Screening for Complicated Grief

Note:  This Whole Health tool focuses on grief related to a death loss.  A focus on other types of losses is beyond the scope of “Coping with Grief” and related tools, although you may find this Whole Health tool helpful when working with a Veteran who has experienced a loss other than death.

Deviations from “typical” (i.e., acute) grief that require more aggressive intervention were described as early as 1944.[1]  In complicated grief, symptoms are long-lasting and may intensify over time; the person has trouble accepting the death and resuming life.  Something is getting in the way of the grief process and not allowing the person to adequately adapt to the loss.[2]  Some bereaved individuals who experience complicated grief do not recognize that their behavior and symptoms are related to a previous loss.[2]

More attention has been focused on complicated grief recently.  Estimates of the prevalence of complicated grief vary widely, based on circumstances and relationship with the deceased.  An estimate published in 2011 indicates that 2%-7% of those bereaved in the general public experience complicated grief.[3]  Prevalence is high among Veterans, a group at risk for disenfranchised (hidden) grief.  Literature notes that complicated grief is critically under recognized and unaddressed in Servicemembers.[4]

A study of 114 Vietnam-era combat Veterans admitted to a PTSD inpatient rehabilitation unit identified that 70% scored higher (i.e., worse) on standardized measures of grief symptoms related to friends lost in combat 30 years previous, than did spouses who were bereaved in the past six months.[5]  Two studies of Servicemembers and Veterans who served after September 11, 2001, revealed that about 80% had experienced the death of someone important to them and almost one-third (31.25% and 30.3%) of those bereaved met criteria for complicated grief.[6][7]  One study involved those seeking care for combat-related PTSD, the other group was receiving outpatient mental health care.  In the PTSD group, complicated grief was more prevalent among Veterans who lost a fellow Servicemember than in those who lost someone close who was not a Servicemember, and it was associated with significantly greater PTSD severity, functional impairment, trauma-related guilt, and lifetime suicide attempts.  In the group receiving outpatient mental health care, rates of complicated grief were the same whether the loss was a fellow Servicemember, family member, or friend, and it was associated with worse PTSD, depression, anxiety, stress, and poorer quality of life above and beyond PTSD.

This research indicates that Servicemembers and Veterans are at increased risk for complicated grief with associated sequelae and highlights the importance of screening for this condition, so that appropriate treatment can be offered.  Screening for complicated grief has been found to be feasible and useful in primary and behavioral health clinics and military mental health clinics.[8][9]

The Brief Grief Questionnaire developed by M. Katherine Shear, MD, and Susan Essock, PhD,[10] is an efficient tool to screen for complicated grief in health care settings.[11][12] To screen for complicated grief

  • Ask the five questions in the Brief Grief Questionnaire during a patient’s appointment.
  • Use with adults bereaved for at least 12 months and children at least 6 months.
  • Screen all bereaved individuals who seek treatment for suicide risk, mood, and anxiety disorders as well. These conditions may require treatment earlier than 6-12 months post bereavement.

Complicated grief, identified as Persistent Complex Bereavement Disorder, has been added to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) published in 2013.[13]  It is in Section III, which contains conditions that are in need of further research.  For diagnosis, grief symptoms must persist to a “clinically significant degree” for at least 12 months (6 months for children) following the death of someone close and be “out of proportion or inconsistent with cultural, religious, or age-appropriate norms.”  A similar classification, Prolonged Grief Disorder, is proposed in the 11th version of the International Classification of Diseases and Related Health Problems (ICD-11) that was released June 2018, will be presented at the World Health Assembly May 2019 for adoption by Member States, and will come into effect January 1, 2022. [14]

For someone who has had a significant loss and whose symptoms are ongoing, differentiating “typical” grief from the more debilitating “complicated grief” or from clinical depression can be tricky.  Shear offers clinicians a concise table comparing characteristics of these conditions.[15]  (Refer to the “Resources” section at the end of the “Coping with Grief” overview.)  Differential diagnosis may best be accomplished via referral to a mental health professional experienced in the area of grief for further assessment and facilitation/support/treatment of mourning.  Patients can experience grief reactions coincidentally with anxiety, depression, and PTSD.

Author(s)

“Screening for Complicated Grief” was written by Charlene Luchterhand MSSW, LCSW (2014, updated 2019).

This Whole Health tool was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

References

  1. Lindemann E. Symptomatology and management of acute grief. 1944. Am J Psychiatry. 1994;151(6 Suppl):155-160.
  2. Worden J. Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner. 4th ed. New York: Springer Publishing Company; 2008.
  3. Kersting A, Brahler E, Glaesmer H, Wagner B. Prevalence of complicated grief in a representative population-based sample. J Affect Disord. 2011;131(1-3):339-343.
  4. Papa A, Neria Y, Litz B. Traumatic Bereavement in War Veterans. Psychiatr Ann. 2008;38:686-691.
  5. Pivar IL, Field NP. Unresolved grief in combat veterans with PTSD. J Anxiety Disord. 2004;18(6):745-755.
  6. Simon NM, O’Day EB, Hellberg SN, et al. The loss of a fellow service member: Complicated grief in post-9/11 service members and veterans with combat-related posttraumatic stress disorder. J Neurosci Res. 2018;96(1):5-15.
  7. Charney ME, Bui E, Sager JC, Ohye BY, Goetter EM, Simon NM. Complicated Grief Among Military Service Members and Veterans Who Served After September 11, 2001. J Trauma Stress. 2018;31(1):157-162.
  8. Patel SR, Cole A, Little V, et al. Acceptability, feasibility and outcome of a screening programme for complicated grief in integrated primary and behavioural health care clinics. Fam Pract. 2019;36(2):125-131.
  9. Delaney EM, Holloway KJ, Miletich DM, Webb-Murphy JA, Lanouette NM. Screening for Complicated Grief in a Military Mental Health Clinic. Mil Med. 2017;182(9):e1751-e1756.
  10. Shear KM, Jackson CT, Essock SM, Donahue SA, Felton CJ. Screening for complicated grief among Project Liberty service recipients 18 months after September 11, 2001. Psychiatr Serv. 2006;57(9):1291-1297.
  11. Simon NM. Treating complicated grief. JAMA. 2013;310(4):416-423.
  12. Ito M, Nakajima S, Fujisawa D, et al. Brief measure for screening complicated grief: reliability and discriminant validity. PLoS One. 2012;7(2):e31209.
  13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C.: American Psychiatric Association; 2013.
  14. Killikelly C, Maercker A. Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability. Eur J Psychotraumatol. 2017;8(Suppl 6):1476441.
  15. Shear MK. Clinical practice. Complicated grief. N Engl J Med. 2015;372(2):153-160.

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