Do we all grieve the same? A multigroup test of the dimensional structure of prolonged grief disorder among Danish bereaved partners and children.

Prolonged Grief Disorder (PGD) is a newly recognized mental disorder in ICD-11 and DSM-5-TR. Several studies using exploratory factor analysis have found a unidimensional structure of the Prolonged Grief-13 (PG-13) measure of PGD. The recently published ICD-11 proposal proposes a distinction between two clusters of symptoms: Separation distress symptoms and associated cognitive, emotional and behavioral symptoms. The aim of the current study is to test competing factor structures of PGD in Danish samples of bereaved. Confirmatory factor analysis was used to test competing models of PGD among two samples of in total 1093 adults that completed the questionnaires 6 months post loss of either a parent or a partner. Convergent and divergent validity was tested via the relationship to depression, anxiety, post-traumatic stress disorder (PTSD) and general wellbeing using regression analysis. The Danish version of the PG 13 appeared to be both valid and reliable. A two-factor model reflecting the division of core- and associated symptoms of prolonged grief disorder provided the best description of the PG-13 among Danish bereaved adults and there was evidence of partial structural invariance of the latent structure of PGD across bereavement types. Convergent and divergent validity analysis supported the validity of the two-factor model of PGD. SIGNIFICANT OUTCOMES: : A latent variable model differing between core- and associated symptomatology of grief is supported. The Danish translation of PG-13 is a valid measure of prolonged grief symptomatology.

The neurobiological reward system in Prolonged Grief Disorder (PGD): A systematic review.

Prolonged Grief Disorder (PGD) is a debilitating condition affecting between 7% and 10% of bereaved individuals. Past imaging and psychological studies have proposed links between PGD's characteristic symptoms - in particular, profound yearning - and the neural reward system. We conducted a systematic review to investigate this connection. On December 19, 2019, we searched six bibliographic databases for data on the neurobiology of grief and disordered grief. We excluded studies of the hypothalamic-pituitary-adrenal (HPA) axis, animal studies, and reviews. After abstract and full-text screening, twenty-four studies were included in the final review. We found diverse evidence for the activation of several reward-related regions of the brain in PGD. The data reviewed suggest that compared to normative grief, PGD involves a differential pattern of activity in the amygdala and orbitofrontal cortex (OFC); likely differential activity in the posterior cingulate cortex (PCC), rostral or subgenual anterior cingulate cortex (ACC), and basal ganglia overall, including the nucleus accumbens (NAc); and possible differential activity in the insula. It also appears that oxytocin signaling is altered in PGD, though the exact mechanism is unclear. Our findings appear to be consistent with, though not confirmative of, conceptualizing PGD as a disorder of reward, and identify directions for future research.

Family caregiver descriptions of stopping chemotherapy and end-of-life transitions.

PURPOSE: The purpose of this study was to describe family caregivers' perspectives of the final month of life of patients with advanced cancer, particularly whether and how chemotherapy was discontinued and the effect of clinical decision-making on family caregivers' perceptions of the patient's experience of care at the end of life (EOL). METHODS: Qualitative descriptive design using semi-structured interviews collected from 92 family caregivers of patients with end-stage cancer enrolled in a randomized clinical trial. We used a phased approach to data analysis including open coding, focused coding, and within and across analyses. RESULTS: We identified three patterns of transitions characterizing the shift away from active cancer treatment: (1) "We Pretty Much Knew," characterized by explicit discussions about EOL care, seemingly shared understanding about prognosis and seamless transitions from disease-oriented treatment to comfort-oriented care, (2) "Beating the Odds," characterized by explicit discussions about disease-directed treatment and EOL care options, but no shared understanding about prognosis and often chaotic transitions to EOL care, and (3) "Left to Die," characterized by no recall of EOL discussions with transitions to EOL occurring in crisis. CONCLUSIONS: As communication and palliative care interventions continue to develop to improve care for patients with advanced cancer, it is imperative that we take into account the different patterns of transition and their unique patient and caregiver needs near the end of life. Our findings reveal considerable, and potentially unwarranted, variation in transitions from active treatment to death.

Cognition, structural brain changes and complicated grief. A population-based study.

BACKGROUND: Several psychosocial risk factors for complicated grief have been described. However, the association of complicated grief with cognitive and biological risk factors is unclear. The present study examined whether complicated grief and normal grief are related to cognitive performance or structural brain volumes in a large population-based study. METHOD: The present research comprised cross-sectional analyses embedded in the Rotterdam Study. The study included 5501 non-demented persons. Participants were classified as experiencing no grief (n = 4731), normal grief (n = 615) or complicated grief (n = 155) as assessed with the Inventory of Complicated Grief. All persons underwent cognitive testing (Mini-Mental State Examination, Letter-Digit Substitution Test, Stroop Test, Word Fluency Task, word learning test - immediate and delayed recall), and magnetic resonance imaging to measure general brain parameters (white matter, gray matter), and white matter lesions. Total brain volume was defined as the sum of gray matter plus normal white matter and white matter lesion volume. Persons with depressive disorders were excluded and analyses were adjusted for depressive symptoms. RESULTS: Compared with no-grief participants, participants with complicated grief had lower scores for the Letter-Digit Substitution Test [Z-score -0.16 v. 0.04, 95% confidence interval (CI) -0.36 to -0.04, p = 0.01] and Word Fluency Task (Z-score -0.15 v. 0.03, 95% CI -0.35 to -0.02, p = 0.02) and smaller total volumes of brain matter (933.53 ml v. 952.42 ml, 95% CI -37.6 to -0.10, p = 0.04). CONCLUSIONS: Participants with complicated grief performed poorly in cognitive tests and had a smaller total brain volume. Although the effect sizes were small, these findings suggest that there may be a neurological correlate of complicated grief, but not of normal grief, in the general population.

Negative religious coping as a correlate of suicidal ideation in patients with advanced cancer.

OBJECTIVE: The purpose of this study is to examine the relationship between negative religious coping (NRC) and suicidal ideation in patients with advanced cancer, controlling for demographic and disease characteristics and risk and protective factors for suicidal ideation. METHODS: Adult patients with advanced cancer (life expectancy ≤6 months) were recruited from seven medical centers in the northeastern and southwestern USA (n = 603). Trained raters verbally administered the examined measures to patients upon study entry. Multivariable logistic regression analyses regressed suicidal ideation on NRC controlling for significant demographic, disease, risk, and protective factors. RESULTS: Negative religious coping was associated with an increased risk for suicidal ideation (OR, 2.65 [95% CI, 1.22, 5.74], p = 0.01) after controlling for demographic and disease characteristics, mental and physical health, self-efficacy, secular coping, social support, spiritual care received, global religiousness and spirituality, and positive religious coping. CONCLUSIONS: Negative religious coping is a robust correlate of suicidal ideation. Assessment of NRC in patients with advanced cancer may identify patients experiencing spiritual distress and those at risk for suicidal ideation. Confirmation of these results in future studies would suggest the need for interventions targeting the reduction of NRC to reduce suicidal ideation among advanced cancer patients.

Correlates of social support in young adults with advanced cancer.

OBJECTIVE: This study examined the relationship between perceived social support, quality of life (QoL), and grief in young adults with advanced cancer. METHODS: Seventy-one young adults (20-40 years) with advanced cancer were administered measures of social support, QoL, and grief. Regression analyses examined the relationship between social support and QoL and grief. RESULTS: Higher levels of total social support were associated with better psychological and existential QoL and less severe grief. Availability of someone to talk to about problems was also associated with better psychological and existential QoL and less severe grief. Tangible support was associated with better psychological and existential QoL. Availability of someone to engage in activities with was only associated with better existential QoL. CONCLUSIONS: These results suggest that enhancing social support may improve psychological well-being in this population. In addition, specific types of social support may be particularly relevant to the psychological well-being of young adults with advanced cancer.

[Incidence of prolonged grief disorder in relatives of patients who die during or after admission in Intensive Care Unit]. / Incidencia del trastorno por duelo prolongado en los allegados de pacientes fallecidos durante o tras ingreso en la Unidad de Cuidados Intensivos.

OBJECTIVES: To determine the incidence of «Prolonged Grief Disorder¼ from one year after the death of a relative admitted to the Intensive Care Unit. MATERIAL AND METHODS: A cross-sectional, longitudinal follow-up study was conducted in a general ICU of a reference hospital. The relatives were evaluated approximately one year after the death using the «Consensus Criteria for Prolonged Grief Disorder¼ as a tool. The prevalence between the first and second years was determined. RESULTS: A total of 151 relatives of patients who died in ICU were included. The follow-up was carried out 22.1±5.3 months after the death. Eleven relatives (10.3%) fulfilled the «Consensus Criteria for Prolonged Grief Disorder¼. Of all the grieving relatives, those identified with prolonged grief disorder are the ones who most often require psychological/psychiatric support. CONCLUSIONS: In a sample of close relatives of patients who died in ICU, a significant minority fulfilled the criteria for «Prolonged Grief Disorder¼ 1-2 years after the death. This condition, which is often overlooked, and could require some kind of psychological treatment, should be taken into consideration.

Elevated rates of prolonged grief disorder in African Americans.

The prevalence of Prolonged Grief Disorder (PGD) in non-Whites is currently unknown. This study was performed to explore the prevalence of PGD in African Americans (AAs). Multivariable analysis of two studies of recently bereaved individuals found AAs to have significantly higher rates of PGD than Whites (21% [14 of 66] vs. 12% [55 of 471], respectively; p = 0.03). Experiencing a loved one's death as sudden or unexpected was also significantly associated with PGD over and above the effects of race/ethnicity. AAs may be at increased risk for the development of PGD. The development of effective interventions to treat PGD highlights the need to identify high-risk individuals and refer them to therapy and suggests the potential need for such therapies to adopt culturally sensitive approaches to care.

Preliminary explorations of the effects of prior trauma and loss on risk for psychiatric disorders in recently widowed people.

BACKGROUND: This study compared the relative influence of childhood and adulthood adversities on current diagnoses of Major Depressive Episode (MDE), Post-Traumatic Stress Disorder (PTSD) and Traumatic Grief (TG) among recently widowed older adults. METHOD: Eighty-five widowed persons were interviewed at a median of 4 months after their loss. The logistic regression procedure was used to estimate the effects of three childhood adversities (parental death, abuse, death of a sibling) and three prior adulthood adversities (death of a child, non-bereavement traumatic event, death of a sibling) on current diagnoses of MDE, PTSD and TG. RESULTS: Adversities occurring in childhood (abuse and death of a parent) were significantly associated with TG and, secondarily, MDE, while adversities occurring in adulthood (non-bereavement traumatic event and death of a child) were only significantly associated with PTSD. The tendency of childhood adversities to predict TG and adult adversities to predict PTSD remained significant even after the clustering of adversities and comorbidity among psychiatric disorders were taken into account. CONCLUSIONS: The results suggest that there is a vulnerability to TG rooted in childhood experiences explicitly, with more recent traumas having a stronger influence on PTSD secondary to widowhood. The distinctive etiological risks for bereavement-related PTSD, MDE, and TG suggest that therapeutic approaches should be tailored to the particular syndrome(s) present.

Instability of attitudes about euthanasia and physician assisted suicide in depressed older hospitalized patients.

The objective of this study was to examine the interest of non-terminally ill hospitalized elderly patients in euthanasia and physician assisted suicide (PAS) and to determine the stability of these interests over time. Patients age 60 or older (n=158), including both a depressed sample and non-depressed control sample, underwent a structured interview evaluating their interest in euthanasia and PAS in the event of a series of hypothetical outcome scenarios. Substantial proportions of subjects (varying from 13.3%-42% depending on the scenario) expressed hypothetical acceptance of euthanasia and PAS. After six months a subset of patients changed their minds about euthanasia and PAS (8% - 26% depending on the scenario), most often in the direction of initial acceptance to later rejection. Patients depressed in the hospital and interested in PAS for the outcome of their current (non-terminal) condition were significantly more likely express unstable opinions, with most rejecting it six months later. Other correlations of instability, in specific scenarios, included being male, experiencing higher baseline suffering, poorer subjective health and lower instrumental support. Because euthanasia and PAS actions are irreversible, findings of instability have important implications both clinically and for design of PAS legislation.

Perspectives on care at the close of life. Caring for bereaved patients: "all the doctors just suddenly go".

Despite the frequency with which physicians encounter bereaved patients, medical training offers little guidance in the provision of bereavement ("after") care. Physicians are often uncertain of how to distinguish between normal and pathological grief reactions in their bereaved patients, and how to manage their health care. Bereavement is associated with declines in health, inappropriate health service use, and increased risk of death. Identifying and intervening on behalf of bereaved patients could help address those increased risks. We examine the experience of a woman widowed for 2 years to illustrate distinctions between symptoms and outcomes of uncomplicated and complicated grief, recommend approaches to physician interactions with bereaved patients, and offer guidelines for professional intervention in aftercare.

Perceived needs and service use of Spanish speaking monolingual patients followed at a Hispanic clinic.

This study compared Spanish speaking monolingual patients at a Hispanic Clinic, with Hispanics and non-Hispanics at a conventional mental health center. A questionnaire in English and Spanish surveyed sociodemographic characteristics and subjectively reported health needs. The monolingual Hispanic Clinic patients perceived a significantly greater need for help with health and benefits, and better access to physical health care providers. Hispanics seen at the Hispanic Clinic report more difficulties managing medications than the other groups suggesting that this problem is not adequately addressed by receiving services in a culturally sensitive clinic, possibly due to the persistent effect of language barriers and low level of education. Additional interventions may be needed to address this problem.

Sex differences in event-related risk for major depression.

BACKGROUND: This study sought to determine if women are more likely than men to experience an episode of major depression in response to stressful life events. METHOD: Sex differences in event-related risk for depression were examined by means of secondary analyses employing data from the Americans' Changing Lives study. The occurrence and time of occurrence of depression onset and instances of stressful life events within a 12-month period preceding a structured interview were documented in a community-based sample of 1024 men and 1800 women. Survival analytical techniques were used to examine sex differences in risk for depression associated with generic and specific stressful life events. RESULTS: Women were approximately three times more likely than men to experience major depression in response to any stressful life event. Women and men did not differ in risk for depression associated with the death of a spouse or child, events affecting their relationship to a spouse/partner (divorce and marital/love problems) or events corresponding to acute financial or legal difficulties. Women were at elevated risk for depression associated with more distant interpersonal losses (death of a close friend or relative) and other types of events (change of residence, physical attack, or life-threatening illness/injury). CONCLUSION: Stressful life events overall, with some exceptions among specific event types, pose a greater risk for depression among women compared to men.

Older adult patients with both psychiatric and substance abuse disorders: prevalence and health service use.

The prevalence and service use among older adults with concurrent psychiatric and substance abuse disorders (the "dually diagnosed") was examined in a cross-sectional survey of a representative national sample of Department of Veterans Affairs mental health program patients (N = 91,752). Rates of dual diagnosis declined significantly (P = 0.001) as the age of the respondents increased (26.7% of patients < 65 years; 6.9% of patients > or = 65 years). Dually diagnosed older adult patients had longer inpatient stays for substance abuse and more outpatient substance abuse visits than did non-dually diagnosed elderly patients, and more outpatient general psychiatric visits than all the contrast groups. Dual diagnosis appears less common among older compared to younger patients, although their heavy use of certain (particularly, outpatient psychiatric) services suggests that should more dually diagnosed patients survive to old age their consumption of some forms of mental health care is likely to be high.

Gender differences in referral to cardiac rehabilitation programs after revascularization.

BACKGROUND: This study examines the influence of gender on the healthcare provider's secondary prevention instruction and cardiac rehabilitation (CR) referral after coronary revascularization procedures such as balloon angioplasty/coronary stenting and coronary bypass surgery (CABG). Cardiac rehabilitation decreases mortality and morbidity, yet only a small percentage of women and men are referred to these programs. The patient population of our university-affiliated CR program consisted of 88% men and 12% women. METHODS: In a matched case observational study, 80 patients (40 men, 40 women) who had undergone coronary revascularization procedures between 1997 and 1998 completed a questionnaire on secondary prevention instruction and written referral to CR programs. Patients were matched for age and coronary revascularization procedure. RESULTS: Women were less likely to be instructed on secondary prevention strategies and CR or referred to CR as compared to men despite being matched for age and undergoing the same procedure. The data demonstrate a gender difference in hospital teaching and referral information for CR after revascularization (P < 0.001). Being a woman was associated with a decreased likelihood of receiving a physician referral to CR after revascularization (P < 0.001). CONCLUSION: The instruction of patients concerning secondary prevention and CR postrevascularization procedures is poor. Within that group, women were far less likely to have CR discussed or referrals made by healthcare professionals. This study demonstrates the need for education initiatives of all healthcare providers on the comprehensive nature and benefits of CR in the secondary prevention of cardiovascular disease, with a particular emphasis on women.

Life-sustaining treatment and assisted death choices in depressed older patients.

OBJECTIVES: The major purpose of this study was to examine the effect of depressed mood in older, medically ill, hospitalized patients on their preferences regarding life-sustaining treatments, physician-assisted suicide (PAS), and euthanasia and to determine the degree to which financial constraints affected their choices. DESIGN: Cross-sectional study. SETTING: General medical hospital. PARTICIPANTS: One hundred fifty-eight medically hospitalized, nondemented patients age 60 or older, mean age 74.1 (range 60-94). The sample was divided, based on Center for Epidemiologic Studies-Depression (CES-D) scores, into a depressed group (n = 71) and a nondepressed control group. MEASUREMENTS: Subjects underwent a structured interview evaluating their life-sustaining treatment choices and whether they would accept or refuse PAS or euthanasia under a variety of hypothetical conditions. These choices were reevaluated with the introduction of financial impact. In addition, assessment included measures of depression, suicide, cognition, social support, functioning, and religiosity. RESULTS: Depression was found to be highly associated with acceptance of PAS and euthanasia in most hypothetical clinical scenarios in addition to patients' current condition. Compared with nondepressed people, depressed respondents were 13 times as likely to accept PAS when considering their current condition (95% confidence interval [CI] 1.68-110.98), and over twice as likely to accept PAS when facing a hypothetical terminal illness or coma. Depression alone was weakly associated with life-sustaining treatment choices but, when financial impact was introduced, significantly more depressed subjects refused treatment options they had previously desired than did nondepressed subjects. The presence of suicidal ideation, even passive ideation, was strongly predictive of life-sustaining treatment refusals and increased interest in PAS and euthanasia. Depression's effect on acceptance of PAS was confirmed by logistic regression, which also showed that religious coping was significantly correlated with less interest in PAS in two hypothetical scenarios. CONCLUSION. Depressed subjects and even subjects with subtle, passive suicidal ideation were markedly more interested in PAS and euthanasia than nondepressed subjects in hypothetical situations. Depressed subjects were also particularly vulnerable to rejecting treatments if financial consequences might have resulted.

Combat trauma: trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men.

Little is known about the risk and course of posttraumatic stress disorder (PTSD), and other forms of dysfunction, associated with combat trauma relative to other traumas. Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and Composite International Diagnostic Interview were administered to a representative national sample of 5,877 persons 15-54 years old in the part 2 subsample of the National Comorbidity Survey. Of the weighted subsample, 1,703 men reported a traumatic event. The risk of PTSD and other forms of dysfunction were compared for men who nominated combat as their worst trauma versus men nominating other traumas as worst, controlling for confounding influences. Men reporting combat as their worst trauma were more likely to have lifetime PTSD, delayed PTSD symptom onset, and unresolved PTSD symptoms, and to be unemployed, fired, divorced, and physically abusive to their spouses than men reporting other traumas as their worst experience.

Quality of life impairments associated with diagnostic criteria for traumatic grief.

BACKGROUND: This study examined the association between a diagnosis of traumatic grief and quality of life outcomes. METHOD. Sixty-seven widowed persons were interviewed at a median of 4 months after their loss. The multiple regression procedure was used to estimate the effects of a traumatic grief diagnosis on eight quality of life domains, controlling for age, sex, time from loss and diagnoses of major depressive episode and post-traumatic stress disorder. RESULTS: A positive traumatic grief diagnosis was significantly associated with lower social functioning scores, worse mental health scores, and lower energy levels than a negative traumatic grief diagnosis. In each of these domains, traumatic grief was found to be a better predictor of lower scores than either major depressive episode or post-traumatic stress disorder. CONCLUSIONS: The results suggest that a traumatic grief diagnosis is significantly associated with quality of life impairments. These findings provide evidence supporting the criterion validity of the proposed consensus criteria and the newly developed diagnostic interview for traumatic grief the Traumatic Grief Evaluation of Response to Loss (TRGR2L).

Diagnostic criteria for traumatic grief.

This article reviews the rationale for the development of diagnostic criteria for Traumatic Grief. Traumatic Grief is a new nosologic entity that a panel of experts recently proposed. It is a direct descendent of the concept of pathologic grief, and it has roots in attachment behavior, separation distress, and traumatic distress. We present consensus, diagnostic criteria for Traumatic Grief and discuss them in relation to another recently proposed set of criteria. In conclusion, we recommend the development of empirically tested, consensus, diagnostic criteria for Traumatic Grief. Diagnostic criteria would facilitate early detection and intervention for those bereaved persons afflicted by this disorder and lead to additional studies of the prevalence, the nature, and the treatment of the disorder.

Factors associated with symptomatic improvement and recovery from major depression in primary care patients.

This article describes a post-hoc analysis of clinical and psychosocial factors and beliefs about health associated with treatment outcome in a sample of depressed primary care patients (N=181) randomly assigned to a standardized treatment or physician's usual care (UC). Different factors were found to predict clinical outcomes for treatment modality [UC vs. interpersonal psychotherapy (IPT) or nortriptyline (NT)] and the type of outcome evaluated (i.e., depressive symptoms at 8 months or symptomatic and functional recovery at 8 months). Factors associated with treatment-specific outcomes are also described. Consistent with prior studies, lower depressive symptom severity at 8 months was associated with higher baseline functioning, minimal medical co-morbidity, race, and standardized pharmacologic or psychotherapeutic treatment. Additionally, an interaction between treatment modality and health locus of control indicated that individuals perceiving more self-control of their health and who received a standardized treatment experienced greater depressive symptom reduction at 8 months. Factors associated with symptomatic and functional recovery from the depressive episode were also examined. Patients who received a standardized treatment (IPT or NT) perceived greater control of their health and lacked a lifetime generalized anxiety disorder or panic disorder were more likely to recover by month 8 than those who received usual care. While clinical severity and treatment adequacy play an important role in both symptomatic improvement and full recovery from a depressive episode, other key factors such as health beliefs and non-depressive psychopathology also influence recovery.