Risk factors for bereavement outcome: a multivariate approach

How We Disenfranchise Grief for Self and Other: An Empirical Study

Disenfranchised grief can be defined as a loss that is not openly acknowledged or a mourning process not recognized socially after a loss. One can also self-disenfranchise as suppressing and not allowing oneself to grieve. The current study aims to examine perceived disenfranchisement, self-disenfranchisement and disenfranchisement of others. For this purpose, three hypothetical unacknowledged loss scenarios, which are pet loss, a romantic relationship break-up and having a psychological disorder, were used to compare self and other disenfranchisement as well as to reveal the relationships to attachment and social support. The findings indicate that the three loss scenarios differ in terms of the acknowledgement of loss, grief and social and professional support for self and others. Subsequently, attachment and social support are significantly related to the evaluations of the disenfranchised grief process. Finally, the implications of the findings are discussed.

Predictors of Complicated Grief During the COVID-19 Pandemic: A Cross-Classified Analysis

The COVID-19 pandemic left many people grieving multiple deaths and at risk for developing symptoms of complicated grief (CG). The present study is a prospective examination of the role of neuroticism and social support in the development of CG symptoms. Findings from cross-classified multilevel models pointed to neuroticism as a risk factor for subsequent CG symptoms. Social support had a stress-buffering effect, emerging as a protective factor following the loss of a first degree relative. More recent loss and younger age of the deceased were both independently associated with heightened CG symptoms. Results from the present study provide insight into heterogeneity in CG symptom development at the between-person level, and variability in CG symptoms within individuals in response to different deaths. Findings could therefore aid in the identification of those at risk for the development of CG symptoms.

The Inventory of Social Expectations in Bereavement: Development and psychometric validation of a new instrument

Negative expectations concerning social interactions contribute to feelings of loneliness. Since loneliness is one of the most pronounced challenges for bereaved individuals, we investigated grief-specific social expectations and its association with loneliness and grief severity. Initially, we developed an Inventory of Social Expectations in Bereavement (ISEB). Its factorial and psychometric validity was then tested in a bereaved sample (N = 344; 28.3 ± 11.1 years; 74.4% female). A two-factor solution for the scale fit the data best (factor 1: "relationship to others," factor 2: "relationship to the deceased") and demonstrated good psychometric validity. Higher ISEB-levels were associated with higher levels in grief severity and loneliness. The results suggest that individual social expectations affect the experience of loneliness after the loss of a significant other. The ISEB assesses these expectations time-efficiently and provides a basis for therapeutic interventions. Expressing expectations as probabilistic beliefs about the future renders them amenable for corrective experiences in clinical practice.

Do insecure attachment styles predict prolonged grief symptoms? Significant null findings

Insecure attachment is proposed to be a risk factor in the development and persistence of severe grief. Although prior research demonstrates positive cross-sectional and longitudinal correlations between attachment styles and prolonged grief symptoms, controlled longitudinal analyses yield fewer convincing results. Therefore, we sought to further clarify the concurrent and longitudinal associations between these constructs. A sample of 225 bereaved Dutch adults (87% women; Mean age: 48.86 years) participated in a three-wave longitudinal survey including measures of attachment anxiety and attachment avoidance at baseline and prolonged grief symptoms at baseline and 6- and 12-month follow-up. Attachment anxiety and attachment avoidance were significantly positively correlated with prolonged grief symptoms at all time-points. However, multiple regressions, controlling for baseline symptoms, showed that attachment anxiety, attachment avoidance, and their interaction did not predict residual change in prolonged grief symptoms. These findings cast doubt on the proposed role of insecure attachment styles in prolonged grief.

Associations of religious and existential variables with psychosocial factors and biomarkers of cardiovascular risk in bereavement

Bereavement increases in prevalence as people age and is associated with multiple psychological and health risks, including cardiovascular risk. Religious and existential variables may play an important role in the health impacts of bereavement. Theorized pathways linking religious and existential variables with health have suggested these associations are due to intermediary psychosocial variables, but have not been tested in bereavement. This research empirically tested these pathways in a bereaved population. In N = 73 adults within 1 year of bereavement (mean age = 64.36), this study examined associations between (1) religious and existential characteristics (religious and spiritual struggles, intrinsic religiosity, and existential quest) and intermediary psychosocial variables (depression, loneliness, and difficulties in emotion regulation), and between (2) intermediary psychosocial variables and bereavement-relevant health outcomes (self-reported health, change in health since last year, grief severity, and cardiovascular biomarkers). Cardiovascular biomarkers (heart rate, heart rate variability, and blood pressure) were collected before, during, and after a laboratory grief recall emotion elicitation. Anticipated associations between self-reported religious and existential characteristics and intermediary variables, and between intermediary variables and self-reported bereavement-relevant outcomes, were consistently observed. However, associations between intermediary variables and cardiovascular biomarkers were largely unobserved. This study examined the role of religious and existential variables in whole-person health after bereavement and is among the first to include biomarkers of cardiovascular risk. Results suggest that although religious and existential variables are associated with important bereavement-related outcomes, these associations may be "skin-deep," and extensions to cardiovascular functioning should be re-examined.

Does time heal all wounds? An investigation of time, grief, and attitudes toward death

When experiencing the loss of a loved one, individuals adapt and change how they understand death, how they interpret the meaning of the loss, and how they remember the deceased. In the present study (N = 164), we investigated whether the time since the loss - recent or distant - was associated with individuals' bereavement, attitudes toward death, and their meaning of death. We found that individuals who experienced a recent loss reported more grief and more negative death attitudes compared to individuals who experienced a loss more than 5 years ago. Moreover, the bereavement appeared to completely mediate the time since the loss and the individuals' attitudes about death. The findings suggest that time-dependent adaptations after a loss shifts individuals' death attitudes, grief symptoms, and thoughts about death.

Widowed Young: The Role of Stressors and Protective Factors for Resilience in Coping with Spousal Loss

While distressing, late life spousal loss is considered a normative life event and most demonstrate resilient recovery from grief. However, for 5-7% of the population spousal loss comes early, before the age of 50, and little is known about the factors that influence adjustment in this population. We used the DPM integrative framework to examine correlates and predictors of mental wellbeing and grief intensity in an international sample of 603 young widows and widowers. Contrary to existing bereavement research, loss-orientated stressors (e.g., expectedness and cause of death) did not predict bereavement outcomes. Employment and financial wellbeing were the only statistically significant restoration-orientated stressors associated with coping, mental wellbeing and grief intensity. We found no significant associations between parental status and coping or bereavement outcomes. Loss-orientated coping, followed by inter and intrapersonal protective factors for resilience and financial wellbeing were the greatest predictors of grief intensity. Loss-orientated coping was highest in early bereavement, the greatest predictor of grief intensity and associated with being unemployed, financial insecurity and decreased protective factors for resilience. Restoration-orientated coping was highest in later bereavement, was a weak predictor of grief intensity and associated with being employed, increased financial wellbeing and protective factors for resilience. Overall, we found the young-widowed population is at heightened risk of poor adjustment. Almost two-thirds reported decreased functioning, probable depression with high rates of psychological distress. Nearly half met diagnostic criteria for prolonged grief disorder. We discuss implications for research and clinical practice.

The lived experiences of young adults grieving an intimate partner or spouse: A phenomenological pilot study

This pilot study explored the lived experiences of six young adults between the ages of 18-32 years grieving an intimate partner or spouse. Through Moustakas's (1994) steps of transcendental phenomenological analysis, four key themes revealed a traumatic initial period after the death, the importance of helpful vs dismissive community support, a continuation of meaningful activities and ritual to honor the deceased, and significant shifts in participants' life plans and worldviews. These themes suggest that clinicians may consider facilitating identity-restructuring exercises (e.g., journaling) and inclusive community spaces to support this unique population of grievers. Implications for future research are discussed, including the suggestion to create more targeted inclusion criteria to improve the clinical relevance of results in future studies.

Markers in Time: Expanding Our Concept of Trauma Triggers to Include Subjective Experiences of Time Among Adults Surviving Traumatic Loss

We outline two studies that collected exploratory data on the meaningful time approach and explore the notion of temporal triggers that emerge in the process of coping with traumatic loss. Qualitative data analysis was completed on data gathered from face-to-face interviews as well as open ended responses to an online survey. 35 themes and sub-codes were identified. 30 of these were replicated in both studies. Our data supported the notion of "markers in time" and identified three clear phases to these markers. Participants also noted the consequences of loss on their lives, and the influence of societal and religious approaches to bereavement on their process of coping. Results of this study support a cyclical approach to understanding coping with loss and provides clinicians working with bereaved individuals yet another tool to address the dynamic experience of bereavement.

Examining individual differences in personality trait changes after negative life events

Personality traits can change throughout the entire life span, but people differ in their personality trait changes. To better understand individual differences in personality changes, we examined personal (personality functioning), environmental (environmental changes), and event-related moderators (e.g., perceived event characteristics) of personality trait changes. Therefore, we used a sample of 1069 participants who experienced a negative life event in the last 5 weeks and assessed their personality traits at five measurement occasions over 6 months. Employing preregistered multilevel lasso estimation, we did not find any significant effects. While exploratory analyses generally confirmed this conclusion, they also identified some effects that might being worth to be considered in future research (e.g., perceived impact and perceived social status changes were associated with changes in agreeableness after experiencing a relationship breakup). In total, our moderators explained less than 2% of variance in personality traits. Nonetheless, our study has several important implications for future research on individual differences in personality change. For example, future research should consider personal, environmental, and event-related moderators, use different analytical methods, and rely on highly powered samples to detect very small effects.

Posttraumatic stress response following the loss of significant close others in the Great East Japan Earthquake: Fukushima Health Management Survey

During the Great East Japan Earthquake, many people experienced the loss of family and friends, among other traumatic events. This study sought to clarify the impact of the loss of significant close others on posttraumatic stress symptoms (PTSS), as well as the factors associated with PTSS, among individuals who experienced the loss of significant close others (i.e., bereaved group). Self-administered questionnaires were mailed to men and women (N = 180,604) aged 16 years and older living in municipalities that included evacuated areas surrounding the Tokyo Electric Power Company's Fukushima Daiichi Nuclear Power Station, which was significantly damaged following an earthquake and tsunami in March 2011, causing subsequent radiation leakage; this mailing yielded a 40.7% response rate, with 57,388 valid responses, in 2012. We used the Posttraumatic Stress Disorder Checklist-Specific (PCL-S) to measure PTSS as the outcome variable. Loss of significant close others in the disaster and respondents' relationship with the deceased constituted the explanatory variables. Basic characteristics and disaster-related factors were the confounding variables. Data were analyzed using chi-square tests and logistic regression analyses. The bereaved group showed more severe PTSS than the nonbereaved group, aOR = 1.58, 95% CI [1.50, 1.67]. The risk of developing PTSS increased if the deceased was a respondent's spouse, aOR = 1.67, 95% CI [1.22, 2.29]; child, 1.51 [1.01, 2.25]; or friend, 1.33 [1.16, 1.53]. Individuals who lose significant close others, including both family and friends, in disasters require close mental health care and, if necessary, should be referred for psychiatric treatment.

When goodbyes matter: The conditional relationship between final conversations and symptoms of depression

An online survey of 528 people who lost someone close to them in the last 5 years was used to test associations between having final conversations (FCs) and depression. The direct effect was nonsignificant, but there were two significant moderation effects. Time since bereavement moderated the FC-depression relationship; there was a negative relationship between FCs and depression shortly following bereavement, but no relationship after more time had passed. The age of the deceased also moderated this relationship; there was a negative relationship between FCs and depression when the deceased was older, but no relationship when the deceased was younger.

Social Isolation, Social Support, and Loneliness Profiles Before and After Spousal Death and the Buffering Role of Financial Resources

Objectives

We provide new evidence on the profiles of social isolation, social support, and loneliness before and after spousal death for older widows. We also examine the moderating effects of gender and financial resources on changes in social health before and after widowhood.

Methods

We use 19 waves of data from the Household, Income and Labour Dynamics in Australia Survey, including 749 widowed individuals and a comparison group of around 8,000 married individuals. We apply coarsened exact matching weights and control for age and time trends. Local polynomial smoothed plots show the profiles of social health from 3 years pre- to 3 years postspousal death. All analyses were stratified by gender.

Results

Spousal death was strongly associated with increased loneliness for women and men, but also an increase in interactions with friends and family not living with the bereaved. For men, financial resources (both income and asset wealth) provided some protection against loneliness. Spousal death was not associated with changes in social support or participation in community activities.

Discussion

We demonstrate that loneliness is a greater challenge of widowhood than social isolation or a lack of social support. Our findings suggest that interventions focusing only on increasing social interactions are unlikely to alleviate loneliness following spousal death. Moreover, policies that reduce the cost of formal social participation may have limited effectiveness in tackling loneliness, particularly for women. Alternative strategies, such as helping the bereaved form a new sense of identity and screening for loneliness around widowhood by health care workers, could be beneficial.

A Multidisciplinary, Family-Oriented Approach to Caring for Parents After Miscarriage: The Integrated Behavioral Health Model of Care

Miscarriage is increasingly gaining recognition, both in scientific literature and media outlets, as a loss that has significant and lasting effects on parents, though often disenfranchised and overlooked by both personal support networks and healthcare providers. For both men and women, miscarriage can usher in intense grief, despair, and difficulty coping, and for women in particular, there is evidence of increased prevalence of depression, anxiety, and post-traumatic stress. Additionally, miscarriage can contribute to decreased relationship satisfaction and increased risk of separation, all while stigma and disenfranchisement create a sense of isolation. Despite this increased need for support, research indicates that many parents experience their healthcare providers as dismissive of the significance of the loss and as primarily focusing only on the physical elements of care. Research exploring the barriers to providers engaging in more biopsychosocial-oriented care has identified time constraints, lack of resources, lack of training in addressing loss, and compassion fatigue as key areas for intervention. This paper will review the biopsychosocial elements of miscarriage and discuss a multidisciplinary, family-oriented approach that can be implemented in healthcare settings to ensure a high quality and holistic level of care for individuals, couples, and families experiencing pregnancy loss.

Parenting through grief: A cross-sectional study of recently bereaved adults with minor children

BACKGROUND

Grieving adults raising parentally-bereaved minor children experience persistently elevated symptoms of depression and grief. However, the factors associated with their mental health outcomes are not well understood.

AIM

To investigate the psychosocial and demographic characteristics associated with grief distress and depressive symptom severity in bereaved adults with minor children.

DESIGN

Cross-sectional, web-based survey.

SETTING/PARTICIPANTS

Eight hundred forty-five bereaved adults raising minor (age <18 years) children who had experienced the death of a co-parent. Primary outcomes were grief distress (Prolonged Grief Disorder-13), depressive symptoms (Patient-Reported Outcomes Measurement Information System-Depression), and widowed parenting self-efficacy (WPSES).

RESULTS

Mean grief scores were 33.5; mean depression scores were 58.3. Among the 690 individuals more than 6 months bereaved, 132 (19.3%) met criteria for prolonged grief disorder. In adjusted models, participants reporting higher grief scores were more recently bereaved, identified as mothers, non-Caucasian, had lower education and income, and had not anticipated their co-parent's death. The statistical modeling results for depression scores were similar to grief scores except that depression was not associated with anticipation of co-parent death. Parents reporting lower WPSES scores had higher grief and depression scores. Retrospective assessments of more intense parenting worries at the time of co-parent death were also associated with higher grief and depression scores.

CONCLUSIONS

For bereaved adults with minor children, unanticipated co-parent death was linked with higher grief distress but not symptoms of depression. Addressing parenting concerns may represent a common pathway for improving the mental health of parentally-bereaved families.

Evaluating the relationship between family resilience and grief-related symptoms: A preliminary analysis

Walsh's Family Resilience Framework offers clinicians a comprehensive theoretical approach for supporting bereaved families. In this study, a total of 139 bereaved adults who lost a family member in the last 5 years were surveyed about their family's resilience processes, their current outlook on life, and their current grief-related symptoms. The data from this sample were analyzed using confirmatory factor analysis and structural regression. Family resilience processes were negatively related to grief symptoms; however, this relationship was mediated by personal meaning. The results suggest that Walsh's Family Resilience Framework may be an appropriate conceptual tool to assess family resilience in bereavement practice.

The Impact of Parental Bereavement on Young People: A Thematic Analysis of Using Online Web Forums as a Method of Coping

A qualitative approach was used to explore how online web forums might facilitate recovery and the process of coping. Ten online web forums written by young people who have personally experienced the death of a parent formed the data of this study. Previous research suggests forum users do not receive the supportive reactions from face-to-face interactions that they desire. Thematic analysis found that forums created an environment where young people can process the bereavement of a parent. Forums allowed young people to use their experience of bereavement to positively support others with similar experiences. The findings imply that the process of using forums can positively impact individuals who have experienced the loss of a parent. This supports recommendations by professionals, to consider online forums as a coping strategy. This study presents one of the few analyses of web forums written by young people who have experienced parental bereavement.

Maternal depression and loss of children under the one-child family planning policy in China: a cross-sectional study of 300 000 women

OBJECTIVES

This study aims to explore the association between maternal depression and the loss of the only child under the family-planning (FP) policy.

DESIGN

Cross-sectional data from a Chinese population-based study were analysed.

SETTING

Population from 10 (5 rural and 5 urban) areas in China.

PARTICIPANTS

Around 300 000 females were included in the study. The FP group was defined as women with one or two live births. Those with no surviving child were classified into the loss-of-only-child group. The non-FP group included women who had more than two live births. Logistic regression was used to assess the relationship between major depressive disorder (MDD) and family types, after stratification and adjustment.

OUTCOME

MDD was assessed using the Composite International Diagnostic Inventory.

RESULTS

The odds of MDD are 1.42 times higher in the FP group in general (OR=1.42, 95% CI: 1.28 to 1.57), as opposed to the non-FP group. In particular, the odds of MDD are 1.36 times greater in the non-loss-of-only-child group (OR=1.36, 95% CI: 1.21 to 1.51) and 2.80 (OR=2.80, 95% CI: 0.88 to 8.94) times greater in the loss-of-only-child group, compared with the non-FP group. The associations between FP groups and MDD appeared to be stronger in the elderly population, in those who were married, less educated and those with a higher household income. The association was found progressively stronger in those who lost their only child.

CONCLUSIONS

People in the FP group, especially those who lost their only child, are more susceptible to MDD than their counterparts in the non-FP group. Mental health programmes should give special care to those who lost their only child and take existing social policies and norms, such as FP policies, into consideration.

Evidence on the Conceptual Distinctness of Normal Grief From Depression

Abstract. Background: The distinctness of grief from depression has been the subject of a long scholarly debate, even influencing definitions of diagnostic criteria. Aims: This study aims at clarifying the issue by a multifaceted analysis of data from a large German sample. Method: A community sample of 406 bereaved persons answered the Wuerzburg Grief Inventory (WGI), a multidimensional grief questionnaire designed to measure normal grief in the German language, and the General Depression Scale – Short Version (GDS-S), a self-report depression scale. Data were analyzed by factor analysis to identify structural (dis-)similarities of the constructs, and analysis of variance (ANOVA) to identify the influence of the factors relationship to the deceased, type of death, and time since loss on grief measures and depression scores. Results: Factor analysis clustered items referring to grief-related impairments and depression into one factor, items referring to other dimensions of grief on separate factors, however. Relationship to the deceased influenced the grief measures impairments and nearness to the deceased, but not depression scores if controlled for impairments. Type of death showed specific effects on grief scores, but not on depression scores. Time since loss influenced grief scores, but not depression scores. Limitations: The analysis is based on a self-selected community sample of grieving persons, self-report measures, and in part, on cross-sectional data. Conclusion: Factor analysis and objective data show a clear distinction of dimensions of grief and depression. The human experience of grief contains a sense of nearness to the lost person, feelings of guilt, and positive aspects of the loss experience in addition to components resembling depression.

A systematic review of loneliness in bereavement: Current research and future directions

Bereaved people suffer from loneliness and loneliness is associated with poor mental health. In this study, this topic is reviewed. An agenda is suggested for future research. Research that is theory-driven, addresses measurement consistency, correlates of loneliness in bereaved and non-bereaved, and treatment is necessary for prevention and intervention.

Emotion regulation among Lebanese adults: Validation of the Emotion Regulation Questionnaire and association with attachment styles

PURPOSE

Validate the Emotion Regulation Questionnaire (ERQ) and evaluate factors associated with emotion regulation among Lebanese adults.

METHODS

A proportionate random sample of 811 participants was chosen from all Lebanese governorates in this cross-sectional study.

FINDINGS

The principal component analysis of the ERQ items yielded two factors (α_Cronbach  = 0.764 and 0.658 for the Cognitive Reappraisal and Expressive Suppression facets, respectively). Higher secure attachment style was linked to higher cognitive reappraisal and expressive suppression. Higher anxious attachment style and anxiety were associated with lower cognitive reappraisal.

PRACTICAL IMPLICATIONS

The Arabic version of the ERQ is a suitable tool for the assessment of emotion regulation tendencies in clinical practice and research. The study came up with results similar to the ones given by many international studies.

Can Less Ever Be More? A Model of Emotion Regulation Repertoire of Social Support (ERROSS)

Do people really fare better if they can rely on many social ties? Research suggests that benefits of interpersonal emotion regulation (ER) can be derived from both large and small social networks. Building on the intrapersonal regulatory flexibility model, we propose the emotion regulation repertoire of social support (ERROSS) model that views effective socioemotional support as the combination of network size and ER strategies, resulting in a repertoire of ER resources one can draw on. Best outcomes in mental health should follow from both a large network and a diverse repertoire of strategies. ERROSS is applied as an example in the context of bereavement, and specific contributions of the model are highlighted.

The experience of bereavement on family caregivers of people with dementia in China

BACKGROUND AND OBJECTIVES

Despite many studies on 'life after care' for family caregivers with dementia in Western societies, little is known about the bereavement experiences of family caregivers in China. The aim of this study was to explore the experience of bereavement on family members of people with dementia in China. It also hopes to inform end-of-life care within communities, providing a theoretical basis for improving the quality of life of bereaved family caregivers.

METHODS

Interpretative phenomenological analysis approach was adapted for this study. Purposive sampling was used to recruit former family caregivers of people with dementia. Semi-structured in-depth interviews with 12 bereaved family caregivers were collected. Thematic analysis was used for data analysis.

FINDINGS

Five themes were identified: recalling the past life, lack of support, uncertainty of the future, social withdrawal and acceptance and release.

CONCLUSION

The experiences of bereavement on family members of people with dementia in China are socially and culturally complex. This article recommends that bereavement should be supported throughout the palliative process of community services and healthcare services. Providing all-round support and education on death and dying can help the family caregivers to pass through grief and help them to maintain their normal life.

Can social support matter? The relationship between social support and mental health among bereaved parents in an only-child society: Evidence from China

Shidu parents (parents who lost their only child) experience poor mental health, and social support is expected to alleviate mental stress and facilitate mental adaptation of bereaved parents. However, the literatures on the effects of social support on mental health of bereaved parents have yield mixed outcomes, and the relationship between social support and mental health among Shidu parents has been unexplored in China. The purpose of this study was to examine the relationship between social support and mental health among Shidu parents in China. Multistage stratified random sampling was conducted to collect data in 2017, and a total of 1,750 Shidu parents were employed as the analytical sample. The Ordinary Least Squares Model and Instrumental Variables (IV) Method were both employed. The variable of community services for the aged provided by the market was employed as the IV of the study considering death taboo inveterately rooted in philosophies and religions in Chinese culture. The results indicated that there was a positive relationship between social support and mental health among Shidu parents, specifically, objective social support and social support utilisation were significantly related to mental health of Shidu parents, while subjective social support was not. Implications of the study include the following: First, it is crucial to help spouse and friends gain appropriate social support skills. Mutual associations can be an important source of social support. Second, objective social support should be given a top priority, and suitable amount, timing, source and structure of social support should be paid more attention to strengthen the 'goodness of fit' between the needs of Shidu parents and support provided. Third, some other social services such as community care, social work services and professional consulting services can be appropriate alternatives to alleviate mental stress of Shidu parents.

Rates and prospective psychosocial correlates of pre-loss grief in cancer and dementia family members

This study examined changes in Pre-Loss Grief (PLG) among individuals whose family member has a life limiting illness and how baseline psychosocial factors predicted PLG. This two-wave study recruited family members of advanced cancer ( N = 100) and dementia ( N = 38) patients. A subsample completed 1-month follow-up (Cancer = 33; Dementia = 28). Higher caregiver burden and female participants predicted greater PLG at follow-up, accounting for baseline PLG. Family members of dementia patients (10.5%) were significantly more likely than family members of cancer patients (2.1%) to be in the “severe PLG” group. Findings demonstrate psychosocial factors related to PLG, informing interventions aimed at reducing PLG.

Validation of a German Version of the Grief Cognitions Questionnaire and Establishment of a Short Form

Background

Whereas the majority of bereaved persons recover from their grief without professional assistance, a minority develops pathological grief reactions. Etiological models postulate that dysfunctional cognitions may perpetuate such reactions. The Grief Cognitions Questionnaire (GCQ) assesses thoughts after bereavement in nine interrelated domains. A short form (GCQ-SF) with four domains is often used. However, an evaluation of the psychometric properties of the GCQ-SF and its utility compared to the GCQ is lacking and these instruments have not been validated in German.

Method

German bereaved persons (time since loss 35.3 ± 34.6 months) responded to an online survey containing the GCQ, measures of grief severity, grief rumination, symptoms of depression and anxiety, and optimism and pessimism. 585 participants (18–78 years, 88% women) were included. Item analyses and confirmatory factor analyses were conducted. Correlations between the GCQ and GCQ-SF and grief rumination, optimism and pessimism assessed construct validity. Criterion-related validity was assessed by comparing whether the correlation of the GCQ (and the GCQ-SF) with grief severity was higher than with anxious and depressive symptoms. Logistic regression and receiver-operator characteristics (ROC) compared the questionnaires on their ability to predict probable prolonged grief ‘caseness’ (ICG ≥ 25, time since loss ≥6 months).

Results

Internal consistencies for both questionnaires were identical and excellent (α = 0.96). Confirmatory factor analyses obtained a satisfactory fit for models with nine and four correlated subscales and respective higher-order factor models. The GCQ and the GCQ-SF correlated higher with grief severity than with other measures of psychopathology. The logistic regression showed a significant association between the GCQ-SF and prolonged grief ‘caseness’. Of the remaining subscales of the GCQ, only one subscale (‘Others’) contributed to the prediction. The ROC analyses showed nearly identical areas under the curve.

Conclusion

The translated GCQ and GCQ-SF demonstrated very good psychometric properties. The correlations with grief severity highlight the questionnaires’ clinical relevance. The questionnaires possessed identical diagnostic specificity and sensitivity. Whenever a timesaving assessment of the most typical grief-specific cognitions is important, the GCQ-SF represents an alternative to the GCQ. The original GCQ may still be superior when a more detailed description of a bereaved person’s cognitions is desirable.

Predicting models of depression or complicated grief among bereaved family members of patients with cancer

OBJECTIVE

To derive and validate a risk scoring system for predicting major depressive disorder (MDD) and complicated grief (CG) among bereaved family members of patients with cancer that is feasible for clinical use.

METHODS

We conducted a secondary analysis of two cross-sectional nationwide bereavement surveys in Japan. From a total of 17,312 bereaved family members of patients with cancer, 8618 and 8619 were randomly assigned to a derivation and a validation group. The Patient Health Questionnaire 9 (PHQ-9) and the Brief Grief Questionnaire (BGQ) were used to assess MDD (PHQ-9 score ≥ 10) and CG (BGQ score ≥ 8), respectively. We compared five models with potential predictive variables that could be easily obtained in daily practice and were included in the bereavement survey (i.e., sociodemographic data).

RESULTS

The model which included variables such as the families' physical/mental health status and preparedness toward bereavement, in addition to their sociodemographic data, was considered modest for predicting the risk of both MDD and CG. The areas around the curve for MDD and CG were 0.74 (95% CI: 0.73-0.76) and 0.74 (95% CI: 0.72-0.75) and 0.78 (95% CI: 0.76-0.79) and 0.77 (95% CI: 0.76-0.79) in the derivation and validation groups, respectively.

CONCLUSIONS

We developed a clinical risk score for predicting MDD and CG among bereaved family members of patients with cancer. However, further research is needed for external validation and assessment regarding its implementation in actual practice.

Depression, Anxiety and Post-traumatic Growth Among Bereaved Adults: A Latent Class Analysis

Background

The death of a loved one can trigger a range of responses, including painful thoughts and emotions, as well as positive changes, such as post-traumatic growth (PTG). To understand more about the relationship between these outcomes this study explored the co-occurrence of depression, anxiety and PTG among a group of bereaved Chinese adults.

Methods

Data were collected from 194 participants, who had lost a first-degree relative. Latent class analysis was used to analyze the data to identify subgroups of participants with shared symptom profiles.

Results

Three classes were identified: a Growth class, a Depression/Anxiety/Growth class and a Depression/Anxiety class. Marital status, social support, close relationship with the deceased and witnessing the suffering of the deceased were identified as differential predictors of class membership.

Conclusion

The findings contribute to our understanding of the potentially wide ranging impacts of bereavement and highlight the important role of stressor characteristics and support and in influencing impairment and positive outcomes.

Outcomes of the grief and communication family support intervention on parent and child psychological health and communication

Parents and children risk developing psychological health problems following the death of a partner/parent and may need professional support. This study used the reliable change criterion and clinically significant change to examine the outcomes of the Grief and Communication Family Support Intervention, comprising three family meetings with a family therapist, among 10 parents and 14 children, using pre-post outcome scores. The results provided preliminary evidence that the Grief and Communication Family Support Intervention may improve self-esteem and reduce anxiety in some parents and may improve communication and reduce internalizing and externalizing problems in some children.

A profile analysis of post-traumatic stress disorder and depressive symptoms among Chinese Shidu parents

BACKGROUND

Due to the one-child policy implemented in China, most families have only one child. When parents experience the death of their only child, these parents receive the label 'Shidu parents'. Shidu is a major public health issue in China. However, the patterns of post-traumatic stress disorder (PTSD) and depressive symptoms that are present in this population remain unclear.

OBJECTIVE

This study aims to identify profiles of PTSD and depressive symptoms among Shidu parents and to explore the predictors of profile membership.

METHODS

A total of 363 participants (M age = 61.5 years, SD = 7.5) were asked to complete questionnaires assessing PTSD, depressive symptoms, perceived social support, and demographic information. Latent profile analyses and multivariate logistic regressions were used.

RESULTS

Three distinct profiles were identified: low (39.4%), moderate (32.8%), and high symptoms (27.8%). Parents who were younger and perceived lower levels of support from family and significant others were more likely to experience higher levels of PTSD and depressive symptoms.

CONCLUSIONS

These results indicate that the severity of PTSD and depressive symptoms tightly cohere, providing evidence for the co-occurrence of PTSD and depressive symptoms after bereavement. The findings provide valuable information for the development of tailored professional interventions for bereaved parents.

Facilitating grief: An exploration of the function of funerals and rituals in relation to grief reactions

The loss of a loved one through death is usually followed by a funeral and engagement in various grief rituals. We examined the association between the evaluation of the funeral, the use of grief rituals and grief reactions. Bereaved individuals from the Netherlands completed questionnaires, six months and three years post-loss (n = 552/289). Although the funeral and rituals were considered helpful, no significant association between evaluation of the funeral and usage of grief rituals and grief reactions was found. More insight in the engagement in rituals will ultimately serve bereaved individuals to cope with loss.

The association of time since spousal loss and depression in widowhood: a systematic review and meta-analysis

PURPOSE

To conduct a systematic review and meta-analysis examining the association of the prevalence of depression and time since spousal loss in widowed people.

METHODS

The databases MEDLINE, Embase and PsycInfo were searched (May 2017) for papers reporting on time since spousal loss in widowed people and the prevalence of common mental disorders. A systematic review was conducted according to MOOSE guidelines. Random effects meta-analyses of the prevalence of depression were conducted by intervals of time since spousal loss.

RESULTS

The literature search identified 12,982 studies of which 22 were eligible for inclusion in the systematic review. Of these, 14 were furthermore eligible for inclusion in the meta-analysis. The summary estimates found in the meta-analysis for the prevalence of depression in the intervals of time since spousal loss were: ≤ 1 month: 38.2% (21.9-55.8%); > 1 month to 3 months: 25.0% (17.3-33.5%); > 3 months to 6 months: 23.1% (18.0-28.7%); > 6 months to 12 months: 19.4% (15.2-24.0%); > 12 months to 18 months: 11.1% (5.3-18.7%); > 18 months to 24 months: 15.2% (12.3-18.2%); > 24 months to 60 months: 10.5% (4.3-18.5%).

CONCLUSION

Widowhood is associated with a high prevalence of depression and the study identifies a population group needing special attention in daily clinical practice. The prevalence is highest in the first month of widowhood, however, continues to be high at least 5 years into widowhood.

Longitudinal Examination of Emotional Functioning in Older Adults After Spousal Bereavement

Objectives

This study examined trajectories of emotional functioning in three domains (depressive symptoms, emotional, and social loneliness) for individuals who experienced spousal bereavement and investigated cross-domain adaptation. We hypothesized that emotional difficulties after bereavement would be more detectable in emotional loneliness than depressive symptoms or social loneliness.

Methods

Using latent class growth analysis, we modeled changes in depressive symptoms, emotional loneliness, and social loneliness from 12 years pre- to 12 years post-bereavement on data from 686 older adults to identify trajectories indicating adaptive and maladaptive functioning in each domain.

Results

Most participants reported depressive symptoms below the clinically relevant threshold by showing a resilient (15.5%) or a slightly elevated (53.5%) trajectory post-bereavement. One third (31%) reported clinically relevant depressive symptoms. More than half of the sample reported emotional loneliness post-bereavement, varying form prolonged (17%), increasing and prolonged (28.3%), and chronically high (8.9%) levels. Remaining participants displayed resilience (13.5%) or recovery (32.3%). Social loneliness showed four trajectories: very low and resilient (43.3%), low and resilient (27.5%), increasing (20.2%), and chronically high (9%) levels. One third of participants maintained adaptive, whereas 12% displayed maladaptive, functioning across all domains post-bereavement.

Discussion

An increase in emotional loneliness was the most commonly observed change after spousal bereavement. This highlights the central role of emotional loneliness in depression after bereavement.

Death of a close friend: Short and long-term impacts on physical, psychological and social well-being

This paper reports the impact of a major life event-death-on the physical, psychological and social well-being of the deceased's close friends. We utilised data from a large longitudinal survey covering a period of 14 years (2002-2015) consisting a cohort of 26,515 individuals in Australia, of whom 9,586 had experienced the death of at least one close friend. This longitudinal cohort dataset comprises responses to the SF-36 (health related quality of life measure) and allowed for analysis of the short and longer-term impacts of bereavement. In order to manage the heterogeneity of the socio-demographics of respondents who did/not experience a death event, we use a new and robust approach known as the Entropy Balancing method to construct a set of weights applied to the bereaved group and the control group (the group that did not experience death). This approach enables us to match the two groups so that the distribution of socio-demographic variables between the two groups are balanced. These variables included gender, age, marital status, ethnicity, personality traits, religion, relative socio-economic disadvantage, economic resources, and education and occupation and where they resided. The data show, for the first time, a range of negative and enduring consequences experienced by people following the death of a close friend. Significant adverse physical and psychological well-being, poorer mental health and social functioning occur up to four years following bereavement. Bereaved females experienced a sharper fall in vitality, suffered greater deterioration in mental health, impaired emotional and social functioning than the male counterparts up to four years after the death. The data show that the level of social connectedness plays an important role in bereavement outcomes. Specifically, we found that less socially active respondents experienced a longer deterioration in physical and psychological health. Finally, we found evidence that the death of a close friend lowered the respondent's satisfaction with their health. Since death of friends is a universal phenomenon, we conclude the paper by reflecting on the need to recognise the death of a close friend as a substantial experience, and to offer support and services to address this disenfranchised grief. Recognising bereaved friends as a group experiencing adverse outcomes can be used internationally to prompt health and psychological services to assist this specific group, noting that there may be substantial longevity to the negative sequelae of the death of a friend. Facilitating bereaved people's support networks may be a fruitful approach to minimising these negative outcomes.

Long-term prevalence and predictors of prolonged grief disorder amongst bereaved cancer caregivers: A cohort study

Context

The short-term impact of prolonged grief disorder (PGD) following bereavement is well documented. The longer term sequelae of PGD however are poorly understood, possibly unrecognized, and may be incorrectly attributed to other mental health disorders and hence undertreated.

Objectives

The aims of this study were to prospectively evaluate the prevalence of PGD three years post bereavement and to examine the predictors of long-term PGD in a population-based cohort of bereaved cancer caregivers.

Methods

A cohort of primary family caregivers of patients admitted to one of three palliative care services in Melbourne, Australia, participated in the study (n= 301). Sociodemographic, mental health, and bereavement-related data were collected from the caregiver upon the patient's admission to palliative care (T1). Further data addressing circumstances around the death and psychological health were collected at six (T2,n= 167), 13 (T3,n= 143), and 37 months (T4,n= 85) after bereavement.

Results

At T4, 5% and 14% of bereaved caregivers met criteria for PGD and subthreshold PGD, respectively. Applying the total PGD score at T4, linear regression analysis found preloss anticipatory grief measured at T1 and self-reported coping measured at T2 were highly statistically significant predictors (bothp< 0.0001) of PGD in the longer term.

Conclusion

For almost 20% of caregivers, the symptoms of PGD appear to persist at least three years post bereavement. These findings support the importance of screening caregivers upon the patient's admission to palliative care and at six months after bereavement to ascertain their current mental health. Ideally, caregivers at risk of developing PGD can be identified and treated before PGD becomes entrenched.

Prolonged grief and attachment security: A latent class analysis

The death of a loved one has been associated with a wide range of mental health outcomes. Attachment theory is one of the primary paradigms for understanding bereavement outcome, yet there is comparatively little examination of the relationship between attachment style and bereavement responses. In this study we use Latent Class Analysis to identify subgroups of bereaved individuals based on patterns of prolonged grief (PG) and major depression symptom co-occurrence in 285 bereaved individuals. We then explored the relationship between these subgroups and attachment anxiety and avoidance. Three new subgroups of individuals were identified: one showing high levels of PGD and depression (PGD/depression), one showing high depression (Depression), and one showing few symptoms (Low). Attachment anxiety significantly differentiated between the three groups; the highest levels of attachment anxiety predicted membership of the PGD/depression group, the lowest levels, membership of the Low group. Attachment avoidance was predictive of greater depressive symptoms, with higher levels of attachment avoidance differentiating the two symptom groups (PGD/depression and depression) from the Low symptom group. These findings underscore the relevance of insecure attachment style to the current understanding of PGD.

Emotional security theory: An application to sibling bereavement

There is a need for guiding theory to understand the experiences and outcomes of bereaved siblings, particularly from a family systems framework. The present study investigated the relevance of emotional security theory in a sample of 72 young adults who experienced sibling bereavement. We investigated (1) whether perceptions of prolonged parental grief predicted key aspects of emotional security (disengagement, preoccupation, and security), and (2) whether emotional security mediated a relation between perceptions of prolonged parental grief and young adult emotional functioning. Results supported the potential utility of emotional security theory as a theoretical framework for understanding sibling bereavement.

Grief and Avoidant Death Attitudes Combine to Predict the Fading Affect Bias

The fading affect bias (FAB) occurs when unpleasant affect fades faster than pleasant affect. To detect mechanisms that influence the FAB in the context of death, we measured neuroticism, depression, anxiety, negative religious coping, death attitudes, and complicated grief as potential predictors of FAB for unpleasant/death and pleasant events at 2 points in time. The FAB was robust across older and newer events, which supported the mobilization-minimization hypothesis. Unexpectedly, complicated grief positively predicted FAB, and death avoidant attitudes moderated this relation, such that the Initial Event Affect by Grief interaction was only significant at the highest 3 quintiles of death avoidant attitudes. These results were likely due to moderate grief ratings, which were, along with avoidant death attitudes, related to healthy outcomes in past research. These results implicate complicated grief and death avoidant attitudes as resiliency mechanisms that are mobilized during bereavement to minimize its unpleasant effects.

The Impact on Mental Health of Losing an Only Child and the Influence of Social Support and Resilience

The number of parents who have lost their only child (PLOCs) has increased annually with the implementation of the birth control policy in mainland China. This study aimed to investigate the mental health status of PLOCs and the influence of social support and resilience. Study 1 recruited 100 PLOCs and 88 nonbereaved parents, and compared differences in depression, anxiety, and loneliness. Study 2 investigated the influence of social support and resilience on the mental health of PLOCs via a mediating model. Results indicate that PLOCs reported more anxiety and depression symptoms than nonbereaved counterparts. Perceived close family support, objective support, and resilience negatively predicted anxiety and depression. In addition, perceived close family support was found to influence mental health via resilience. The current findings reveal that losing an only child has long-term negative impacts on the mental health of PLOCs. However, perceived close family support and objective support can protect their mental health either directly or indirectly via resilience.

Moving on: Factors associated with caregivers' bereavement adjustment using a random population-based face-to-face survey

BACKGROUND

Providing care at end of life has consequences for caregivers' bereavement experience. 'Difficulty moving on with life' is an informative and unbiased symptom of prolonged grief disorder. Predictors of bereaved caregivers' ability to 'move on' have not been examined across the population.

AIM

To identify the characteristics of bereaved hands-on caregivers who were, and were not, able to 'move on' 13-60 months after the 'expected' death of someone close.

DESIGN

The South Australian Health Omnibus is an annual, random, cross-sectional community survey. From 2000 to 2007, respondents were asked about providing care for someone terminally ill and their subsequent ability to 'move on'. Multivariable logistic regression models explored the characteristics moving on and not moving on.

SETTING

Respondents were aged ⩾15 years and lived in households within South Australia. They had provided care to someone who had died of terminal illness in the preceding 5 years.

RESULTS

A total of 922 people provided hands-on care. In all, 80% of caregivers (745) had been able to 'move on'. Closeness of relationship to the deceased, increasing caregiver age, caregiver report of needs met, increasing time since loss, sex and English-speaking background were significantly associated with 'moving on'. A closer relationship to the deceased, socioeconomic disadvantage and being male were significantly associated with not 'moving on'.

CONCLUSION

These results support the relevance of 'moving on' as an indicator of caregivers' bereavement adjustment. Following the outcomes of bereaved caregivers longitudinally is essential if effective interventions are to be developed to minimise the risk of prolonged grief disorder.

Risk factors for suicide in offspring bereaved by sudden parental death from external causes

BACKGROUND

Parentally bereaved offspring have an increased suicide risk as a group, but the ability to identify specific individuals at risk on the basis of risk and protective factors is limited. The present study aimed to investigate to what degree different risk factors influence suicide risk in offspring bereaved by parental death from external causes.

METHODS

Based on Norwegian registers, individual-level data were retrieved for 375 parentally bereaved suicide cases and 7500 parentally bereaved gender- and age-matched living controls. Data were analysed with conditional logistic regression.

RESULTS

Bereaved offspring with low social support, indicated by offspring's single status and repeated changes in marital status and residence, had a significantly increased suicide risk compared to bereaved offspring with high social support. Moreover, low socioeconomic status, having an immigration background, having lost both parents and loss due to suicide significantly increased suicide risk.

LIMITATIONS

Several variables relevant to bereavement outcome, such as coping mechanisms and the quality of the parent-offspring relationship are impossible to examine by utilizing population registers. Moreover, the availability of data did not enable the measurement of marital stability and residence stability across the entire lifespan for older individuals.

CONCLUSIONS

Healthcare professionals should be aware of the additional risk posed by the identified risk factors and incorporate this knowledge into existing practice and risk assessment in order to identify individuals at risk and effectively target bereaved family and friends for prevention and intervention programs. Ideal follow-up for bereaved families should include a specific focus on mobilizing social support.

How do risk factors affect bereavement outcomes in later life? An exploration of the mediating role of dual process coping

This study is an exploratory study that aims to examine the mediating role of dual process coping in the relationship between risk factors and bereavement outcomes. A total of 178 Hong Kong Chinese bereaved older adults reported their bereavement-related information, dual process coping (Dual Coping Inventory, DCI), complicated grief (Inventory of Complicated Grief; ICG), depression (Geriatric Depression Scale, GDS) and loneliness (De Jong Gierveld Loneliness Scale, DJG) in face-to-face structured interviews. Results suggested that subjective traumatic death predicted complicated grief, depression, and loneliness via loss-orientated (LO) coping, whereas having lost a spouse rather than having lost a parent predicted loneliness via restoration-orientated (RO) coping. Future interventions may reconsider the use of LO coping and explore alternatives for traumatized bereaved older adults, and encourage RO coping for those experiencing spousal loss.

The fading affect bias shows positive outcomes at the general but not the individual level of analysis in the context of social media

Unpleasant affect fades faster than pleasant affect (e.g., Walker, Vogl, & Thompson, 1997); this effect is referred to as the Fading Affect Bias (FAB; Walker, Skowronski, Gibbons, Vogl, & Thompson, 2003a). Research shows that the FAB is consistently related to positive/healthy outcomes at a general but not at a specific level of analysis based on event types and individual differences (e.g., Gibbons et al., 2013). Based on the positive outcomes for FAB and negative outcomes for social media (Bolton et al., 2013; Huang, 2010), the current study examined FAB in the context of social media events along with related individual differences. General positive outcomes were shown in the form of robust FAB effects across social media and non-social media events, a larger FAB for non-social media events than for social media events, negative correlations of FAB with depression, anxiety, and stress as well as a positive correlation of FAB with self-esteem. However, the lack of a negative correlation between FAB and anxiety for social media events in a 3-way interaction did not show positive outcomes at a specific level of analysis. Rehearsal ratings mediated the 3-way interaction. Implications are discussed.