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Brief report
a r t i c l e
i n f o
Article history:
Received 27 December 2009
Accepted 3 June 2010
Available online 1 July 2010
Keywords:
Prevalence
Determinant
Complicated grief
General population
Epidemiology
Cancer
a b s t r a c t
Background: Few epidemiological studies have examined complicated grief in the general
population, especially in Asian countries. Therefore, this study aimed to explore the prevalence
and predictors of complicated grief among community dwelling individuals in Japan.
Methods: A questionnaire survey regarding grief and related issues was conducted on
community dwelling individuals aged 4079 who were randomly sampled from census tracts.
Complicated grief was assessed using the Brief Grief Questionnaire. Stepwise logistic regression
analysis was conducted in order to identify predictors of complicated grief.
Results: Data from 969 responses (response rate, 39.9%) were subjected to analysis. The analysis
revealed 22 (2.4%) respondents with complicated grief and 272 (22.7%) with subthreshold
complicated grief. Respondents who were found to be at a higher risk for developing complicated
grief had lost their spouse, lost a loved one unexpectedly, lost a loved one due to stroke or cardiac
disease, lost a loved one at a hospice, care facility or at home, or spent time with the deceased
everyday in the last week of life.
Limitations: Limitations of this study include the small sample size, the use of self-administered
questionnaire, and the fact that the diagnoses of complicated grief were not based on robust
diagnostic criteria.
Conclusions: The point prevalence of complicated grief within 10 years of bereavement was 2.4%.
Complicated grief was maintained without signicant decrease up to 10 years after bereavement.
When subthreshold complicated grief is included, the prevalence of complicated grief boosts up to
a quarter of the sample, therefore, routine screening for complicated grief among the bereaved is
desired. Clinicians should pay particular attention to the bereaved families with abovementioned
risk factors in order to identify people at risk for future development of complicated grief.
2010 Elsevier B.V. All rights reserved.
1. Background
Grief, or the emotional reaction to bereavement, is a normal,
natural human experience. Most people manage to come terms
with grief over time. Nevertheless, it is associated with a period
353
354
3. Results
Of 5000 questionnaires that were distributed, 44 were
returned as undeliverable and 1970 responses were received
(response rate: 39.9 ). Of these, 63 were excluded because of
signicant missing data. Among the remaining responses, 808
were excluded because the respondents had not experienced
bereavement within the past ten years, 117 were excluded
because of bereavement within the past six months, and 7
were excluded because they had experienced the loss of a
child. Finally, a total 969 of responses were subjected to
analysis. The demographic data of the sample is shown in
Table 1.
The results of the BGQ are presented in Table 2 according
to severity of grief and sociodemographic variables. Among
all participants, 22 respondents (2.4%) had scores of 8 or
higher on the BGQ, and were thus considered too complicated
grief, and 272 respondents (22.7%) scored between 5 and 7,
and were considered to be suffering from some symptoms of
complicated grief (subthreshold complicated grief). Using the
chi-square test, signicant differences in BGQ score were
observed for gender, relationship with the deceased, whether
Table 1
Demographic data of the participants.
Gender
Age
Primary caregiver
Time from bereavement
Cause of death
Place of death
Expected death
Days spent with the deceased
during the end-of-life period
Male
Female
4049
5059
6069
7079
Spouse
Parent(s)
Parent(s)-in-law
Sibling(s)
Others
Yes
No
612 months
12 years
23 years
34 years
45 years
56 years
67 years
78 years
89 years
910 years
Cancer
Stroke
Cardiac disease
Others
Home
General hospital
Hospice/PCU
Care facility
Others
Expected death
Unexpected death
Everyday
46 day/week
13 day/week
None
Missing data
405
564
225
354
379
11
61
468
247
96
97
462
507
112
138
138
120
88
85
102
62
49
75
357
99
108
405
181
654
34
62
38
546
423
207
92
216
335
119
41.8
58.2
23.2
36.5
39.1
1.1
6.3
48.3
25.5
9.9
10.0
47.7
52.3
11.6
14.2
14.2
12.4
9.1
8.8
10.5
6.4
5.1
7.7
36.8
10.2
11.1
41.8
18.7
67.5
3.5
6.4
3.9
56.3
44.6
21.4
9.5
22.3
34.6
12.3
355
Table 2
Prevalence and severity of complicated grief.
Total
Gender
Age
Primary caregiver
Time from bereavement
Cause of death
Place of death
Expected death
Days spent with the deceased during
the end-of-life period
Male
Female
4049
5059
6069
7079
Spouse
Parent(s)
Parent(s)-in-law
Sibling(s)
Others
Yes
No
612 months
12 years
23 years
34 years
45 years
56 years
67 years
78 years
89 years
910 years
Cancer
Stroke
Cardiac disease
Others
Home
General hospital
Hospice/PCU
Care facility
Others
Expected
Unexpected
Everyday
46 days/week
13 days/week
None
(%)
Complicated grief
(%)
207
79
128
44
77
82
4
29
108
30
24
16
128
77
30
39
26
23
14
13
22
9
12
19
94
18
30
64
35
142
11
9
10
116
75
63
31
41
56
22.7
20.6
24.2
20.5
23.0
23.3
40.0
50.0
24.5
12.9
27.6
16.8
29.7
16.1
28.3
28.9
19.8
20.5
16.5
16.7
23.4
15.8
25.5
28.4
28.2
19.6
28.6
16.8
20.6
23.0
35.5
15.3
29.4
21.6
25.1
31.0
34.4
19.1
17.1
22
4
18
6
7
8
1
5
11
2
3
1
13
9
2
3
2
1
5
2
1
3
0
3
9
5
3
5
2
16
1
0
3
8
11
10
3
1
5
2.4
1.0
3.4
2.8
2.1
2.3
10.0
8.6
2.5
0.9
3.4
1.1
3.0
1.9
1.9
2.2
1.5
0.9
5.9
2.6
1.1
5.3
0.0
4.5
2.7
5.4
2.9
1.3
1.2
2.6
3.2
0.0
8.8
1.5
3.7
4.9
3.3
0.5
1.5
p
0.02
0.48
b 0.001
b 0.001
0.19
b 0.01
0.04
0.05
b 0.001
356
Table 3
Binary logistic regression analysis of predictive variables for presence of complicated grief.
Gender
Relationship (vs. spouse)
Parents
Parents-in-law
Siblings
Others
Primary carer
Type_of_Illness (vs cancer)
Stroke
Cardiac
Others
Place_of_Death (vs. home)
General hospital
Hospice
Care facility
Others
Unexpected death
Days spent with the deceased during
end-of-life period (vs. everyday)
46 days/week
13 days/week
None
Beta
S.D.
Wald
d.f.
0.3
0.3
2.0
1.7
0.7
0.7
0.2
0.5
0.6
0.6
0.6
0.4
1.3
1.2
1.0
0.5
0.5
0.5
1.0
2.7
2.7
3.0
0.9
0.4
0.6
0.7
0.6
0.4
0.8
51.6
16.6
7.6
1.3
1
0.2
26.5
6.1
5.5
4.2
125.0
4.7
18.5
15.7
22.2
4.9
39.0
1
4
1
1
1
0.43
1
3
1
1
1
4
1
1
1
1
1
3
0.37
b0.001
b0.001
b0.01
0.25
1.72
0.68
b0.001
0.01
0.02
0.04
b0.001
b0.05
b0.001
b0.001
b0.001
0.03
b0.001
0.8
0.6
2.7
0.5
0.5
0.6
1
1
1
0.11
0.21
b0.001
2.5
1.5
21.1
Exp (B)
95%
C.I.
Lower
Upper
0.74
0.38
1.43
0.13
0.19
2.02
0.44
1.19
0.05
0.06
0.61
0.52
0.35
0.62
6.77
6.66
2.74
3.58
3.35
0.36
1.31
1.22
0.13
9.79
9.19
0.95
0.38
14.73
15.61
19.84
2.42
0.16
4.32
4.01
5.72
1.10
0.92
50.18
60.80
68.76
5.32
2.13
0.53
0.07
0.84
0.20
0.02
5.42
1.44
0.21
the referral to the palliative care unit was either too early or
too late (Morita et al., 2009). Furthermore, transferring a
loved one from a hospital to a hospice or a care facility caused
feelings of guilt among family members, because such an
action was perceived as a withdrawal from active participation in treatment and even as turning their back on their
loved one. Preferences for end-of-life care vary between
individuals, meaning that some prefer to spend their end-oflife period at home, while others prefer hospitals. It has been
reported that those who are of relatively older age, those who
prefer unawareness of death and pride and beauty in their
concept of good death are more likely to hope to die in a
general hospital than in a hospice (Sanjo et al., 2007).
Potential discordance between the preference of the bereaved and that of the deceased may have caused dissatisfaction and/or feelings of guilt concerning the place of death.
In Japanese clinical settings, the family's approval has the
strongest inuence on the nal decision (Sato et al., 2008).
Poor communication with the physician may have contributed to the negative feelings about transferring the patients
to hospice (Morita et al., 2004). Toward the end-of-life
period, the patient's family is expected to play a central role in
medical decision making, therefore, the family is faced with
increasing burden regarding end-of-life care, which may
contribute to the higher prevalence of subsequent grief
among those who used a hospice.
Respondents who spent time with the deceased everyday
during the end-of-life period were signicantly more likely to
experience complicated grief, compared with those who did
not spend time with the deceased during the same period. We
presume that the time spent together during this period is an
indicator of the quality of the bond between the respondent
and the deceased, meaning that those who had strong bond
with the deceased spent more time with the deceased during
the end-of-life period and were, therefore, more likely to
experience complicated grief. Another possible interpretation
is that those who spend every day with the deceased during
the last week of life experienced heavier caregiver burden,
which lead to an increased risk of subsequent complicated
grief (Rossi Ferrario et al., 2004; Schulz et al., 2001).
This study contains some limitations. First, the response rate
was low, although the rate was acceptable for a mail-based
survey conducted on the general population. Second, the
background variables of the non-respondents are unknown;
therefore, we cannot rule out that the demographic distribution
of the sample was skewed. However, the distributions of the
cause and place of death are quite similar to the national
statistics. For example, the proportion of deaths in Japan due to
cancer, stroke and cardiac disease are 30.0%, 15.9%, and 11.1%,
respectively, and place of death is 12.7% for home, 81.1% for
hospital, and 3.9% for care facility (Japan Ministry of Health and
Labor). Third, the reliability of the data was compromised
because the data solely depended on the participants' selfreports. Finally, the diagnostic reliability of complicated grief is
relatively weak as denite diagnostic criteria for complicated
grief have yet to been established, although more stringent
criteria are currently under consideration (Forstmeier and
Maercker, 2007; Prigerson et al., 2009).
Despite these limitations, our results are noteworthy
because this is the rst epidemiological study to investigate
the prevalence and risk factors of complicated grief in the
general population in Japan. In consideration of the fact that
complicated grief is highly inuenced by cultural background,
our report should be considered pioneering research on
complicated grief in Asia.
In conclusion, our population-based study revealed that
point prevalence of complicated grief within 10 years of
bereavement is 2.4%, which is comparable with other common
mental disorders. Complicated grief seems to be maintained for
a long time, without decrease even 10 years after bereavement.
The spouse of a patient, those who have lost a loved one
unexpectedly, due to stroke or cardiac disease, those who have
lost one in a hospice, care facility or at home, and those who
spent time with the deceased everyday in the last week of life
are at higher risk for complicated grief. Clinicians should pay
particular attention to these predictors in order to identify
people at risk for future development of complicated grief.
When subthreshold complicated grief is included, the prevalence of complicated grief boosts up to a quarter of the sample,
therefore, routine screening for complicated grief among the
bereaved is desired. Further study implication includes prevalence study using the more stringent criteria that have been
proposed for DSM-V and ICD-11 and assessing other psychiatric
morbidities.
Role of funding source
This study was fully supported by the Grant-in-Aid for Cancer Research
endowed to M.M from the Ministry of Health, Labor and Welfare, Japan
(MHLW); the MHLW had no further role in study design; in the collection,
analysis and interpretation of data; in the writing of the report; and in the
decision to submit the paper for publication.
Conict of Interest
All the authors declare no conicting interests.
357
Acknowledgements
The authors express gratitude to Rieko Kimura, R.N. for
coordinating the study.
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