Elsevier

Journal of Affective Disorders

Volume 170, 1 January 2015, Pages 15-21
Journal of Affective Disorders

Research report
The impact of losing a child on the clinical presentation of complicated grief

https://doi.org/10.1016/j.jad.2014.08.021Get rights and content

Abstract

Background

It is unclear whether bereaved parents with Complicated Grief (CG) struggle with their grief differently than others with CG. This study addressed this question by comparing CG severity, CG-related symptoms, thoughts and behaviors, and comorbid psychiatric diagnoses of bereaved parents with CG to the diagnoses and symptoms of others with CG.

Methods

Baseline data from 345 participants enrolled in the Healing Emotions After Loss (HEAL) study, a multi-site CG treatment study, were used to compare parents with CG (n=75) to others with CG (n=275). Data from the parent group was then used to compare parents with CG who had lost a younger child (n=24) to parents with CG who had lost an older child (n=34). Demographic and loss-related data were also gathered and used to control for confounders between groups.

Results

Parents with CG demonstrated slightly higher levels of CG (p=0.025), caregiver self-blame (p=0.007), and suicidality (p=0.025) than non-parents with CG. Parents who had lost younger children were more likely to have had a wish to be dead since the loss than parents who had lost older children (p=0.041).

Limitations

All data were gathered from a treatment research study, limiting the generalizability of these results. No corrections were made for multiple comparisons. The comparison of parents who lost younger children to parents who lost older children was limited by a small sample size.

Conclusions

Even in the context of CG, the relationship to the deceased may have a bearing on the degree and severity of grief symptoms and associated features. Bereaved parents with CG reported more intense CG, self-blame, and suicidality than other bereaved groups with CG, though this finding requires confirmation. The heightened levels of suicidal ideation experienced by parents with CG, especially after losing a younger child, suggest the value of routinely screening for suicidal thoughts and behaviors in this group.

Introduction

A meaningful portion of the bereaved population, likely between 5 and 10 percent, experiences clinically significant distress and impairment due to unresolved or complicated grief (Prigerson et al., 2009 ; Kersting et al., 2011). These bereaved individuals often report continued yearning for the deceased, anger and bitterness, shock and disbelief, and other hallmarks of intense and prolonged grief long after they might have been expected to have integrated their grief and “moved on” (Prigerson et al., 1999, Shear et al., 2005, Simon et al., 2011). They have worse physical health (Prigerson et al., 1997) and higher rates of suicidal ideation than those who have integrated their grief more successfully (Latham and Prigerson, 2004, Szanto et al., 2006).

Conceptualized as a combination of separation distress and traumatic distress that interrupts the grieving process (Prigerson et al., 1999, Zisook and Shear, 2009), complicated grief (CG) is distinct from both major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) (Boelen et al., 2003, Shear et al., 2011, Simon et al., 2011, Spuij et al., 2012). Several diagnostic criteria have been proposed for CG (Prigerson et al., 1999, Shear et al., 2011, American Psychiatric Association, 2013), and a validated measure, the Inventory of Complicated Grief (ICG; Prigerson et al., 1995), has been commonly used for case identification in research.

Bereaved parents may suffer more than those who have lost another relation (Zisook and Lyons, 1988, Cleiren, 1991, Gamino et al., 1998, Middleton et al., 1998), and bereaved parents may be among the most vulnerable group to develop CG (Kersting et al., 2011). Indeed, it is common for parents to experience what appear to be many of the core symptoms of complicated grief following the death of the child. For example, parents often struggle to accept the fact of the death (Wheeler, 2001) and those that lose their children to SIDS report being shocked and stunned at the loss (Cornwell et al., 1977). Anger and overwhelming sadness are not uncommon emotions, especially for parents who have lost children to accidents, suicides, or homicides (Dyregrov, 1990, Murphy et al., 1999). Lasting feelings of guilt and a search for meaning are common themes (Wheeler, 2001, Murphy et al., 2003), and appear to be more prevalent in bereaved parents than in those who have lost a different relation (Cleiren, 1991).These reactions, if they endure and converge to impair functioning, are precisely the symptoms of complicated grief (Prigerson et al., 2009, Shear et al., 2011).

Among those with CG, however, it is unclear whether the loss of a child is associated with unique characteristics or greater suffering than other loses. In particular, do parents with CG report greater hardships than others with CG? In this paper, we have attempted to answer these questions by comparing the clinical characteristics and associated features of bereaved parents with CG to those with CG who have lost a different relation, such as a spouse or sibling. We hypothesized that bereaved parents with CG would present with more severe CG, depression, and suicidal ideation when compared to others with CG. In addition, because of the unique caregiving role and expectations related to being a parent (Shear and Shair, 2005, Hendrickson, 2009), we also predicted that bereaved parents would endorse higher levels of guilt and self-blame than others.

Section snippets

Study design and sample

A cross-sectional design was used for this analysis. Data were obtained from 345 bereaved adults who participated in the “Healing Emotions After Loss” (HEAL) study, a 4-site clinical trial sponsored by the NIMH, investigating the efficacy of citalopram and Complicated Grief Therapy (CGT) for treating CG [ClinicalTrials.gov Identifier: NCT01179568]. This report utilizes baseline data from all individuals randomized from March 1st 2010 to January 16th 2014.

Consenting participants randomized into

Sample demographics and demographic differences between groups

This sample of HEAL study participants (N=345) tended to be white (83%), female (79%), and about half had completed college (52%). The most common type of loss was to an illness lasting longer than a month (43%), and on average this loss occurred more than four years before baseline (mean=4.74, SD=7.12). Further demographic information can be found in Table 1.

Compared to the bereaved other group (N= 275), the bereaved parent group (N=70) was older (59.2 vs. 51.4 years old, t(179.43)=5.47, p

Discussion

Bereaved parents in the HEAL study appear to have more severe CG than those who have suffered another loss, though this difference appears modest and does not lie in their experiencing more depression, as predicted. Rather, bereaved parents showed higher levels of yearning and preoccupation with the deceased, disbelief in the death, anger, caregiver self-blame, and suicidal thoughts and behaviors than others. Of particular clinical relevance is the finding that almost 80% of the parents who

Role of funding source

Funding for the HEAL study was provided by the National Institute of Mental Health (NIMH R01 MH085297), the American Foundation for Suicide Prevention, and the John Majda Foundation. They had no further role in this manuscript׳s study design, in the analysis and interpretation of data, in the writing of the report, or in the decision to submit the paper.

Conflict of interest

Authors declare that they have no conflict of interest.

Acknowledgments

The authors would like to thank the National Institute of Mental Health (Grant no. NIMH-5R01MH085297), the American Foundation for Suicide Prevention (Grant no. AFSP- LSRG-S-172-12), and the John Majda Foundation for their financial support of the HEAL study. In addition, the authors would like to thank Katherine Seay and Tera Thomas for their help with the submission process.

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