systematic literature review (5-6 Empirical studies) based on poverty (as predictors) associated with child abuse
PREDICTORS OF COMPLICATED GRIEF: A SYSTEMATIC REVIEW OF EMPIRICAL STUDIES
ELIZABETH A. LOBB
Cunningham Centre for Palliative Care, Calvary Health Care Sydney, Korgarah, New South Wales; WA Centre for Cancer and Palliative Care
within the Curtin Health Innovation Research Institute, Curtin University of Technology; and School of Nursing, Midwifery and Postgraduate Medicine,
Edith Cowan University, Perth, Western Australia, Australia
LINDA J. KRISTJANSON and SAMAR M. AOUN
WA Centre for Cancer and Palliative Care within the Curtin Health Innovation Research Institute, Curtin University of Technology, Perth,
Western Australia, Australia
LEANNE MONTEROSSO
WA Centre for Cancer and Palliative Care within the Curtin Health Innovation Research Institute, Curtin University of Technology, and School of Nursing, Midwifery and Postgraduate Medicine, Edith Cowan University,
Perth, Western Australia, Australia
GEORGIA K. B. HALKETT
WA Centre for Cancer and Palliative Care within the Curtin Health Innovation Research Institute, Curtin University of Technology, Perth,
Western Australia, Australia
ANNA DAVIES
National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
Received 20 November 2009; accepted 21 February 2010. This research was funded by the Commonwealth of Australia, Department of Health &
Ageing. We acknowledge the guidance and support of the project staff and reference group at the Australian Government Department of Health and Ageing. The opinions expressed in this document are those of the authors and not necessarily those of the Australian Govern- ment. We would also like to acknowledge and thank the members of our Expert Panel for their comments and reviews: Ms. Julie Dunsmore, Mr. Chris Hall, Mr. Mal McKissock, Dr. Anne Atkinson, Professor Richard Bryant, Ms. Kate Sullivan, Ms. Trudy Hansen, and Ms. Jane Mowll. Finally, many thanks to our administrative support officer, Ms Helen Morris.
Address correspondence to Elizabeth A. Lobb, Cunningham Centre for Palliative Care Calvary Health Care Sydney, Kogarah, New South Wales 2217, Australia. E-mail: Liz.Lobb@sesiahs.health.nsw.gov.au
Death Studies, 34: 673–698, 2010 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print=1091-7683 online DOI: 10.1080/07481187.2010.496686
673
A systematic review of the literature on predictors of complicated grief (CG) was undertaken with the aim of clarifying the current knowledge and to inform future planning and work in CG following bereavement. Predictors of CG prior to the death include previous loss, exposure to trauma, a previous psychiatric history, attachment style, and the relationship to the deceased. Factors associa- ted with the death include violent death, the quality of the caregiving or dying experience, close kinship relationship to the deceased, marital closeness and dependency, and lack of preparation for the death. Perceived social support played a key role after death, along with cognitive appraisals and high distress at the time of the death. Inconsistent definitions of CG and measurement tools were noted in the earlier studies reviewed. Limitations identified in the studies included use of cross-sectional designs, heterogeneous samples, high attrition, demographic differences between cases and controls, differences in length of time since death, and differences in types of death experienced. Notwithstanding these limitations, some consistent findings have emerged. Further research into conceptualizations of CG in terms of attachment theory and constructivist and cognitive-behavioral concepts of finding purpose and meaning after bereavement is warranted.
Our research team undertook a systematic review of literature on complicated grief (CG), and this article reports our analysis of the research that examined its predictors. The term complicated grief refers to a pattern of adaptation to bereavement that involves the presentation of certain grief-related symptoms at a time beyond that which is considered adaptive. These symptoms include marked and chronic separation distress, such as longing and searching for the deceased, loneliness, and preoccupation with thoughts of the deceased; and symptoms of traumatic distress, such as feelings of disbelief, mistrust, anger, shock, detachment from others, and experiencing somatic symptoms of the deceased. These symptoms have been shown to be distinct from depressive and anxiety symptom clusters (Bonanno et al., 2007; Lichtenthal, Cruess, & Prigerson, 2004; Prigerson et al., 1995, 1996, 1999). People who suffer from CG experience a sense of ‘‘persistent and disturbing disbelief regarding the death’’ and resistance to accepting the painful reality (Shear & Shair, 2005, p. 253) for at least 6 months to the point of functional impairment. Intense yearning and longing for the deceased continues, along with frequent pangs of intense, painful emotions. ‘‘Thoughts of the loved one remain preoccupying, often including distressing intrus- ive thoughts related to the death, and there is avoidance of a range of situations and activities that serve as a reminder of the painful
674 E. A. Lobb et al.
loss. Interest and engagement in ongoing life is limited or absent’’ (Shear & Shair, 2005, p. 253). It is estimated that between 10% and 20% of bereaved people experience CG (Byrne & Raphael, 1994; Middleton, Burnett, Raphael, & Martinek, 1996; Prigerson et al., 1995, 1996, 1999; Prigerson & Jacobs, 2001a). CG was previously referred to as traumatic grief but was renamed to avoid confusion with posttraumatic stress disorder. More recent terminology has been reported as complicated grief disorder (Zhang, El-Jawahri, & Prigerson, 2006) or prolonged grief disorder (PGD; Prigerson et al., 2009).
Literature Search Strategy and Results
We searched the following specialist databases and resources: MEDLINE, PsychInfo, CINAHL, EMBASE, APAIS, DRUG, AIATISIS bibliography, Current Contents, Science Citation Index, Cochrane Collaboration=Evidence Based Medicine, PsychBOOK, Dissertation Abstracts International, CareSearch, Australian Government Department of Health and Ageing Website, and other additional websites. The following criteria were used to identify material that would be included in the review: evidence based, published in a peer-reviewed journal, published between 1990 and 2007, and seminal work published pre-1990 and published in the English language. Relevant professional and research organiza- tions and leading authors in the field were contacted to identify any additional published or ‘‘in press’’ research of relevance; conse- quently some recent relevant papers have also been included.
Abstracts that appeared to discuss CG and met the inclusion criteria were selected and retrieved (Anna Davies). Because of the inconsistent use of adjectives to describe CG and the various conceptualizations of the disorder, if the abstract did not contain enough information to ascertain whether or not the article was rel- evant, the full article was retrieved. A second reviewer (Elizabeth A. Lobb) assessed 50% of the abstracts to confirm appropriateness of inclusion of the articles. Full text versions of the abstracts were then obtained. Articles that met the inclusion criteria and pre- sented original research about CG were evaluated and data from these articles were extracted into evidence tables (Anna Davies). Eighty percent of the included material was checked by a second reviewer to determine if it met the inclusion criteria (Georgia
Predictors of Complicated Grief 675
K. B. Halkett), and 10% of these studies were cross-checked by a third reviewer to confirm the evidence ratings for the papers (Samar M. Aoun). Fifty percent of excluded materials were checked by a second reviewer (Elizabeth A. Lobb) to confirm exclusion. In summary, the literature review identified 2,518 refer- ences as potentially relevant. Of these, 889 references were selec- ted for evidence-based assessment and 151 were reviewed. Forty articles examined predictors of CG, and a synthesis of these find- ings are reported here.
Results
Predictors for CG
Our review identified forty studies that examined predictors of risk for CG within the construct of CG as defined in this review (see Table 1). The majority of studies measured CG using the Inventory of Complicated Grief (Prigerson et al., 1995) or the Texas Revised Inventory of Grief (Faschingbauer, 1981).
Predictors Associated with Childhood
Risk factors specific to CG suggest that insecure attachments play a crucial role. Participants in studies who reported prior adversities in life were generally more distressed following bereavement than those who did not report adversities. In particular, childhood separation anxiety, adversities occurring in childhood (such as the death of parent and childhood abuse) had a greater impact and were associated with CG in response to subsequent bere- avement in adult life (Silverman, Johnson, & Prigerson, 2001; Vanderwerker, Jacobs, Murray-Parkes, & Prigerson, 2006).
Predictors Associated with Dependency
In a study of pre-loss predictors of CG as a consequence of conju- gal loss, a clear bereavement pattern predictor was found to be excessive dependency both as dependency on the spouse and as a more general personality trait. Less instrumental support and a greater likelihood of having a healthy spouse were also reported as predictors (Bonanno et al., 2002). In examining the relationship
676 E. A. Lobb et al.
T A B L E
1 S u m m ar y o f S tu d ie s o n P re d ic to rs
o f C o m p li ca te d G ri ef
(n ¼ 4 0 )
A u th o rs
P o p u la ti o n
R es u lt s
B ee ry
et al .,
1 9 9 7
E ld er ly
sp o u se s o f te rm
in al ly
il l (n ¼ 7 0 )
C ar eg iv er
b u rd en
w as
fo u n d to
b e si g n if ic an
tl y as so ci at ed
w it h b o th
tr au
m at ic
g ri ef
an d d ep
re ss io n . N o si g n if ic an
t as so ci at io n w as
fo u n d
b et w ee n th e ti m e sp en
t ca ri n g an
d d u ra ti o n o f ca re -g iv in g w it h ei th er
d ep
re ss io n o r tr au
m at ic
g ri ef . C h an
g e in
ro le
fu n ct io n o f th e ca re g iv er
w as
as so ci at ed
w it h d ep
re ss io n , b u t n o t tr au
m at ic
g ri ef . N o si g n if ic an
t as so ci at io n w as
fo u n d fo r ca re g iv er s’ g ra ti fi ca ti o n w it h ei th er
d ep
re ss io n
o r tr au
m at ic
g ri ef .
V an
D o o rn
et al ., 1 9 9 8
C ar er s o f te rm
in al ly
il l sp o u se
(n ¼ 5 9 )
S ec u ri ty -e n h an
ci n g an
d su p p o rt iv e m ar ri ag es
(p re -l o ss ) w er e p o si ti v el y
as so ci at ed
w it h se v er it y o f tr au
m at ic
g ri ef
sy m p to m s. In se cu re
at ta ch
m en
t st y le s w er e si g n if ic an
tl y as so ci at ed
w it h b o rd er li n e le v el s o f
tr au
m at ic
g ri ef . A tt ac h m en
t st y le
an d m ar it al
q u al it y d id
n o t in te ra ct
an d
w er e n o t as so ci at ed
w it h d ep
re ss io n .
B ri n tz en
- h o fe S zo c
et al ., 1 9 9 9
E ld er ly
sp o u se s o f ca n ce r
p at ie n ts (n ¼ 3 7 )
E n m es h m en
t w as
as so ci at ed
w it h in cr ea se d p sy ch
o lo g ic al
d is tr es s. In
p ar ti cu la r, co m p li ca te d g ri ef
in th e su rv iv in g sp o u se
w as
as so ci at ed
w it h
h ig h er
le v el s o f d is tr es s, d ep
re ss io n , an
d an
x ie ty . T h is st u d y su p p o rt s th e
m er it s o f sc re en
in g su rv iv in g sp o u se s b ef o re
th e d ea th
o f th ei r sp o u se .
C h en
et al ., 1 9 9 9
F u tu re
b er ea v ed
sp o u se s
(n ¼ 1 5 0 )
W id o w s h ad
h ig h er
m ea n sy m p to m
le v el s fo r tr au
m at ic
g ri ef , d ep
re ss io n ,
an d an
x ie ty
at al l fo u r ti m e p o in ts
p o st -l o ss . H ig h tr au
m at ic
g ri ef
sy m p to m
le v el s at
6 m o n th s p re d ic te d p h y si ca l h ea lt h o u tc o m es
at 2 5
m o n th s fo r b o th
m en
an d w o m en
. H ig h tr au
m at ic
g ri ef
sy m p to m
le v el s
in fi rs t y ea r p o st -l o ss
te n d ed
to h av e a st ro n g er
in fl u en
ce o n th e p h y si ca l
an d m en
ta l h ea lt h o f w id o w er s in cl u d in g h o sp it al iz at io n ca n ce r, st ro k e,
o r h ea rt at ta ck .
(C on ti n u ed )
677
T A B L E
1 C o n ti n u ed
A u th o rs
P o p u la ti o n
R es u lt s
S il v er m an
et al .,
2 0 0 1
R ec en
tl y w id o w ed
(n ¼ 8 5 )
P ar ti ci p an
ts w h o re p o rt ed
p ri o r ad
v er si ti es
in th ei r li fe
w er e g en
er al ly
m o re
d is tr es se d fo ll o w in g b er ea v em
en t th an
th o se
w h o d id
n o t re p o rt
ad v er si ti es . In
p ar ti cu la r, ad
v er si ti es
o cc u rr in g in
ch il d h o o d , su ch
as d ea th
o f a p ar en
t an
d ab
u se , se em
ed to
h av e a g re at er
im p ac t an
d w er e
si g n if ic an
tl y as so ci at ed
w it h tr au
m at ic
g ri ef .
M el h em
et al .,
2 0 0 1
B er ea v ed
in p sy ch
o th er ap
y g ro u p (n ¼ 2 3 )
C o m p li ca te d g ri ef
sc o re s an
d fu n ct io n al
im p ai rm
en t w er e h ig h er
am o n g
p at ie n ts w it h m o re
th an
o n e co n cu rr en
t A x is I d ia g n o si s. H en
ce , p ri o r
p sy ch
ia tr ic
il ln es s m ay
b e a ri sk
fa ct o r fo r tr au
m at ic
g ri ef .
P ip er
et al ., 2 0 0 1
P sy ch
ia tr ic
o u t- p at ie n ts
(n ¼ 2 3 5 ) A x is I d ia g n o si s
T im
e si n ce
lo ss
w as
in d ic at iv e o f lo n g -t er m
co m p li ca te d g ri ef . S ig n if ic an
tl y
h ig h er
le v el s o f so ci al
d y sf u n ct io n an
d d ep
re ss io n d is tu rb an
ce v ar ia b le s
w er e fo u n d in
th e se v er e co m p li ca te d g ri ef
g ro u p (n ¼ 7 9 ). D ep
re ss io n ,
an x ie ty , an
d g ri ef
sy m p to m at ic
d is tr es s w er e si g n if ic an
tl y h ig h er
fo r
se v er e co m p li ca te d g ri ef
g ro u p co m p ar ed
to m o d er at e co m p li ca te d g ri ef
an d th o se
w h o h ad
n o t ex
p er ie n ce d lo ss .
B ar ry
et al ., 2 0 0 2
B er ea v ed
el d er s (n ¼ 1 2 2 )
L ac k o f p re p ar at io n fo r th e d ea th
w as
as so ci at ed
w it h co m p li ca te d g ri ef .
P er ce p ti o n o f su ff er in g , h o w
d ra w n o u t th e d ea th
w as , o r v io le n t d ea th
w as
n o t as so ci at ed
w it h co m p li ca te d g ri ef .
B o n an
n o et
al .,
2 0 0 2
W id o w ed
o ld er
p er so n s
(n ¼ 2 0 5 )
E x ce ss iv e d ep
en d en
cy o n sp o u se
sp ec if ic al ly
an d as
a g en
er al
p er so n al it y
v ar ia b le , le ss
in st ru m en
ta l su p p o rt , an
d th e g re at er
li k el ih o o d o f h av in g a
h ea lt h y sp o u se
w er e as so ci at ed
w it h co m p li ca te d g ri ef .
B o el en
et al .,
2 0 0 3 a
B er ea v ed
1 st d eg re e re la ti v es
(n ¼ 3 2 9 )
E ac h o f th e co g n it iv e v ar ia b le s w as
si g n if ic an
tl y re la te d to
tr au
m at ic
g ri ef ,
d ep
re ss io n , an
d an
x ie ty
sy m p to m s se v er it y . F o rt y -n in e p er ce n t o f
v ar ia n ce
in tr au
m at ic
g ri ef
se v er it y w as
ex p la in ed
b y th e g lo b al
n eg at iv e
b el ie fs
ab o u t li fe , th re at en
in g in te rp re ta ti o n s o f g ri ef
re ac ti o n s, n eg at iv e
678
b el ie fs
ab o u t th e w o rl d , an
d th e fu tu re . T en
p er ce n t o f IT
G sc o re
v ar ia n ce
w as
ex p la in ed
b y d em
o g ra p h ic v ar ia b le s (a g e, ti m e si n ce
lo ss , &
le v el
o f ed
u ca ti o n ).
D y re g ro v et
al .,
2 0 0 3
C h il d lo ss
(n ¼ 2 3 2 ), su ic id e
(n ¼ 1 2 8 ), S ID
S (n ¼ 3 6 ),
ac ci d en
t (n ¼ 6 8 )
S el f- is o la ti o n w as
fo u n d to
b e th e b es t p re d ic to r o f p sy ch
o so ci al
d is tr es s
an d b ei n g fe m al e p re d ic te d co m p li ca te d g ri ef
in th e su ic id e an
d S ID
S sa m p le s. T h er e w as
n o ev id en
ce o f su ic id e su rv iv o rs
h av in g g re at er
d if fi cu lt ie s in
ad ap
ti n g to
th e d ea th
co m p ar ed
w it h su rv iv o rs
o f S ID
S o r
ac ci d en
ts .
Jo n es
et al ., 2 0 0 3
A d u lt s w it h se ri o u s m en
ta l
il ln es s (n ¼ 1 4 8 )
L ac k o f p re p ar at io n fo r p ar en
ta l d ea th
re su lt ed
in m o re
se v er e an
d p ro lo n g ed
g ri ef
(n ¼ 3 3 ).
S w ar te
et al .,
2 0 0 3
S u rv iv o rs
o f ca n ce r p at ie n ts
w h o d ie d b y eu
th an
as ia
(n ¼ 1 8 9 ) an
d n at u ra l d ea th
(n ¼ 3 1 6 )
L es s tr au
m at ic
g ri ef , le ss
cu rr en
t fe el in g s o f g ri ef , an
d le ss
P T S re ac ti o n s
w er e fo u n d in
fa m il y an
d fr ie n d s o f ca n ce r p at ie n ts
w h o d ie d fr o m
eu th an
as ia
in co m p ar is o n to
n at u ra l d ea th , ev en
af te r ad
ju st m en
t fo r
o th er
ri sk
fa ct o rs .
B o el en
et al .,
2 0 0 3 b
B er ea v ed
in d iv id u al s (n ¼ 2 3 4 )
N eg at iv e in te rp re ta ti o n s o f g ri ef
re ac ti o n s w er e h ig h ly
as so ci at ed
w it h th e
d eg re e to
w h ic h th es e re ac ti o n s w er e ex
p er ie n ce d as
d is tr es si n g , th e
d eg re e to
w h ic h m o u rn er s en
g ag ed
in av o id an
ce b eh
av io rs
an d th e
se v er it y o f th e sy m p to m s o f tr au
m at ic
g ri ef
an d d ep
re ss io n . B eh
av io ra l
an d co g n it iv e av o id an
ce st ra te g ie s w er e si g n if ic an
tl y re la te d to
th e
se v er it y o f tr au
m at ic
g ri ef
an d d ep
re ss io n .
M it ch
el l et
al .,
2 0 0 4
B er ea v ed
b y su ic id e (n ¼ 6 0 ),
cl o se ly
re la te d (n ¼ 2 7 ), an
d d is ta n tl y re la te d (n ¼ 3 3 )
C lo se ly
re la te d su ic id e su rv iv o rs
ex p er ie n ce d n ea rl y tw
ic e th e le v el
o f
co m p li ca te d g ri ef
th an
d is ta n tl y re la te d su rv iv o rs .
M el h em
et al .,
2 0 0 4 a
A d o le sc en
ts ex
p o se d to
p ee r
su ic id e (n ¼ 1 4 6 )
C o m p li ca te d g ri ef
at 6 m o n th s w as
si g n if ic an
tl y as so ci at ed
w it h fe m al e
g en
d er , p ar ti ci p an
ts ’ fe el in g th at
th ey
co u ld
h av e d o n e so m et h in g to
p re v en
t th e d ea th
an d a p re v io u s h is to ry
o f d ep
re ss io n .
(C on ti n u ed )
679
T A B L E
1 C o n ti n u ed
A u th o rs
P o p u la ti o n
R es u lt s
G o o d en
o u g h
et al ., 2 0 0 4
P ar en
ts o f a ch
il d w h o d ie d
fr o m
ca n ce r (n ¼ 2 5
m o th er – fa th er
d y ad
s)
F at h er s re p o rt ed
si g n if ic an
tl y h ig h er
le v el s o f d ep
re ss io n , an
x ie ty , an
d st re ss
w h en
a ch
il d d ie d in
h o sp it al
ra th er
th an
at h o m e.
M o th er s te n d ed
to sh o w
sm al le r d if fe re n ce s in
p sy ch
o lo g ic al
o u tc o m es
as a fu n ct io n o f
p la ce
o f d ea th . S h o rt er
ti m e si n ce
ch il d ’s d ea th , h ig h er
d ep
re ss io n sc o re s,
an d h ig h er
le v el
o f fa m il y fr ic ti o n w as
as so ci at ed
w it h h ig h er
ra ti n g s o f
tr au
m at ic d is tr es s, se p ar at io n d is tr es s, an
d co re
g ri ef . M o th er s h ad
h ig h er
ra ti n g s o f tr au
m at ic
d is tr es s an
d co re
g ri ef . D ea th
in h o sp it al
w as
as so ci at ed
w it h h ig h er
co re
g ri ef
sc o re s.
M ac ia s et
al .,
2 0 0 4
A d u lt s w it h se ri o u s m en
ta l
il ln es s (n ¼ 1 4 8 )
C o m p li ca te d g ri ef
w as
as so ci at ed
w it h th e n u m b er
o f si tu at io n al
fa ct o rs
th at
o cc u rr ed
cl o se r to
d ea th
(n ¼ 1 8 ): e. g ., re si d in g w it h th e in d iv id u al ,
su d d en
n es s o f th e d ea th , h av in g lo w
so ci al
su p p o rt , an
d co n cu rr en
t st re ss o rs .
H ar d is o n et
al .,
2 0 0 5
P sy ch
o lo g y st u d en
ts (n ¼ 5 0 8 )
B er ea v ed
in so m n ia cs
h ad
si g n if ic an
tl y h ig h er
co m p li ca te d g ri ef
sc o re s th an
b er ea v ed
n o n -i n so m n ia cs . B er ea v em
en t- re la te d sl ee p v ar ia b le s
(d re am
in g o f d ec ea se d an
d ru m in at in g ab
o u t th e d ec ea se d ) w er e
si g n if ic an
tl y re la te d to
co m p li ca te d g ri ef
sy m p to m s. C o m p li ca te d g ri ef
w as
m o re
fr eq
u en
t in
tr au
m at ic al ly
b er ea v ed
y o u n g ad
u lt s.
D re w et
al ., 2 0 0 5
B er ea v ed
p ar en
ts (n ¼ 5 6 )
P ar en
ts o f a ch
il d w h o h ad
a st em
ce ll tr an
sp la n t an
d d ie d in
h o sp it al
h ad
a g re at er
li k el ih o o d o f m ee ti n g th e cr it er ia
fo r co m p li ca te d g ri ef
th an
fo r
th o se
p ar en
ts w h o se
ch il d h ad
n o t re ce iv ed
a st em
ce ll tr an
sp la n t.
S im
o n et
al .,
2 0 0 5
P eo
p le
w it h D S M -I V b ip o la r
(n ¼ 1 0 3 )
C o m p li ca te d g ri ef
sa m p le
re p o rt ed
li fe ti m e h is to ry
o f a su ic id e at te m p t.
C o m p li ca te d g ri ef
as so ci at ed
w it h h ig h er
ra te s o f cu rr en
t al co h o l ab
u se ,
cu rr en
t p an
ic d is o rd er
(w it h o r w it h o u t ag o ra p h o b ia ), p h o b ic
av o id an
ce ,
an d li fe ti m e o b se ss iv e- co m p u ls iv e d is o rd er . C o m p li ca te d g ri ef
w as
as so ci at ed
to p o o re r fu n ct io n in g an
d p o o re r le v el s o f so ci al
su p p o rt .
680
W ij n g aa rd s- d e
M ei j et
al .,
2 0 0 5
B er ea v ed
p ar en
ts (n ¼ 2 1 9 )
G ri ef
w as
p re d ic te d b y ch
il d ’s ag e, ca u se
an d u n ex
p ec te d n es s o f d ea th , an
d th e n u m b er
o f re m ai n in g ch
il d re n .
V an
d er w er k er
et al ., 2 0 0 6
R ec en
tl y b er ea v ed
co m m u n it y
re si d en
ts (n ¼ 2 8 3 )
C h il d h o o d se p ar at io n an
x ie ty
w as
si g n if ic an
tl y as so ci at ed
w it h co m p li ca te d
g ri ef
af te r co n tr o ll in g fo r g en
d er , le v el
o f ed
u ca ti o n , k in sh ip
re la ti o n sh ip ,
h is to ry
o f p sy ch
ia tr ic
d is o rd er s, an
d h is to ry
o f ch
il d h o o d ab
u se .
Jo h n so n et
al .,
2 0 0 6
C o m m u n it y b er ea v ed
(n ¼ 1 7 0 )
R es p o n d en
ts w it h co m p li ca te d g ri ef , g en
er al
an x ie ty
d is o rd er , an
d m aj o r
d ep
re ss iv e d is o rd er
an d th o se
w h o re p o rt ed
si g n if ic an
t su ic id al
id ea ti o n
h ad
si g n if ic an
tl y el ev at ed
B er ea v em
en t D ep
en d en
cy S ca le sc o re s re la ti v e
to th o se
w it h o u t th es e co n d it io n s.
B o el en
, S tr o eb
e, S ch
u t, &
Z ij er v el d ,2 0 0 6
In d iv id u al s <
5 m o n th s fr o m
b er ea v em
en t (n ¼ 9 7 )
N eg at iv e b el ie fs
ab o u t se lf , li fe , an
d th e fu tu re , an
d th re at en
in g
in te rp re ta ti o n s o f g ri ef
re ac ti o n s w er e as so ci at ed
w it h sy m p to m s o f
co n cu rr en
t p ro sp ec ti v e co m p li ca te d g ri ef .
B o el en
, v an
d en
B o u t, &
v an
d en
H o u t,
2 0 0 6
B er ea v ed
in d iv id u al s (n ¼ 5 6 )
C o n ti n u in g b o n d s w it h th e d ec ea se d th ro u g h re co v er in g m em
o ri es
w as
a st ro n g p re d ic to r o f g ri ef
b u t n o t d ep
re ss io n , w h er ea s co n ti n u in g b o n d s
th ro u g h th e u se
o f th e d ec ea se d p er so n ’s p o ss es si o n s w as
a w ea k
p re d ic to r o f b o th
g ri ef
an d d ep
re ss io n .
S ch
u lz
et al .,
2 0 0 6
B er ea v ed
ca re g iv er s (n ¼ 2 1 7 )
C ar eg iv er s w h o h av e h ig h le v el s o f p re -l o ss
d ep
re ss iv e sy m p to m s an
d b u rd en
, w h o re p o rt ed
p o si ti v e fe at u re s o f ca re -g iv in g , an
d w h o w er e
ca ri n g fo r m o re
co g n it iv el y im
p ai re d p at ie n ts w er e m o re
li k el y to
re p o rt
cl in ic al
le v el s o f co m p li ca te d g ri ef
p o st -l o ss .
N ei m ey er
et al .,
2 0 0 6
B er ea v ed
p sy ch
o lo g y st u d en
ts (n ¼ 5 0 6 )
A n in te ra ct io n em
er g ed
b et w ee n se n se -m
ak in g an
d o n g o in g at ta ch
m en
t to
th e d ec ea se d , su g g es ti n g th at
st ro n g co n ti n u in g b o n d s p re d ic te d g re at er
le v el
o f tr au
m at ic
g ri ef
an d se p ar at io n d is tr es s, b u t o n ly
w h en
th e
su rv iv o r w as
u n ab
le to
m ak e se n se
o f th e lo ss
in p er so n a,
p ra ct ic al ,
ex is te n ti al
o r sp ir it u al
te rm
s. H o ll an
d et
al .,
2 0 0 6
B er ea v ed
co ll eg e st u d en
ts (n ¼ 1 ,0 2 2 )
L o w
se n se -m
ak in g an
d lo w
b en
ef it -f in d in g w er e as so ci at ed
w it h h ig h er
le v el s o f co m p li ca te d g ri ef .
(C on ti n u ed )
681
T A B L E
1 C o n ti n u ed
A u th o rs
P o p u la ti o n
R es u lt s
H eb
er t et
al .,
2 0 0 6
B er ea v ed
ca re g iv er s (n ¼ 2 2 2 )
C ar eg iv er s w h o w er e u n p re p ar ed
fo r th e d ea th
h ad
m o re
d ep
re ss io n ,
an x ie ty
an d co m p li ca te d g ri ef
sy m p to m s.
C u rr ie r et
al .,
2 0 0 6
B er ea v ed
p sy ch
o lo g y st u d en
ts (n ¼ 1 0 5 6 )
A lo w ca p ac it y fo r se n se -m
ak in g em
er g ed
as an
ex p la n at o ry
m ec h an
is m
fo r
th e as so ci at io n b et w ee n v io le n t lo ss
an d co m p li ca te d g ri ef .
S h ea r et
al .,
2 0 0 6
B er ea v ed
fr o m
S ep
te m b er
1 1
(n ¼ 1 4 9 )
In d iv id u al s w h o lo st a fa m il y m em
b er
w er e m o re
li k el y th an
th o se
w h o lo st
an ac q u ai n ta n ce
to sc re en
p o si ti v e fo r co m p li ca te d g ri ef .
H er b er t et
al .,
2 0 0 7
B er ea v ed
ca re g iv er s (n ¼ 1 ,2 2 9 )
A ft er
co n tr o ll in g fo r si g n if ic an
t co v ar ia te s, fr eq
u en
t at te n d an
ce at
re li g io u s
se rv ic es , m ee ti n g s an
d = o r ac ti v it ie s w er e as so ci at ed
w it h le ss
d ep
re ss io n
an d le ss
co m p li ca te d g ri ef
in th e b er ea v ed
. M el h em
et al .,
2 0 0 7
B er ea v ed
ch il d re n an
d ad
o le sc en
ts (n ¼ 1 2 9 )
C o m p li ca te d g ri ef
in ch
il d re n an
d ad
o le sc en
ts w as
si g n if ic an
tl y re la te d to
fu n ct io n al
im p ai rm
en t ev en
af te r co n tr o ll in g fo r cu rr en
t d ep
re ss io n ,
an x ie ty , an
d P T S D . C o m p li ca te d g ri ef
w as
al so
as so ci at ed
w it h o th er
m ea su re s o f p sy ch
o p at h o lo g y in cl u d in g su ic id al
id ea ti o n .
Jo h n so n et
al .,
2 0 0 7
W id o w ed
ad u lt s (n ¼ 1 9 2 )
A h ig h le v el
o f p er ce iv ed
p ar en
ta l co n tr o l d u ri n g ch
il d h o o d w as
as so ci at ed
w it h el ev at ed
le v el s o f d ep
en d en
cy o n th e d ec ea se d sp o u se
an d w it h
sy m p to m s o f co m p li ca te d g ri ef .
682
R il ey
et al ., 2 0 0 7
B er ea v ed
m o th er s (n ¼ 3 5 )
M o re
o p ti m is ti c m o th er s re p o rt ed
le ss
in te n se
g ri ef
re ac ti o n s an
d le ss
d is tr es s in d ic at iv e o f co m p li ca te d g ri ef . A d d it io n al ly , m o th er s w h o
u su al ly
co p ed
ac ti v el y h ad
le ss
in te n se
g ri ef
re ac ti o n s. M o th er s w h o
h ab
it u al ly
co p ed
u si n g p o si ti v e re fr am
in g h ad
le ss
in te n se
g ri ef
re ac ti o n s
an d le ss
co m p li ca te d g ri ef .
O tt et
al ., 2 0 0 7
B er ea v ed
ad u lt s (n ¼ 1 4 1 )
T h o se
ca te g o ri ze d in
th e ch
ro n ic
g ri ef
cl u st er
ex p er ie n ce d th e h ig h es t le v el
o f g ri ef
an d d ep
re ss io n , m o re
su d d en
d ea th s, th e lo w es t se lf -e st ee m , an
d th e h ig h es t m ar it al
d ep
en d en
cy an
d m et
cr it er ia
fo r co m p li ca te d g ri ef .
K ee se e et
al .,
2 0 0 8
B er ea v ed
p ar en
ts (n ¼ 1 5 7 )
T h e ca u se
o f th e d ea th
(v io le n t in
n at u re ) si g n if ic an
tl y p re d ic te d in te n si ty
o f co m p li ca te d g ri ef ; se n se -m
ak in g an
d b en
ef it -f in d in g si g n if ic an
tl y
in cr ea se d th e p o rt io n o f v ar ia n ce
ex p la in ed
in g ri ef
se v er it y ; b en
ef it -
fi n d in g w as
fo u n d to
p re d ic t lo w er
se v er it y o f co m p li ca te d g ri ef .
M et zg er
& G ra y ,
2 0 0 8
B er ea v ed
m em
b er s o f o n li n e
su p p o rt g ro u p (n ¼ 6 0 )
A s th e le v el
o f in te ra ct io n w it h a d y in g lo v ed
o n e in cr ea se d , m o re
fe at u re s
o f C G
w er e en
d o rs ed
. E x p re ss io n o f fe el in g s o f lo v e an
d af fe ct io n an
d co n ti n u ed
af fi li at io n an
d cl o se n es s w er e si g n if ic an
tl y p o si ti v el y as so ci at ed
w it h co m p li ca te d g ri ef .A
g re at er
d eg re e o f co m m u n ic at io n w as
re la te d to
h ig h er
le v el s o f co m p li ca te d g ri ef
af te r an
ex p ec te d lo ss . P re -l o ss
ac ce p ta n ce
w as
as so ci at ed
w it h lo w er
co m p li ca te d g ri ef .
T o m ar k en
et al .,
2 0 0 8
C ar eg iv er s o f ca n ce r p at ie n ts
(n ¼ 2 4 8 )
P es si m is ti c th in k in g an
d se v er it y o f st re ss fu l li fe
ev en
ts w as
an im
p o rt an
t fa ct o r in
d ev el o p in g co m p li ca te d g ri ef .
683
between marital quality and adjustment to the impending death of a terminally ill spouse, van Doorn and colleagues (van Doorn, Kasl, Beery, Jacobs, & Prigerson, 1998) found that having a secure, supportive spouse and an insecure attachment style contributed independently to the severity of CG symptoms. Other studies found that relationships with the deceased that were close, support- ive, confiding and dependent were associated with an increased risk of CG (Bonanno et al., 2002; Carr, House, Wortman, Nesse, & Kessler, 2001; Prigerson, Maciejewski, & Rosenheck, 2000). A history of strict parental control during childhood may be associa- ted with risk for the development of spousal dependence and post-bereavement CG symptoms (Johnson, Zhang, Greer, & Prigerson, 2007). Expressions of continuing bonds were found to be related to maladjustment in bereavement (Boelen, Stroebe, Schut, & Zijerveld, 2006). Maintaining continuing bonds by feeling calmed and supported by memories of the deceased were reported as a strong predictor of intensity of grief symptoms, independent of initial grief symptom severity (Boelen, Stroebe, et al., 2006).
Gender differences in spousal bereavement was examined by Chen and colleagues (Chen et al., 1999). Widows had higher mean symptom levels of CG, which were found to predict sleep changes at the anniversary of the death of the spouse. For widowers, high symptoms of CG predicted hospitalization and having a physical health event such as cancer, stroke, or a heart attack (Chen et al., 1999). Bereavement-related sleep variables (dreaming of the decreased and ruminating about the deceased) were significantly associated with CG symptomatology, with insomnia proving to be a significant predictor of CG, along with the nature of the death (whether violent or not), the younger age of the deceased, level of closeness with the deceased, recency of the loss, relationship to the deceased, and gender of the bereaved, with women showing greater grief (Hardison, Neimeyer, & Lichstein, 2005).
Predictors Associated with Cognitive Behavioral Conceptualizations
Cognitive behavioral conceptualizations of CG propose that negative cognition plays a core role in the development and per- sistence of emotional problems after bereavement as it generates negative emotions that can lead mourners to engage in counterpro- ductive attempts to avoid the implications and the pain of the loss
684 E. A. Lobb et al.
(Boelen, van den Bout, & van den Hout, 2006). Boelen et al. (2006) found cognitive variables such as negative beliefs about the self, life, and the future and threatening interpretations of grief reactions to be strongly related to concurrent and prospective levels of CG. These findings support their earlier work where cognitive variables such as global negative beliefs, negative worldview (Boelen, van den Bout, & van den Hout, 2003b), and avoidance of emotional problems (Boelen, van den Bout, & van den Hout, 2003a) pre- dicted CG. Additionally, individuals who are generally averse to lifestyle change were more vulnerable to CG (Beery et al., 1997). Conversely, a study of bereaved parents by Riley, LaMontagne, Hepworth, and Murphy (2007) found that dispositional factors such as optimism, active coping, positive reframing, support seek- ing, and perceived social support were associated with less symp- toms of CG.
The various component processes of meaning reconstruction (sense-making, benefit-finding, and progressive identity change) and their relationship to CG have been studied by Neimeyer and his colleagues. Currier, Holland, and Neimeyer (2006) evaluated the possible mediating role of sense-making between the cause of death and CG. Results support the notion that although the objec- tive circumstances of the loss carry weight, the survivor’s subjective interpretation of the loss is more influential in explaining ensuing grief responses and that sense-making is a more critical pathway to CG than the objective cause of death (violent or natural; Currier et al., 2006). This is supported by a study of bereaved parents, where inability to make sense of the death emerged as the most salient predictor of grief severity, greatly outweighing such factors as cause of death, gender of the parent, or number of months or years since the loss (Keesee, Currier, & Neimeyer, 2008).
Similarly, Holland, Currier, and Neimeyer (2006) examined the role of sense-making, benefit-finding, and time since loss in pre- dicting CG among a sample of college students. They reported that when a great deal of sense has been made of the loss, finding benefit or a ‘‘silver-lining’’ in the grief experience was associated with poorer grief outcomes—although in the absence of sense-making, it may mitigate grief. Moreover, the interaction of sense-making and benefit-finding in predicting symptoms of CG remained robust regardless of cause of death or relationship to the deceased (Holland et al., 2006).
Predictors of Complicated Grief 685
Finally, several variables concerning the survivor, his or her relationship to the deceased, and the nature of the death as risk factors for CG were studied by Neimeyer, Baldwin, and Gillies (2006). An interaction emerged between sense-making and ongoing attachment to the deceased, suggesting that strong continuing bonds predicted greater levels of CG, but only when the survivor was unable to make sense of the loss in personal, practical, existen- tial, and spiritual terms (Neimeyer et al., 2006).
Predictors of CG in Traumatic Death
In studies of adolescents exposed to a peer’s suicide, CG at 6 months was significantly associated with gender (female). The presence of a previous history of anxiety disorders, feeling that they could have done something to prevent the death, financial problems, and a previous history of depression were all associated with PTSD at 6 months and were associated with an 81% risk of CG (Melhem, Day, Shear, Reynolds, & Brent, 2004b). In an ongoing 5-year study of the impact of parental loss on adolescents, the correlation between CG, and the number of months since the death was low but statistically significant (Melhem, Moritz, Walker, Shear, & Brent, 2007). The offspring’s feelings that others were accountable for the death were associated with higher scores of CG, along with the offspring feeling others blamed him or her for the death. CG scores were not higher in children and adoles- cents who lost a parent to suicide compared to children who lost a parent to accident or sudden natural death (Melhem et al., 2007).
Adults bereaved by suicide of a family member experienced nearly twice the level of CG as distantly related survivors (Mitchell, Kim, Prigerson, & Mortimer-Stephens, 2004). In particular, spouses, parents, and children had significantly higher mean CG scores than in-laws, friends, or coworkers. Relationships classi- fication to the deceased explained 43% of variance in CG scores, suggesting that professional assessments and interventions should take into account the familial and=or social relationship of the bereaved to the deceased. Similarly, Shear, Jackson, Essock, Donahue, and Felton (2006) found that individuals whose family member died in the September 11, 2001, terrorist attacks were more likely than those whose acquaintance died to screen positive for CG.
686 E. A. Lobb et al.
A report on parents bereaved by their child’s death by suicide, sudden infant death and child accidents found that there was no evidence of suicide survivors having greater difficulties in adapting to the death compared with survivors of SIDS or accidents; however, being female predicted CG in the suicide and SIDS sample (Dyregrov, Nordanger, & Dyregrov, 2003). In studies of bereaved parents, a shorter time from diagnosis of cancer to death (Goodenough, Drew, Higgins, & Trethewie, 2004); the death of the child in hospital following stem cell transplantation versus death at home (Drew, Goodenough, Maurice, Foreman, & Willis, 2005); and the child’s age, cause, and unexpectedness of the death and the number of remaining children (Wijngaards-de Meij et al., 2007) were found to be associated with CG.
Predictors Associated with Caregiving
Advance preparations for the loss, as well as having a good support network, have been associated with lower risk for bereavement- related complications in caregivers (Vanderwerker & Prigerson, 2004). Conversely, pessimistic thinking and experiencing a number of severe stressful life events in caregivers of cancer patients were important predictors in their developing CG (Tomarken et al., 2008). A study by Barry, Kasl, and Prigerson (2002) evaluated the association between a bereaved person’s perceptions of the death, such as their extent of suffering and preparedness for the death, and found that lack of preparedness for the death was associated with CG at baseline, at 4 months, and at 9 months, suggesting that persons who perceive themselves as unprepared for the death may be at risk of bereavement-associated morbidity. Similarly, a study in a large cohort of caregivers of persons with dementia found that caregivers who were not at all prepared for the death had worse mental health, exhibited more depressive, CG, and anxiety symptoms at the first and subsequent assessment after the death even when controlling for mul- tiple factors such as the caregiver’s physical and mental health before the death (Hebert, Dang, & Schulz, 2006). In another study from this group of researchers, religious beliefs and practices were found to be important for all caregivers of persons with dementia but after con- trolling for significant covariates, frequent attendance at religious ser- vices, meetings, and=or activities was associated with less depression and less CG in the bereaved (Herbert, Dang, & Schulz, 2007).
Predictors of Complicated Grief 687
Caregivers of terminally ill spouses, who had higher levels of depression and burden pre-loss, and who reported positive aspects of caregiving pre-loss were found to be at a heightened risk of CG along with caregivers who perceived they were unsup- ported after the death (Schulz, Boerner, Shear, Zhang, & Gitlin, 2006). A study that examined the effects of changes in role func- tion, caregiving tasks, caregiver burden, and gratification on symptoms of CG found that caregiver burden was significantly associated with the spouse’s level of depression and CG (Beery et al., 1997). Bereaved family members and close friends of terminally ill cancer patients who died by legal euthanasia in The Netherlands coped better with respect to grief symptoms and PTSD than bereaved family and friends of comparable cancer patients who died a natural death (Swarte, van der Lee, van der Bom, van der Bout, & Heintz, 2003). In another study, as caregivers’ level of interaction with a dying loved one increased, they endorsed more features of CG (Metzger & Gray, 2008). Expression of feelings of love and affection and continued affiliation and closeness was positively associated with CG. A greater degree of communication was related to higher levels of CG after an expected loss. Similar to other studies, pre-loss acceptance was associated with less CG (Metzger & Gray, 2008).
Predictors of CG Among Adults with Serious Mental Illness
Predictors of CG among adults with serious mental illness indicate the situational factors surrounding the death including residing with the close friend or family member at the time of the death, the suddenness of the death, low social support, concurrent stressors, lack of preparation for parental death, and higher levels of social dysfunction were associated with a more severe grief reactions (Jones et al., 2003; Macias et al., 2004; Piper, Ogrodniczuk, Azim, & Weideman, 2001). In another population of psychiatric patients, self-reported anxiety, depression, and a concurrent Axis 1 diagnosis was associated with CG (Melhem, Day, Shear, Day, Reynolds, & Brent, 2004b). Increased panic attacks, alcohol abuse comorbidity, higher rates of suicide attempts, greater functional impairment and poorer social support were found in a population of patients with bipolar disorder
688 E. A. Lobb et al.
(Simon et al., 2005). In particular in the CG group, more patients reported a lifetime history of suicide attempts, and this association did not diminish after controlling for lifetime panic disorders, with CG more than doubling of the odds of a lifetime suicide attempt (Simon et al., 2005).
Discussion
The nature of CG and its relationship to other syndromes and conditions and questions about how CG should be defined, assessed, and classified have been topics of significant and persist- ent debate (Stroebe, van Son, Stroebe, Kleber, Schut, & van den Bout, 2000). However, there has been a lack of evidence for good practice in bereavement research and services, especially for those who might be at risk of CG following bereavement. Moreover, there is great diversity in the use of adjectives to describe variations from normal grief, and the conceptualizations of CG differed according to the theoretical approach taken by the investigators. This definitional and theoretical confusion has created uncertainty for health care providers and services that endeavor to make sense of the complex and apparently conflict- ing literature. In undertaking this systematic review we note that in more recent studies there is increased consistency in the terminology and measure used for CG.
A small percentage of the population (approximately 10% to 20%) experiences CG. CG symptoms, which when elevated and when they extend beyond 6 months (Prigerson & Jacobs, 2001b), predict substantial morbidity such as risk of cancer, cardiac events, increased alcohol and tobacco consumption and suicidal ideation (Chen et al., 1999; Prigerson et al., 1995, 1997). Unlike the symp- toms of bereavement-related depression, the symptoms of CG have been found to persist despite the passage of time and the treatment of the bereaved with tricyclic antidepressants (Jacobs, Nelson, & Zisook, 1987; Pasternak et al., 1991; Prigerson et al., 1995, 1996).
The framework developed by Stroebe and Schut provides a succinct categorization for the consideration of risk factors (Stroebe, Hansson, Stroebe, & Schut, 2001). These are determined as situational factors related to the death, personal factors such as gender and characteristics prior to the death, and interpersonal
Predictors of Complicated Grief 689
factors such as the availability of social and emotional support from family and friends.
Our review relating to situational factors associated with the death provides some evidence that those bereaved by traumatic death such as suicide have an increased risk of CG. This supports the notion that the unique features of traumatic death, when present in suicide or in any other traumatic loss, account for much of the variance in bereavement outcome in comparison to natural causes of death. There were a number of limitations in these stu- dies and further investigations are warranted, such as longitudinal studies to determine whether CG and depression are preludes to suicidal ideation. Of note in the studies on suicidal ideation was the consistent use of the Inventory of Complicated Grief in assessment of this group (Mitchell, Kim, Prigerson, & Mortimer, 2005; Prigerson et al., 1999).
Consistent with the notion that CG is fundamentally an attachment disorder, personal factors, in particular insults to a sense of security caused by weak parental bonding in childhood, present a vulnerability to the onset of CG later in life (Silverman et al., 2001; Vanderwerker et al., 2006). Because of the cross-sectional designs of these studies, recall bias could have inflated the associations between disorders and prior adversities. In addition, the small sample sizes, stratification, and the rarity of some outcomes suggest that the estimate of risk may not be reliable. Given the findings that having an insecure attachment style and excessive dependency, both in the form of dependency on the spouse and as a more general personality trait, are predictive of CG (Bonanno et al., 2002; van Doorn et al., 1998), interventions that promote secure alternative attachments to others and emotional re-engagement are needed. Results of studies on cognitive appraisal such as interpreting grief reactions as indicating mental insanity, inadequate adaptation, or personal incompetence (Boelen et al., 2003b); assigning negative meanings to grief reactions (Boelen et al., 2003b) and cognitive and emotional upheaval surrounding the death of a healthy spouse (Bonanno, Wortman, & Nesse, 2004) support the notion that negative interpretations of grief reactions in themselves do not indicate disturbance. They can, however, play a role in the development and maintenance of emotional problems after bereavement. As Bonnano et al. (2004) would argue, perhaps cognitive appraisals
690 E. A. Lobb et al.
influence the degree to which these reactions are experienced as distressing. Consequently they can then influence the degree to which mourners engage in avoidance strategies that are likely to impede recovery and may serve to exacerbate and prolong grief rather than ameliorate grief reactions.
The role of meaning-making has emerged as a key factor in CG. Although the circumstances of the death are influential in grief responses, it appears that the survivor’s subjective interpretation of the loss and being able to make sense of the loss in personal, practical, existential, and spiritual terms is influential in explaining ensuing grief responses, as documented in several studies (Neimeyer, Burke, Mackay, & Stringer, 2010).
Situational factors related to the death include place of death (e.g., hospital vs. home); the time from diagnosis to death (Goodenough et al., 2004); perceptions of the death being more violent and lack of preparedness for the death (Barry et al., 2002); a pattern of high distress pre-death (Boerner, Wortman, & Bonanno, 2005); and persistent feelings of being stunned or shocked by the death (Prigerson, 1996). The question of ‘‘preparedness’’ for death and the degree of trauma and suffering associated with the person’s death may be pertinent issues when examining family members who may be at greater risk for a CG response. Preparation for the person’s death and a sense that death was peaceful and not distressing may be factors associated with a more favorable bereavement response. Reducing caregiver burden, treating depression before the death of the loved one, and providing supportive psychosocial or skills training caregiver interventions can help the caregiver better manage the sequelae of death (Schulz et al., 2006).
Limitations
We acknowledge two types of limitations: those related to the methodology of conducting systematic reviews and those more specific to the nature of CG. All types of studies are subject to bias, with systematic reviews being subject to the same biases possible in the original studies reviewed, as well as biases specifically related to the review process. Biases include publication bias, time-lag bias, multiple publication bias, language bias, and outcome report- ing bias (Egger, Juni, Bartlett, Holenstein, & Sterne, 2003). Other
Predictors of Complicated Grief 691
biases can result if the methodology to be used in a review is not defined before the review commences. Detailed knowledge of studies performed in the area of interest may influence the eligibility criteria for inclusion of studies in the review and may therefore result in biased results. For example, studies with more positive results may preferentially be included in a review, thus biasing the results and overestimating effects.
We endeavored to conduct a comprehensive review by contacting key authors for information about current studies that may be either ‘‘in press’’ or published recently. In addition, the use of broad terms in our searches, cross-referencing, and searches by author’s name has produced a thorough systematic review. Searches were limited to articles published in English. English- language journals are predominantly published in first-world countries, and this may subsequently limit exposure to some bereavement issues. Studies may not be listed in this review because of the journal not being cited on the database or the database not providing an abstract.
The challenges of undertaking research to investigate CG have been well-documented and include inconsistent use of definitions, instruments, cross-sectional designs, heterogeneous samples, high attrition, demographic differences between cases and controls, differences in length of time since death, differences in types of death experienced, and use of recruitment techniques that may contribute to biases in sample characteristics. In addition, the time that measurements were undertaken and the use of self-report data may have created recall biases. In particular, the limitations in the studies on predictors of CG typically included small sample sizes, in particular in studies where stratification was undertaken. However, some recent exceptions in the form of large-scale studies suggest that stronger evidence in predicting CG is emerging (e.g., Currier et al., 2006; Neimeyer et al., 2006).
In undertaking our systematic review, the evidence base applied in classifying literature was the Australian National Health & Medical Research Council’s (NH&MRC) evidence hierarchy. Levels of evidence range from Level 1 (systematic review of all relevant randomized controlled trials to Level IV (case series, either pretest or posttest; NH&MRC, 2000). The majority of stu- dies in our review (n ¼ 40) were categorized as Level of Evidence III-2—IV according to that is, either comparative studies with
692 E. A. Lobb et al.
concurrent or historical controls, case-control studies (or interrup- ted time series with a control group); or two or more single arms or case series (either posttest or pretest and posttest; Kristjanson, Lobb, Aoun, Monterosso, & Halkett, 2005). However, other indicators of quality in individual studies, such as sample size, quality of instrumentation, reliability of interviews or diagnosis can be of more relevance. We noted, for example, an increased consistency in the use of measurement tools in later studies that we reviewed, along with increased sample sizes.
Conclusions
A large proportion of studies on predictors of CG have related to spousal=conjugal grief in later life. Few studies have been under- taken with children or adolescents to address CG, although more recently Melham and colleagues are building a body of work with adolescents. No studies were identified in this review that specifically addressed CG in indigenous populations. The bulk of the research material in this area identified focussed on intergenerational grief or historical grief.
Notwithstanding the limitations mentioned in the previous section, some direction has emerged. Further research into concep- tualizations of CG in terms of attachment theory and constructivist and cognitive-behavioral concepts of finding purpose and meaning after bereavement is warranted. This systematic review has confirmed the need for targeted research to address the gaps in knowledge that exist in the area of CG. Without systematic and trustworthy investigations, health professionals, and service providers endeavor to provide interventions and services based on anecdotal experiences and trial-and-error approaches.
References
Barry, L. C., Kasl, S. V., & Prigerson, H. G. (2002). Psychiatric disorders among bereaved persons: The role of perceived circumstances of death and preparedness for death. American Journal of Geriatric Psychiatry, 10, 447–457.
Beery, L. C., Prigerson, H. G., Bierhals, A. J., Santucci, L. M., Newsom, J. T., Maciejewski, P. K., et al. (1997). Traumatic grief, depression and care giving in elderly spouses of the terminally ill. Omega: The Journal of Death & Dying, 35, 261–279.
Predictors of Complicated Grief 693
Boelen, P. A., Stroebe, M. S., Schut, H. A. W., & Zijerveld, A. M. (2006). Continuing bonds and grief: A prospective analysis. Death Studies, 30, 767–776.
Boelen, P. A., van den Bout, J., & van den Hout, M. A. (2003a). The role of cognitive variables in psychological functioning after the death of a first degree relative. Behaviour, Research and Therapy, 41, 1123–1136.
Boelen, P. A., van den Bout, J., & van den Hout, M. A. (2003b). The role of negative interpretations of grief reactions in emotional problems after bereavement. Journal of Behavior Therapy and Experimental Psychiatry, 34, 225–238.
Boelen, P. A., van den Bout, J., & van den Hout, M. A. (2006). Negative cognitions and avoidance in emotional problems after bereavement: A prospective study. Behaviour Research and Therapy, 44, 1657–1672.
Boerner, K., Wortman, C. B., & Bonanno, G. A. (2005). Resilient or at risk? A 4-year study of older adults who initially showed high or low distress following conjugal loss. The Journals of Gerontology, 60B, 67–73.
Bonanno, G. A., Neria, Y., Mancini, A., Coifman, K. G., Litz, B., & Insel, B. (2007). Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity. Journal of Abnormal Psychology, 116, 342–351.
Bonanno, G. A., Wortman, C. B., Lehman, D. R., Tweed, R. G., Haring, M., & Sonnega, J. (2002). Resilience to loss and chronic grief: A prospective study from pre-loss to 18-months post-loss. Journal of Personality and Social Psychology, 83, 1150–1164.
Bonanno, G. A., Wortman, C. B., & Nesse, R. M. (2004). Prospective patterns of resilience and maladjustment during widowhood. Psychology and Aging, 19, 260–271.
BrintzenhofeSzoc, K. M., Smith, E. D., & Zabora, J. R. (1999). Screening to predict complicated grief in spouses of cancer patients. A Multidisciplinary Journal of Cancer Care, 7, 233–239.
Byrne, G. J., & Raphael, B. (1994). A longitudinal study of bereavement phenomena in recently widowed elderly men. Psychological Medicine, 24, 411–421.
Carr, D., House, J. S., Wortman, C. B., Nesse, R. M., & Kessler, R. C. (2001). Psychological adjustment to sudden and anticipated spousal loss among older widowed persons. The Journals of Gerontology, 56B, S237–S248.
Chen, J. H., Bierhals, A. J., Prigerson, H. G., Kasl, S. V., Mazure, C. M., & Jacobs, S. (1999). Gender differences in the effects of bereavement-related psycho- logical distress in health outcomes. Psychological Medicine, 29, 367–380.
Currier, J. M., Holland, J. M., & Neimeyer, R. A. (2006). Sense-making, grief, and the experience of violent loss: Toward a mediational model. Death Studies, 30, 403–428.
Drew, D., Goodenough, B., Maurice, L., Foreman, T., & Willis, L. (2005). Parental grieving after a child dies from cancer: is stress from stem cell transplant a factor? International Journal of Palliative Nursing, 11, 266–273.
Dyregrov, K., Nordanger, D., & Dyregrov, A. (2003). Predictors of psychosocial distress after suicide, SIDS and accidents. Death Studies, 27, 143–165.
694 E. A. Lobb et al.
Egger, M., Juni, P., Bartlett, C., Holenstein, F., & Sterne, J. (2003). How important are comprehensive literature searches and assessment of trial quality in systematic reviews? Empirical study. Health Technology Assessments, 7, 1–76.
Faschingbauer, T. R. (1981). The Texas Revised Inventory of Grief manual. Houston, TX: Honeycomb.
Goodenough, B., Drew, D., Higgins, S., & Trethewie, S. (2004). Bereavement outcomes for parents who lose a child to cancer: Are place of death and sex of parent associated with differences in psychological functioning? Psycho-oncology, 13, 779–791.
Hardison, H. G., Neimeyer, R. A., & Lichstein, K. L. (2005). Insomnia and complicated grief symptoms in bereaved college students. Behavioral Sleep Medicine, 3, 99–111.
Herbert, R. S., Dang, Q. Y., & Schulz, R. (2006). Preparedness for the death of a loved one and mental health in bereaved caregivers of patients with dementia: Findings from the REACH study. Journal of Palliative Medicine, 9, 683–693.
Herbert, R., Dang, Q., & Schulz, R. (2007). Religious beliefs and practices are associated with better mental health in family caregivers of patients with dementia: Findings from the REACH Study. American Journal of Geriatric Psychiatry, 15, 292–390.
Holland, J. M., Currier, J. M., & Neimeyer, R. A. (2006). Meaning reconstruction in the first two years of bereavement: The role of sense-making and benefit-finding. Omega: The Journal of Death and Dying, 53, 175–191.
Jacobs, S. C., Nelson, J. C., & Zisook, S. (1987). Treating depressions of bereave- ment with antidepressants. Psychiatric Clinics of North America, 10, 501–510.
Johnson, J. G., Vanderwerker, L. C., Bornstein, R. F., Zhang, B., & Prigerson, H. G. (2006). Development and validation of an instrument for the assess- ment of dependency among bereaved persons. Journal of Psychopathology and Behavioral Assessment, 28, 301–318.
Johnson, J. G., Zhang, B. H., Greer, J. A., & Prigerson, H. G. (2007). Parental control, partner dependency, and complicated grief among widowed adults in the community. Journal of Nervous and Mental Disease, 195, 26–30.
Jones, D., Harvey, J., Giza, D., Rodican, C., Barreira, P., & Macias, C. (2003). Parental death in the lives of people with serious mental illness. Journal of Loss & Trauma, 8, 307–322.
Keesee, N. J., Currier, J. M., & Neimeyer, R. A. (2008). Predictors of grief following the death of one’s child: The contribution of finding meaning. Journal of Clinical Psychology, 64, 1145–1163.
Kristjanson, L. J., Lobb, E. A., Aoun, S., Monterosso, L., & Halkett, G. (2005). A systematic review of the literature on complicated grief. Canberra, Australia: Commonwealth of Australia, Department of Health & Ageing.
Lichtenthal, W. G., Cruess, D. G., & Prigerson, H. G. (2004). A case for establishing complicated grief as a distinct mental disorder in DSM-V. Clinical Psychology Review, 24, 637–662.
Macias, C., Jones, D., Harvey, J., Barreira, P., Harding, C., & Rodican, C. (2004). Bereavement in the context of serious mental illness. Psychiatric Services, 55, 421–426.
Predictors of Complicated Grief 695
Melhem, N., Day, N., Shear, K., Day, R., Reynolds, C. F., & Brent, D. A. (2004a). Predictors of complicated grief among adolescents exposed to a peer’s suicide. Journal of Loss & Trauma, 9, 21–34.
Melhem, N., Day, N., Shear, K., Day, R., Reynolds, C. F., & Brent, D. A. (2004b). Traumatic grief among adolescents exposed to their peer’s suicide. American Journal of Psychiatry, 161, 1411–1416.
Melhem, N. M., Moritz, G., Walker, M., Shear, M. K., & Brent, D. (2007). Phenomenology and correlates of complicated grief in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 493–499.
Melhem, N., Rosales, C., Karageorge, J., Reynolds, C. F., Frank, E., & Shear, K. (2001). Comorbidity of axis 1 disorders in patients with traumatic grief. The Journal of Clinical Psychiatry, 62, 884–87.
Metzger, P. L., & Gray, M. J. (2008). End-of-life communication and adjustment pre-loss communication as a predictor of bereavement-related outcomes. Death Studies, 32, 301–325.
Middleton, W., Burnett, P., Raphael, B., & Martinek, N. (1996). The bereavement response: A cluster analysis. The British Journal of Psychiatry, 169, 167–171.
Mitchell, A., Kim, Y., Prigerson, H., & Mortimer-Stephens, M. (2004). Complicated grief in survivors of suicide. Crisis, 25, 12–18.
Mitchell, A., Kim, Y., Prigerson, H. G., & Mortimer, M. (2005). Complicated grief and suicidal ideation in adult survivors of suicide. Suicide & Life-Threatening Behavior, 35, 498–506.
National Health & Medical Research Council. (2000). How to review the evidence: Systematic identification and review of the scientific literature. Canberra, Australia: Commonwealth of Australia.
Neimeyer, R. A., Baldwin, S. A., & Gillies, J. (2006). Continuing bonds and reconstructing meaning: Mitigating complications in bereavement. Death Studies, 30, 715–738.
Neimeyer, R. A., Burke, L., Mackay, M., & Stringer, J. (2010). Grief therapy and the reconstruction of meaning: From principles to practice. Journal of Contemporary Psychotherapy, 40, 73–83.
Ott, C. H., Lueger, R. J., Kelber, S. T., & Prigerson, H. G. (2007). Spousal bereavement inolder adults: Common, resilient, and chronic grief with defining characteristics. Journal of Nervous and Mental Disease, 195, 332–341.
Pasternak, R. E., Reynolds, C. F., Schlernitzauer, M., Hoch, C. C., Buysse, D. J., & Houck, P. R. (1991). Acute open-trial nortriptyline therapy of bereavement-related depression in late life. The Journal of Clinical Psychiatry, 52, 307–310.
Piper, W. E., Ogrodniczuk, J. S., Azim, H. F., & Weideman, R. (2001). Prevalence of loss and complicated grief among psychiatric outpatients. Psychiatric Services, 52, 1069–1074.
Prigerson, H., Bierhals, A. J., Kasl, S. V., Reynolds, C. F., Shear, K., Newsom, J. T., et al. (1996). Complicated grief as a disorder distinct from bereavement-related depression and anxiety: A replication study. American Journal of Psychiatry, 153, 1484–1486.
696 E. A. Lobb et al.
Prigerson, H., Bierhals, A. J., Kasl, S. V., Reynolds, C. F., Shear, M. K., Day, N., et al. (1997). Traumatic grief as a risk factor for mental and physical morbidity. American Journal of Psychiatry, 154, 616–623.
Prigerson, H., Bridge, J., Maciejewski, P., Beery, L. C., Rosenheck, R., Jacobs, S., et al. (1999). Influence of traumatic grief on suicidal ideation among young adults. American Journal of Psychiatry, 156, 1994–1995.
Prigerson, H., Frank, E., Kasl, S. V., Reynolds, C. F., Anderson, B., Zubenko, G. S., et al. (1995). Complicated grief and bereavement-related depression as distinct disorders: Preliminary empirical validation in elderly bereaved spouses. American Journal of Psychiatry, 152, 22–30.
Prigerson, H., & Jacobs, S. (2001a). Perspectives on care at the close of life— Caring for bereaved patients: ‘‘All the doctors just suddenly go.’’ Journal of the American Medical Association, 286, 1369–1376.
Prigerson, H., & Jacobs, S. (2001b). Traumatic grief as a distinct disorder. In M. S. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbook of bereave- ment (pp. 613–645). Washington, DC: American Psychological Association Press.
Prigerson, H., Maciejewski, P. K., Reynolds, C. F., Bierhals, A. J., Newsom, J. T., Fasiczka, A., et al. (1995). Inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research, 59, 65–79.
Prigerson, H., Shear, M. K., Newsom, J. T., Frank, E., Reynolds, C. F., Maciejewski, P. K., et al. (1996). Anxiety among widowed elders: Is it distinct from depression and grief? Anxiety, 2, 1–12.
Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., et al. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V ICD-11. PloS Medicine, 6, 1–12.
Prigerson, H. G., Maciejewski, P. K., & Rosenheck, R. (2000). The interactive effects of marital harmony and widowhood on health, health service utiliza- tion and costs. Gerontologist, 40, 349–357.
Riley, L. P., LaMontagne, L. L., Hepworth, J. T., & Murphy, B. A. (2007). Parental grief responses and personal growth following the death of a child. Death Studies, 31, 277–299.
Schulz, R., Boerner, K., Shear, K., Zhang, S., & Gitlin, L. N. (2006). Predictors of complicated grief among dementia caregivers: A prospective study of bereavement. American Journal of Geriatric Psychiatry, 14, 650–658.
Shear, K., & Shair, H. (2005). Attachment, and loss, and complicated grief. Developmental Psychobiology, 47, 253–267.
Shear, K. M., Jackson, C. T., Essock, S. M., Donahue, S. A., & Felton, C. J. (2006). Screening for complicated grief among Project Liberty service recipients 18 months after September 11, 2001. Psychiatric Services, 59, 1291–1297.
Silverman, G. K., Johnson, J. G., & Prigerson, H. G. (2001). Preliminary explora- tions of the effects of prior trauma and loss on risk for psychiatric disorders in recently widowed people. The Israel Journal of Psychiatry and Related Sciences, 38, 202–215.
Simon, N. M., Pollack, M. H., Fischmann, D., Perlman, C. A., Muriel, A. C., Moore, C. W., et al. (2005). Complicated grief and its correlates in patients with bipolar disorder. Journal of Clinical Psychiatry, 66, 1105–1110.
Predictors of Complicated Grief 697
Stroebe, M., Hansson, R. O., Stroebe, W., & Schut, H. (Eds.). (2001). Handbook of bereavement research. Washington, DC: American Psychological Association.
Stroebe, M., van Son, M., Stroebe, W., Kleber, R., Schut, H., & van den Bout, J. (2000). On the classification and diagnosis of pathological grief. Clinical Psychology Review, 20, 57–75.
Swarte, N. B., van der Lee, M. L., van der Bom, J. G., van der Bout, J., & Heintz, P. M. (2003). Effects of euthanasia on the bereaved family and friends: A cross sectional study. British Medical Journal, 327, 189–192.
Tomarken, A., Holland, J., Schachter, S., Vanderwerken, L., Zuckerman, E., Nelson, C., et al. (2008). Factors of complicated grief pre-death in caregivers of cancer patients. Psycho-oncology, 17, 105–111.
van Doorn, C., Kasl, S., Beery, L. C., Jacobs, S., & Prigerson, H. G. (1998). The influence of marital quality and attachment styles on traumatic grief and depressive symptoms. Journal of Nervous & Mental Disease, 186, 566–573.
Vanderwerker, L. C., Jacobs, S. C., Murray-Parkes, C., & Prigerson, H. G. (2006). An exploration of associations between separation anxiety in childhood and complicated grief in later-life. Journal of Nervous & Mental Diseases, 194, 121–123.
Vanderwerker, L. C., & Prigerson, H. G. (2004). Social support and technological connectedness as protective factors in bereavement. Journal of Loss & Trauma, 9, 45–57.
Wijngaards-de Meij, L., Stroebe, M., Schut, H., Stroebe, W., van den Bout, J., van der Heijden, P., et al. (2005). Couples at risk following the death of a child: Predictors of grief versus depression. Journal of Counselling and Clinical Psychology, 73, 617–622.
Zhang, B. H., El-Jawahri, A., & Prigerson, H. G. (2006). Update on bereavement research: Evidence-based guidelines for the diagnosis and treatment of complicated bereavement. Journal of Palliative Medicine, 9, 1188–1203.
698 E. A. Lobb et al.
Copyright of Death Studies is the property of Routledge and its content may not be copied or emailed to
multiple sites or posted to a listserv without the copyright holder's express written permission. However, users
may print, download, or email articles for individual use.