BMJ  2007;334:962-963 (12 May), doi:10.1136/bmj.39206.507488.BE

Editorials

Complicated grief after bereavement

Psychological interventions may be effective

Some bereaved people develop severe long term reactions to their loss. This kind of reaction may be associated with adverse health outcomes and has recently been termed "complicated grief."¹ The syndrome is more common after unexpected and violent deaths such as suicide.^{2 3} People bereaved by suicide are also more likely than those bereaved by other deaths to experience stigmatisation, shame, guilt, and a sense of rejection.⁴

People going through normal or uncomplicated grief reactions after a death usually do not need or benefit from specific interventions other than support—indeed these may be contraindicated.⁵ The potentially severe implications for people who develop complicated grief suggest, however, that special treatment may be indicated. But are these interventions effective?

The randomised controlled trial reported by de Groot and colleagues in this week's BMJ is one of few evaluations in this field.⁶ The findings indicate that provision of a cognitive behaviour counselling programme of four sessions to relatives and spouses bereaved by suicide between three and six months after the death may have some benefits compared with usual care. Thus, while treatment groups did not differ at 13 months after the death in prevalence of complicated grief, the programme seemed to help prevent maladaptive grief reactions and perceptions of blame for the death.

This study highlights the question of how complicated grief differs from normal grief, and other possible bereavement outcomes, and how clinicians—especially in primary care—should best manage people at risk. A syndrome of complicated grief has been proposed for inclusion in the fifth version of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.¹ In contrast to uncomplicated grief, people with complicated grief seem to be in a state of chronic mourning. The proposed criteria require that the bereaved person has persistent and disruptive yearning, pining, and longing for the deceased. The criteria include four out of eight symptoms that must be experienced frequently or to a severely distressing and disruptive degree (or both). The eight symptoms are trouble accepting the death, inability to trust others since the death, excessive bitterness related to the death, uneasiness about moving on with life, detachment from other people to whom the person was previously close, the feeling that life is now meaningless, the view that the future holds no prospect for fulfilment, and agitation since the death. Importantly, to fulfil the diagnosis these symptoms must have persisted for at least six months. They must also have resulted in considerable impairment in social, occupational, and other major areas of functioning.¹ Complicated grief may be associated with increased risk of cancer, hypertension, cardiac events, and suicidal ideation,¹ plus adverse health behaviours such as increased smoking and alcohol misuse.⁷ Although complicated grief is associated with an increased risk of depressive disorders, it is clearly distinguished from depression.⁸

Detection of people at risk is important. Sudden unexpected deaths appear to be associated with greater risk. Risk is also increased if the relationship with the deceased person was a dependent one. Other factors include early family experiences that may have undermined the person's sense of security—such as abuse and neglect or separation anxiety—and lack of a supportive network.¹ Practitioners may therefore be able to identify some people at risk. However, given the usual limitations of using risk factors for determining prognosis, monitoring the bereaved through occasional brief contact will also be important, especially as people who develop complicated grief may be reluctant to seek help from clinicians.¹ This will also provide opportunity for giving support. For people bereaved by suicide, self help can be encouraged through recommended reading material.⁹

But what can be done to help people at risk, or those identified with a complicated grief reaction? The results of the trial by de Groot and colleagues indicate that specific interventions at an early stage may be helpful for people at risk who have experienced a sudden loss. The brevity of the intervention (four sessions) makes it attractive, although replication and improved results of such an intervention would increase confidence in recommending it. Once complicated grief has been identified, a more intensive approach designed to treat the condition seems to be effective, especially for people who have experienced a sudden violent loss.¹⁰ Provision of cognitive behaviour therapy through an interactive internet based programme has also had impressive results.¹¹ Development of more resources to manage complicated grief is clearly required, together with further evaluations. However, current evidence indicates that not only is complicated grief a serious adverse outcome of bereavement, but that it may be dealt with effectively through carefully designed interventions.

University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

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2. Mitchell AM, Kim Y, Prigerson HG, Mortimer MK. Complicated grief and suicidal ideation in adult survivors of suicide. Suicide Life Threat Behav 2005;35:498-506.[CrossRef][ISI][Medline]
3. de Groot MH, de Keijser J, Neeleman J. Grief shortly after suicide and natural death: a comparitive study among spouses and first-degree relatives. Suicide Life Threat Behav 2006;36:418-31.[CrossRef][ISI][Medline]
4. Jordan JR. Is suicide bereavement different? A reassessment of the literature. Suicide Life Threat Behav 2001;31:91-102.[CrossRef][ISI][Medline]
5. Jordan JR, Neimeyer RA. Does grief counselling work? Death Studies 2003;2
6. de Groot M, de Keijser J, Neeleman J, Kerkhof A, Nolen W, Burger H. Cognitive behaviour therapy to prevent complicated grief among relatives and spouses bereaved by suicide: cluster randomised controlled trial. BMJ 2007 doi: 10.1136/bmj.39161.457431.55[Abstract/Free Full Text]
7. Prigerson HG, Bierhals AJ, Kasl SV, Reynolds CF 3rd, Shear MK, Day N, et al. Traumatic grief as a risk factor for mental and physical morbidity. Am J Psychiatry 1997;154:616-23.[Abstract]
8. Boelen PA, Van Den Bout J, de Keijser J. Traumatic grief as a disorder distinct from bereavement-related depression and anxiety: a replication study with bereaved mental health care patients. Am J Psychiatry 2003;160:1339-41.[Abstract/Free Full Text]
9. Department of Health. Help is at hand: a resource for people bereaved by suicide and other sudden, traumatic death. London: DoH, 2006. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4139006
10. Shear K, Frank E, Houck PR, Reynolds CF. Treatment of complicated grief: a randomized controlled trial. JAMA 2005;293:2601-8.[Abstract/Free Full Text]
11. Wagner B, Knaevelsrud C, Maercker A. Internet-based cognitive-behavioral therapy for complicated grief: a randomized controlled trial. Death Studies 2006;30:429-53.[CrossRef][ISI][Medline]

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Relevant Article

Cognitive behaviour therapy to prevent complicated grief among relatives and spouses bereaved by suicide: cluster randomised controlled trial

Marieke de Groot, Jos de Keijser, Jan Neeleman, Ad Kerkhof, Willem Nolen, and Huibert Burger
BMJ 2007 334: 994. [Abstract] [Full Text] [PDF]