Impact of early or delayed elective resection in complicated diverticulitis
Predictors of complicated grief: a systematic review of empirical studies
27
PLEASE SCROLL DOWN FOR ARTICLE This article was downloaded by: [Edith Cowan University] On: 15 February 2011 Access details: Access Details: [subscription number 907464807] Publisher Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37- 41 Mortimer Street, London W1T 3JH, UK Death Studies Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t713657620 Predictors of Complicated Grief: A Systematic Review of Empirical Studies Elizabeth A. Lobb abc ; Linda J. Kristjanson b ; Samar M. Aoun b ; Leanne Monterosso bc ; Georgia K. B. Halkett b ; Anna Davies d a Cunningham Centre for Palliative Care, Calvary Health Care Sydney, Korgarah, New South Wales b WA Centre for Cancer and Palliative Care within the Curtin Health Innovation Research Institute, Curtin University of Technology, Perth, Western Australia, Australia c School of Nursing, Midwifery and Postgraduate Medicine, Edith Cowan University, Perth, Western Australia, Australia d National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory, Australia Online publication date: 19 August 2010 To cite this Article Lobb, Elizabeth A. , Kristjanson, Linda J. , Aoun, Samar M. , Monterosso, Leanne , Halkett, Georgia K. B. and Davies, Anna(2010) 'Predictors of Complicated Grief: A Systematic Review of Empirical Studies', Death Studies, 34: 8, 673 — 698 To link to this Article: DOI: 10.1080/07481187.2010.496686 URL: http://dx.doi.org/10.1080/07481187.2010.496686 Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
Transcript of Predictors of complicated grief: a systematic review of empirical studies
PLEASE SCROLL DOWN FOR ARTICLE
This article was downloaded by: [Edith Cowan University]On: 15 February 2011Access details: Access Details: [subscription number 907464807]Publisher RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Death StudiesPublication details, including instructions for authors and subscription information:http://www.informaworld.com/smpp/title~content=t713657620
Predictors of Complicated Grief: A Systematic Review of Empirical StudiesElizabeth A. Lobbabc; Linda J. Kristjansonb; Samar M. Aounb; Leanne Monterossobc; Georgia K. B.Halkettb; Anna Daviesd
a Cunningham Centre for Palliative Care, Calvary Health Care Sydney, Korgarah, New South Wales b
WA Centre for Cancer and Palliative Care within the Curtin Health Innovation Research Institute,Curtin University of Technology, Perth, Western Australia, Australia c School of Nursing, Midwiferyand Postgraduate Medicine, Edith Cowan University, Perth, Western Australia, Australia d NationalCentre for Epidemiology and Population Health, Australian National University, Canberra, AustralianCapital Territory, Australia
Online publication date: 19 August 2010
To cite this Article Lobb, Elizabeth A. , Kristjanson, Linda J. , Aoun, Samar M. , Monterosso, Leanne , Halkett, Georgia K.B. and Davies, Anna(2010) 'Predictors of Complicated Grief: A Systematic Review of Empirical Studies', Death Studies,34: 8, 673 — 698To link to this Article: DOI: 10.1080/07481187.2010.496686URL: http://dx.doi.org/10.1080/07481187.2010.496686
Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf
This article may be used for research, teaching and private study purposes. Any substantial orsystematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply ordistribution in any form to anyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contentswill be complete or accurate or up to date. The accuracy of any instructions, formulae and drug dosesshould be independently verified with primary sources. The publisher shall not be liable for any loss,actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directlyor indirectly in connection with or arising out of the use of this material.
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 ofTechnology; 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 HealthInnovation Research Institute, Curtin University of Technology, Perth,
Western Australia, Australia
LEANNE MONTEROSSO
WA Centre for Cancer and Palliative Care within the Curtin HealthInnovation Research Institute, Curtin University of Technology, and School ofNursing, 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 HealthInnovation Research Institute, Curtin University of Technology, Perth,
Western Australia, Australia
ANNA DAVIES
National Centre for Epidemiology and Population Health, Australian NationalUniversity, 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 groupat the Australian Government Department of Health and Ageing. The opinions expressed inthis 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 fortheir 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 CareCalvary Health Care Sydney, Kogarah, New South Wales 2217, Australia. E-mail:[email protected]
Death Studies, 34: 673–698, 2010Copyright # Taylor & Francis Group, LLCISSN: 0748-1187 print=1091-7683 onlineDOI: 10.1080/07481187.2010.496686
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A systematic review of the literature on predictors of complicated grief (CG)was undertaken with the aim of clarifying the current knowledge and to informfuture planning and work in CG following bereavement. Predictors of CG priorto the death include previous loss, exposure to trauma, a previous psychiatrichistory, attachment style, and the relationship to the deceased. Factors associa-ted with the death include violent death, the quality of the caregiving or dyingexperience, close kinship relationship to the deceased, marital closeness anddependency, and lack of preparation for the death. Perceived social supportplayed a key role after death, along with cognitive appraisals and high distressat the time of the death. Inconsistent definitions of CG and measurement toolswere noted in the earlier studies reviewed. Limitations identified in the studiesincluded use of cross-sectional designs, heterogeneous samples, high attrition,demographic differences between cases and controls, differences in length of timesince death, and differences in types of death experienced. Notwithstandingthese limitations, some consistent findings have emerged. Further research intoconceptualizations of CG in terms of attachment theory and constructivist andcognitive-behavioral concepts of finding purpose and meaning after bereavementis warranted.
Our research team undertook a systematic review of literatureon complicated grief (CG), and this article reports our analysis ofthe research that examined its predictors. The term complicated griefrefers to a pattern of adaptation to bereavement that involves thepresentation of certain grief-related symptoms at a time beyondthat which is considered adaptive. These symptoms includemarked and chronic separation distress, such as longing andsearching for the deceased, loneliness, and preoccupation withthoughts of the deceased; and symptoms of traumatic distress, suchas feelings of disbelief, mistrust, anger, shock, detachment fromothers, and experiencing somatic symptoms of the deceased. Thesesymptoms have been shown to be distinct from depressive andanxiety 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 ‘‘persistentand disturbing disbelief regarding the death’’ and resistance toaccepting the painful reality (Shear & Shair, 2005, p. 253) for atleast 6 months to the point of functional impairment. Intenseyearning and longing for the deceased continues, along withfrequent pangs of intense, painful emotions. ‘‘Thoughts of theloved one remain preoccupying, often including distressing intrus-ive thoughts related to the death, and there is avoidance of a rangeof situations and activities that serve as a reminder of the painful
674 E. A. Lobb et al.
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loss. Interest and engagement in ongoing life is limited or absent’’(Shear & Shair, 2005, p. 253). It is estimated that between 10% and20% of bereaved people experience CG (Byrne & Raphael, 1994;Middleton, Burnett, Raphael, & Martinek, 1996; Prigerson et al.,1995, 1996, 1999; Prigerson & Jacobs, 2001a). CG was previouslyreferred to as traumatic grief but was renamed to avoid confusionwith posttraumatic stress disorder. More recent terminology hasbeen reported as complicated grief disorder (Zhang, El-Jawahri,& Prigerson, 2006) or prolonged grief disorder (PGD; Prigersonet 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, AustralianGovernment Department of Health and AgeingWebsite, and otheradditional websites. The following criteria were used to identifymaterial that would be included in the review: evidence based,published in a peer-reviewed journal, published between 1990and 2007, and seminal work published pre-1990 and published inthe English language. Relevant professional and research organiza-tions and leading authors in the field were contacted to identify anyadditional 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 inclusioncriteria were selected and retrieved (Anna Davies). Because ofthe inconsistent use of adjectives to describe CG and the variousconceptualizations of the disorder, if the abstract did not containenough information to ascertain whether or not the article was rel-evant, the full article was retrieved. A second reviewer (ElizabethA. Lobb) assessed 50% of the abstracts to confirm appropriatenessof inclusion of the articles. Full text versions of the abstracts werethen obtained. Articles that met the inclusion criteria and pre-sented original research about CG were evaluated and data fromthese articles were extracted into evidence tables (Anna Davies).Eighty percent of the included material was checked by a secondreviewer to determine if it met the inclusion criteria (Georgia
Predictors of Complicated Grief 675
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K. B. Halkett), and 10% of these studies were cross-checked by athird reviewer to confirm the evidence ratings for the papers(Samar M. Aoun). Fifty percent of excluded materials werechecked by a second reviewer (Elizabeth A. Lobb) to confirmexclusion. 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. Fortyarticles 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 ofrisk for CG within the construct of CG as defined in this review(see Table 1). The majority of studies measured CG usingthe Inventory of Complicated Grief (Prigerson et al., 1995) orthe Texas Revised Inventory of Grief (Faschingbauer, 1981).
Predictors Associated with Childhood
Risk factors specific to CG suggest that insecure attachments play acrucial role. Participants in studies who reported prior adversitiesin life were generally more distressed following bereavement thanthose who did not report adversities. In particular, childhoodseparation anxiety, adversities occurring in childhood (such asthe death of parent and childhood abuse) had a greater impactand 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 beexcessive dependency both as dependency on the spouse and asa more general personality trait. Less instrumental support and agreater likelihood of having a healthy spouse were also reportedas predictors (Bonanno et al., 2002). In examining the relationship
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TABLE
1Su
mmaryof
Stud
ieson
Predictors
ofCom
plicated
Grief
(n¼40
)
Authors
Pop
ulation
Results
Beery
etal.,
1997
Elderly
spou
sesof
term
inally
ill(n¼70
)Caregiver
burden
was
foun
dto
besign
ifican
tlyassociated
withboth
trau
matic
griefan
ddep
ression.Nosign
ifican
tassociationwas
foun
dbetweenthetimespen
tcaringan
ddurationof
care-givingwitheither
dep
ressionor
trau
matic
grief.Chan
gein
role
functionof
thecaregiver
was
associated
withdep
ression,but
not
trau
matic
grief.Nosign
ifican
tassociationwas
foun
dforcaregivers’gratificationwitheither
dep
ression
ortrau
matic
grief.
Van
Doo
rnet
al.,19
98Carersof
term
inally
illspou
se(n¼59
)Se
curity-enhan
cingan
dsupportive
marriages
(pre-loss)
werepositively
associated
withseverity
oftrau
matic
griefsymptoms.Insecure
attach
men
tstyles
weresign
ifican
tlyassociated
withborderlin
elevelsof
trau
matic
grief.Attachmen
tstylean
dmarital
qualitydid
not
interact
and
werenot
associated
withdep
ression.
Brintzen
-hofeS
zoc
etal.,19
99
Elderly
spou
sesof
cancer
patients(n¼37
)Enmeshmen
twas
associated
withincreasedpsych
olog
ical
distress.In
particular,complicated
griefin
thesurvivingspou
sewas
associated
with
higher
levelsof
distress,dep
ression,a
ndan
xiety.
Thisstud
ysupportsthe
meritsof
screen
ingsurvivingspou
sesbeforethedeath
oftheirspou
se.
Chen
etal.,19
99Futurebereavedspou
ses
(n¼15
0)W
idow
shad
higher
meansymptom
levelsfortrau
matic
grief,dep
ression,
andan
xietyat
allfour
timepoints
post-loss.Hightrau
matic
grief
symptom
levelsat
6mon
thspredictedphysical
healthou
tcom
esat
25mon
thsforbothmen
andwom
en.Hightrau
matic
griefsymptom
levels
infirstyear
post-loss
tended
tohaveastrongerinflue
nce
onthephysical
andmen
talhealthof
widow
ersinclud
inghospitalizationcancer,stroke,
orheartattack.
(Continu
ed)
677
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TABLE
1Con
tinue
d
Authors
Pop
ulation
Results
Silverman
etal.,
2001
Recen
tlywidow
ed(n¼85
)Participan
tswhoreportedprior
adversitiesin
theirlifeweregenerally
more
distressedfollo
wingbereavemen
tthan
thosewhodid
not
report
adversities.In
particular,ad
versitiesoccurringin
child
hoo
d,such
asdeath
ofaparen
tan
dab
use,
seem
edto
haveagreaterim
pactan
dwere
sign
ifican
tlyassociated
withtrau
matic
grief.
Melhem
etal.,
2001
Bereavedin
psych
otherap
ygrou
p(n¼23
)Com
plicated
griefscores
andfunctional
impairm
entwerehigher
amon
gpatientswithmorethan
oneconcurren
tAxisIdiagn
osis.Hen
ce,prior
psych
iatric
illnessmay
bearisk
factor
fortrau
matic
grief.
Piper
etal.,20
01Psych
iatric
out-patients
(n¼23
5)AxisIdiagn
osis
Tim
esince
loss
was
indicativeof
long-term
complicated
grief.Sign
ifican
tly
higher
levelsof
social
dysfunctionan
ddep
ressiondisturban
cevariab
les
werefoun
din
thesevere
complicated
griefgrou
p(n¼79
).Dep
ression,
anxiety,
andgriefsymptomatic
distressweresign
ifican
tlyhigher
for
severe
complicated
griefgrou
pcompared
tomod
eratecomplicated
grief
andthosewhohad
not
experiencedloss.
Barry
etal.,20
02Bereavedelders(n¼12
2)Lackof
preparationforthedeath
was
associated
withcomplicated
grief.
Perception
ofsuffering,
how
drawnou
tthedeath
was,or
violen
tdeath
was
not
associated
withcomplicated
grief.
Bon
annoet
al.,
2002
Widow
edolder
persons
(n¼20
5)Excessive
dep
enden
cyon
spou
sespecifically
andas
ageneral
personality
variab
le,lessinstrumen
talsup
port,an
dthegreaterlik
elihoo
dof
havinga
healthyspou
sewereassociated
withcomplicated
grief.
Boe
lenet
al.,
2003
aBereaved1stdegreerelatives
(n¼32
9)Eachof
thecogn
itivevariab
leswas
sign
ifican
tlyrelatedto
trau
matic
grief,
dep
ression,an
dan
xietysymptomsseverity.Forty-ninepercentof
varian
cein
trau
matic
griefseverity
was
explained
bytheglob
alnegative
beliefs
abou
tlife,
threaten
inginterpretation
sof
griefreaction
s,negative
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beliefs
abou
ttheworld,an
dthefuture.Ten
percentof
ITG
score
varian
cewas
explained
bydem
ographicvariab
les(age,tim
esince
loss,&
levelof
education).
Dyregrovet
al.,
2003
Child
loss
(n¼23
2),suicide
(n¼12
8),SIDS(n¼36
),acciden
t(n¼68
)
Self-isolation
was
foun
dto
bethebestpredictorof
psych
osocialdistress
andbeingfemalepredictedcomplicated
griefin
thesuicidean
dSIDS
samples.Therewas
noeviden
ceof
suicidesurvivorshavinggreater
difficultiesin
adap
tingto
thedeath
compared
withsurvivorsof
SIDSor
acciden
ts.
Jones
etal.,20
03Adults
withseriou
smen
tal
illness(n¼14
8)Lackof
preparationforparen
taldeath
resulted
inmoresevere
and
prolongedgrief(n¼33
).Sw
arte
etal.,
2003
Survivorsof
cancerpatients
whodiedbyeu
than
asia
(n¼18
9)an
dnatural
death
(n¼31
6)
Lesstrau
matic
grief,less
curren
tfeelings
ofgrief,an
dless
PTSreaction
swerefoun
din
family
andfriendsof
cancerpatients
whodiedfrom
euthan
asia
incomparison
tonatural
death,even
afterad
justmen
tfor
other
risk
factors.
Boe
lenet
al.,
2003
bBereavedindividua
ls(n¼23
4)Negativeinterpretation
sof
griefreaction
swerehighly
associated
withthe
degreeto
whichthesereaction
swereex
periencedas
distressing,
the
degreeto
whichmou
rnersen
gagedin
avoidan
cebeh
aviors
andthe
severity
ofthesymptomsof
trau
matic
griefan
ddep
ression.Beh
avioral
andcogn
itiveavoidan
cestrategies
weresign
ifican
tlyrelatedto
the
severity
oftrau
matic
griefan
ddep
ression.
Mitch
ellet
al.,
2004
Bereavedbysuicide(n¼60
),closelyrelated(n¼27
),an
ddistantlyrelated(n¼33
)
Closely
relatedsuicidesurvivorsex
periencednearlytw
icethelevelof
complicated
griefthan
distantlyrelatedsurvivors.
Melhem
etal.,
2004
aAdolescents
exposed
topeer
suicide(n¼14
6)Com
plicated
griefat
6mon
thswas
sign
ifican
tlyassociated
withfemale
gender,participan
ts’feelingthat
they
couldhavedon
esomethingto
preventthedeath
andapreviou
shistory
ofdep
ression.
(Continu
ed)
679
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TABLE
1Con
tinue
d
Authors
Pop
ulation
Results
Goo
den
ough
etal.,20
04Paren
tsof
ach
ildwhodied
from
cancer(n¼25
mother–father
dyads)
Fathersreportedsign
ifican
tlyhigher
levelsof
dep
ression,an
xiety,
and
stress
when
ach
ilddiedin
hospital
rather
than
athom
e.Motherstended
toshow
smallerdifferencesin
psych
olog
ical
outcom
esas
afunctionof
place
ofdeath.S
hortertimesince
child
’sdeath,h
igher
dep
ressionscores,
andhigher
levelof
family
friction
was
associated
withhigher
ratings
oftrau
maticdistress,separationdistress,an
dcore
grief.Mothershad
higher
ratings
oftrau
matic
distressan
dcore
grief.Death
inhospital
was
associated
withhigher
core
griefscores.
Maciaset
al.,
2004
Adults
withseriou
smen
tal
illness(n¼14
8)Com
plicated
griefw
asassociated
withthenum
ber
ofsituational
factorsthat
occurred
closer
todeath
(n¼18
):e.g.,residingwiththeindividua
l,sudden
nessof
thedeath,havinglow
social
support,an
dconcurren
tstressors.
Hardison
etal.,
2005
Psych
olog
ystud
ents
(n¼50
8)Bereavedinsomniacs
had
sign
ifican
tlyhigher
complicated
griefscores
than
bereavednon
-insomniacs.Bereavemen
t-relatedsleepvariab
les
(dream
ingof
deceasedan
druminatingab
outthedeceased)were
sign
ifican
tlyrelatedto
complicated
griefsymptoms.Com
plicated
grief
was
morefreq
uentin
trau
matically
bereavedyo
ungad
ults.
Drewet
al.,20
05Bereavedparen
ts(n¼56
)Paren
tsof
ach
ildwhohad
astem
celltran
splantan
ddiedin
hospital
had
agreaterlik
elihoo
dof
meetingthecriteria
forcomplicated
griefthan
for
thoseparen
tswhosech
ildhad
not
received
astem
celltran
splant.
Simon
etal.,
2005
Peo
ple
withDSM
-IVbipolar
(n¼10
3)Com
plicated
griefsample
reportedlifetim
ehistory
ofasuicideattempt.
Com
plicated
griefassociated
withhigher
ratesof
curren
talcohol
abuse,
curren
tpan
icdisorder
(withor
withou
tagorap
hob
ia),phob
icavoidan
ce,
andlifetim
eob
sessive-compulsive
disorder.Com
plicated
griefwas
associated
topoo
rerfunctioningan
dpoo
rerlevelsof
social
support.
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Wijn
gaards-de
Meijet
al.,
2005
Bereavedparen
ts(n¼21
9)Grief
was
predictedbych
ild’sage,causean
dun
expectednessof
death,and
thenum
ber
ofremainingch
ildren.
Van
derwerker
etal.,20
06Recen
tlybereavedcommun
ity
residen
ts(n¼28
3)Child
hoo
dseparationan
xietywas
sign
ifican
tlyassociated
withcomplicated
griefaftercontrollin
gforgender,level
ofed
ucation,k
inship
relation
ship,
history
ofpsych
iatric
disorders,an
dhistory
ofch
ildhoo
dab
use.
Johnsonet
al.,
2006
Com
mun
itybereaved
(n¼17
0)Respon
den
tswithcomplicated
grief,general
anxietydisorder,an
dmajor
dep
ressivedisorder
andthosewhoreportedsign
ifican
tsuicidal
ideation
had
sign
ifican
tlyelevated
Bereavemen
tDep
enden
cyScalescores
relative
tothosewithou
ttheseconditions.
Boe
len,S
troe
be,
Schut,&
Zijerveld,200
6
Individua
ls<
5mon
thsfrom
bereavemen
t(n¼97
)Negativebeliefs
abou
tself,life,
andthefuture,an
dthreaten
ing
interpretation
sof
griefreaction
swereassociated
withsymptomsof
concurren
tprospective
complicated
grief.
Boe
len,vanden
Bou
t,&
van
den
Hou
t,20
06
Bereavedindividua
ls(n¼56
)Con
tinuingbon
dswiththedeceasedthroug
hrecoveringmem
orieswas
astrongpredictorof
griefbut
not
dep
ression,whereascontinuingbon
ds
throug
htheuseof
thedeceasedperson’spossessionswas
aweak
predictorof
bothgriefan
ddep
ression.
Schulzet
al.,
2006
Bereavedcaregivers
(n¼21
7)Caregiverswhohavehighlevelsof
pre-lossdep
ressivesymptomsan
dburden
,whoreportedpositivefeatures
ofcare-giving,
andwhowere
caringformorecogn
itivelyim
pairedpatientsweremorelik
elyto
report
clinical
levelsof
complicated
griefpost-loss.
Neimeyer
etal.,
2006
Bereavedpsych
olog
ystud
ents
(n¼50
6)Aninteractionem
ergedbetweensense-m
akingan
don
goingattach
men
tto
thedeceased,sugg
estingthat
strongcontinuingbon
dspredictedgreater
levelof
trau
matic
griefan
dseparationdistress,but
only
when
the
survivor
was
unab
leto
makesense
oftheloss
inpersona,
practical,
existential
orspiritua
lterm
s.Hollandet
al.,
2006
Bereavedcolle
gestud
ents
(n¼1,02
2)Low
sense-m
akingan
dlow
ben
efit-findingwereassociated
withhigher
levelsof
complicated
grief.
(Continu
ed)
681
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TABLE
1Con
tinue
d
Authors
Pop
ulation
Results
Heb
ertet
al.,
2006
Bereavedcaregivers
(n¼22
2)Caregiverswhowereun
prepared
forthedeath
had
moredep
ression,
anxietyan
dcomplicated
griefsymptoms.
Currier
etal.,
2006
Bereavedpsych
olog
ystud
ents
(n¼10
56)
Alowcapacityforsense-m
akingem
ergedas
anex
planatorymechan
ism
for
theassociationbetweenviolen
tloss
andcomplicated
grief.
Shearet
al.,
2006
Bereavedfrom
September
11(n¼14
9)Individua
lswholostafamily
mem
ber
weremorelik
elythan
thosewholost
anacqu
aintance
toscreen
positiveforcomplicated
grief.
Herbertet
al.,
2007
Bereavedcaregivers(n¼1,22
9)After
controllin
gforsign
ifican
tcovariates,freq
uentattendan
ceat
relig
ious
services,meetings
and=or
activities
wereassociated
withless
dep
ression
andless
complicated
griefin
thebereaved.
Melhem
etal.,
2007
Bereavedch
ildrenan
dad
olescents(n¼12
9)Com
plicated
griefin
child
renan
dad
olescentswas
sign
ifican
tlyrelatedto
functional
impairm
enteven
aftercontrollin
gforcurren
tdep
ression,
anxiety,
andPTSD
.Com
plicated
griefwas
also
associated
withother
measuresof
psych
opatholog
yinclud
ingsuicidal
ideation
.Johnsonet
al.,
2007
Widow
edad
ults(n¼19
2)A
highlevelof
perceived
paren
talcon
trol
duringch
ildhoo
dwas
associated
withelevated
levelsof
dep
enden
cyon
thedeceasedspou
sean
dwith
symptomsof
complicated
grief.
682
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Rile
yet
al.,20
07Bereavedmothers(n¼35
)Moreop
timisticmothersreportedless
intense
griefreaction
san
dless
distressindicativeof
complicated
grief.Additionally,motherswho
usua
llycoped
actively
had
less
intense
griefreaction
s.Motherswho
hab
itua
llycoped
usingpositiverefram
inghad
less
intense
griefreaction
san
dless
complicated
grief.
Ottet
al.,20
07Bereavedad
ults(n¼14
1)Thosecatego
rizedin
thech
ronic
griefclusterex
periencedthehighestlevel
ofgriefan
ddep
ression,moresudden
deaths,thelowestself-esteem,an
dthehighestmarital
dep
enden
cyan
dmet
criteria
forcomplicated
grief.
Keeseeet
al.,
2008
Bereavedparen
ts(n¼15
7)Thecauseof
thedeath
(violentin
nature)
sign
ifican
tlypredictedintensity
ofcomplicated
grief;sense-m
akingan
dben
efit-findingsign
ifican
tly
increasedtheportion
ofvarian
ceex
plained
ingriefseverity;ben
efit-
findingwas
foun
dto
predictlower
severity
ofcomplicated
grief.
Metzger
&Gray,
2008
Bereavedmem
bersof
onlin
esupportgrou
p(n¼60
)Asthelevelof
interactionwithadyinglovedon
eincreased,m
orefeatures
ofCG
wereen
dorsed.Exp
ressionof
feelings
oflove
andaffectionan
dcontinue
daffilia
tion
andclosen
essweresign
ifican
tlypositivelyassociated
withcomplicated
grief.Agreaterdegreeof
commun
icationwas
relatedto
higher
levelsof
complicated
griefafteran
expectedloss.Pre-loss
acceptance
was
associated
withlower
complicated
grief.
Tom
arkenet
al.,
2008
Caregiversof
cancerpatients
(n¼24
8)Pessimisticthinkingan
dseverity
ofstressfullifeeven
tswas
anim
portant
factor
indevelop
ingcomplicated
grief.
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between marital quality and adjustment to the impending death ofa 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 contributedindependently to the severity of CG symptoms. Other studiesfound that relationships with the deceased that were close, support-ive, confiding and dependent were associated with an increasedrisk of CG (Bonanno et al., 2002; Carr, House, Wortman, Nesse,& Kessler, 2001; Prigerson, Maciejewski, & Rosenheck, 2000). Ahistory of strict parental control during childhood may be associa-ted with risk for the development of spousal dependence andpost-bereavement CG symptoms (Johnson, Zhang, Greer, &Prigerson, 2007). Expressions of continuing bonds were found tobe related to maladjustment in bereavement (Boelen, Stroebe,Schut, & Zijerveld, 2006). Maintaining continuing bonds by feelingcalmed and supported by memories of the deceased were reportedas a strong predictor of intensity of grief symptoms, independent ofinitial grief symptom severity (Boelen, Stroebe, et al., 2006).
Gender differences in spousal bereavement was examined byChen and colleagues (Chen et al., 1999). Widows had higher meansymptom levels of CG, which were found to predict sleep changesat the anniversary of the death of the spouse. For widowers, highsymptoms of CG predicted hospitalization and having a physicalhealth event such as cancer, stroke, or a heart attack (Chen et al.,1999). Bereavement-related sleep variables (dreaming of thedecreased and ruminating about the deceased) were significantlyassociated with CG symptomatology, with insomnia proving tobe a significant predictor of CG, along with the nature of the death(whether violent or not), the younger age of the deceased, levelof closeness with the deceased, recency of the loss, relationshipto the deceased, and gender of the bereaved, with women showinggreater grief (Hardison, Neimeyer, & Lichstein, 2005).
Predictors Associated with Cognitive Behavioral Conceptualizations
Cognitive behavioral conceptualizations of CG propose thatnegative cognition plays a core role in the development and per-sistence of emotional problems after bereavement as it generatesnegative emotions that can lead mourners to engage in counterpro-ductive attempts to avoid the implications and the pain of the loss
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(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 reactionsto be strongly related to concurrent and prospective levels of CG.These findings support their earlier work where cognitive variablessuch as global negative beliefs, negative worldview (Boelen, vanden Bout, & van den Hout, 2003b), and avoidance of emotionalproblems (Boelen, van den Bout, & van den Hout, 2003a) pre-dicted CG. Additionally, individuals who are generally averse tolifestyle 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 factorssuch 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 andhis colleagues. Currier, Holland, and Neimeyer (2006) evaluatedthe possible mediating role of sense-making between the cause ofdeath and CG. Results support the notion that although the objec-tive circumstances of the loss carry weight, the survivor’s subjectiveinterpretation of the loss is more influential in explaining ensuinggrief responses and that sense-making is a more critical pathwayto CG than the objective cause of death (violent or natural; Currieret al., 2006). This is supported by a study of bereaved parents,where inability to make sense of the death emerged as the mostsalient predictor of grief severity, greatly outweighing such factorsas cause of death, gender of the parent, or number of months oryears since the loss (Keesee, Currier, & Neimeyer, 2008).
Similarly, Holland, Currier, and Neimeyer (2006) examinedthe role of sense-making, benefit-finding, and time since loss in pre-dicting CG among a sample of college students. They reported thatwhen a great deal of sense has been made of the loss, finding benefitor a ‘‘silver-lining’’ in the grief experience was associated withpoorer grief outcomes—although in the absence of sense-making,it may mitigate grief. Moreover, the interaction of sense-makingand benefit-finding in predicting symptoms of CG remained robustregardless of cause of death or relationship to the deceased(Holland et al., 2006).
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Finally, several variables concerning the survivor, his or herrelationship to the deceased, and the nature of the death as riskfactors for CG were studied by Neimeyer, Baldwin, and Gillies(2006). An interaction emerged between sense-making and ongoingattachment to the deceased, suggesting that strong continuingbonds predicted greater levels of CG, but only when the survivorwas 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 6months was significantly associated with gender (female). Thepresence of a previous history of anxiety disorders, feeling thatthey could have done something to prevent the death, financialproblems, and a previous history of depression were all associatedwith PTSD at 6 months and were associated with an 81% risk ofCG (Melhem, Day, Shear, Reynolds, & Brent, 2004b). In anongoing 5-year study of the impact of parental loss on adolescents,the correlation between CG, and the number of months since thedeath was low but statistically significant (Melhem, Moritz,Walker, Shear, & Brent, 2007). The offspring’s feelings that otherswere accountable for the death were associated with higher scoresof CG, along with the offspring feeling others blamed him or herfor the death. CG scores were not higher in children and adoles-cents who lost a parent to suicide compared to children who losta parent to accident or sudden natural death (Melhem et al., 2007).
Adults bereaved by suicide of a family member experiencednearly twice the level of CG as distantly related survivors (Mitchell,Kim, Prigerson, & Mortimer-Stephens, 2004). In particular,spouses, parents, and children had significantly higher meanCG 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 shouldtake into account the familial and=or social relationship of thebereaved to the deceased. Similarly, Shear, Jackson, Essock,Donahue, and Felton (2006) found that individuals whosefamily member died in the September 11, 2001, terrorist attackswere more likely than those whose acquaintance died to screenpositive for CG.
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A report on parents bereaved by their child’s death by suicide,sudden infant death and child accidents found that there was noevidence of suicide survivors having greater difficulties in adaptingto the death compared with survivors of SIDS or accidents;however, being female predicted CG in the suicide and SIDSsample (Dyregrov, Nordanger, & Dyregrov, 2003). In studies ofbereaved parents, a shorter time from diagnosis of cancer to death(Goodenough, Drew, Higgins, & Trethewie, 2004); the death of thechild in hospital following stem cell transplantation versus death athome (Drew, Goodenough, Maurice, Foreman, & Willis, 2005);and the child’s age, cause, and unexpectedness of the death andthe 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 supportnetwork, have been associated with lower risk for bereavement-related complications in caregivers (Vanderwerker & Prigerson,2004). Conversely, pessimistic thinking and experiencing a numberof severe stressful life events in caregivers of cancer patients wereimportant predictors in their developing CG (Tomarken et al.,2008). A study by Barry, Kasl, and Prigerson (2002) evaluated theassociation 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 withCG at baseline, at 4 months, and at 9 months, suggesting that personswho perceive themselves as unprepared for the death may be at riskof bereavement-associated morbidity. Similarly, a study in a largecohort of caregivers of persons with dementia found that caregiverswho were not at all prepared for the death had worse mental health,exhibitedmore depressive, CG, and anxiety symptoms at the first andsubsequent assessment after the death even when controlling for mul-tiple factors such as the caregiver’s physical and mental health beforethe death (Hebert, Dang, & Schulz, 2006). In another study from thisgroup of researchers, religious beliefs and practices were found to beimportant 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 depressionand less CG in the bereaved (Herbert, Dang, & Schulz, 2007).
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Caregivers of terminally ill spouses, who had higher levels ofdepression and burden pre-loss, and who reported positiveaspects of caregiving pre-loss were found to be at a heightenedrisk 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 onsymptoms of CG found that caregiver burden was significantlyassociated with the spouse’s level of depression and CG (Beeryet al., 1997). Bereaved family members and close friends ofterminally ill cancer patients who died by legal euthanasia inThe Netherlands coped better with respect to grief symptomsand PTSD than bereaved family and friends of comparablecancer 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 oneincreased, they endorsed more features of CG (Metzger & Gray,2008). Expression of feelings of love and affection and continuedaffiliation and closeness was positively associated with CG. Agreater degree of communication was related to higher levels ofCG after an expected loss. Similar to other studies, pre-lossacceptance 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 indicatethe situational factors surrounding the death including residingwith the close friend or family member at the time of the death,the suddenness of the death, low social support, concurrentstressors, lack of preparation for parental death, and higher levelsof social dysfunction were associated with a more severegrief reactions (Jones et al., 2003; Macias et al., 2004; Piper,Ogrodniczuk, Azim, & Weideman, 2001). In another populationof psychiatric patients, self-reported anxiety, depression, and aconcurrent Axis 1 diagnosis was associated with CG (Melhem,Day, Shear, Day, Reynolds, & Brent, 2004b). Increased panicattacks, alcohol abuse comorbidity, higher rates of suicideattempts, greater functional impairment and poorer social supportwere found in a population of patients with bipolar disorder
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(Simon et al., 2005). In particular in the CG group, more patientsreported a lifetime history of suicide attempts, and this associationdid not diminish after controlling for lifetime panic disorders, withCG 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 andconditions 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 denBout, 2000). However, there has been a lack of evidence for goodpractice in bereavement research and services, especially forthose who might be at risk of CG following bereavement.Moreover, there is great diversity in the use of adjectives todescribe variations from normal grief, and the conceptualizationsof CG differed according to the theoretical approach taken bythe investigators. This definitional and theoretical confusion hascreated uncertainty for health care providers and services thatendeavor to make sense of the complex and apparently conflict-ing literature. In undertaking this systematic review we notethat in more recent studies there is increased consistency in theterminology and measure used for CG.
A small percentage of the population (approximately 10% to20%) experiences CG. CG symptoms, which when elevated andwhen 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 CGhave been found to persist despite the passage of time and thetreatment 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 asuccinct categorization for the consideration of risk factors(Stroebe, Hansson, Stroebe, & Schut, 2001). These are determinedas situational factors related to the death, personal factors such asgender and characteristics prior to the death, and interpersonal
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factors such as the availability of social and emotional support fromfamily and friends.
Our review relating to situational factors associated with thedeath provides some evidence that those bereaved by traumaticdeath such as suicide have an increased risk of CG. This supportsthe notion that the unique features of traumatic death, whenpresent in suicide or in any other traumatic loss, account for muchof the variance in bereavement outcome in comparison to naturalcauses of death. There were a number of limitations in these stu-dies and further investigations are warranted, such as longitudinalstudies to determine whether CG and depression are preludes tosuicidal ideation. Of note in the studies on suicidal ideationwas the consistent use of the Inventory of Complicated Grief inassessment of this group (Mitchell, Kim, Prigerson, & Mortimer,2005; Prigerson et al., 1999).
Consistent with the notion that CG is fundamentally anattachment disorder, personal factors, in particular insults to asense of security caused by weak parental bonding in childhood,present a vulnerability to the onset of CG later in life (Silvermanet al., 2001; Vanderwerker et al., 2006). Because of thecross-sectional designs of these studies, recall bias could haveinflated the associations between disorders and prior adversities.In addition, the small sample sizes, stratification, and the rarityof some outcomes suggest that the estimate of risk may not bereliable. Given the findings that having an insecure attachmentstyle and excessive dependency, both in the form of dependencyon the spouse and as a more general personality trait, arepredictive of CG (Bonanno et al., 2002; van Doorn et al., 1998),interventions that promote secure alternative attachments to othersand emotional re-engagement are needed. Results of studies oncognitive appraisal such as interpreting grief reactions as indicatingmental insanity, inadequate adaptation, or personal incompetence(Boelen et al., 2003b); assigning negative meanings to griefreactions (Boelen et al., 2003b) and cognitive and emotionalupheaval surrounding the death of a healthy spouse (Bonanno,Wortman, & Nesse, 2004) support the notion that negativeinterpretations of grief reactions in themselves do not indicatedisturbance. They can, however, play a role in the developmentand maintenance of emotional problems after bereavement. AsBonnano et al. (2004) would argue, perhaps cognitive appraisals
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influence the degree to which these reactions are experienced asdistressing. Consequently they can then influence the degree towhich mourners engage in avoidance strategies that are likely toimpede recovery and may serve to exacerbate and prolong griefrather than ameliorate grief reactions.
The role of meaning-making has emerged as a key factor inCG. Although the circumstances of the death are influential in griefresponses, it appears that the survivor’s subjective interpretation ofthe loss and being able to make sense of the loss in personal,practical, existential, and spiritual terms is influential in explainingensuing grief responses, as documented in several studies(Neimeyer, Burke, Mackay, & Stringer, 2010).
Situational factors related to the death include place ofdeath (e.g., hospital vs. home); the time from diagnosis to death(Goodenough et al., 2004); perceptions of the death being moreviolent 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 orshocked by the death (Prigerson, 1996). The question of‘‘preparedness’’ for death and the degree of trauma and sufferingassociated with the person’s death may be pertinent issues whenexamining family members who may be at greater risk for a CGresponse. Preparation for the person’s death and a sense that deathwas peaceful and not distressing may be factors associated with amore favorable bereavement response. Reducing caregiverburden, treating depression before the death of the loved one,and providing supportive psychosocial or skills training caregiverinterventions can help the caregiver better manage the sequelaeof death (Schulz et al., 2006).
Limitations
We acknowledge two types of limitations: those related to themethodology of conducting systematic reviews and those morespecific to the nature of CG. All types of studies are subject to bias,with systematic reviews being subject to the same biases possible inthe original studies reviewed, as well as biases specifically relatedto the review process. Biases include publication bias, time-lagbias, multiple publication bias, language bias, and outcome report-ing bias (Egger, Juni, Bartlett, Holenstein, & Sterne, 2003). Other
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biases can result if the methodology to be used in a review is notdefined before the review commences. Detailed knowledge ofstudies performed in the area of interest may influence theeligibility criteria for inclusion of studies in the review and maytherefore result in biased results. For example, studies with morepositive results may preferentially be included in a review, thusbiasing the results and overestimating effects.
We endeavored to conduct a comprehensive review bycontacting key authors for information about current studies thatmay be either ‘‘in press’’ or published recently. In addition, theuse of broad terms in our searches, cross-referencing, and searchesby 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-worldcountries, and this may subsequently limit exposure to somebereavement issues. Studies may not be listed in this reviewbecause of the journal not being cited on the database or thedatabase not providing an abstract.
The challenges of undertaking research to investigate CGhave been well-documented and include inconsistent use ofdefinitions, instruments, cross-sectional designs, heterogeneoussamples, high attrition, demographic differences between casesand controls, differences in length of time since death, differencesin types of death experienced, and use of recruitment techniquesthat may contribute to biases in sample characteristics. In addition,the time that measurements were undertaken and the use ofself-report data may have created recall biases. In particular, thelimitations in the studies on predictors of CG typically includedsmall sample sizes, in particular in studies where stratificationwas undertaken. However, some recent exceptions in the formof large-scale studies suggest that stronger evidence in predictingCG is emerging (e.g., Currier et al., 2006; Neimeyer et al., 2006).
In undertaking our systematic review, the evidence baseapplied 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 allrelevant randomized controlled trials to Level IV (case series,either pretest or posttest; NH&MRC, 2000). The majority of stu-dies in our review (n¼ 40) were categorized as Level of EvidenceIII-2—IV according to that is, either comparative studies with
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concurrent or historical controls, case-control studies (or interrup-ted time series with a control group); or two or more single arms orcase series (either posttest or pretest and posttest; Kristjanson,Lobb, Aoun, Monterosso, & Halkett, 2005). However, otherindicators of quality in individual studies, such as sample size,quality of instrumentation, reliability of interviews or diagnosiscan be of more relevance. We noted, for example, an increasedconsistency in the use of measurement tools in later studies thatwe reviewed, along with increased sample sizes.
Conclusions
A large proportion of studies on predictors of CG have relatedto spousal=conjugal grief in later life. Few studies have been under-taken with children or adolescents to address CG, althoughmore recently Melham and colleagues are building a body of workwith adolescents. No studies were identified in this reviewthat specifically addressed CG in indigenous populations. The bulkof the research material in this area identified focussed onintergenerational grief or historical grief.
Notwithstanding the limitations mentioned in the previoussection, some direction has emerged. Further research into concep-tualizations of CG in terms of attachment theory and constructivistand cognitive-behavioral concepts of finding purpose and meaningafter bereavement is warranted. This systematic review hasconfirmed the need for targeted research to address the gaps inknowledge that exist in the area of CG. Without systematicand trustworthy investigations, health professionals, and serviceproviders endeavor to provide interventions and services basedon anecdotal experiences and trial-and-error approaches.
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