Prevalence and comorbidity of prolonged grief disorder in a sample of caregivers of patients in a vegetative state

Anticipatory grief prevalence among caregivers of persons with a life-threatening illness: A meta-analysis

OBJECTIVES

Caring for a family member with a life-threatening illness may lead to increased levels of psychological morbidity. Given the lack of recognition of caregivers' grief, this study aimed to determine the prevalence of anticipatory grief disorders in caregivers of persons with a life-threatening illness for better intervention and management.

METHODS

CINAHL, Cochrane, Embase, Medline, PubMed, Scopus, PsycINFO and Web of Science were searched up to 21 March 2021 without language and time restrictions. The quality of the included studies was assessed with Hoy's criteria. A random-effects model was applied to calculate pooled prevalence rates, and multi-regression was performed to examine heterogeneity among studies.

RESULTS

A total of 3278 citations were retrieved, and 18 studies met the eligibility criteria involving 5470 caregivers. The pooled prevalence of anticipatory grief was 24.78% (95% CI 19.04% to 30.99%). The prevalence rates were significantly higher in female caregivers (16.64%; 95% CI 12.24% to 21.53%) compared with male caregivers (6.11%; 95% CI 4.55% to 7.87%). The married group also had a higher risk (14.66%; 95% CI 10.66% to 19.16%) than single group (5.47%; 95% CI 4.31% to 6.76%).

CONCLUSIONS

The overall pooled prevalence is substantially higher compared with after-loss grief in the general population and supported the presumptions that preloss grief has a greater magnitude compared with after-loss grief. Bereavement support, educational programmes and relevant resources should be delivered even before the actual loss to address the burden of caregivers.

How attachment style, mentalization and preparedness for death are associated with pre-loss grief symptoms' severity: A network analysis study in caregivers of terminally ill cancer patients

Several psychological dimensions influence the psychological adjustment of terminally ill cancer patients' caregivers, during the end-of-life phase. The present study explored the associations between attachment styles, mentalization, preparedness for death, and the severity of pre-loss grief symptoms in 102 caregivers of terminal cancer patients. The results of the network analysis showed that insecure attachment dimensions were positively associated with several central pre-loss grief symptoms. Mentalization and preparedness for death showed negative associations with several pre-loss grief symptoms. Interestingly, bitterness showed a negative association with need for approval and a positive association with mentalization. The results provided insight into the grieving process for palliative care providers to implement effective caregiver support interventions.

The effects of caregiver's burden on dynamic structure in disorder of consciousness families: An observational study

INTRODUCTION

Disorder of consciousness is a clinical condition due to severe brain damage. The impact of consciousness disorder on the family is characterized by a combination of biopsychosocial factors. The burden and suffering perceived by caregivers can cause psychological distress characterized by anxiety, depression, and physical illness. The aim of the study was to investigate the interaction between family dynamics and caregiver burden.

METHODS

We enlisted 35 caregivers of subjects in a minimally conscious state. Two skilled psychologists administered the Olson's Adaptability and Family Cohesion Assessment Scale and the Novak's Burden Inventory Caregiver Scale to assess family function and family burden, respectively.

RESULTS

We found that the caregiver burden correlates with the family adaptability and cohesion, as well as with enmeshment, rigidity, and disengagement.

CONCLUSION

Findings suggest that the traumatic event does not affect the family structure. Families are able to maintain a balanced functioning and control distress.

The experience of family caregivers caring for a patient with chronic disorders of consciousness: a qualitative content analysis

BACKGROUND

Management of a patient with chronic disorders of consciousness is a long-term and stressful situation for family caregivers.

AIMS

The aim of this study was to describe the experiences of family caregivers of patients with chronic disorders of consciousness.

METHODS

Purposeful sampling was used, data were collected through semi-structured, in-depth interviews at participants' homes. Data were analysed using qualitative content analysis.

FINDINGS

Results indicated that family caregivers of patients with chronic disorders of consciousness face many difficulties in providing care to vegetative state (VS) and minimally conscious state (MCS) patients; they experience it as a challenging type of care, which influences their mental health.

CONCLUSION

Family caregivers are faced with many challenges because of the high burden of care, round-the-clock concern, taking care of an alive but unresponsive patient without receiving enough support. They experience mental and inner turmoil because of social isolation and dealing with contradictory feelings in their daily life.

Psychological Distress after a Diagnosis of Malignant Mesothelioma in a Group of Patients and Caregivers at the National Priority Contaminated Site of Casale Monferrato

BACKGROUND

Patients of malignant mesothelioma (MM) and their caregivers face significant physical and psychological challenges. The purpose of the present study is to examine the emotional impact after the diagnosis of MM in a group of patients and familial caregivers in a National Priority Contaminated Site (NPCS).

METHODS

A sample of 108 patients and 94 caregivers received a sociodemographic/clinical questionnaire, the Beck Depression Inventory II, the Davidson Trauma Scale, the Coping Orientation to the Problems Experienced-New Italian Version, and the Defense style questionnaire. The risk of depressive and post-traumatic stress disorder (PTSD) symptoms in relation to the strategies of coping and defense mechanisms was estimated in patients and caregivers separately by logistic regression models.

RESULTS

For patients, a high risk of depression was associated with high usage of Defense Style Questionnaire (DSQ) Isolation (OR: 53.33; 95% CI: 3.22-882.30; p = 0.01) and DSQ Somatization (OR: 16.97; 95% CI: 1.04-275.90; p = 0.05). Other significant risks emerged for some coping strategies and some defenses regarding both depression and trauma in patients and caregivers.

CONCLUSIONS

This research suggests that for both patients and caregivers unconscious adaptive processes have a central role in dealing with overwhelming feelings related to the disease.

The prevalence of complicated grief among Chinese people at high risk: A systematic review and meta-analysis

OBJECTIVE

This unprecedented systematic review aims to unearth the rate of CG among Chinese people.

METHODS

Data sources were from PsycINFO, ProQuest Databases, Web of Science, PsycARTICLES, China National Knowledge Infrastructure (CNKI), WanFang, Taiwan Periodical Literature System (TPLS), HKInChiP from the inception to June 2019. The eligibility criteria for inclusion were (a) including or useful to calculate the prevalence of CG in Chinese settings, (b) published in journals, (c) containing information on sample size, (d) full texts either written in English or in Chinese are available. Thirteen studies were engaged in meta-analytic evaluation after the systematic review. They were appraised by the risk of bias (RoB) for publication-quality and synthesized through meta-analysis for identifying the prevalence of CG among Chinese people.

RESULTS

Meta-analysis revealed a pooled estimate of CG of 22.0% (95% CI: 0.111-0.391). The studies identified in this review were of methodological heterogeneousness and focused on the population at high risk of CG. They were a moderate or high risk of bias.

CONCLUSION

Results warrant the need to conduct a population-based and quality study to investigate the prevalence of CG in Chinese people. Many suggestions on treatment for Chines people with CG were provided.

Locked-in your heart-shaped box: Familial-role and attachment orientation as predictors of grief in prolonged disorders of consciousness vs. death

Death or prolonged disorders of consciousness (DOC) of a loved one are both considered relational-losses that severely disrupt attachment-bonds. Grief in both conditions was compared by exploring the impact of familial-role and attachment-orientation. In DOC, caregivers' grief was found significantly intensified relative to Death. Familial-role impacted grief in both conditions alike, with partners' heightened grief in DOC reflecting the complexity of their stagnant bonds. In Death, avoidance-attachment mitigated grief, while in DOC anxiety-attachment accentuated grief, we suggest that while physical-separation in death facilitates the modification of continuing attachment-schema, in DOC, modification may be required while the patient is still alive.

"It gets better. It can´t be worse than what we have been through." Family accounts of the minimally conscious state

OBJECTIVES

The aim of this qualitative study was to explore family life when a family member is in a chronic minimally conscious state (MCS). Experiences with the health care system were also explored.

METHODS

As part of a larger qualitative study of family life after a family member suffers severe physical injury, we conducted a focus group interview with five family members of three patients in a chronic MCS. The participants included three mothers, one father, and one sibling. The length of time since the brain injuries was four, four, and ten years. A thematic analysis was conducted.

RESULTS

Three main themes emerged. Each family reflected on the challenges of maintaining family unity. They also revealed how they had dealt with the ambiguity and severity of the situation, including the communication with the health care system. Finally, they described their journeys back toward a normal, everyday family life.

CONCLUSIONS

The findings demonstrate challenges faced by family members but also their capacity to withstand and overcome adversity. Clinicians are reminded to maintain a long-term perspective and understand the importance of helping families adjust, maintain hope for a better future, and mitigate their psychological pain.

Partially dead, partially separated: establishing the mechanism between ambiguous loss and grief reaction among caregivers of patients with prolonged disorders of consciousness

OBJECTIVES:

To trace the psychological mechanism underlying caregivers' emotional experience in prolonged disorders of consciousness, by examining the mediating role of boundary ambiguity in the relationship between ambiguous loss and grief.

DESIGN:

Cross-sectional design.

SETTING:

The Respiratory Rehabilitation Division of a long-term medical and rehabilitation institute.

SUBJECTS:

A total of 64 primary caregivers (69% female) of patients in a vegetative state ( n = 49) or minimally conscious state ( n = 15), with a mean age of 55.5 (SD = 12.3) years. Participants were mostly the patient's children (62%) or partners (27%). The mean caregiving duration was 4.9 (SD = 5.1) years.

MAIN MEASURES:

The Boundary Ambiguity Scale, the Revised Need for Closure Scale, an adapted version of the multifactor Two-Track Bereavement Questionnaire, and a sociodemographic questionnaire, which included items regarding caregiving: frequency of visits and perception of the patient's psychological presence.

RESULTS:

(1) Caregivers' grief scores (total TTBQ: mean = 2.97; SD = 0.55) did not significantly differ from those exhibited by a normative bereavement sample. (2) Time since injury did not affect caregivers' grief scores (three-year cut-point; P > .05). (3) Mediation analyses revealed that boundary ambiguity (mean = 34.03; SD = 7.55) significantly mediates the relationship between need for closure ( B = .11; confidence interval (CI) = .04-.23) and grief; frequency of visits ( B = .05, CI = .02-.10) and grief and perception of psychological presence ( B = .26, CI = .00-.61) and grief in three separate models.

CONCLUSION:

Ambiguity concerning relational boundaries hinders caregivers' ongoing grief reaction and impedes their ability to integrate the loss. High frequency of visits, belief in the patient's psychological presence and difficulties in tolerating uncertainty are all clinical manifestations of caregivers' entangled experience.

Grief, anger and despair in relatives of severely brain injured patients: responding without pathologising

The training and expertise of healthcare professionals in diagnosing and treating pathology can mean that every situation is treated as an instance of illness or abnormality requiring treatment. This medicalised perspective is often evident in clinical approaches to family members of people with prolonged disorders of consciousness. This editorial was stimulated by reviewing an article (final version now published in this issue) concerning the distress of families with severely brain injured relatives,(2) and by reading the larger body of literature to which that article contributes. It was also prompted by the recent publication of national clinical guidelines in the UK about the management of prolonged disorders of consciousness. In this editorial we highlight the depth and range of emotional reactions commonly experienced by families with a severely brain injured relative. We suggest that clinicians should understand such emotions as normal responses to a terrible situation, and consider the ways in which clinical practice can be adapted to avoid contributing to family trauma.

The psychological impact of prolonged disorders of consciousness on caregivers: a systematic review of quantitative studies

OBJECTIVE

Systematic review of the nature, frequency and severity of psychological experiences of people who have a close relationship with a person with a prolonged disorder of consciousness.

DATA SOURCES

Cochrane Library, Web of Science, PsycINFO, PubMed, Embase^®, MEDLINE^®, Allied and Complementary Medicine™, were searched from inceptions until December 2016 with additional hand searching of reference lists of included articles.

REVIEW METHODS

Studies were included that used quantitative methodologies and psychological measures to investigate experiences. The PRISMA statement was followed with inclusion criteria set a priori. A data synthesis summarized psychological constructs studied.

RESULTS

A total of 18 studies (ranging between n = 16-487 participants) met the inclusion criteria with 15 of 18 studies focused on the primary caregiver. A total of 23 standardized psychological measures were identified to assess four primary psychological constructs: Loss and grief, psychological wellbeing changes, burden and use of coping strategies.

CONCLUSIONS

Small sample sizes, limited variables and reliance on observational methods affected quality. Caregivers do find ways to manage independently, but some exhibit clinically significant psychological distress that does not change over time alone and may get worse.

Portuguese validation of the Prolonged Grief Disorder Questionnaire–Predeath (PG–12): Psychometric properties and correlates

Objective:

This study aimed to contribute to the validation of the Portuguese version of the Prolonged Grief Disorder Questionnaire–Predeath (PG–12), examining its psychometric properties, including factorial, discriminant, and predictive validity. The prevalence of predeath prolonged grief disorder (PGD) and its psychosocial correlates were also analyzed.

Method:

The PG–12 was assessed in a sample of family caregivers (FCs) of oncological patients in palliative care. The factorial and discriminant validity of the PG–12 were evaluated by confirmatory factor analysis. The prevalence of predeath PGD was calculated and correlated with sociodemographic characteristics, perception of illness, intensity of care, coping, and caregiver burden. Prospective data were used to assess predictive validity.

Results:

The sample was composed of 94 FCs, mostly female (78.8%) and daughters (61.3%), with a mean age of 52.02 (SD = 12.87). The PG–12 has been shown to be reliable, to have high internal consistency, to be monofactorial in structure, and to be independent from depression, anxiety, and burden, although predeath grief influences these symptoms. In our sample, 33% met the criteria for predeath PGD. The circumstances and coping mechanisms are also correlated with predeath grief. The PG–12 has also been shown to be predictive of postdeath outcome.

Significance of results:

The PG–12 can be a useful screening tool for early identification of risk for maladjustment to loss among family caregivers.

Attachment Style Dimensions Can Affect Prolonged Grief Risk in Caregivers of Terminally Ill Patients With Cancer

Objective:

The aim of the present study was to evaluate the predictive role of attachment dimensions on the risk of prolonged grief. Sixty caregivers of 51 terminally ill patients with cancer who had been admitted in a hospice were selected.

Methods:

Caregivers were interviewed using Attachment Scale Questionnaire, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, and Prolonged Grief Disorder 12 (PG-12).

Results:

The consort caregivers showed higher PG-12 level compared to the sibling caregivers. Anxiety, depression, need for approval, and preoccupation with relationships levels were significantly correlated with PG-12 scores.

Conclusion:

Female gender, high levels of depression, and preoccupation with relationships significantly predicted higher levels of prolonged grief risk.

Lessons from the 2004 Asian tsunami: Nature, prevalence and determinants of prolonged grief disorder among tsunami survivors in South Indian coastal villages

BACKGROUND

Prolonged grief disorder (PGD), previously called complicated grief, is associated with significant distress and long-term disability, and it may complicate assessments for post-traumatic stress disorder (PTSD) after traumatic events.

METHODS

In order to distinguish PGD from PTSD, we conducted a cross-sectional survey among tsunami survivors in five tsunami-affected coastal villages in India, 9 months after the Asian tsunami.

RESULTS

Prevalence of PGD among 643 tsunami survivors was 14.2% (95% confidence interval (CI): 11.5%-16.9%) and among the 351 bereaved survivors was 25.9% (95% CI: 21.3%-30.5%). Spousal bereavement, extensive damage to homes, fewer years of education, and absence of tsunami-related physical injury differentiated those with PGD, after adjusting for potential confounders (p < .05). These factors were distinct from the factors associated with post-traumatic stress symptoms (PTSS) among these survivors. Scores on the avoidance, hyper-arousal and intrusion subscales of the Impact of Events Scale-Revised were significantly lower in those with PGD alone than in those with PTSS or with both disorders.

CONCLUSION

Our findings support the validity of PGD in a non-Western post-disaster community and its distinctness from PTSD. They have important public health implications in planning responses to natural disasters and for future revisions of diagnostic classifications.

Multiple Victims: The Result of Caring Patients in Vegetative State

Background:

Having a patient in a vegetative state in the family is a complicated and stressful experience. Caring for such patients with complete disability at home is very challenging.

Objectives:

The present study aimed to explore the outcomes of caring for patients in a vegetative state for families and caregivers at home.

Patients and Methods:

In this qualitative study, 16 vegetative patients’ caregivers were selected through purposive sampling. Unstructured interviews and observations were used for data gathering. Data collection was continued until saturation of data and emergence of the main themes. Data analysis was performed by the content analysis method.

Results:

The analysis of the gathered data led to three themes: “lost main caregiver”, “affected caring partner” and “affected family”. Each theme had some subthemes and subcategories.

Conclusions:

The three emerged themes in this study showed that all the family members of vegetative patients, depending on their responsibilities, were affected by physical, mental, social and economic issues.

The temporal relationship between change in symptoms of prolonged grief and posttraumatic stress following old age spousal bereavement

BACKGROUND

High levels of prolonged grief symptoms (PGS) and posttraumatic stress symptoms (PTS) are relatively common following bereavement. The two types of bereavement complications share some but not all of the same features. Little research has studied which of the two precedes the other following the death of a loved one. The purpose of this study was to examine the temporal relationship between change in PGS and PTS during the first 4 years following old age spousal loss.

METHODS

Participants were 237 Danes (40% male; mean age = 73 years, SD = 4.4; range 65-81) who during the year of 2006 lost their spouse. Participants completed self-report questionnaires at 6 months (n = 237), 13 months (n = 198), 18 months (n = 192), and 48 months (n = 213) post loss. Main outcome measures were Inventory of Complicated Grief-Revised and the Harvard Trauma Questionnaire.

RESULTS

Lower level mediation analyses were performed. Results indicated that PGS mediated 83% of the relationship between time and PTS, whereas PTS only mediated 17% of the relationship between time and PGS. These results suggest that changes in PGS mediated changes in PTS following spousal bereavement to a greater extent than vice versa.

CONCLUSIONS

The findings in the present study indicate that changes in PGS may precede and potentially directly impact changes in PTS following bereavement. This tentative conclusion points to the potential value of targeting PGS in psychological interventions at an early point in the long-term perspective following old age spousal bereavement.

Prolonged grief symptoms related to loss of physical functioning: examining unique associations with medical service utilization

PURPOSE

Prolonged grief, a severe and chronic form of grieving most commonly studied in the context of bereavement, may have relevance to losses associated with chronic illness (e.g. grief related to loss of functioning or loss of a planned future). The purpose of the present study is to examine the unique associations between prolonged grief symptoms and service utilization patterns.

METHODS

An online self-report assessment battery was administered among a sample of 275 older adults with at least one chronic illness that caused significant physical impairment.

RESULTS

Even after statistically controlling for relevant physical health (e.g. severity of physical limitations, somatic symptoms, number of chronic illnesses) and psychosocial variables (e.g. social support, depression/anxiety), more severe prolonged grief symptoms were associated with a greater number of emergency room visits, overnight stays in the hospital and total nights in the hospital.

CONCLUSIONS

These findings highlight the importance of screening for prolonged grief symptomatology with older individuals with a debilitating chronic illness.

IMPLICATIONS FOR REHABILITATION

Recent evidence suggests that prolonged grief may have relevance for losses associated with physical illness. The present study shows that prolonged grief reactions related to physical illness (e.g. grieving the loss of functioning) are uniquely associated with increased hospital-based service utilization. Given the relevance of prolonged grief reactions in this population, practitioners may wish to assess for these symptoms. Future clinical research should focus on developing interventions to target prolonged grief symptoms associated with these losses.

The prevalence, comorbidity and risks of prolonged grief disorder among bereaved Chinese adults

Few epidemiological studies have investigated prolonged grief disorder (PGD) in the general population of Asian countries, including China. The aim of this study was to explore the rates and risks of PGD, and the association between PGD, post-traumatic stress disorder (PTSD), depression and anxiety in bereaved Chinese adults. The PG-13, PTSD Checklist-Civilian Version (PCL-C), Zung Self-Rating Depression Scale (SDS) and Zung Self-Rating Anxiety Scale (SAS) were administered to 445 subjects. Prevalence within the general population of China was 1.8% (i.e., 8/445). Among the eight subjects who met the PGD diagnosis, 75%, 87.5% and 75% scored above the cut-off point on the PCL-C, SDS and SAS, respectively, although a portion remained free from comorbidity. ANOVA, correlation analysis and stepwise multiple regression analysis demonstrated that kinship to deceased, age of the deceased, religion belief and cause of death were predictive of prolonged grief. A small proportion of bereaved persons may exhibit PGD. There is a substantial but far from complete overlap between PGD and the other three diagnoses. Bereaved parents and the widowed have high risk of PGD. These findings highlight the need for prevention, diagnosis and treatment for PGD patients.

A study of the psychological distress in family caregivers of patients with prolonged disorders of consciousness during in-hospital rehabilitation

OBJECTIVES

To study psychological distress in a sample of caregivers of patients affected by prolonged disorders of consciousness during hospital stay in the Neurorehabilitation Unit.

MATERIALS AND METHODS

Twenty-four caregivers of 22 patients affected by prolonged disorders of consciousness admitted to postacute rehabilitation center, completed self-reported questionnaires for assessment of depressive symptoms, state and trait anxiety, psychophysiological disturbances, prolonged grief disorder, psychological coping strategies, quality of perceived needs, perceived social support, and caregiver burden; at admission, and after four and eight months.

RESULTS

At admission depressive symptoms were found in 20/24 caregivers, high levels of anxiety in 16, and relevant psychophysiological disturbances in 10 participants; eight caregivers (32%) met criteria for prolonged grief disorder. The scores on questionnaires did not differ as a function of relatives' diagnosis (vegetative state vs. minimally conscious state). The longitudinal study (n = 18) showed a progressive and statistically significant increase of "emotional burden" during the hospital stay, whereas the remaining variables did not change significantly.

CONCLUSIONS

Data confirmed the presence of severe psychological problems in caregivers of patients with prolonged disorders of consciousness. The levels of psychological distress tend to be constant over time, while the emotional burden increases.

Caregivers of patients with disorders of consciousness: coping and prolonged grief

OBJECTIVES

To study the relationship between coping strategies and prolonged grief disorder (PGD) in caregivers of patients with disorders of consciousness: vegetative state (VS) or minimally conscious state (MCS).

MATERIALS AND METHODS

Fifty-three caregivers of 43 patients with VS or MCS were assessed using PG-12 and Brief COPE-28. Mean differences for each coping strategy between caregivers of patients with/without PGD were compared using Bonferroni-adjusted t-tests, and the size effect was calculated (Cohen's d).

RESULTS

The frequency of PGD was very high (n = 32; 60.40%). The most common coping strategies were problem-focused: active coping (mean = 6.41; SD = 1.02), Instrumental support (mean = 6.41; SD = 1.06), Planning (mean = 6.32; SD = 1.01) and Acceptance (mean = 6.20; SD = 1.29). Acceptance predicted a lower presence of PGD (P = 0.001; Cohen's d = 1.02), while Denial (P = 0.003; Cohen's d = 0.98) and Self-blame (P = 0.004, Cohen's d = 0.91) increased the presence of PGD.

CONCLUSIONS

The caregivers of patients with VS or MCS show a high risk of PGD. Problem-focused coping strategies are the most used. Acceptance is highly protective of PGD, and Denial and Self-blame are associated with an increased presence of PGD. PGD in caregivers of patients in VS or MCS should be evaluated, Acceptance and problem-focused strategies should be promoted, and Denial and Self-blame should be diminished.