms? In this observational single-center cohort study, relatives of deceased critically ill patients were surveyed 6 months later, using the Inventory of Complicated Grief (ICG) and the Brief-COPE questionnaire to assess CG symptoms and coping strategies, respectively. Patients' and relatives' characteristics were obtained. The primary outcome was the ICG sum score. Relatives of 89 of the 298 patients who died in the ICU during the study period were included. The mean ICG sum score (SD) was 41.6+10.9. Eighty-four relatives (94.4%) had an ICG score of >25. Multivariable analysis revealed that being a partner affected the ICG sum score significantly (coefficient 4.9, 95% confidence interval [1.8; 8.0], p=0.003), as did the coping strategies self-distraction (coefficient 4.4, 95% CI [2.5; 6.3], p<0.001), acceptance (coefficient -4.4, 95% CI [-6.3; -2.5], p<0.001), and self-blame (coefficient 3.8, 95% CI [1.4; 6.3], p=0.002). Almost all relatives of deceased critically ill patients show symptoms of CG. Relatives' functional and dysfunctional coping strategies may be associated with their CG symptoms. Knowledge of individual relatives' coping strategies may be helpful in supporting them. Adequate supportive interventions should be developed.

Reflective functioning mediates the relationship between insecure adult attachment and the severity of prolonged grief symptoms.

This study aimed to investigate the mediation role of reflective functioning (i.e., certainty and uncertainty about mental states) in the relationship between insecure attachment (i.e., attachment avoidance and attachment anxiety ) and the severity of prolonged grief symptoms. A cross-sectional study was conducted with 329 bereaved participants (51.7% females, mean age= 46.94 ± 14.62 years). Participants completed the Prolonged Grief Scale (PG-13), the Attachment Style Questionnaire (ASQ), and the Reflective Functioning Questionnaire (RFQ). Demographic and bereavement-related information were also collected. Certainty about mental states fully mediated the relationship between both the attachment avoidance and attachement anxiety and severity of prolonged grief symptoms. The findings of this study indicate that reflective functioning impairment, specifically certainty about mental states of self and others, mediate the paths from insecure attachment to prolonged grief symptoms. This suggests that improving reflective functioning may contribute to the treatment bereaved individuals at risk of PGD.