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A minority of bereaved adults experiences prolonged grief disorder, depression, and/or posttraumatic stress disorder, with heightened risks observed among bereaved parents. Cognitive-behavioural therapies, both face-to-face and online, have demonstrated efficacy in treating post-loss mental health problems. Mobile phone applications potentially offer an efficient and cost-effective way to deliver self-help to bereaved adults, yet controlled effectiveness studies are lacking. Therefore, we examined the short-term efficacy of the My Grief app, based on cognitive-behavioural therapy, in 248 bereaved parents, in a randomised controlled trial (Clinicaltrials.gov, identifier: NCT04552717). Participants were randomly allocated to access to the My Grief app ( n  = 126) or a waitlist ( n  = 122). At baseline and post-assessment, symptoms of prolonged grief, posttraumatic stress, and depression, negative grief cognitions, rumination, and avoidance were assessed. Reductions in prolonged grief and posttraumatic stress symptoms and negative cognitions in the intervention group were larger than in the control group, albeit with small effect sizes. Fifteen app users reported negative experiences with the app; for example, some mentioned that it elicited painful memories and emotions related to their loss. My Grief appears to achieve modest improvements in mental health in bereaved parents. Given that it is accessible and low-cost, it is an important addition to the suite of prolonged grief interventions.

Background: Prolonged grief disorder (PGD) has been added to the ICD-11 and DSM-5-TR. The Traumatic Grief Inventory-Self Report Plus (TGI-SR+) assesses self-rated PGD intensity as defined in ICD-11 and DSM-5-TR. The TGI-SR + is available in multiple languages, but has not been validated yet in Norwegian. Objective: The aim of this study was to evaluate the psychometric properties of the Norwegian TGI-SR + . Method: Bereaved adults ( N  = 307) whose child or sibling died ≥6 months ago due to a sudden or violent loss completed the TGI-SR + and measures for posttraumatic stress, depression, and precursor PGD symptoms. We examined the factor structure and internal consistency of the ICD-11 and DSM-5-TR PGD items. Convergent validity and known-groups validity was evaluated. Probable PGD cases, pair-wise agreement between diagnostic scoring rules for both PGD criteria-sets, and cut-off scores were calculated. Results: The 1-factor model for ICD-11 and DSM-5-TR PGD showed the best fit and demonstrated good internal consistency. Convergent validity was supported by strong associations between summed ICD-11 and DSM-5-TR PGD scores and summed posttraumatic stress, depression, and precursor prolonged grief scores. Known-groups validity was supported by PGD intensity being related to educational level and time since loss. The perfect pair-wise agreement was reached using the ICD-11 and DSM-5-TR PGD diagnostic scoring rules. The optimal cut-off score for detecting probable PGD cases, when summing all TGI-SR + items, was ≥73. Conclusions: The Norwegian TGI-SR + seems a valid and reliable instrument to assess ICD-11 and DSM-5-TR PGD intensity after losing a child or sibling under traumatic circumstances.

Background: In China, mental health services do not currently meet the needs of bereaved people with symptoms of prolonged grief disorder (PGD). Internet-based grief interventions may help fill this gap, but such programmes have not yet been developed or evaluated in China. The proposed study aims to investigate the effectiveness, acceptability, and feasibility of an online self-help intervention programme named Healing Grief for bereaved Chinese with prolonged grief, and to explore the psychological mechanisms of potential improvements. Methods: We designed a two-arm randomised controlled trial. At least 128 participants will be randomly assigned to either an Internet-based intervention group or a waitlist-control group. The Internet-based intervention will be developed based on the dual process model, integrating techniques of psychoeducation, behavioural activation, cognitive reappraisal, and meaning reconstruction, and will be delivered via expressive writing. The intervention comprises six modules, with two sessions in each module, and requires participants to complete two sessions per week and complete the intervention in 6 weeks. The primary outcomes include effectiveness, acceptability, and feasibility. The effectiveness will be assessed by measures of prolonged grief, posttraumatic stress, anxiety, and depressive symptoms. Acceptability and feasibility will be evaluated using survey and interview on user experience characteristics. Secondary outcomes include moderators and mediators, such as dual process coping, grief rumination, mindfulness, and continuing bond, to explore the psychological mechanisms of potential improvement. Assessments will take place at pre-intervention, post-intervention, and 3-month follow-up. Conclusion: The proposed study will determine the effectiveness, acceptability, and feasibility of the newly developed online self-help intervention for bereaved Chinese with prolonged grief and clarify how the intervention helps with symptom improvements. Such an intervention may play an important role in easing the imbalance between the delivery and receipt of bereavement psychological services in China.

Background: Levels of prolonged grief symptoms (PGS) and post-traumatic stress symptoms (PTSS) can be high, many years following bereavement after terror, but knowledge concerning somatic health is scarce. Terrorism is a serious public health challenge, and increased knowledge about long-term somatic symptoms and insomnia is essential for establishing follow-up interventions after terrorism bereavement. Objective: To study the prevalence of somatic symptoms and insomnia and their association with PGS, PTSS, and functional impairment among terrorism-bereaved parents and siblings. Methods: A cross-sectional quantitative study included 122 bereaved individuals from the Utøya terror attack in Norway in 2011. The sample comprised 88 parents and 34 siblings aged 19 years and above ( M age  = 49.7 years, SD age  = 13.8 years, 59.8% females). The participants completed questionnaires 8 years after the attack assessing somatic symptoms (Children's Somatic Symptoms Inventory) and insomnia (Bergen Insomnia Scale) along with measures of PGS (Inventory of Complicated Grief), PTSS (Impact of Event Scale-Revised), and functional impairment (Work and Social Adjustment Scale). Results: Fatigue was the most frequently reported somatic symptom (88% of females and 65% of males). Females reported statistically significantly more somatic symptoms than males. In total, 68% of the bereaved individuals scored above the cut-off for insomnia. There were no statistically significant gender differences for insomnia. Female gender, intrusion, and arousal were associated with somatic symptoms. Intrusion and somatic symptoms were associated with insomnia. Somatic symptoms, avoidance, and hyperarousal were associated with functional impairment. Conclusion: Many bereaved parents and siblings report somatic symptoms and insomnia eight years after the terror attack. Somatic symptoms are associated with functional impairment. Long-term follow-up and support after traumatic bereavement should focus on somatic symptoms and insomnia.

Background: Prolonged grief disorder (PGD) has been included in the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders 5 Text Revision (DSM-5-TR). Loss-related avoidance behavior perpetuates grief and effective interventions for prolonged grief symptoms target such avoidance behavior. Yet, behaviors characterized by approach of loss-related cues (i.e. rumination, yearning, proximity seeking) are also implicated in prolonged grief reactions. Objective: To solve this paradox, we will test the Approach Avoidance Processing Hypothesis, which holds that loss-related approach and avoidance behaviors co-occur in PGD, using latent class analyses (LCA). Methods: Two-hundred eighty-eight bereaved adults (92% female) completed questionnaires assessing loss-related approach behaviors (rumination, yearning, proximity seeking), loss-related avoidance behaviors (anxious avoidance, experiential avoidance) and ICD-11 and DSM-5-TR prolonged grief symptoms. Results: LCA demonstrated the best fit for a three-class solution comprising a low approach/low avoidance class ( n  = 98, 34%), a high approach/low avoidance class ( n  = 79, 27%), and a high approach/high avoidance class ( n  = 111, 39%). The latter class showed significantly higher prolonged grief symptom levels and higher odds of probable PGD compared to the other classes. Conclusions: Co-occurrence of loss-related approach and avoidance appears characteristic to prolonged grief reactions. Distinguishing bereaved people with these behavioral patterns from those solely experiencing loss-related approach behaviors may improve the efficacy of PGD therapies.

Background: Around 10% of bereaved youths experience symptoms of prolonged grief disorder (PGD). Recently, PGD was included in the two main classification systems for mental disorders: the ICD-11 and DSM-5-TR. Assessing PGD symptoms in youth is currently hindered by the lack of instruments for ICD-11 and DSM-5-TR criteria. To fill this gap, we developed an instrument to assess PGD symptoms in children and adolescents, the Traumatic Grief Inventory - Kids - Clinician-Administered (TGI-K-CA), based on input of grief experts and bereaved children., Methods: Five experts rated the items on alignment with DSM-TR and ICD-11 PGD symptoms and comprehensibility. The adjusted items were then presented to seventeen bereaved youths ( Mdn age  = 13.0 years, range = 8-17 years). Using the Three-Step Test Interview (TSTI), children were asked to verbalize their thoughts while answering the items., Results: Issues raised by experts were mostly related to alignment with the DSM-5-TR/ICD-11 symptom, ambiguous formulation of the items, or low comprehensibility for children and adolescents. Items raising fundamental issues according to experts were adjusted. The TSTI showed that children encountered relatively few problems with the items. Frequently reported problems with some of the items (e.g. regarding comprehensibility) led to final adjustments., Conclusion: With input from grief experts and bereaved youths, an instrument to assess PGD symptoms as defined in DSM-5-TR and ICD-11 in bereaved youths was finalized. Further quantitative research is currently undertaken to evaluate the instrument's psychometric qualities.

Background: Participating in a criminal trial may increase the likelihood of developing psychopathology. In 2021, people bereaved by a plane disaster (flight MH17) had the opportunity to deliver a victim personal statement (VPS) in Dutch court. Objective: This longitudinal mixed-method study examined different aspects of 84 bereaved people's experiences with VPS delivery. Method: Motivations to deliver, or not deliver, an oral VPS were examined qualitatively using thematic content analysis. Whether background and loss-related variables were related to the decision to deliver a VPS was examined using binary logistic regression analyses. Between-group (delivered VPS vs. did not) and within-group (pre- vs. post-VPS) comparisons were made regarding prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression levels using t -tests and paired t -tests. Results: Bereaved people were most frequently motivated to deliver an oral VPS to describe the impact of the incident, while those who did not deliver an oral VPS commonly wanted to protect themselves from the perceived emotional burden. None of the correlates - i.e. biological sex, age, level of education, number of losses, and (closest) relationship to the deceased - were related to the decision to deliver a VPS. Lastly, significantly higher PGD, PTSD, and depression levels were reported by people who delivered a VPS than those who did not, before and after the court hearing. No significant within-group differences were found over time. Conclusions: Professionals may provide emotional support to bereaved people who want to deliver a VPS and manage their expectations if they want to deliver a VPS for the purpose of symptom reduction. Future research may benefit from examining other ways in which VPS delivery might have beneficial or detrimental effects for specific individuals. Overall, implementing VPS delivery in court on the basis of emotional restoration remains empirically unsupported, if defined as a reduction in psychopathological levels.

Background: Research on bereavement after terrorism is limited and primarily aiming on short-term consequences. Objective: To better understand the long-term health consequences of terrorism, we studied bereaved parents and siblings eight years after the Utøya terrorist attack in Norway. We examined the participants' symptom levels of prolonged grief (PG) and post-traumatic stress (PTS), as well as their psychosocial functioning and employment status. Method: Bereaved parents ( n  = 88) and siblings ( n  = 34) aged 19 and above (mean age  = 49.7 years, SD = 13.8 years, 59.8% female) completed the Inventory of Complicated Grief (ICG), the Impact of Event Scale-Revised (IES-R), and the Work and Social Adjustment Scale (WSAS) to assess PG, PTS, and functional impairment, respectively. In addition, information about employment status was obtained. The proportion of participants scoring above recommended thresholds on the ICG, IES-R, and WSAS was calculated. Differences between parents and siblings and gender differences on these measures were examined. Results: In total, 62.3% of the participants had scores on the ICG indicating a risk for prolonged grief, while 45.9% scored over cutoff on the IES. There was a high overlap between symptoms of PG and PTS. Females had significantly higher scores on both the ICG and the IES compared to males. There were no differences between parents and siblings regarding PG and PTS symptoms. One out of three showed severe functional impairment on the WSAS. Approximately 30% of all the bereaved were outside the labour force, and one third of the parents had become unable to work after the terrorist attack. Conclusion: Many bereaved parents and siblings, following the Utøya terror attack, report long-lasting health consequences with symptoms of PG and PTS and functional impairment. The results suggest a need for follow up of bereaved after a terror attack and identify family members in need of health services.

Background: COVID-19 deaths elevate the prevalence of prolonged grief and post-traumatic stress symptoms among the bereaved, yet few studies have examined potential positive outcomes. Moreover, how COVID-19 bereavement affects individual-level mental health outcomes is under-researched., Objective: This is the first study to use latent profile analysis (LPA) to identify heterogeneous profiles of prolonged grief, post-traumatic stress and post-traumatic growth among people bereaved due to COVID-19 and to identify predictors of latent class membership., Methods: Four hundred and twenty-two Chinese participants who were bereaved due to COVID-19 completed an online survey between September and October 2020. The survey included the International (ICD-11) Prolonged Grief Disorder Scale (IPGDS), the Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5) and the Post-traumatic Growth Inventory (PTGI). LPA was run in Mplus, and the 3-step auxiliary approach was used to test the predicting effects of potential predictors of latent class membership identified with chi-square tests and ANOVAs., Results: Four latent profiles were identified: resilience (10.7%), growth (20.1%), moderate-combined (42.2%) and high-combined (27.0%). The bereaved who shared a close relationship with the deceased and identified COVID-19 as the fundamental cause of death were more likely to be in the high-combined group. A conflictful bereaved-deceased relationship reduces the chance of being in the growth group. Moreover, the death of a younger person and loss of a partner attributed to maladaptive outcomes., Conclusions: Serious attention needs to be paid to the mental health issues of people bereaved due to COVID-19 because nearly 70% of this group would have a moderate-combined or high-combined symptom profile. Special care should be given to those who lost someone younger, lost a partner or shared a close relationship with the deceased. Grief therapies that work on the conflicts between the deceased and the bereaved and unfinished business can be applied to facilitate growth., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background : The loss of a loved one due to suicide can be a traumatic event associated with prolonged grief and psychological distress. Objective : This study examined the efficacy of an Internet-based cognitive-behavioural grief therapy (ICBGT) specifically for people bereaved by suicide. Methods : In a randomized controlled trial, 58 participants with prolonged grief disorder (PGD) symptoms who had lost a close person to suicide were randomly allocated either to the intervention group (IG) or waitlist-control group (WCG). The 5-week intervention comprised ten writing assignments in three phases: self-confrontation, cognitive restructuring, and social sharing. Symptoms of PGD, common grief reactions after suicide, depression, and general psychopathology were assessed at pre-, post-test and follow-up. Results : Between-group effect sizes were large for the improvement of PGD symptoms in treatment completers (d ppc2  = 1.03) and the intent-to-treat analysis (d ppc2  = 0.97). Common grief reactions after suicide and depressive symptoms also decreased in the IG compared to the WCG (moderate to large effects). The results are stable over time. Only for general psychopathology, there was no significant time by group interaction effect found. Conclusions : The ICBGT represents an effective treatment approach for people suffering from PGD symptoms after bereavement by suicide. Considering the effect sizes, the small treatment dose, duration, and the stability of the results, the ICBGT constitutes an appropriate alternative to face-to-face grief interventions., Competing Interests: The authors have no competing interests to declare in relation to this article., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background : The ability to adapt to the psychosocial disruptions associated with the refugee experience may influence the course of complicated grief reactions. Objective : We examine these relationships amongst Myanmar refugees relocated to Malaysia who participated in a six-week course of Integrative Adapt Therapy (IAT). Method : Participants (n = 170) included Rohingya, Chin, and Kachin refugees relocated to Malaysia. At baseline and six-week post-treatment, we applied culturally adapted measures to assess symptoms of Prolonged Complex Bereavement Disorder (PCBD) and adaptive capacity to psychosocial disruptions, based on the Adaptive Stress Index (ASI). The ASI comprises five sub-scales of safety/security (ASI-1); bonds and networks (ASI-2); injustice (ASI-3); roles and identity (ASI-4); and existential meaning (ASI-5). Results : Multilevel linear models indicated that the relationship between baseline and posttreatment PCBD symptoms was mediated by the ASI scale scores. Further, ASI scale scores assessed posttreatment mediated the relationship between baseline and posttreatment PCBD symptoms. Mediation of PCBD change was greatest for the ASI II scale representing disrupted bonds and networks. Conclusion : Our findings are consistent with the informing model of IAT in demonstrating that changes in adaptive capacity, and especially in dealing with disrupted bonds and networks, may mediate the process of symptom improvement over the course of therapy., Competing Interests: No potential conflict of interest was reported by the authors., (© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Complicated grief (CG) is a debilitating syndrome characterized by persisting and intense distress and impairment after the death of a loved one. The biological mechanisms associated with this syndrome remain unclear but may involve neurobiological pathways implicated in the stress response and attachment systems. The neuropeptide oxytocin has been implicated in attachment and social behaviour, and loss of social bonds has been associated with disruptions in oxytocin signalling. Furthermore, prior research has reported associations between circulating oxytocin and other mental illnesses, including depression. The present pilot study aimed to examine plasma levels of oxytocin in bereaved adults with primary CG ( n = 47) compared to age- and sex-matched bereaved individuals with primary Major Depressive Disorder (MDD) ( n = 46), and bereaved individuals without any mental disorder ( n = 46). In unadjusted analyses comparing groups according to primary diagnosis, oxytocin levels were significantly higher for primary CG compared to primary MDD ( p = 0.013), but not compared to bereaved controls ( p = 0.069). In adjusted regression models, having a primary or probable (Inventory of Complicated Grief ≥ 30) diagnosis of CG was associated with significantly higher oxytocin levels ( p = 0.001). While additional research is needed, findings from our pilot study provide preliminary support for recent conceptualizations of CG implicating a role for oxytocin and the attachment system. Importantly, these findings contribute to the limited current knowledge about possible biological correlates of CG.

Background : Prolonged grief disorder (PGD) causes significant impairment in approximately 7% of bereaved people. Although cognitive behaviour therapy (CBT) has been shown to effectively treat PGD, there is a need to identify predictors of treatment non-response. Methods : PGD patients ( N = 80) were randomly allocated to receive 10 weekly two-hour group CBT sessions and (a) four individual sessions of exposure therapy or (b) CBT without exposure. PGD was assessed by self-report measures at baseline, post-treatment ( N =  61), and six-months ( N =  56) after treatment. Results : Post-treatment assessments indicated that greater reduction in grief severity relative to pretreatment levels was associated with being in the CBT/Exposure condition, and lower baseline levels of self-blame and avoidance. At follow-up, greater grief symptom reduction was associated with being in the CBT/Exposure condition and lower levels of avoidance. Conclusions : These patterns suggest that strategies that target excessive self-blame and avoidance during treatment may enhance response to grief-focused cognitive behaviour therapy.

Background. After the 2011 terror attack on Utøya Island, a collective visit was organized for bereaved families. There is limited knowledge whether bereaved families can benefit from such visits after terror. Objective. This study aims to explore how bereaved families experienced visiting the site of death after the 2011 terror attack. Method. As part of in-depth interviews, 22 parents and 16 siblings were asked whether they had visited Utøya and, if so, how they experienced the visit. Participants' responses were analysed using thematic analysis. Results. The results showed that for the majority of the bereaved, visiting Utøya had been important in processing their loss. Three key themes emerged as to what they considered important with the visit: 'seeing the actual place of death', 'seeking factual information', and 'learning to know the island'. These factors were associated both with beneficial reactions (e.g. accepting the reality of the loss increased cognitive clarity) and with distressing reactions (e.g. intrusive thoughts, re-enactment images), but the benefits had outweighed the distress. Having the opportunity for multiple visits seemed to optimize the benefits. Conclusion. Bereaved families should be offered the opportunity to visit the site of death after terror., (© 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Prolonged grief disorder is proposed for the International Classification of Diseases (ICD-11), though it was rejected as a diagnosis for DSM-5., Objective: This review outlines findings and defines important areas for future research viewed from a lifespan perspective., Results: The development and psychometric evaluation of measures for the new diagnosis is paramount, specifically for children and adolescents. Treatments need to be adapted for specific subgroups and research findings have to be disseminated into various professional settings.

Background: Treatments for adolescents affected by long-term loss in low- and middle-income countries are lacking. As school-based interventions are cost-efficient and easy to disseminate, an evaluation of this treatment setting for adolescents is worthwhile., Objective: Examining the effect of a school-based unstructured emotional writing intervention (sensu Pennebaker, group 1) about the loss of a parent to reduce adaptation problems to loss, compared to writing about a hobby (group 2), and non-writing (group 3)., Method: We randomly assigned 14-18-year-old Rwandan orphans to one of the three conditions (n=23 per condition). Before and after the intervention, subjects completed the Prolonged Grief Questionnaire for Adolescents and the Mini International Neuropsychiatric Interview for Children and Adolescents, Part A, on depression as self-report measures of long-term effects of early parental loss., Results: Repeated measures analyses of variance showed no differential effect for any of the three conditions but revealed a significant effect of time at posttest regarding grief severity. Reduction of grief symptoms was significantly higher in subjects with elevated grief. Depressive symptoms showed no significant change from pre- to posttest in the emotional writing condition, whereas they significantly decreased in the control condition., Conclusions: RESULTS imply that unstructured, brief emotional writing might not be indicated in adolescents affected by early parental loss who show severe and long-term distress; a more structured approach seems recommendable.

Complicated grief (CG) is a common and often under-acknowledged cause of profound impairment experienced after the loss of a loved one. Although both clinical and basic research suggests that pharmacological agents might be of use in the treatment of CG, research on pharmacological approaches to this condition is still scarce. Three open-label trials and one randomized trial on bereavement-related depression suggest that tricyclic antidepressants may be effective, although they may be more efficacious for depressive symptoms than for grief-specific symptoms. Four open-label trials (total number of participants, 50) of selective serotonin reuptake inhibitors (SSRIs) have yielded results, providing very preliminary support that they might be effective in the treatment of CG, both as a standalone treatment and in conjunction with psychotherapeutic interventions. These more recent studies have shown an effect on both depression and grief-specific scales. Furthermore, therapeutic interventions for CG may be more effective in conjunction with SSRI administration. Given the small number of pharmacological studies to date, there is a need for randomized trials to test the potential efficacy of pharmacological agents in the treatment of CG.

Following the death of a loved one, a small group of grievers develop an abnormal grieving style, termed complicated or prolonged grief. In the effort to establish complicated grief as a disorder in DSM and ICD, several attempts have been made over the past two decades to establish symptom criteria for this form of grieving. Complicated grief is different from depression and PTSD yet often comorbid with other psychological disorders. Meta-analyses of grief interventions show small to medium effect sizes, with only few studies yielding large effect sizes. In this article, an integrative cognitive behavioral treatment manual for complicated grief disorder (CG-CBT) of 25 individual sessions is described. Three treatment phases, each entailing several treatment strategies, allow patients to stabilize, explore, and confront the most painful aspects of the loss, and finally to integrate and transform their grief. Core aspects are cognitive restructuring and confrontation. Special attention is given to practical exercises. This article includes the case report of a woman whose daughter committed suicide.