Inventory Of Complicated Grief Score Research Articles

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.

Long-term bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study

Background: Severe grief is highly distressing and prevalent up to 1 year post-death among people bereaved during the first wave of COVID-19, but no study has assessed changes in grief severity beyond this timeframe. Aim: Understand the trajectory of grief during the pandemic by reassessing grief symptoms in our original cohort 12–18 months post-death. Design: Prospective matched cohort study. Settings/participants: Family members of decedents who died in an acute care hospital between November 1, 2019 and August 31, 2020 in Ottawa, Canada. Family members of patients who died of COVID (COVID +ve) were matched 2:1 with those who died of non-COVID illness (COVID −ve) during pandemic wave 1 or immediately prior to its onset (pre-COVID). Grief was assessed using the Inventory of Complicated Grief (ICG). Results: Follow-up assessment was completed by 92% (111/121) of family members in the initial cohort. Mean ICG score on the 12–18-month assessment was 19.9 (SD = 11.8), and severe grief (ICG > 25) was present in 28.8% of participants. One-third (33.3%) had either a persistently high (>25) or worsening ICG score (⩾4-point increase between assessments). Using a modified Poisson regression analysis, persistently high or worsening ICG scores were associated with endotracheal intubation in the deceased, but not cause of death (COVID +ve, COVID −ve, pre-COVID) or physical presence of the family member in the final 48 h of life. Conclusions: Severe grief is a substantial source of psychological morbidity in the wake of the COVID-19 pandemic, persisting more than a year post-death. Our findings highlight an acute need for effective and scalable means of addressing severe grief.

The Relationship Between Childhood Trauma Experience and Complicated Grief: The Importance of Psychological Support for Individuals Coping With Pet Loss in Korea.

Loss of companion animals can result in various psychological reactions, including complicated grief, depression, anxiety, and insomnia. However, research on the prevalence of patients requiring clinical intervention is limited. Moreover, research examining the relationship between childhood trauma and psychological symptoms after pet loss is lacking. Therefore, this study aimed to investigate the rates of clinically significant psychological distress after pet loss and the impact of childhood trauma on adults who have experienced pet loss. An online survey was conducted with non-clinical adult participants who had experienced the loss of a companion animal. Psychiatric characteristics were evaluated using standardized assessments, including the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7), and the Insomnia Severity Index (ISI). Childhood trauma was evaluated using the Childhood Trauma Questionnaire (CTQ). In a sample of 137 individuals who had experienced pet loss, the percentages of those who exceeded the cutoff points were 55% for the ICG, 52% for the PHQ-9, 40% for the GAD-7, and 32% for the ISI. The group that reported childhood trauma exhibited significantly higher scores on the ICG (t = 2.16, P = 0.032), PHQ-9 (t = 3.05, P = 0.003), GAD-7 (t = 2.61, P = 0.010), and ISI (t = 2.11, P = 0.037) than in the group without childhood trauma. For participants who experienced pet loss for less than one year, there was no significant difference in the ICG between the trauma and non-trauma groups, as both had extremely high scores. However, the trauma group had a significantly higher PHQ-9 (t = 2.58, P = 0.012) than the non-trauma group. In contrast, for participants who experienced pet loss for more than one year, the trauma group had a significantly higher ICG (t = 2.22, P = 0.03) than the non-trauma group, while there was no significant difference in the PHQ-9. Additionally, the emotional abuse scores on the CTQ were most significantly correlated with the ICG scores even after controlling for depressive symptoms. People who experienced pet loss had significant psychological symptoms, ranging from 32% to 55%. Childhood trauma experiences affect complicated grief, depressive symptoms, anxiety symptoms, insomnia and prolonged grief disorder after pet loss. After pet loss, people with childhood trauma may require more psychological help than those without trauma.

Dwelling in prolonged grief: Resting state functional connectivity during oxytocin and placebo administration.

Clinical theories of adaptation in bereavement highlight a need for flexible shifting between mental states. However, prolonged motivational salience of the deceased partner may be a complicating factor, particularly when coupled with perseverative thinking about the loss. We investigated how prolonged grief symptoms might relate to resting state functional brain network connectivity in a sample of older adults (n=38) who experienced the death of a partner 6-36 months prior, and whether intranasal oxytocin (as a neuropeptide involved in pair-bonding) had differential effects in participants with higher prolonged grief symptoms. Higher scores on the Inventory of Complicated Grief (ICG) were associated with lower anticorrelation (i.e., higher functional connectivity) between the defaultretrosplenial - cingulo-operculardACC network pair. Intranasal oxytocin increased functional connectivity in the same defaultretrosplenial - cingulo-operculardACC circuit but ICG scores did not moderate effects of oxytocin, contrary to our prediction. Higher ICG scores were associated with longer dwell time in a dynamic functional connectivity state featuring positive correlations among default, frontoparietal, and cingulo-opercular networks, across both placebo and oxytocin sessions. Dwell time was not significantly affected by oxytocin, and higher prolonged grief symptoms were not associated with more variability in dynamic functional connectivity states over the scan. Results offer preliminary evidence that prolonged grief symptoms in older adults are associated with patterns of static and time-varying functional network connectivity and may specifically involve a default network-salience-related circuit that is sensitive to oxytocin.

Are empathy profiles and perceived social support associated with depressive and grief-related symptoms in suicide survivors?

To investigate the link between empathy, perceived social support, and depressive and grieving symptoms in suicide survivors. Scores on the Beck Depression Inventory (BDI), Inventory of Complicated Grief (ICG), Prolonged Grief Disorder (PGD), Interpersonal Reactivity Index (IRI), and the Social Support section of the Interpersonal Questionnaire were collected from 265 survivors. Relations were tested via multivariate regression models. Lower Perspective Taking (PT) was related with higher levels of BDI score, and higher Personal Distress (PD) was associated with higher BDI, ICG, and PGD scores. Higher levels of Social Support were related with higher BDI and ICG (but not PGD) scores. Empathic PD and PT, and perceived social support are differently associated with depression and grief-related symptoms. Empathy-focused psychotherapies and empowerment of social support may reduce symptoms in suicide survivors.

Post-Traumatic Growth in Parents following Their Child's Death in a Pediatric Intensive Care Unit.

Background: Although bereaved parents suffer greatly, some may experience positive change referred to as post-traumatic growth. Objective: Explore the extent to which parents perceive post-traumatic growth after their child's death in a pediatric intensive care unit (PICU), and associated factors. Design: Longitudinal parent survey conducted 6 and 13 months after a child's death. Surveys included the Post-traumatic Growth Inventory-Short Form (PTGI-SF), a 10-item measure with range of 0-50 where higher scores indicate more post-traumatic growth. Surveys also included the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-8 (PHQ-8) for depression, the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), a single item on perceived overall health, and sociodemographics. Setting/Subjects: One hundred fifty-seven parents of 104 children who died in 1 of 8 PICUs affiliated with the U.S. Collaborative Pediatric Critical Care Research Network. Results: Of participating parents, 62.4% were female, 71.6% White, 82.7% married, and 89.2% had at least a high school education. Mean PTGI-SF scores were 27.5 ± 12.52 (range 5-50) at 6 months and 28.6 ± 11.52 (range 2-49) at 13 months (p = 0.181). On multivariate modeling, higher education (compared with those not completing high school) and higher 6-month ICG scores (reflecting more complicated grief symptoms) were associated with lower 13-month PTGI-SF scores (p = 0.005 and 0.033, respectively). Conclusion: Parents bereaved by their child's PICU death perceive a moderate degree of post-traumatic growth in the first 13 months after the death however variability is wide. Education level and complicated grief symptoms may influence parents' perception of post-traumatic growth.

The Association between Therapeutic Alliance and Parental Health Outcomes following a Child's Death in the Pediatric Intensive Care Unit.

Therapeutic alliance reflects the strength and quality of the physician-patient/family relationship. We investigated the association between therapeutic alliance and bereaved parents' mental health and perceived overall health following their child's death in a pediatric intensive care unit (PICU). Bereaved parents were surveyed 6 months after their child's death in a PICU affiliated with the Collaborative Pediatric Critical Care Research Network. Parents were evaluated for complicated grief, depression, and post-traumatic stress using the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire (PHQ-8), and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), respectively. Overall health was evaluated using a single item. Therapeutic alliance between parents and their deceased child's PICU physicians was assessed using the Human Connection scale (HCS). Two hundred and thirty-five parents of 158 deceased children completed surveys. Mean ICG score was 34.4 ± 14.9 with 142 (60.4%) parents screening positive for complicated grief. Mean PHQ-8 score was 9.1 ± 6.2 with 102 (43.4%) screening positive for at least moderate depression. Mean SPRINT score was 14.6 ± 8.2 with 122 (51.9%) screening positive for post-traumatic stress disorder. Overall health was perceived as fair for 47 (20.0%) parents and poor for 10 (4.3%). Using multivariable modeling, higher HCS score (greater therapeutic alliance) was significantly associated with lower (better) ICG score (-0.23, 95% CI -0.42, -0.04, p = 0.018). HCS score was not significantly associated with PHQ-8, SPRINT, or overall health scores. We conclude that bereaved parents experience a high level of adverse mental health symptoms including complicated grief, depression, and post-traumatic stress symptoms. Greater therapeutic alliance with PICU physicians may lessen symptoms of complicated grief during bereavement.

Posttraumatic Distress Symptoms and Their Response to Treatment in Adults With Prolonged Grief Disorder.

Posttraumatic stress disorder and prolonged grief disorder (PGD) arise following major life stressors and may share some overlapping symptomatology. This study aimed to examine the presence and response to treatment of posttraumatic stress symptoms (PTSS) in bereaved adults with a primary diagnosis of PGD. A randomized controlled trial of 395 adults with PGD (defined as an Inventory of Complicated Grief score ≥ 30 plus confirmation on structured clinical interview) randomly assigned participants to either complicated grief treatment (CGT) with citalopram, CGT plus placebo, citalopram, or placebo between March 2010 and September 2014. This secondary analysis examined the presence of PTSS (per the Davidson Trauma Scale) at baseline and change in PTSS with treatment using longitudinal mixed-effects regression and examined the role of violent compared to nonviolent deaths (loss type). High levels of PTSS were present at baseline, regardless of loss type, and were associated with increased functional impairment (P < .001). CGT with placebo demonstrated efficacy for PTSS compared to placebo in both threshold (OR = 2.71; 95% CI, 1.13-6.52; P = .026) and continuous (P < .001; effect size d = 0.47) analyses, and analyses were suggestive of a greater effect for CGT plus citalopram compared to citalopram alone (threshold analysis: OR = 2.84; 95% CI, 1.20-6.70; P = .017; continuous analysis: P = .053; d = 0.25). In contrast, citalopram did not differ from placebo, and CGT plus citalopram did not differ from CGT plus placebo. Bereavement-related PTSS are common in bereaved adults with PGD in the context of both violent and nonviolent death and are associated with poorer functioning. CGT shows efficacy for PTSS, while the antidepressant citalopram does not. : ClinicalTrials.gov identifier: NCT01179568.

The relationship of loneliness with mental health trajectories in bereaved older adults

<h3>Introduction</h3> Losing a loved one often results in acute grief and depressive symptoms. The vast majority of older individuals are resilient and return to normal functioning within a year after a loss. However, a significant minority develop mental health complications, including prolonged grief disorder and bereavement-related depression. This can lead to adverse consequences, including physical and cognitive decline, impairment in global functioning, and early mortality. The contributing factors that increase the likelihood of adverse mental health outcomes in bereaved individuals have not been fully elucidated. This study explores the relationship of loneliness with grief and depressive symptom trajectories in older adults after an attachment loss. <h3>Methods</h3> 45 individuals over age 50 and within 13 months following the death of a loved one completed a comprehensive clinical assessment at the baseline visit (week 0), including the UCLA Loneliness Scale-3, the Inventory of Complicated Grief (ICG), and the Hamilton Depression Rating Scale (HAM-D). All participants completed a 6-month longitudinal study; ICG and HAM-D were completed at weeks 8, 16, and 26 (endpoint). Statistical analyses: Two classes of mixed-effects models, where covariates are fixed effects and patient-specific dependents are random effects, were considered. Cross-sectional models were used to investigate relationships between loneliness and grief and depressive symptoms at baseline. Longitudinal models were used to examine the relationship of baseline loneliness scores with grief and depressive symptoms across the 6-month study duration. In longitudinal models, the interactions between time elapsed since baseline and dynamic measurements (complicated grief and depressive symptom scores) were examined. A hierarchical variance-covariance structure for random effects, informed by clustering of clinical trajectories, was used to determine participant trajectories. Age, gender, days since the loss, and cumulative medical illness rating scale for geriatrics scores were included as covariates in all models. The R statistical software (version 3.6.3) was utilized for data analyses. <h3>Results</h3> Cross-sectionally, loneliness was positively associated with scores on the ICG (p<0.01) and HAM-D (p<0.01) in separate models, after adjusting for covariates. However, the loneliness-ICG relationship was no longer significant when HAM-D was included as a covariate in an extended model (p=0.32). Mediation analyses revealed that the loneliness-ICG relationship was mediated by baseline HAM-D scores. In contrast, the loneliness-HAM-D relationship remained significant even after including ICG as a covariate (p=0.01). Longitudinally, baseline loneliness scores were associated with worsening HAM-D scores over time (p<0.01); this association persisted over 6 months (p<0.01). The loneliness-ICG longitudinal relationship was not significant. Of additional interest were the co-movement patterns expressed by HAM-D and ICG: adults following a C-shaped trajectory for HAM-D scores were likely to demonstrate a similar trajectory with ICG scores. <h3>Conclusions</h3> Loneliness was independently associated with grief and depression symptom severity in older adults following bereavement. However, the baseline loneliness-grief symptom association was mediated by depression. Since loneliness could predict depressive symptom trajectories in older grieving individuals, interventions targeting loneliness may also improve depression outcomes in this study population. Although the co-movement analysis was exploratory (i.e., this was used to inform the structure of the covariance matrix for random effects in analytic models), it has implications for future treatment intervention study designs. <h3>Funding</h3> This research was funded by NIMH grants R01 MH122490 and R21 MH109807 (Goveas); Costigan Family Foundation (Goveas); and UL1TR001436

Pre-Loss Group Therapy for Family Caregivers of Persons With Dementia: Translation Into Practice

We developed Pre-Loss Group Therapy (PLGT) for dementia caregivers at risk for Complicated Grief (CG). PLGT is a manualized ten-session multi-modal group therapy that includes elements of cognitive behavior therapy, motivational interviewing, exposure therapy, memory revisiting, meaning-making, and self-care. We implemented and evaluated three PLGT cohorts in three long-term care facilities with family caregivers at-risk for CG whose care recipient had a life expectancy of 6 months or less and resided in a long-term care facility (NT = 24). Evaluation of participant preparedness for the death of the persons with dementia (PWD), self-care and grief outcomes showed significant improvement across multiple domains between pre and post-group, notably a statistically significant decrease in grief as measured by the Inventory of Complicated Grief score from baseline (M = 25.67, SE=1.80) to post-group (M = 14.41, SE=1.65) t(21)= 6.280, p<0.001. Clinician-rated grief severity declined (N=22, β = –0.472, SE = 0.018, p < 0.001) per week and grief improvement increased (N=22, β = 0.259, SE = 0.023, p < 0.001) per week, as assessed on the Clinician Global Impressions Scale. We subsequently trained two LCSWs to conduct PLGT, and both clinical outcomes and treatment fidelity and skills measures achieved performance levels of master clinician-trainers. Family caregivers at risk for CG may benefit from group therapy targeting preparedness and pre-loss grief experience, as we provide with PLGT. Manualized PLGT is suitable for implementation by LCSWs in the settings of hospice and long-term care.

Group therapy for family caregivers of PWD at risk for complicated grief: A feasibility and efficacy analysis of pre‐loss group therapy

AbstractBackgroundOur previous evaluation of Complicated Grief Group Therapy (CGGT) in bereaved dementia family caregivers demonstrated efficacy and identified intervention elements suitable for adaption into a preventative care approach.MethodWe adapted CGGT treatment elements into a manualized 10 session pre‐loss group psychotherapy—Pre‐Loss Group Therapy (PLGT)—for dementia caregivers at risk for Complicated Grief (CG). We implemented and evaluated three PLGT cohorts in three long‐term care facilities with family caregivers at‐risk for CG whose care recipient had a life expectancy of 6 months or less and resided in a long‐term care facility (NT = 24).ResultEvaluation of participant preparedness for the death of the person with dementia (PWD), self‐care and grief outcomes showed significant improvement across domains between pre and post‐group. Notably, there was a statistically significant decrease in grief as measured by the Inventory of Complicated Grief score from baseline (M = 25.67, SE=1.80) to post‐group (M = 14.41, SE=1.65) t(21)= 6.280, p&lt;0.001 and a statistically significant increase in meaning making as measured by the Grief and Meaning Reconstruction Inventory score from baseline (M = 111.74, SE=1.96) to post‐group (M = 116.46, SE=1.65) t(21)= ‐3.197, p&lt;0.01. Clinician‐rated grief severity declined (N=22, β = –0.472, SE = 0.018, p &lt; 0.001) per week and grief improvement increased (N=22, β = 0.259, SE = 0.023, p &lt; 0.001) per week, as assessed on the Clinician Global Impressions Scale. We evaluated Early‐Stage intervention feasibility components of recruitment, retention, treatment fidelity, as well as PLGT participant acceptability, tolerability, satisfaction and treatment adherence. Of participants, 75% completed at least 80% of sessions, and 91% completed all assessments. Each feasibility target was achieved.ConclusionThis is the first known application of proven therapeutic strategies to address CG applied to high‐risk dementia caregivers prior to the death of the PWD. Caregivers at risk for CG may benefit from group therapy targeting preparedness and pre‐loss grief experience, as we provide with PLGT. PLGT holds promise for translation into comprehensive caregiver support programs and delivered to active caregivers of living PWD at risk for CG across community and in the settings of hospice and long‐term care.

Amygdala Functional Connectivity Features in Grief: A Pilot Longitudinal Study

ObjectiveAcute grief, in an important minority of older adults, can become protracted, intense, and debilitating, leading to the development of complicated grief (CG). However, the neurobiologic mechanisms underlying a maladaptive grief response after an attachment loss are unknown. The current study aimed to examine the amygdala brain network features that cross-sectionally explain the symptom variance and longitudinally relate to grief symptom trajectories after an attachment loss. MethodsBaseline amygdala functional connectivity (Fc) was assessed using a seed-based resting-state functional magnetic resonance imaging method in 35 adults who were within 1-year after death of a loved one and 21 healthy comparison (HC) participants. Magnetic resonance imaging scans were obtained at baseline, and clinical assessments, including the inventory of complicated grief (ICG) were completed at weeks 0, 8, 16, and 26 (endpoint). ResultsRelative to HC participants, grief participants showed increased amygdala Fc in the posterior default mode (bilateral medial temporal lobes and left precuneus) and thalamus. Amygdala Fc in the default mode and ventral affective regions positively correlated with ICG scores at baseline. Furthermore, increased baseline amygdala functional connections with the dorsal frontal executive control and salience network regions correlated with worsening ICG scores over time. These longitudinal findings persisted after controlling for covariates, including baseline depressive and anxiety symptoms. ConclusionThese results provide novel preliminary evidence suggesting amygdala-based brain network measures to cross-sectionally explain symptom variance and longitudinally correlate with grief symptom trajectories in grievers. Amygdala brain network function measures may have the potential to serve as biomarkers of CG.

Polish version of the Inventory of Complicated Grief - preliminary validation.

The purpose of the following study was to verify the psychometric properties of the Polish version of the Inventory of Complicated Grief. 278 people who experienced loss of a close relative or a friend participated in the research on adaptation of the tool. The following research methods were applied: ICG (Inventory of Complicated Grief), BDI (Beck Depression Inventory), STAI (State-Trait Anxiety Inventory), IES-R (Impact of Events Scale-Revised), AHS (Adult Hope Scale), LOT-R (Life Orientation Test-Revised), GSES (General Self-Efficacy Scale), MSTAT-2 (Multiple Stimulus Types Ambiguity Tolerance). The statistical analyses conducted as part of the research prove the Polish version of the ICG to be a reliable and valid tool (Cronbach's alpha = 0.941). Amoderate positive correlation was noted between the overall ICG score and depression (r = 0.50; p < 0.001), post-traumatic stress disorder (r = 0.67; p < 0.001) and trait anxiety (r = 0.59; p < 0.001). The general ICG results also display negative correlation between variables related to positive expectations of the future: optimism (r = -0.37; p < 0.001), hope for success (r =-0.19; p =0.001), general self-efficacy (r = - 0.27; p < 0.001), and ambiguity tolerance (r = - 0.27; p < 0.001). The conducted confirmatory factor analysis (CFA) revealed that the one-factor model of the Polish version of the Inventory of Complicated Grief can be considered wellfitted to the data (correlation of measurement errors was allowed). Preliminary studies on the adaptation of the Polish version of the ICG prove, therefore, that it is a valid and reliable tool. However, further research is needed to help better understand the structure of complicated grief symptoms.

Stigma, grief and depressive symptoms in help-seeking people bereaved through suicide

BackgroundThe painful experience of mourning after suicide can be further complicated by the stigma surrounding suicide survival. We investigated how grief and depression influence the perception of stigma towards survivors in a sample of help-seeking persons bereaved through suicide. MethodsCross-sectional design. Information on sociodemographic variables and responses to the Stigma of Suicide Survivor Scale, Beck Depression Inventory (BDI) and Inventory of Complicated Grief (ICG) was collected from 240 people bereaved through suicide who consecutively accessed an online support initiative. ResultsDespite the strong correlation between ICG and BDI scores, the intensity of depressive but not of grief symptoms was related to perceived stigma towards survivors. Time since loss was also positively related to levels of perceived stigma against survivors. The links between depression and perceived stigma persisted after taking into account relationship with the deceased and other sociodemographic factors. LimitationsThe main study limitations are the cross-sectional design, reliance on self-report measures, and the self-selection of the sample of people bereaved through suicide, seeking help through a website. Social support was not measured and the sample included a large proportion of women. ConclusionsSpecific interventions designed for persons bereaved by suicide should consider that psychological distress and mourning are qualitatively different reactions to a suicide loss. The relationship among perceived stigma, depressive suffering and time elapsed since the suicide loss suggests the usefulness of closely investigating the experience of stigma in all people bereaved through suicide with depressive symptoms, even long after the event.

Acceptability, feasibility and outcome of a screening programme for complicated grief in integrated primary and behavioural health care clinics.

Complicated grief, a syndrome of persistent grief diagnosed >6 months following the loss of someone close is expected to be included in the 11th revision of the International Classification of Diseases as a new diagnosis called prolonged grief disorder. Complicated grief is associated with impaired functioning and health comorbidity and does not respond to treatments for depression. Individuals may seek help in primary care where providers need to be familiar with the syndrome. This study examines the acceptability, feasibility and outcome of a screening programme for complicated grief among diverse adults receiving behavioural health services in integrated primary care. Behavioural health providers (n = 14) administered the Brief Grief Questionnaire and the Inventory of Complicated Grief during routine assessment and completed an acceptability survey. Descriptive statistics described rates of complicated grief symptoms and sample demographics, health and service use. Most providers (71%) reported the Brief Grief Questionnaire to be a moderate to very useful assessment instrument and the Inventory of Complicated Grief moderate to very useful for developing a treatment plan (57%). Of the 2425 patients screened, 1015 reported a loss over 6 months ago. Of these 1015, 28% (n = 282) screened positive on the Brief Grief Questionnaire and 22% (n = 228) endorsed symptoms of complicated grief (Inventory of Complicated Grief score ≥25), considered at high risk for needing clinical care. A screening programme for identifying complicated grief was acceptable to providers, feasible to implement and useful in identifying complicated grief in integrated primary care clinics.

Treatment of Complicated Grief in Survivors of Suicide Loss: A HEAL Report.

Suffering associated with complicated grief (CG) is profound. Because suicide loss survivors are susceptible to developing CG, identifying effective treatments for suicide loss survivors with CG is a high priority. This report provides data on the acceptability and effectiveness of antidepressant medication and complicated grief therapy (CGT), a CG-targeted psychotherapy, for suicide loss survivors with CG identified by an Inventory of Complicated Grief score ≥ 30. This is a secondary analysis of data collected from March 2010 to September 2014 for a 4-site, double-blind, placebo-controlled randomized trial comparing the effectiveness of antidepressant medication alone or in combination with CGT for participants with CG (score ≥ 30 on the Inventory of Complicated Grief) who were bereaved by suicide (SB; n = 58), accident/homicide (A/H; n = 74), or natural causes (NC; n = 263). Using mode of death as a grouping factor, we evaluated acceptability of treatments by comparing 12-week medication and 16-session CGT completion; we evaluated effectiveness by comparing response at week 20, defined by a score of 1 or 2 on the Complicated Grief Clinical Global Impressions-Improvement scale (CG-CGI-I), and additional secondary response measures. Among participants receiving medication alone, SB medication completion rates (36%) were lower than rates for A/H (54%) and NC (68%; χ² = 11.76, P < .01). SB medication completion rates were much higher for SB individuals receiving CGT (82%; χ² = 12.45, P < .001) than for SB individuals receiving medication alone. CGT completion rates were similar in the 3 groups (SB = 74%, A/H = 64%, NC = 77%; χ² = 2.48, P = .29). For SB participants receiving CGT, CG-CGI-I response rates were substantial (64%), but lower compared to the other groups (A/H = 93%, NC = 84%; χ² = 8.00, P < .05). However, on all other outcomes, changes from baseline for SB participants were comparable to those for A/H and NC participants, including number and severity of grief symptoms, suicidal ideation, and grief-related impairment, avoidance, and maladaptive beliefs. These results raise concern about the acceptability of medication alone as a treatment for complicated grief in treatment-seeking suicide-bereaved adults. In contrast, CGT is an acceptable and promising treatment for suicide-bereaved individuals with complicated grief. ClinicalTrials.gov identifier: NCT01179568.

P.3.005 - Interactions of oxytocin receptor gene variation with behavioural inhibition and adult separation anxiety in complicated grief

Complicated grief (CG) refers to the severe and prolonged (≥ 6 months) grief reaction following the loss of a beloved person that occurs in approximately 10 – 20% of bereaved individuals and is associated with an increased risk for the development of depression and anxiety disorders [1]. So far, the underlying processes contributing to the vulnerability to CG are not yet well understood but likely comprise the complex interplay of genetic, temperamental and psychological factors that interactively influence the severity and persistence of grief reactions. In light of its central role in social behavior, stress regulation and attachment, the oxytocin receptor (OXTR) gene may play a key role in the conferral of CG. Additionally, temperamental traits such as behavioral inhibition (BI) or psychological characteristics such as symptoms of separation anxiety (SA) may predispose to the development of CG. For instance, adult SA has been linked to higher symptom severity and impairment in individuals with CG [2]. Therefore, the present study for the first time aimed to address the involvement of OXTR gene variation in the emergence of CG and the potential moderating effects of BI and SA. To this end, 96 adult outpatients (70 female, 26 male; mean age ± SD = 39.96 ± 12.71 years) with DSM-IV mood and anxiety disorders were assessed for CG using the Inventory of Complicated Grief (ICG). All patients were genotyped for OXTR rs2254298 and characterized for BI using the Retrospective Self-Report of Inhibition (RSRI) and SA symptoms using the Adult Separation Anxiety Scale (ASA-27). Patients were grouped according to genotype (GG vs. AG/AA carriers). The influence of grouped OXTR genotype, RSRI and ASA-27 scores, respectively, on ICG score was investigated via hierarchical multiple regression analyses. No differences were observed with regard to age, sex, or questionnaire scores (all p ≥ 0.05). No main effects of OXTR genotype, RSRI or ASA-27 scores on CG were observed, however ICG scores differed as a function of OXTR genotype and RSRI score (OXTR x BI, p=0.031), and, on a trend-level, ASA-27 score (OXTR x ASA, p=0.064). Specifically, in patients homozygous for the OXTR G allele, increased levels of both BI and ASA were related to higher ICG scores. Of note, this pattern appears to be reversed under conditions of low BI or low ASA. In line with the ‘differential susceptibility hypothesis’ [3], the present findings suggest that while OXTR GG genotype carriers are more vulnerable to the development of CG in the presence of risk-increasing factors, they at the same time are the least likely to develop CG in the absence of these risk factors. Taken together, the present results for the first time provide evidence for an interaction of OXTR gene variation with BI and potentially also symptoms of adult SA in the moderation of clinically relevant grief reactions and may therefore inspire new insights into the development and improvement of therapeutic options in the prevention and treatment of CG.

A Two-Tiered Strategy for Preventing Complications of Bereavement in the First Thirteen Months Post-Loss: A Pilot Study Using Peer Supports with Professional Therapist Back-up

This feasibility and acceptance pilot study for preventing complications of bereavement within the first year post loss recruited 20 adult grievers within 9 months of becoming bereft and assigned consenting subjects to peer supporters trained by a non-profit bereavement support organization for weekly or bi-weekly telephone-based peer support until month 13 post-loss. Subjects who met DSM-5 criteria for major depressive disorder or showed an Inventory of Complicated Grief (ICG) score exceeding 19, 6 months or more post loss, were assigned to 12 to 16 weeks of interpersonal psychotherapy (IPT) with an experienced therapist. Eight and six subjects completed the protocol assigned to peer support and IPT, respectively, with pre/post Patient Health Questionnaire-9 scores of 5.38 (2.45) versus 3.25 (4.13) (p = 0.266) and 16.67 (7.17) versus 8.40 (5.73) (p =0.063); and pre/post ICG scores of 12.50 (4.72) versus 5.00 (2.51) (p = 0.016) and 35.17 (5.12) versus 8.4 (5.73) (p = 0.063). Implications of this two-tiered model of early intervention for preventing complications of grief are discussed.

Risk factors for mental health problems and complicated grief in bereaved families of motor vehicle accident victims

This study examined the risk factors for mental health problems and complicated grief in bereaved families using a nationwide sample of 453 Japanese adults who had lost a family member to a motor vehicle accident within three years. The results indicate that 31.0% of participants had K6 scores > 13 and 61.0% had ICG (Inventory of Complicated Grief) scores > 26. A higher K6 score was associated with secondary victimization and support seeking, whereas a higher ICG score was associated with the death of a child. Dispute over the liability for the accident and the resulting anxiety, measured by the Japanese version of ECR (Experiences in Close Relationships), were common predictors of higher K6 and ICG scores. The results suggest that complicated grief is more dependent on the circumstances of the death, whereas mental health problems are more affected by a participant’s coping after the death, implying that effective support and interventions are necessary for mental health problems and complicated grief after a violent death.

Effects of Mental Health Support on the Grief of Bereaved People Caused by Sewol Ferry Accident.

Few studies have assessed the overall effects of multi-centered, complicated mental health support on the grief process. This study investigated the broader influence of mental health support provided practically to the bereaved family on the severity of complicated grief. Ninety-three bereaved family members of the Sewol ferry accident were recruited. Severity of complicated grief, post-traumatic stress disorder (PTSD) and depressive disorder was assessed through self-reporting questionnaire, inventory of complicated grief (ICG), PTSD Check List-5 (PCL-5) and Patient Health Questionnaire-9 (PHQ-9). We also included demographic, socioeconomic, health-related variables, and Functional Social Support Questionnaire (FSSQ), which affect the ICG score. Participants were divided into 4 groups based on the experience of psychotherapy or psychiatry clinic service before the accident and mental health support after the disaster. In univariate analysis, these 4 groups showed a significant difference in the mean ICG score (P = 0.020). Participants who received mental health support only after the Sewol ferry accident (group 2) showed a lower mean ICG score than those who received neither psychotherapy or psychiatry clinic service before the disaster nor mental health support after the accident (group 4). There was no significant correlation between the ICG score and other variables except for subjective health status measured 1 month after the disaster (P = 0.005). There was no significant difference in PCL-5 (P = 0.140) and PHQ-9 scores (P = 0.603) among groups, respectively. In conclusion, mental health support significantly reduced the severity of grief only in those participants who had not received any psychotherapy or psychiatry clinic service before the accident.