peer reviewed journal articles on grief

Bereavement and reactions of grief among children and adolescents: Present data and perspectives

Affiliations.

• 1 Service universitaire de psychiatrie de l'enfant et de l'adolescent, CHU de Toulouse, TSA 40031, 31059 Toulouse cedex 9, France; UMR 1027, Inserm, Université Toulouse III, Toulouse, France. Electronic address: [email protected].
• 2 Psychiatry Department, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States.
• 3 Service universitaire de psychiatrie de l'enfant et de l'adolescent, CHU de Toulouse, TSA 40031, 31059 Toulouse cedex 9, France.
• 4 Centre de ressource douleur soins palliatifs pédiatriques, CHU de Toulouse, Toulouse, France.
• 5 Service universitaire de psychiatrie de l'enfant et de l'adolescent, CHU de Toulouse, TSA 40031, 31059 Toulouse cedex 9, France; UMR 1027, Inserm, Université Toulouse III, Toulouse, France.
• PMID: 32921494
• DOI: 10.1016/j.encep.2020.05.007

Losing a loved one is among the most common and stressful traumatic events that a child or and adolescent can experience and can be associated with mental health and somatic disorders, as well as a range of life issues and potentially negative outcomes that may impact longitudinal development. Complicated grief, a disorder that has been studied primarily among adults, has received increasing recognition among children and adolescents in recent years. The demonstration of the distinctive character of grief reactions in relation to major depressive disorder and posttraumatic stress disorder has resulted in the inclusion of "persistent complex bereavement disorder" in an annex section of DSM-5 and of "prolonged grief disorder" in ICD-11. The grieving process in children and adolescents is not linear and is often characterised by periods of regression. Developmental phases should be taken into account to understand and clinically describe grief reactions occurring during childhood and adolescence. There are currently numerous interventions for bereaved children and adolescents, but little evidence to support them. More research focusing on the understanding of the underlying mechanisms and the risk factors for complicated grief among children and adolescents, as well as the implementation of evidence-based interventions, is definitely warranted.

Keywords: Bereavement; Children and adolescents; Complicated grief; Deuil; Deuil compliqué; Enfants et adolescents; Facteurs de risque; Grief reactions; Risk factors; Réactions de deuil.

Copyright © 2020 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.

• Bereavement*
• Depressive Disorder, Major* / epidemiology
• Diagnostic and Statistical Manual of Mental Disorders
• International Classification of Diseases

• Article Information

Top, The curves represent grief indicators as functions of time based on nonlinear regression models estimated from the data (N = 233). The data markers along the x-axis are determined by the mean value of time from loss for the individuals included in the 10 groups of observations (n = 23 observations per group for 9 groups; n = 26 observations for 1 group). The corresponding error bars indicate SDs. These 10 groups of observations were formed by ordering all of the observations used in the regression analyses (N = 233) by increasing time postloss (observations that occurred at the same time postloss were randomly assigned a position in the ordered sequence of observations for that time), and then assigning the first 23 observations on this ordered list to the first group, the next 23 observations to the second group, etc. The regression curves are based on the analysis of individual data points (N = 233) for which time from loss varies from 1.5 to 23 months. Bottom, The curves represent grief indicators as functions of time based on nonlinear regression models after the following rescaling procedure: ψ( t ) = [ Y ( t ) − Y min ]/ Y max − Y min ], where Y ( t ) is the model value for the grief indicator at time t , and Y min and Y max are the minimum and maximum model values of the grief indicator, respectively, between 1 and 24 months postloss. The 5 grief indicators achieve their respective maximum values in the exact sequence (disbelief, yearning, anger, depression, and acceptance) predicted by the hypothesized theory of grief presented in Figure 1 .

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Maciejewski PK , Zhang B , Block SD , Prigerson HG. An Empirical Examination of the Stage Theory of Grief. JAMA. 2007;297(7):716–723. doi:10.1001/jama.297.7.716

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An Empirical Examination of the Stage Theory of Grief

Author Affiliations: Department of Psychiatry, Women's Health Research, and Magnetic Resonance Research Center, Yale University School of Medicine, New Haven, Conn (Dr Maciejewski); Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Mass (Ms Zhang and Drs Block and Prigerson); and Department of Psychiatry, Brigham and Women's Hospital, and Harvard Medical School Center for Palliative Care, Boston, Mass (Drs Block and Prigerson).

Context  The stage theory of grief remains a widely accepted model of bereavement adjustment still taught in medical schools, espoused by physicians, and applied in diverse contexts. Nevertheless, the stage theory of grief has previously not been tested empirically.

Objective  To examine the relative magnitudes and patterns of change over time postloss of 5 grief indicators for consistency with the stage theory of grief.

Design, Setting, and Participants  Longitudinal cohort study (Yale Bereavement Study) of 233 bereaved individuals living in Connecticut, with data collected between January 2000 and January 2003.

Main Outcome Measures  Five rater-administered items assessing disbelief, yearning, anger, depression, and acceptance of the death from 1 to 24 months postloss.

Results  Counter to stage theory, disbelief was not the initial, dominant grief indicator. Acceptance was the most frequently endorsed item and yearning was the dominant negative grief indicator from 1 to 24 months postloss. In models that take into account the rise and fall of psychological responses, once rescaled, disbelief decreased from an initial high at 1 month postloss, yearning peaked at 4 months postloss, anger peaked at 5 months postloss, and depression peaked at 6 months postloss. Acceptance increased throughout the study observation period. The 5 grief indicators achieved their respective maximum values in the sequence (disbelief, yearning, anger, depression, and acceptance) predicted by the stage theory of grief.

Conclusions  Identification of the normal stages of grief following a death from natural causes enhances understanding of how the average person cognitively and emotionally processes the loss of a family member. Given that the negative grief indicators all peak within approximately 6 months postloss, those who score high on these indicators beyond 6 months postloss might benefit from further evaluation.

The notion that a natural psychological response to loss involves an orderly progression through distinct stages of bereavement has been widely accepted by clinicians and the general public. Bowlby and Parkes 1 - 4 were the first to propose a stage theory of grief for adjustment to bereavement that included 4 stages: shock-numbness, yearning-searching, disorganization-despair, and reorganization. Kübler-Ross 5 adapted Bowlby and Parkes' theory to describe a 5-stage response of terminally ill patients to awareness of their impending death: denial-dissociation-isolation, anger, bargaining, depression, and acceptance. The stage theory of grief became well-known and accepted, and has been generalized to a wide variety of losses, including children's reactions to parental separation, 3 adults' reactions to marital separation, 6 and clinical staffs' reactions to the death of an inpatient. 7 A 1997 survey conducted by Downe-Wamboldt and Tamlyn 8 documented the heavy reliance of medical education on the Kübler-Ross model of grief. The National Cancer Institute currently maintains a Web site on loss, grief, and bereavement that describes the phases of grief. 9 As entrenched as the notion of phases of grief may be, the hypothesized sequence of grief reactions has previously not been investigated empirically.

Several bereavement scholars have investigated particular aspects of, or diagrammed changes in, grief reactions over time. 10 - 14 Bonanno et al 10 found 5 divergent grieving trajectories from preloss to 18 months postloss (common grief, chronic grief, chronic depression, improvement during bereavement, and resilience). Wortman and Silver 13 examined and disproved the necessity of 1 stage in the grief theory when they found that depression was not an inevitable response to loss. Based on Bowbly and Parkes’ 1 - 4 and Kübler-Ross’ 5 theories, Jacobs 14 synthesized and illustrated the hypothesized stage theory of grief, in which the normal response to loss progresses through the following grief stages: numbness-disbelief, separation distress (yearning-anger-anxiety), depression-mourning, and recovery. To date, no study has explicitly tested whether the normal course of adjustment to a natural death progresses through stages of disbelief, yearning, anger, depression, and acceptance.

The identification of the patterns of typical grief symptom trajectories is of clinical interest because it enhances the understanding of how individuals cognitively and emotionally process the death of someone close. Such knowledge aids in the determination of whether a specific pattern of bereavement adjustment is normal or not. Once the normal patterns of grief are known, individuals with abnormal bereavement adjustment can be identified and referred for treatment when indicated.

This study used data from a sample of community-based bereaved individuals to examine the course of disbelief, yearning, anger, depression, and acceptance as described by Jacobs 14 from 1 to 24 months postloss. Figure 1 illustrates the hypothesized sequence of stages of grief for this analysis. Because approximately 94% of US deaths result from natural causes (eg, vehicle crashes, suicide), 15 deaths from unnatural causes (eg, car crashes, suicide) were excluded thereby enabling the results to be generalized to the most common types of deaths. Individuals who met the criteria for complicated grief disorder 16 , 17 also were excluded so that the results would represent normal bereavement reactions. Although the proposed stage theory of grief 1 - 5 , 14 does not specify the precise timing of the stages, Jacobs 14 described the normal grieving process and each of its stages as being completed within 6 months following the loss of a loved one. However, in the absence of an established, empirical foundation for the length of time associated with the normal grieving process, the normal grieving process was not assumed to be limited to 6 months postloss in this study. Instead, the grief indicators were examined as functions of time up to 24 months postloss.

The Yale Bereavement Study, a longitudinal examination of grief in a community-based sample of bereaved individuals, collected data between January 2000 and January 2003, and was funded by the National Institute of Mental Health. For greater Bridgeport / Fairfield, Conn, the names of the newly bereaved (≤6 months) were obtained from the division of the American Association of Retired Persons Widowed Persons Service, a community-based outreach program. For the New Haven, Conn, metropolitan and surrounding areas, names were obtained from obituaries listed in the New Haven Register , through newspaper advertisements, fliers, personal referrals, and referrals from the chaplain's office of the St Raphael Hospital. A comparison between greater Bridgeport / Fairfield Bureau of Vital Records death certificates and the Widowed Persons Service list during the same 3-month period revealed that the Widowed Persons Service listings captured 95% of all deaths leaving behind a widowed individual, suggesting that the listing provided an unbiased and comprehensive ascertainment of recently widowed individuals in the sampled region. Participants recruited from greater New Haven (37.0%) did not differ significantly from participants recruited from greater Bridgeport / Fairfield (63.0%) with respect to sex, income, education, race / ethnicity, or quality of life. Participants recruited from greater New Haven were significantly younger (mean [SD] age, 59.7 [16.4] years) than participants from Bridgeport / Fairfield (mean [SD], 63.2 [11.5] years) ( P  = .05). The institutional review boards of all participating sites approved the research protocol.

Individuals were invited to participate in the study via a letter that described how their names were obtained, identified the investigators, outlined the aims and procedures, and noted that they would be contacted by study staff in the following week unless they informed us of their wish not to be contacted. Of the 575 persons contacted, 317 (55.1%) agreed to participate. Reasons for nonparticipation included reluctance to participate in research (n = 11; 4.3%); being too busy (n = 46; 17.8%); being too upset (n = 27; 10.5%); “doing fine” (n = 23; 8.9%); not being interested or having no reason (n = 145; 56.2%); and having other reasons (n = 6; 2.3%). Compared with participants, nonparticipants were significantly more likely to be male (25.9% vs 37.2%; P <.001) and older (mean [SD] age, 61.7 [13.1] years vs 68.8 [13.7] years) ( P <.001). Non–English-speaking persons and those considered too frail to complete the interview were ineligible. The 317 participants were interviewed at a mean (SD) of 6.3 (7.0) months after the death of a loved one. The first follow-up interview (n = 296; 93.4%) was completed at a mean (SD) of 10.9 (6.1) months postloss; second follow-up interview (n = 263; 83.0%) at a mean (SD) of 19.7 (5.8) months postloss. Written informed consent was obtained from all individuals enrolled in the study.

Of the 317 individuals identified, 58 were excluded because they met criteria for complicated grief disorder, 19 because they survived traumatic deaths, and 14 because they had missing data on examined measures. The study sample (N = 233) consisted of individuals who did not meet criteria for complicated grief disorder 16 , 17 during the study; had a family member or loved one who died from natural not traumatic causes; and had at least 1 complete assessment of the 5 grief indicators included in the stage theory of grief within 24 months postloss. The participants were significantly older (mean [SD] age, 62.9 [13.1] years; 53.5% aged ≥65 years) and more likely to be white (97.0%) than the excluded individuals (mean [SD] age, 58.5 [15.0] years; 90.4% white) but did not significantly differ with respect to sex, income, education, and relationship to the deceased. The vast majority of participants were spouses of the deceased (83.8%). The remaining participants (16.2%) were adult children, parents, or siblings of the deceased.

The data from the participants were compared with data from the 2005 US Census ( Table 1 ). 18 Compared with the US widowed population, the study participants were younger, more likely to be male, and a higher proportion were white. Compared with the US general population aged 25 years or older, the study participants were better educated and had a higher median household income.

The indicators of disbelief, yearning, anger, and acceptance of the death were assessed using single items obtained from the rater-administered version of the Inventory of Complicated Grief-Revised, formerly known as the Traumatic Grief Response to Loss. 19 Although it would have been preferable to use separate scales for the assessment of yearning, disbelief, anger, and acceptance of the death, no such scales exist for each of these grief stages. To maximize consistency across measures, single items were used for all grief phase indicators. Single-item interview screenings have proven remarkably accurate in the prediction of depression. 20 The frequency, rather than severity, of each grief indicator was used as the response format in the Inventory of Complicated Grief-Revised because frequency has proven to be a more effective means of evaluating the impact of events. 21 Grief phase indicators were measured using a 5-point Likert scale in which 1 equaled less than once per month; 2, monthly; 3, weekly; 4, daily; and 5, several times per day. These items showed moderately high correlations with the total Inventory of Complicated Grief-Revised score at baseline interview, which ranged in magnitude from 0.47 to 0.57 (all comparisons yielded P <.001). To enhance comparability in the measurement of each indicator, depression was assessed using the single-item depressed mood in the Hamilton Rating Scale for Depression. 22 The correlation between depressed mood and the total Hamilton Rating Scale for Depression score at baseline interview was 0.65 ( P <.001). To be consistent with the scale levels of other grief indicators, all levels of depressed mood were increased by 1 so that 1 indicated “absence of depressed mood” and 5 indicated “patient reports virtually only these feeling states in his spontaneous verbal and non-verbal communication.”

Individuals self-identified their racial/ethnic status according to the racial/ethnic categories defined in the US Census. 18 They also reported the cause of death for the family member or loved one. For deaths due to a terminal illness, the date of the diagnosis was recorded. Diagnoses of the terminal illness within 6 months (52/199; 26.1%) were compared with those 6 months or longer (147/199; 73.9%) prior to the death. Six months was used as the threshold because terminal diagnoses of less than 6 months resulted in smaller, less reliable groupings and elsewhere 16 , 17 it has been determined that 6 months is the time after which normal grief can be distinguished from complicated grief disorder.

Statistical analyses were conducted to test for significant differences in the magnitude of each of the 5 grief indicators within each of the 3 postloss periods (≤6 months [1-6 months category], >6 to ≤12 months [6-12 months category], and >12 to ≤24 months [12-24 months category]); to compare the pattern of changes in the absolute levels of each of the 5 grief indicators over time; and to determine when each of the 5 grief indicators achieved its maximum value.

Specifically, single-sample t tests and nonlinear, ordinary least squares regression analyses were used to examine the differences in magnitude between grief indicators at a given time postloss and changes in grief indicators as a function of time postloss. Single-sample t tests were used to examine within-person differences in magnitude between the 5 grief indicators postloss at 1 to 6 months, 6 to 12 months, and 12 to 24 months and within-person temporal changes in magnitude of each grief indicator postloss between 1 to 6 months and 6 to 12 months and between 6 to 12 months and 12 to 24 months.

Nonlinear, ordinary least squares regression analyses were used to model the trajectory of each grief indicator as a function of time postloss. Because the stage theory of grief predicts the sequential rise and fall of each of the grief indicators as a function of time postloss (ie, phase), we chose the following parametric functional form that would capture such phases:

Y  = [ A + B (− t / τ + 1)] exp (−½ t / τ ) + C

where Y represents the value of the grief indicator and the term t / τ represents time postloss with t scaled by the model parameter τ . The expression [ A + B (− t / τ + 1)] exp (−½ t / τ ) represents a linear combination of normalized (weighted) zero-order and first-order Laguarre polynomials, scaled by the model parameters A and B , respectively, included to capture the anticipated rise and fall in the data. Model parameter C represents the asymptotic value that the grief indicator approaches as time postloss increases to infinity. One observation per person (N = 233), selected randomly among those observations that contained complete data for each of the 5 grief indicators within 24 months postloss, was used to fit these regression models. For each grief indicator, the model parameters τ , A , B , and C were estimated by means of nonlinear, ordinary least squares regression implemented using PROC MODEL in SAS version 9.1 (SAS Institute Inc, Cary, NC). P  < .05 was considered significant.

A series of multivariable analyses of variance were conducted to evaluate whether demographic variables and report of diagnosis of terminal illness within 6 months of the death were significantly related to the 5 grief indicators or to the within-person differences between or temporal changes in the 5 grief indictors.

The means and SDs for the 5 grief indicators of disbelief, yearning, anger, depression, and acceptance postloss at 1 to 6 months, 6 to 12 months, and 12 to 24 months appear in Table 2 . Within each period, acceptance is greater than disbelief, yearning, anger, and depression; yearning is greater than disbelief, anger, and depression; and depression is greater than anger. Between 1 and 6 months postloss and 6 and 12 months postloss, disbelief and yearning decline and acceptance increases. From 6 to 12 months postloss and 12 to 24 months postloss, disbelief, yearning, anger, and depression decline and acceptance increases.

More specifically, acceptance is significantly greater than disbelief (1-6 months postloss: t 142  = 10.79, P <.001; 6-12 months postloss: t 208  = 23.16, P <.001; 12-24 months postloss: t 204  = 31.88, P <.001), yearning (1-6 months postloss: t 142  = 2.11, P  = .04; 6-12 months postloss: t 208  = 10.80, P <.001; 12-24 months postloss: t 204  = 19.39, P <.001), anger (1-6 months postloss: t 142  = 12.66, P <.001; 6-12 months post-loss: t 208  = 23.14, P <.001; 12-24 months postloss: t 204  = 35.24, P <.001), and depression (1-6 months postloss: t 142  = 11.64, P <.001; 6-12 months postloss: t 208  = 18.84, P <.001; 12-24 months postloss: t 204  = 29.97, P <.001).

Yearning is significantly greater than disbelief (1-6 months postloss: t 169  = 13.57, P <.001; 6-12 months postloss: t 210  = 15.57, P <.001; 12-24 months postloss: t 204  = 12.49, P <.001), anger (1-6 months postloss: t 170  = 16.43, P <.001; 6-12 months postloss: t 209  = 15.10, P <.001; 12-24 months postloss: t 204  = 12.43, P <.001), and depression (1-6 months postloss: t 170  = 14.40, P <.001; 6-12 months postloss: t 211  = 9.75, P <.001; 12-24 months postloss: t 204  = 9.41, P <.001).

Depression is significantly greater than anger (1-6 months postloss: t 173  = 3.61, P <.001; 6-12 months postloss: t 209  = 5.32, P <.001; 12-24 months postloss: t 204  = 3.16, P  = .002).

Disbelief is significantly greater than anger at 1 to 6 months postloss ( t 172  = 3.22, P  = .002); depression is significantly greater than disbelief at 6 to 12 months postloss ( t 210  = 5.22, P <.001) and at 12 to 24 months postloss ( t 204  = 2.19, P  = .03).

Between 1 and 6 months postloss and 6 and 12 months postloss, disbelief ( t 157  = 4.78, P <.001) and yearning ( t 156  = 7.89, P <.001) decline and acceptance increases ( t 130  = 3.91, P <.001). Between 6 and 12 months postloss and 12 and 24 months postloss, disbelief ( t 190  = 2.84, P  = .005), yearning ( t 191  = 5.96, P <.001), anger ( t 189  = 3.91, P <.001), and depression ( t 192  = 5.60, P <.001) decline and acceptance increases ( t 188  = 3.37, P <.001).

Figure 2 displays the results of the nonlinear regression analyses. According to the models displayed in the top part of Figure 2 , acceptance increases monotonically (uniformly in 1 direction), and is greater than each of the other grief indicators between 1 and 24 months postloss. Yearning increases between 1 and 4 months postloss, decreases between 4 and 24 months postloss, and is greater than disbelief, anger, and depression between 1 and 24 months postloss. Disbelief decreases monotonically between 1 and 24 months, is greater than anger between 1 and 6 months postloss, and is greater than depression between 1 and 4 months postloss. Depression increases between 1 and 6 months postloss, decreases between 6 and 24 months, is greater than disbelief postloss between 4 and 24 months, and is greater than anger between 1 and 24 months postloss. Anger increases between 1 and 5 months postloss and decreases between 5 and 24 months postloss. The close agreement between the models and the data in the top part of Figure 2 indicates that the phasic functional form specified in the regression models adequately represent the data.

The bottom part of Figure 2 displays the regression models following a rescaling procedure that constrains each grief indicator to fall within the interval of 0 through 1. In the top part of Figure 2 , the relative locations in time of the peaks of the grief indicators are obscured because the curves are not side by side, thereby making comparisons difficult. Those comparisons are facilitated in the bottom part of Figure 2 by placing all of the indicators on the same scale. The 5 grief indicators achieved their respective maximum values in the sequence (disbelief, yearning, anger, depression, and acceptance) predicted by the stage theory of grief. Given that there are 120 possible sequences of these 5 indicators, the probability that the observed sequence is exactly the sequence predicted by the stage theory of grief by chance alone is P  = .008.

Based on the results of the multivariable analyses of variance, the demographic factors of age, sex, race/ethnicity (white/nonwhite), education, and income and a terminal illness diagnosis reported within 6 months of the death were largely unrelated to within-person differences and temporal changes in the grief indictors throughout the study observation period (1-6, 6-12, and 12-24 months postloss). Education beyond high school was significantly associated with grief indicators 12 to 24 months postloss (Wilks λ = 0.94, F 5,199  = 2.52; P  = .03), due to its significant associations with lesser disbelief ( P  = .05) and depression ( P  = .003), and with greater acceptance ( P  = .02) during that period. Education beyond high school was also significantly associated with within-person differences in grief indicators 6 to 12 months postloss (Wilks λ = 0.95, F 4,204  = 2.51; P  = .04) and 12 to 24 months postloss (Wilks λ = 0.94, F 4,200  = 3.11; P  = .02) due to its significant associations with greater differences between acceptance and each of the other grief indicators during each of those periods. Widowhood (compared with loss of a parent, child, or sibling in this study group) was significantly associated with within-person differences in grief indicators 1 to 6 months postloss (Wilks λ = 0.93, F 4,135  = 2.51; P  = .05), due to its significant associations with a greater difference between yearning and depression ( P  = .02) and a lesser difference between acceptance and yearning ( P  = .01) during that period. Report of a terminal illness diagnosis within 6 months of the death was significantly associated with grief indicators 12 to 24 months postloss (Wilks λ = 0.93, F 5,172  = 2.62; P  = .03), due to its significant association with lower acceptance of the death ( P  = .008) during that period.

Results of this study identify normal patterns of grief processing over time following the natural death of a loved one. Given that the vast majority (94%) of deaths in the United States are the result of natural causes, 15 the findings reflect how the average person psychologically processes a typical death of a close family member. Although the temporal course of the absolute levels of the 5 grief indicators did not follow that proposed by the stage theory of grief, 14 when rescaled and examined for each indicator's peak, the data fit the hypothesized sequence exactly.

In terms of absolute frequency, and counter to the stage theory, disbelief was not the initial, dominant grief indicator. Acceptance was the most often endorsed item. Evidently, a high degree of acceptance, even in the initial month postloss, is the norm in the case of natural deaths. This contrasts with individuals who survived a family member's traumatic death and those who met criteria for complicated grief disorder, 16 both groups of whom were found in preliminary analyses to have significantly lower levels of acceptance relative to the study sample. The lower frequency of acceptance of the death among participants who reported that the patient's terminal illness diagnosis was within 6 months compared with 6 months or longer prior to the death suggests that prognostic awareness may promote acceptance of the death. This result is consistent with findings reported elsewhere indicating that preparation for the death is associated with better psychological adjustment to the loss. 23 Future research that examines the effects of prospective rather than retrospective reports of prognostic awareness on the bereaved survivor's acceptance are needed before definitive conclusions can be drawn.

Yearning was the most frequent negative psychological response reported throughout the study observation period (1-6, 6-12, and 12-24 months postloss). Yearning was significantly more common than depressed mood despite the exclusive focus in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition 24 bereavement section on depressive symptomatology: “As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sadness . . . The bereaved individual typically regards the depressed mood as ‘normal,’ . . . The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss.” 24 (p684) Findings from this report demonstrate that yearning, not depressive mood, is the salient psychological response to natural death. They indicate that depressive mood in normally bereaved individuals tends to peak at approximately 6 months postloss and does not occur prior to 2 months postloss. Findings elsewhere 25 , 26 indicate that chronically elevated levels of yearning are a cause for clinical concern. Taken together, these results imply a need for revision of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition with respect to bereavement.

Models that tested for phasic episodes of each grief indicator revealed that disbelief about the death is highest initially. As disbelief declined from the first month postloss, yearning rose until 4 months postloss and then declined. Anger over the death was fully expressed at 5 months postloss. After anger declines, severity of depressive mood peaks at approximately 6 months postloss and thereafter diminishes in intensity through 24 months postloss. Acceptance increased steadily through the study observation period ending at 24 months postloss. Because of the minuscule probability that by chance alone these 5 grief indicators would achieve their respective maximum values in the precise hypothesized sequence, 14 these results provide at least partial support for the stage theory of grief.

The results also offer a point of reference for distinguishing between normal and abnormal reactions to loss. Given that the negative grief indicators all peak within 6 months, those individuals who experience any of the indicators beyond 6 months postloss would appear to deviate from the normal response to loss. These findings also support the duration criterion of 6 months postloss for diagnosing complicated grief disorder, 16 , 17 , 19 , 25 or what is now referred to as prolonged grief disorder. 26 Unlike the term complicated , which is defined as “difficult to analyze, understand, explain,” 27 prolonged grief disorder accurately describes a bereavement-specific mental disorder based on symptoms of grief that persist longer than is normally the case (ie, >6 months postloss based on the results of the present study). Furthermore, prolonged grief disorder permits the recognition of other psychiatric complications of bereavement, such as major depressive disorder and posttraumatic stress disorder. Additional analyses are needed to examine grief trajectories among those meeting criteria for prolonged grief disorder.

The mode of death may be an important factor that influences the course of bereavement adjustment. In the present study, individuals bereaved by traumatic deaths (eg, vehicle crashes, suicide) were removed. Bereavement adjustment following deaths from traumatic causes may be more difficult to process and demonstrate higher degrees of disbelief and anger and lower levels of acceptance than those reported herein. A recent study found that those bereaved by traumatic vs natural deaths had greater difficulty in making sense of the loss. 28 Participants who reported that the family member or loved one's terminal illness was diagnosed within 6 months of the death did not differ significantly from other participants with respect to their level of grief indicators. However, the participants who reported the diagnosis within 6 months of the death did report acceptance of the death significantly less often. Subanalyses revealed that disbelief within 6 months postloss was also significantly higher in those for whom the patient's terminal illness diagnosis was reported to be within 6 months prior to death. Thus, the manner and forewarning of the death appear to affect the processing of grief. Studies are needed to explore the pattern of grief trajectories among the survivors bereaved by traumatic causes of death.

The results should be understood in light of several study limitations. Ideally, all individuals would have been assessed immediately after the loss rather than beginning at month 1 postloss. Due to respect for the initial mourning period and institutional review board concerns about harm to participants, we did not interview individuals within a month of the death. In addition, it would have been better to analyze data that reassessed individuals each month from 0 to 24 months postloss. However, no such data exist nor does the stage theory 1 - 5 specify in what month postloss each stage would predominate. And, although we acknowledge that other grief indicators might have been used, the various proxy measures (eg, stunned for disbelief, bitterness for anger, hopelessness for depression, quality of life scores for acceptance/recovery) all revealed remarkably similar patterns to those presented herein. We chose to present the items that fit most closely with the stage indicators illustrated in the literature. 14

It should be noted that participants were younger and less likely to be male compared with the study nonparticipants, and that the study sample may be more resilient than is typically the case given the low prevalence of depression (8.9% of the individuals had a Hamilton Rating Scale for Depression summary score of ≥17) compared with other samples of bereaved individuals. 29 - 31 Samples with more males or with older and more distressed individuals might reveal a different pattern of grief trajectories than those presented herein. Although the study sample does show some gross similarities with the US widowed population in terms of age, sex, and race / ethnicity, and with other comparable groups in terms of education and median household income, it is not directly representative of either the US widowed or US general population. Nevertheless, age, income, race / ethnicity, and sex were not significantly associated with the magnitude or course of grief and the representativeness of the Yale Bereavement Study would not appear to restrict the generalizability of the results to the US widowed population. Despite these limitations, given that the Yale Bereavement Study provides one of the most comprehensive longitudinal assessments of grief, these data are as adequate as any available for testing the stages of grief over time.

In conclusion, the results of this study provide what appears to be the first empirical examination of the stage theory of grief. They indicate that in the circumstance of natural death, the normal response involves primarily acceptance and yearning for the deceased. Each grief indicator appears to peak in the sequence proposed by the stage theory. Regardless of how the data are analyzed, all of the negative grief indicators are in decline by approximately 6 months postloss. The persistence of these negative emotions beyond 6 months is therefore likely to reflect a more difficult than average adjustment and suggests the need for further evaluation of the bereaved survivor and potential referral for treatment. The results provide an evidence base from which to educate clinicians (eg, primary and palliative care physicians, geriatricians, psychiatrists, oncologists, related hospital and hospice staff, bereavement counselors) and laypersons (eg, patients, family members, friends) about what to expect following the death of a family member or loved one.

Corresponding Author: Holly G. Prigerson, PhD, Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, 44 Binney St SW, G440A, Boston, MA 02115 ( [email protected] ).

Author Contributions: Drs Maciejewski and Prigerson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design : Maciejewski, Prigerson.

Acquisition of data : Prigerson.

Analysis and interpretation of data : Maciejewski, Zhang, Block, Prigerson.

Drafting of the manuscript : Maciejewski, Zhang, Prigerson.

Critical revision of the manuscript for important intellectual content : Maciejewski, Zhang, Block, Prigerson.

Statistical analysis : Maciejewski, Zhang.

Obtained funding : Maciejewski, Prigerson.

Administrative, technical, or material support : Zhang, Prigerson.

Study supervision : Maciejewski, Block, Prigerson.

Financial Disclosures: None reported.

Funding/Support: This work was supported by grants MH56529 (awarded to Dr Prigerson) and MH63892 (awarded to Dr Prigerson) from the National Institute of Mental Health and grant CA106370 (awarded to Dr Prigerson) from the National Cancer Institute; and grant NS044316 (awarded to Dr Maciejewski) from the National Institute of Neurological Disorders and Stroke. Funding also was provided by the Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, and Women's Health Research at Yale University.

Role of the Sponsors: The National Institute of Mental Health, National Cancer Institute, National Institute of Neurological Disorders and Stroke, Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, and Women's Health Research at Yale University had no direct input into the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

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• v.316(7134); 1998 Mar 14

Coping with loss

Bereavement in adult life.

Doctors are well acquainted with loss and grief. Of 200 consultations with general practitioners, a third were thought to be psychological in origin; of these, 55—a quarter of consultations overall—were identified as resulting from types of loss. 1 In order of frequency the types of loss included separations from loved others, incapacitation, bereavement, migration, relocation, job losses, birth of a baby, retirement, and professional loss.

After a major loss, such as the death of a spouse or child, up to a third of the people most directly affected will suffer detrimental effects on their physical or mental health, or both. 2 Such bereavements increase the risk of death from heart disease and suicide as well as causing or contributing to a variety of psychosomatic and psychiatric disorders. About a quarter of widows and widowers will experience clinical depression and anxiety during the first year of bereavement; the risk drops to about 17% by the end of the first year and continues to decline thereafter. 2 Clegg found that 31% of 71 patients admitted to a psychiatric unit for the elderly had recently been bereaved. 3

Despite this there is also evidence that losses can foster maturity and personal growth. Losses are not necessarily harmful.

Yet the consequences of loss are so far reaching that the topic should occupy a large place in the training of health care providers—but this is not the case. One explanation for this omission is the assumption that loss is irreversible and untreatable: there is nothing we can do about it, and the best way of dealing with it is to ignore it. This attitude may help us to live with the fact that, despite modern science, 100% of our patients still die and that before they die many will suffer lasting losses in their lives. Sadly, it means that, just when they need us most, our patients and their grieving relatives find that we back away.

Summary points

• Losses are a common cause of illness; they often go unrecognised
• Conflicting urges lead to a variety of expressions of grief; even so there is a pattern to the process of grieving
• A knowledge of the factors that predict problems in bereavement enables these to be anticipated and prevented
• Grief may be avoided or it may be exaggerated and prolonged
• Doctors can help to prepare people for the losses that are to come
• People may need permission and encouragement to grieve and to stop grieving

Recent approaches to loss

A 1944 study of bereaved survivors of a night club fire focused attention on the psychology of bereavement, and led to the development of services for the bereaved and to other types of crisis intervention services. 4 It established grief as a distinct syndrome with recognisable symptoms and course, amenable to positive or negative influences. This, in turn, fuelled interest in the new fields of preventive psychiatry and community mental health. Elizabeth Kubler Ross’s studies extended this understanding to dying people, 5 and helped to provide a conceptual framework for the humanitarian work of Dame Cicely Saunders and the other pioneers of the hospice movement.

More recently the improvements in palliative care have led to improvements in home care for the dying. Home care nurses have bridged the gap and general practitioners have had a central role, not only in caring for dying patients and their families but also in supporting people through many other losses. This is the main theme of this series, which draws together authorities with special knowledge of the losses which afflict our patients and their families and looks at the practical implications for doctors.

The components of grief

Three main components affect the process of grieving. They include the urge to look back, cry, and search for what is lost, and the conflicting urge to look forward, explore the world that now emerges, and discover what can be carried forward from the past. Overlying these are the social and cultural pressures that influence how the urges are expressed or inhibited. The strength of these urges varies greatly and changes over time, giving rise to constantly changing reactions.

Most adults do not wander the streets crying aloud for a dead person. Bereaved people often try to avoid reminders of the loss and to suppress the expression of grief. What emerges is a compromise, a partial expression of feelings that are experienced as arising compellingly and illogically from within.

Much empirical evidence supports the claims of the psychoanalytic school that excessive repression of grief is harmful and can give rise to delayed and distorted grief—but there is also evidence that obsessive grieving, to the exclusion of all else, can lead to chronic grief and depression. The ideal is to achieve a balance between avoidance and confrontation which enables the person gradually to come to terms with the loss. Until people have gone through the painful process of searching they cannot “let go” of their attachment to the lost person and move on to review and revise their basic assumptions about the world. This process, which has been termed psychosocial transition, is similar to the relearning that takes place when a person becomes disabled or loses a body part.

The course of grief

• Disorganisation and despair
• Reorganisation

The normal course of grief

Human beings can anticipate their own death and the deaths of others. Unlike the grief that follows loss, anticipatory grief increases the intensity of the tie to the person whose life is threatened and evokes a strong tendency to stay close to them.

Although the moment of death is usually a time of great distress, this is usually quickly repressed and, in Western society, the impact is soon followed by a period of numbness which lasts for hours or days. This is sometimes referred to as the first phase of grieving. 6 It is soon followed by the second phase, intense feelings of pining for the lost person accompanied by intense anxiety. These “pangs of grief” are transient episodes of separation distress between which the bereaved person continues to engage in the normal functions of eating, sleeping, and carrying out essential responsibilities in an apathetic and anxious way.

All appetites are diminished, weight is lost, concentration and short term memory are diminished, and the bereaved person often becomes irritable and depressed. This eventually gives place to the third phase of grieving, disorganisation and despair. Many find themselves going over the events which led up to the loss again and again as if, even now, they could find out what went wrong and put it right. The memory of the dead person is never far away and about a half of widows report hypnagogic hallucinations in which, at times of drowsiness or relaxation, they see or hear the dead person near at hand. These hallucinations are distinguished from the hallucinations of psychosis by the circumstances in which they arise and by their transience—they disappear as soon as the bereaved arouse themselves. A sense of the dead person near at hand is also common and may persist.

As time passes the intensity and frequency of the pangs of grief tend to diminish, although they often return with renewed intensity at anniversaries and other occasions which bring the dead person strongly to mind. Consequently the phases of grief should not be regarded as a rigid sequence that is passed through only once. The bereaved person must pass back and forth between pining and despair many times before coming to the final phase of reorganisation.

After a major loss such as the death of a loved spouse or partner, the appetite for food is often the first appetite to return. By the third or fourth month of bereavement the weight that was lost initially has usually returned, and by the sixth month many people have put on too much weight. It may be many more months before people begin to care about their appearance, and for sexual and social appetites to return. Most people will recognise that they are recovering at some time in the course of the second year.

Assessing the risk

Much research, in recent years, has enabled us to identify people at special risk after bereavement either because the circumstances of the bereavement are unusually traumatic or because they are themselves already vulnerable (box). These risk factors can give rise to complicated forms of grief that can culminate in mental illness. A clear understanding of these factors will often enable us to prevent psychiatric disorder in bereaved patients.

Factors increasing risk after bereavement

Traumatic circumstances  Death of a spouse or child  Death of a parent (particularly in early childhood or adolescence)

Sudden, unexpected, and untimely deaths (particularly if associated  with horrific circumstances)

Multiple deaths (particularly disasters)

Deaths by suicide

Deaths by murder or manslaughter

Vulnerable people General:  Low self esteem

Low trust in others

Previous psychiatric disorder

Previous suicidal threats or attempts

Absent or unhelpful family

Ambivalent attachment to deceased person

Dependent or inter-dependent attachment to deceased person

Insecure attachment to parents in childhood (particularly learned fear  and learned helplessness)

Complicated grief

Bereavement has physiological as well as emotional effects (lower box). It also affects physical health: after bereavement, the immune response system is temporarily impaired 7 , 8 and there are endocrine changes such as increased adrenocortical activity and increases in serum prolactin and growth hormone, 2 as in other situations that evoke depression and distress.

Complications of bereavement

• Impairment of immune response system
• Increased adrenocortical activity
• Increased serum prolactin
• Increased growth hormone
• Psychosomatic disorders
• Increased mortality from heart disease (especially in elderly widowers)

Psychiatric Non-specific:

• Depression (with or without suicide risk)
• Anxiety or panic disorders
• Other psychiatric disorders
• Post-traumatic stress disorder
• Delayed or inhibited grief
• Chronic grief

A variety of psychiatric disorders can also be caused by bereavement, the commonest being clinical depression, anxiety states, panic syndromes, and post-traumatic stress disorder. These often coexist and overlap with each other, as they do with the more specific morbid grief reactions. These last disorders are of special interest for the light that they shed on why some people come through bereavement unscathed or strengthened by the experience while others “break down.”

It is a paradox that people who cope with bereavement by repressing the expression of grief are more likely to break down later than are people who burst into tears and get on with the work of grieving. The former are more liable to sleep disorders, depression, and hypochondriacal symptoms resembling the symptoms of the illness that caused the bereavement (“identification symptoms”). Not all psychogenic symptoms, however, are a consequence of repressed or avoided grief. Some reflect the loss of security which often follows a major loss and causes people to misinterpret as sinister the normal symptoms of anxiety and tension.

At the other end of the spectrum of morbid grief are people who express intense distress before and after bereavement. Subsequently they cannot stop grieving and go on to suffer from chronic grief. This may reflect a dependent relationship with the dead person, or it may follow the loss of someone who was ambivalently loved. In the former case the bereaved person cannot believe that he or she can survive without the support of the person on whom they had depended. In the latter, their grief is complicated by mixed feelings of anger and guilt that make it difficult for them to stop punishing themselves (“Why should I be happy now that my partner is dead?”).

Some degree of ambivalence is present in all relationships. To some degree its effects can be assuaged by conscientious care during the last illness, and many people will recall “We were never closer.” If members the family have been encouraged and supported so that they have been able to care, and the death has been peaceful, anger and guilt are much less likely to complicate the course of grieving.

These two patterns of grieving often seem to occur in “avoiders” (people with a tendency to avoidance) and “sensitisers” (those with a tendency to obsessive preoccupation), respectively. 9

Preventing and treating complicated grief

Doctors are in a unique position to help people through the turning points in their lives which arise at times of loss. In order to fulfil this role we need information and skills. One of our problems as caregivers is our ignorance of our patients’ view of the world. Not only do we seldom know what they know or think they know about the situation they face, we do not even know how that situation is going to change their lives. It follows that we need to find out these things and, where possible, add to their knowledge or correct any misperceptions, taking care to use language that they can understand. (This is easier said than done when words like “cancer” and “death” mean different things to doctors than they do to most patients.) Above all, we should spend time helping them to talk through and to make sense of the implications of the information we have given. If need be, we should see them several times to facilitate this process of growth and change. General practitioners, because they are likely to know the person, are often well placed to provide this “trickle” of care. For most bereaved people the natural and most effective form of help will come from their own families, and only about a third will need extra help from outside the family.

Anticipatory guidance

Members of health care teams can often prepare people for the losses that are to come. People need time to achieve a balance between avoidance and confrontation with painful realities, and we need to take this into account when we impart information that is likely to prove traumatic. One way is to divide the information that needs to be confronted into “bite sized chunks.” Doctors do this when we break bad news a little at a time, telling a patient as much as we think he or she is able to take in. Patients seldom ask questions unless they are ready for the answers, and they will usually ask precisely what they want to know and no more. It follows that we should invite questions and listen carefully to what is asked rather than assuming that we know what the patient is ready to know. By monitoring the input of information, a person can control the speed with which they process that information.

Although a little anxiety increases the rate and efficiency with which we process information, too much anxiety slows us down and impairs our ability to cope, our thought processes become disorganised and we “go to pieces.” Anything that enables us to keep anxiety within tolerable limits will help us to cope better with the process of change. If we are breaking bad news (box) it helps to do so in pleasant, home-like surroundings and to invite the recipient to bring someone who can provide emotional support. A few minutes spent putting people at their ease and establishing a relationship of trust will not only make the whole experience less traumatic for them but it will increase their chance of taking in and making sense of the information which we then provide.

Breaking bad news

• Consider social support (who to ask to be present)
• Consider setting (where to meet)
• Try to establish a relationship of mutual respect and trust
• Discover what the patient or the family knows or think they know already
• Invite questions
• Give information at a speed and in a language that will be understood
• Monitor what has been understood
• Recognise that it takes time to hear and understand bad news
• Give the patient or the family time to react emotionally
• Give verbal and non-verbal reassurance of the normality of their reaction
• Stay with the patient or the family until they are ready to leave
• Offer further opportunities for clarification, information, or support

Supporting bereaved people

A visit from the general practitioner to the family home on the day after a death has occurred enables us to give emotional support and to answer any questions about the death and its causes that may be troubling the family. Newly bereaved people often feel and behave, for a while, like frightened and helpless children and will respond best to the kind of support that is normally given by a parent. A touch or a hug will often do more to facilitate grieving than any words.

During the next few weeks bereaved people need the support of those they can trust. We can often reassure them of the normality of grief, explain its symptoms, and show by our own behaviour and attitudes that it is permissible to express grief. If we feel moved to tears at such times there is no harm in showing it. Bereaved people may need reassurance that they are not going mad if they break down, that the frightening symptoms of anxiety and tension are not signs of mortal illness, and that they are not letting the side down if they withdraw, for a while, from their accustomed tasks.

As time passes people may also need permission to take a break from grieving. They cannot grieve all the time and may need permission to return to work or do other things that enable them to escape, even briefly, from grief. It is only if they get the balance between confrontation and avoidance wrong that difficulties are likely to ensue.

The first anniversary is often a time of renewed grieving, but thereafter the need to stop grieving and move forward in life may create a new set of problems. People may need reassurance that their duty to the dead is done, as well as encouragement to face the world that is now open to them. The most important thing we have to offer is our confidence in their personal worth and strength. We should beware of becoming the “strong” doctor who will look after the “weak” patient for ever, but this does not mean that we become angry and dismissive, reprimanding the patient for becoming “dependent.” In the end, most bereaved people come through the experience stronger and wiser than they went into it. It is rewarding to see them through.

In the acute stages it is usually best to give support by personal contact, preferably in the client’s home. Later the help of a group in which bereaved people can learn from each other, as well as a counsellor, may be helpful. Organisations such as Cruse Bereavement Care and the member organisations of the National Association of Bereavement Services may be able to provide either of these types of help. The Compassionate Friends (for bereaved parents), Lesbian and Gay Bereavement, Support after Murder and Manslaughter (SAMM), and the Widow-to-Widow programmes that exist in the United States and other parts of the world provide mutual help by bereaved people for others with the same types of bereavement.

Further reading

Markus AC, Parkes CM, Tomson P, Johnstone M. Psychological  problems in general practice . Oxford: Oxford University Press,  1989.

Parkes CM. Bereavement: studies of grief in adult life. 3rd ed.  Harmondsworth: Pelican, 1998.

Funding: No additional funding.

Conflict of interest: None.

The articles in this series are adapted from Coping with Loss , edited by Colin Murray Parkes and Andrew Markus, which will be published in July.

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Open Access

Peer-reviewed

Research Article

Grief interventions for people bereaved by suicide: A systematic review

Contributed equally to this work with: Katja Linde, Julia Treml

Affiliation Department of Psychosomatic Medicine and Psychotherapy, University of Leipzig, Leipzig, Germany

* E-mail: [email protected]

• Katja Linde, 
• Julia Treml, 
• Jana Steinig, 
• Michaela Nagl, 
• Anette Kersting

• Published: June 23, 2017
• https://doi.org/10.1371/journal.pone.0179496
• Reader Comments

Adaption to the loss of a loved one due to suicide can be complicated by feelings of guilt, shame, responsibility, rejection, and stigmatization. Therefore people bereaved by suicide have an increased risk for developing complicated grief which is related to negative physical and mental disorders and an increased risk for suicidal behavior. Grief interventions are needed for this vulnerable population. The aim of this systematic review was to provide an overview of the current state of evidence concerning the effectiveness of interventions that focus on grief for people bereaved by suicide.

We conducted a systematic literature search using PubMed, Web of Science, and PsycINFO for articles published up until November 2016. Relevant papers were identified and methodological quality was assessed by independent raters. A narrative synthesis was conducted.

Seven intervention studies met the inclusion criteria. Two interventions were based on cognitive-behavioral approaches, four consisted of bereavement groups, and one utilized writing therapy. As five of the seven interventions were effective in reducing grief intensity on at least one outcome measure, there is some evidence that they are beneficial. Bereavement groups tend to be effective in lowering the intensity of uncomplicated grief, as are writing interventions in lowering suicide-specific aspects of grief. Cognitive-behavioral programs were helpful for a subpopulation of people who had high levels of suicidal ideation.

On average, methodological quality was low so the evidence for benefits is not robust. The stability of treatment effects could not be determined as follow-up assessments are rare. Generalizability is limited due to homogeneous enrollments of mainly female, white, middle-aged individuals.

Conclusions

People bereaved by suicide are especially vulnerable to developing complicated grief. Therefore, grief therapies should be adapted to and evaluated in this population. Prevention of complicated grief may be successful in populations of high risk individuals.

Citation: Linde K, Treml J, Steinig J, Nagl M, Kersting A (2017) Grief interventions for people bereaved by suicide: A systematic review. PLoS ONE 12(6): e0179496. https://doi.org/10.1371/journal.pone.0179496

Editor: Gianni Virgili, Universita degli Studi di Firenze, ITALY

Received: May 11, 2016; Accepted: May 31, 2017; Published: June 23, 2017

Copyright: © 2017 Linde et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: We acknowledge support from the German Research Foundation (DFG) and Universität Leipzig within the program of Open Access Publishing. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Suicide is a leading cause of death in the U.S. In 2013, 41,149 suicides were reported; that is 12.6 deaths per 100,000 people [ 1 ]. Worldwide suicides represent a major public health problem with 804,000 deaths per year—one death every 40 seconds [ 2 ].

Losing a loved one is one of the most stressful experiences in life. It has been estimated that for every suicide at least six people experience intense grief [ 3 ]. Grief can be seen as a natural response to the loss of a loved one [ 4 ]. Within the vast majority of bereaved people, grief intensity decreases within the first year after the loss [ 5 ] and a successful adaptation to a life without the deceased is possible without developing any severe physical or mental symptoms [ 4 , 6 , 7 ]. These people undergo a grief process which can be very painful and exhausting but does not ultimately require treatment [ 8 ]. To describe this grief process, the terms “non-pathological grief”, “normal”, and “uncomplicated grief” are used interchangeably in literature. Based on Zisook and Shear’s recommendation [ 9 ], we have chosen to use the term “uncomplicated grief” in this systematic review. Basically grief after the loss of a loved one due to suicide resembles grief after a loss by other causes of death. However, people bereaved by suicide differ in terms of suicide-specific aspects of grief that make the bereavement process more complicated [ 10 ]. They experience more intense feelings of rejection, a greater need to conceal the cause of the death, and more shame, blaming and social stigmatization than other survivor groups [ 10 – 13 ], even though these reactions are not unique to people bereaved by suicide [ 14 ]. A history of mental disorders in the family, prior suicidal attempts of the deceased, and strained family relations [ 11 , 12 , 15 , 16 ], as well as less social support after the death [ 10 , 12 ] can also complicate adaption to the loss. Furthermore, people who have found the body of someone who has died by suicide have often described this as being a very traumatic event that evokes flashbacks and intrusive thoughts [ 17 , 18 ] and can further impede the adaption to the loss.

In the following, suicide survivors refer to people who have lost a significant other due to suicide.

The specific circumstances surrounding the loss of a loved one by suicide may contribute to the increased risk of suicide survivors developing a pathological grief reaction [ 18 , 19 ]. Currently, besides “pathological grief”, the terms “persistent”, “traumatic”, “prolonged”, and “complicated” grief are used to describe a condition whereby bereaved people are not able to adapt to or accept the finality of their loss, and the grieving process is complicated, slowed, or halted [ 4 ]. For consistency, we have chosen to use the term “complicated grief” in this manuscript. There has been active discussion in recent years about recognizing complicated grief as a distinct mental disorder and establishing diagnostic criteria for it [ 20 – 24 ]. At present, it is already integrated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [ 25 ] as Persistent Complex Bereavement Disorder in section III, a section that contains conditions needing further research. It is also being considered for inclusion in the eleventh revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) as Prolonged Grief Disorder [ 23 ].

Complicated grief is characterized by intense longing, intrusive preoccupation with the circumstances of the loss, self-blame, avoidance of thoughts or memories of the deceased, avoidance of previously shared activities, and inadequate adaptation to the loss [ 4 ]. While complicated grief is estimated to occur in about seven percent of the bereaved in general [ 26 ], people bereaved by suicide are at higher risk of developing complicated grief [ 27 – 29 ]. Mitchell et al. [ 28 ] reported that, on average, 43% of people bereaved by suicide scored above the caseness threshold of complicated grief one month after the loss. People closely related to the deceased such as their children, spouses and parents experienced nearly twice the level of complicated grief as those who are more distantly related. Three months post-loss De Groot et al. [ 27 ] found that 25% of people bereaved by suicide experienced complicated grief compared to 13% bereaved by natural causes of death. Estimates of complicated grief more than one year post-loss vary from 35% in first-degree relatives and spouses [ 30 ] to 78% in parents [ 31 ]. Complicated grief is associated with several negative health outcomes including cancer, hypertension, cardiac problems, sleep disturbance, reduced quality of life, psychiatric comorbidity including Major Depression and Posttraumatic Stress Disorder, and work and social impairment [ 24 , 32 – 37 ]. Furthermore, people who suffer from complicated grief are at higher risk for suicidal ideation and behavior [ 28 , 38 – 40 ] leading to greater mortality rates in this population. Additionally, suicide bereavement itself poses as a risk factor for suicide especially in partners or spouses and parents of people who died by suicide [ 41 , 42 ]. Therefore, suicide survivors are especially in need of interventions aimed at reducing their grief. Studies revealed that suicide survivors report having a great need for professional help in coping with their loss [ 43 , 44 ], particularly in comparison to people bereaved by natural causes of death [ 27 ]. In a study by Wilson and Marshall [ 44 ], the vast majority of people bereaved by suicide indicated needing professional support in managing their grief. At the same time, only about half of them reported having actually received help from crisis teams, self-help or guided support groups, mental health services, psychiatrists, psychologists, nurses, or other counselors. Although the need for interventions is demonstrably great, little is known about the effectiveness of grief interventions for people bereaved by suicide. Previous reviews have been compromised by various limitations including: an unsystematic review process and a too narrow focus on adults only [ 12 ], a too broad focus on studies evaluating effects of interventions on people bereaved by suicide’s general mental health, but not specifically their grief process [ 45 , 46 ]. Furthermore, the last review done before the present one only included studies published before September 2009 [ 46 ]. Since then several new studies have been published with results that had yet to be synthesized in a review. A systematic review focusing solely on grief as an outcome variable and not limited to a specific population could contribute to an understanding of effective treatments for people bereaved by suicide.

Schut and Stroebe [ 47 ] distinguished three types of bereavement interventions: primary preventive interventions, secondary preventive interventions and tertiary preventive interventions. The first intervention offers professional help to all bereaved persons irrespective of whether intervention is indicated. Secondary preventive interventions are designed for bereaved people at high risk for experiencing a complicated form of grief, i. e. for instance people bereaved due to suicide or homicide. Tertiary preventive interventions are targeted towards bereaved people who are experiencing complications in their grieving process. The purpose of this systematic review is to evaluate the effects of secondary and tertiary interventions on grief for people bereaved by suicide. Hereby, the target outcome grief (in terms of uncomplicated grief, suicide-specific aspects of grief or complicated grief) is taken into consideration.

Literature search

The systematic review was conducted in accordance with the PRISMA statement [ 48 ]. A systematic literature search for English language papers published from the earliest indexed studies up to November 2016 was conducted using the electronic databases PubMed/Medline, PsycINFO, and Web of Science. The following search terms were used in titles and abstracts: (suicid* OR self-killing) AND (grief OR grieving OR bereave* OR mourning) AND (survivor* OR relative* OR dependant* OR family OR parent OR spouse* OR widow* OR child* OR sibling* OR peer* OR friend*) AND (prevention OR intervention OR postvention OR treatment OR program* OR therapy OR counsel* OR support).Additionally, the reference lists of all relevant papers as well as reviews concerning interventions for the bereaved were scanned.

Inclusion criteria

To be included in the present systematic review, studies had to meet the following inclusion criteria: (1) publication in a peer reviewed journal, (2) empirical study, (3) inclusion of participants bereaved through suicide, (4) evaluation of any kind of intervention (5) quantitative measure of (complicated) grief, (6) assessments that include at least pre- and post- or follow-up-measurements. Due to the broad scope of the systematic review no restrictions concerning the age of participants or their relationship to the deceased were applied. There were also no limitations on the types of interventions considered.

Articles were excluded if they (1) were not written in English (2) were reviews, case studies, case series, descriptive or qualitative studies, or (3) included suicide survivors as a non-definable subgroup of otherwise bereaved individuals.

After removing duplicates, the first three authors independently screened the title and abstracts for eligible studies. Papers that did not meet the inclusion criteria were excluded. The full text of potentially relevant papers was independently examined by the first three authors. Disagreements were resolved by discussion. If necessary, all authors of this systematic review were consulted until consensus was reached.

Data extraction

Data extraction from each study meeting the inclusion criteria was done by the first author and independently checked for accuracy by the third author. Disagreements were resolved through discussion. Data was extracted into a data extraction sheet. Variables extracted included: the author(s) of the study, study title and publication year, study design, inclusion and exclusion criteria, number and characteristics of participants (gender, age), characteristics of bereavement outcomes (time since bereavement, relationship to the deceased), characteristics of the intervention and of comparison groups (individual or group intervention, duration, frequency of contact, kind of control group), time points of assessment, outcome measures, drop-out rates, statistical analyses applied, main results, and information necessary for evaluating methodological quality (e.g. confounders).

Quality assessment

Methodological quality was assessed independently by the first and fourth author using the Quality Assessment Tool for Quantitative Studies [ 49 ]. The studies were rated in relation to the following six components: selection bias, study design, confounders, blinding, data collection method, withdrawal and dropouts. Values between 1 “strong”, 2 “moderate”, and 3 “weak” were assigned. Disagreements were discussed with all authors until consensus was reached. The results of the quality assessment were used to describe the overall quality of the included studies and to score the quality of each individual study.

Data synthesis

The included studies were highly diverse in terms of study design, characteristics and intensity of interventions, as well as outcome measures. Therefore, based on recent guidance [ 50 ], a narrative synthesis of the data was conducted instead of pooling data for a meta-analytic approach. Similarities and differences between study findings were analyzed with regard to study characteristics, recruitment criteria, characteristics of participants and bereavement, characteristics of the intervention, outcome measures, and methodological quality. Studies were grouped according to whether they had an inactive or active comparison group, and whether they had a focus on uncomplicated grief, suicide-specific aspects of grief, or complicated grief.

Study characteristics

In total, N = 952 titles and abstracts were identified using electronic databases. Of those, 305 were excluded because they were duplicates, and 647 were screened by the first three authors for inclusion in the systematic review. Of these, 580 publications were excluded due to not meeting the inclusion criteria. An additional 12 publications were identified through screening reference lists of relevant papers and reviews. In total, 67 publications were screened full-text by the first three authors and seven studies met the eligibility criteria ( Fig 1 ). One of those studies was described in two articles [ 30 , 51 ] and only the most recent article which incorporates the older one was included in this systematic review.

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The included studies were published between 1992 and 2014. Four studies were conducted in the USA [ 52 – 55 ], one in the Netherlands [ 51 ], one in Canada [ 56 ], and one in Belgium [ 57 ].

Recruitment criteria

In four of the included studies, participants were recruited both through self- and professional referral [ 51 – 54 ], two used self-referral only [ 56 , 57 ], and one used researcher referral [ 55 ].

Overall, the studies had few inclusion and exclusion criteria ( Table 1 ). Of those who reported inclusion criteria (5/7), two required the loss of a loved one, one the loss of a first-degree relative or spouse, and one the loss of a spouse to suicide. One study was explicitly restricted to participants older than 15 years [ 51 ], and three studies were restricted to participants older than 18 years [ 53 , 56 , 57 ]. Three studies were restricted to a specific time since bereavement varying between a loss within the past eight weeks [ 51 ] and two years [ 55 , 57 ]. None of the studies restricted study participation according to the intensity of grief, presence of complicated grief, or other mental health problems. Only Kovac and Range [ 55 ] restricted study participation to those survivors who stated that they had been very close to the deceased and very upset by their death.

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Characteristics of participants and bereavement

The sample size varied from 19 to 122 participants ( Table 1 ) with the majority of studies (6/7) including fewer than 85 participants. The majority of participants in all of the studies were women. The proportion of men varied from 18.8 to 32.8 percent ( Table 1 ). Except for the study by Kovac and Range [ 55 ], which included students with a mean age of 23.98 years, in all the other studies, participants were, on average, middle-aged adults (mean age range from 43.00 to 48.6 years). None of the studies focused on children, adolescents, or older adults. Where information about ethnic data was available (3/7), the majority of participants were Caucasian.

Six of seven studies gave information about the relationship to the deceased ( Table 1 ). In four of these studies [ 51 , 54 , 56 , 57 ], the participants had diverse relationships (e.g., children, parents, partner) to the deceased, and in two studies [ 52 , 53 ], only spouses or partners were included. Where reported ( Table 1 ), the most frequent relationships were partners, children, and parents. None of the studies focused on mental health care professionals such as psychiatrists or psychotherapists or people with other occupations who are at higher risk of knowing someone who has died by suicide. Average time since bereavement varied between studies from less than 2.5 months [ 52 , 53 ] to five years [ 56 ]. The Barlow et al. [ 56 ] study was an outlier in this case as time since bereavement in all the other studies was less than or around 12 months.

Four of seven studies provided at least some information about the deceased. In the two studies that reported the sex of the deceased [ 51 , 56 ] the majority were men. Mean age of the deceased was assessed in four studies and varied from 28.90 years (SD = 10.84) for the whole sample in the study by Kovac and Range [ 55 ] to 46.00 (SD = 15.2) years for the comparison group in the study by de Groot et al.[ 51 ]. Only one study reported the method of suicide [ 53 ]. In this study, most frequently used were gunshot and carbon monoxide poisoning.

Characteristics of interventions

The majority of studies (5/7) evaluated group interventions, one studied a mixture of individual and group interventions [ 57 ], and one assessed an individual intervention [ 55 ] ( Table 1 ). Where reported, the duration of the interventions ranged between two [ 55 ] and 16 weeks [ 56 ] with most of the interventions lasting about eight weeks. In the majority of the studies (6/7), single intervention sessions lasted between 90 and 120 minutes, while the sessions in the study by Kovac and Range [ 55 ] only lasted 15 minutes. The frequency of contact varied from four times within two weeks [ 55 ] to four times every two to three weeks [ 51 ]. The intervention sessions usually took place once a week [ 52 – 54 ].

Except for two studies [ 55 , 56 ], all interventions were delivered by mental health professionals or a combination of mental health professionals and a trained survivor ( Table 1 ). Of these, only one was delivered by a clinical psychologist [ 57 ]. In the two other studies, the researcher [ 55 ] and a trained survivor delivered the intervention [ 56 ]. No study explicitly stated having used an intervention manual. Only one study stated that supervision was provided for those who delivered the intervention [ 51 ].

One study evaluated the effectiveness of the intervention without a comparison group [ 56 ] and three studies compared the intervention to an inactive comparison group [ 51 , 54 , 57 ]. Two interventions were based on cognitive behavioral therapy [ 51 , 57 ], one was a peer support program [ 56 ], and one a bereavement group program [ 54 ]. Three studies compared the effectiveness of an intervention to an active comparison group [ 52 , 53 , 55 ]. One compared an emotional writing condition to a neutral writing condition [ 55 ], and two compared a bereavement group postvention to a social group postvention [ 52 , 53 ].

Five of seven studies explicitly mentioned the theoretical background of their intervention. In two studies, the intervention emphasized the 12 therapeutic factors of group therapy formulated by Yalom, 1995 [ 52 , 53 ]. In two other studies, the intervention was based on the conceptualization of complicated grief by Boelen et al., 2006 [ 51 , 57 ], and one intervention was based on the writing paradigm formulated by Pennebaker, 1986 [ 55 ].

Outcomes measures

Various measures were used ranging from a self-generated single item evaluating grief intensity [ 54 ] to seven different standardized grief measures. The standardized grief measures and their psychometric properties are described in Table 2 . The majority of instruments were self-report questionnaires but one was a structured interview for clinical use. Four instruments had a focus on uncomplicated grief, one on suicide-specific aspects of grief, and only two on complicated grief. Of those, the Inventory of Traumatic Grief (ITG) was used in a scale format to assess the intensity of complicated grief. The Traumatic Grief Evaluation of Response to Loss (TRGR2L) was used to diagnose complicated grief in participants based on consensus criteria of complicated grief [ 51 ]. Only two studies included not only post intervention but also follow-up assessments at intervals ranging from six [ 55 ] to 12 months [ 53 ].

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Methodological quality

Table 3 provides an overview of the assessment of methodological quality for each study. Studies were rated in relation to selection bias, study design (including randomization), confounders, blinding, data collection method, withdrawal, and dropouts. Overall, study quality was weak. No study received a strong rating on any of the six components of methodological quality. The biggest problems were selection bias and blinding as none of the studies recruited a representative sample, and none described the outcome assessor or the participants as having been blinded. Additionally, two studies used a non-randomized study design [ 54 , 56 ] and only one study [ 51 ] based their analysis on intention-to-treat analyses.

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Study findings

Studies without a comparison group..

One study [ 56 ] evaluated a four-month suicide bereavement peer support program within a one-group pre-post design ( N = 19). The majority of participants reported deaths within the past five years. The intervention consisted of personal meetings or telephone conversations between peer supporters and participants. No further information is provided regarding the intervention. From pre- to post-assessment, three out of six subscales measuring uncomplicated grief (Despair, Detachment, and Disorganization) indicated significant reductions (see Fig 2 ). Due to the uncontrolled study design, it is impossible to attribute these changes solely to the effects of the intervention. The study was also limited by the small sample size and a high study drop-out rate of nearly 50 percent. Overall, methodological quality was low ( Table 3 ).

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Studies comparing the intervention to an inactive comparison group.

Three studies compared the intervention to an inactive comparison group. In two studies, the effectiveness of the intervention was evaluated with regard to uncomplicated grief [ 54 , 57 ] and in two studies with regard to complicated grief [ 51 , 57 ] (see Fig 3 ).

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With regard to uncomplicated grief, study findings were mixed ( Fig 3 ). Faberow et al. [ 54 ] evaluated an 8-week “Survivors After Suicide” bereavement group program ( N = 82) and found positive intervention effects. Time since bereavement varied between three and 24 months with 77% of participants reporting deaths within the past eight months. The intervention consisted of a group therapy developed to provide support in dealing with difficult emotions and coping with grief. Uncomplicated grief was significantly reduced from pre- to post-assessment in the intervention but not in the comparison group. Validity is limited due to the non-randomized study design and the lack of controlling for pre-treatment differences in grief intensity between the groups. Furthermore, the results are only reported as changes in percentages but no total scores and method of analyses are described. Therefore results cannot be replicated.

No intervention effect was found in a methodologically sound randomized-controlled trial (RCT) by Wittouck et al. regarding uncomplicated grief [ 57 ]. They evaluated an intervention based on cognitive-behavioral therapy ( N = 83). Time since bereavement was, on average, eleven months. The intervention comprised psychoeducation regarding aspects of suicide (illustrating the suicidal process and explaining a comprehensive explanatory model of suicidal behavior), aspects of bereavement in general and specific to suicide (including myths regarding content, course and cultural context of grief) and coping (discussing the dual-process model of coping with bereavement [ 63 ]). No significant effect of the intervention was found using a generalized grief reactions measure ( Fig 3 ).

With regard to the intensity of complicated grief, study findings were ambiguous. Of the two methodologically sound randomized controlled studies [ 51 , 57 ], one did not find any treatment effects for bereaved persons in general [ 57 ] and one found a treatment effect but only for a subgroup of bereaved individuals who suffered from suicidal ideation before treatment [ 51 ]. The study finding no intervention effect is the RCT by Wittouck et al. [ 57 ] which was described above. Besides using a generalized grief reactions measure they also applied a measure for complicated grief symptoms but found again no significant effect of the intervention. In the RCT done by De Groot et al. [ 51 ], a family-based grief counselling program based on cognitive-behavioral therapy was evaluated ( N = 122). Time since bereavement was less than 2.5 months. This time frame was chosen in order to intervene before negative beliefs become fixed. Among other things, the intervention consisted of cognitive restructuring, consolidation of support, family grief and communication, and improving problem solving. In their initial analyses, no significant differences at the post-assessment were found between the intervention and comparison groups with or without controlling for covariates. Later they reanalyzed the data and evaluated the program in subgroups of participants with (22%) and without suicidal ideation (78%). Although the self-report questionnaire indicated no significant intervention effects on complicated grief symptoms in participants with or without suicidal ideation, the intervention was shown to be effective on a diagnostic level of complicated grief as assessed in clinical interviews ( Fig 3 ). The analyses showed that, among participants with suicidal ideation, those who received the intervention were diagnosed with complicated grief at post-assessment significantly less frequently than participants who did not receive the intervention. Within the intervention group, a nearly equal percentage of participants with and without suicidal ideation (20.9 vs. 21.2%) developed a maladaptive grief reaction at post-assessment, whereas within the comparison group, 72.7 percent of participants with suicidal ideation developed a maladaptive grief reaction compared to 25.0 percent of participants without suicidal ideation.

Studies comparing the intervention to an active comparison group.

Three studies compared an intervention to an active comparison group [ 52 , 53 , 55 ]. All of the studies evaluated the effectiveness of interventions with regard to uncomplicated grief and one also focused on suicide-specific aspects of grief [ 55 ] ( Fig 4 ).

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With regard to uncomplicated grief, study findings were mixed. Whereas one study found that the intervention was more effective than the active comparison group [ 52 ], two studies found no significant differences between the intervention and active comparison groups [ 53 , 55 ]. In an RCT, Constantino and Bricker [ 52 ] compared the effects of an eight-week bereavement group to an eight-week social group postvention ( N = 32). Time since bereavement was not reported. The bereavement group emphasized the twelve curative factors of group psychotherapy as formulated by Yalom 1985, whereas the social group promoted the principles of socialization, recreation, and leisure. Out of nine different aspects of uncomplicated grief, three aspects (Despair, Rumination, Depersonalization) were significantly reduced in both groups and only one (Anger/Hostility) was significantly reduced from pre- to post-assessment in the intervention group but not in the active comparison group ( Fig 4 ). The later RCT done by Constantino et al. [ 53 ] was a replication of the study done by Constantino and Bricker [ 52 ]. The same study design, measures, and interventions were used but the sample size was twice as large ( N = 60). Time since bereavement was, on average, 10.91 months with a range from one to 27 months. Besides pretest and posttest assessments there were also 6- and 12-months follow-up assessments. No significant differences between the intervention and active comparison group were found since both groups significantly reduced their levels of grief ( Fig 4 ). Kovac and Range [ 55 ] compared in an RCT a two-week profound writing condition with a two-week trivial writing condition ( N = 42). Time since bereavement was on average 13.26 years in the intervention and 11.95 years in the comparison group. Participants in the intervention group were asked to write for 15 minutes about events and emotions surrounding their loss, whereas participants in the comparison group were asked to describe neutral events such as their bedroom. There were no significant differences between the two groups with regard to the uncomplicated grief measure used.

However, with regard to suicide-specific aspects of grief, Kovac and Range [ 55 ] found significant reductions in the intervention group in the time between the post- and 6-month follow-up assessments as opposed to an active comparison group. This finding holds for the total score of the measure, but not for any of the subscales.

This systematic review provides an overview of the effects of intervention programs on grief of people bereaved by the suicide of a loved one. Studies which focused on uncomplicated grief, suicide-specific aspects of grief, and complicated grief were included. The evidence available from this systematic review provides important insight into current research gaps and has practical implications. Overall, although a remarkable proportion of the population is affected by the suicide of a loved one and is therefore at elevated risk of experiencing complicated courses of grief, only seven intervention studies were identified that were eligible for our systematic review. All of them were secondary interventions and five studies (71.4%) showed a reduction in grief intensity for at least one measure.

Of the five studies focusing on uncomplicated grief, results were mixed as three studies showed positive effects [ 52 , 54 , 56 ] and two did not [ 53 , 55 ]. Due to the weak methodological quality of those studies showing some positive evidence, the results should be interpreted with caution and seen as preliminary. One study [ 55 ] investigated the effect of a secondary intervention on suicide-specific aspects of grief. It has been found that participants who wrote about their bereavement experiences four times for 15 minutes over a period of two weeks reported a greater decrease of suicide-specific aspects of grief than people randomized to an attentional control condition. It can be concluded that a rather short and easy to implement intervention based on the writing paradigm developed by Pennebaker, 1986 [ 64 ] has an effect on aspects of grief specific to losing a significant other to suicide. Difficult emotions in relation to the traumatic death might be inhibited or suppressed in people bereaved by suicide or concealed as a consequence of stigmatization and lower level of support from others. Being invited to write openly in a safe environment about emotions and thoughts surrounding the suicide might have resulted in a reduction of suicide-specific aspects of grief. These results are in line with two other studies that found writing interventions to be effective in reducing the grief of bereaved individuals [ 65 , 66 ].

The effectiveness of secondary interventions on complicated grief in people bereaved by suicide was only investigated in two studies. One of the two randomized-controlled studies [ 57 ] with the highest level of methodological quality in this systematic review did not find any intervention effect on complicated grief. This result is in line with a meta-analysis which also found no significant overall effect of preventive interventions on complicated grief [ 67 ]. However, the second study [ 51 ] found that a cognitive-behavioral intervention was effective in the prevention of complicated grief in a subset of participants with high levels of suicidal ideation at the beginning of the study. The result that the same intervention was not effective in a sample of people bereaved by suicide in general [ 30 ] but only in a subset with high levels of suicidal ideation [ 51 ] leads to the conclusion that the effectiveness of the intervention depends on the risk level of the participants. 22% of the sample suffered from suicidal ideation three months after the loss. These suicide ideators showed significantly higher levels of neuroticism as well as lower levels of mastery and self-esteem compared to non-ideators at the beginning of the study. Furthermore they had been significantly more often diagnosed as depressed (46.2 vs. 20.2%) or anxious (38.5 vs 16.0%) in the past and had attempted suicide more often than non-ideators (18.5 vs 2.1%). They had also more often lost a child or spouse to suicide than non-ideators and showed less favorable bereavement outcomes three months post-loss with significantly higher levels of complicated grief and depression. An intervention that is based on the cognitive-behavioral concept of complicated grief [ 68 ] and contains elements of psychoeducation, enhancement of emotional processing, family communication, problem solving skills, and consolidating resources of support seems to be a promising method for preventing complicated grief in a high risk group of people bereaved by suicide. However, these results should be seen as preliminary as they were derived from post-hoc subgroup analyses. They need to be replicated in a study that randomizes people with high levels of suicidal ideation to a treatment and comparison group. Furthermore, it seems to be a promising strategy with regard to the prevention of complicated grief to provide secondary intervention to high-risk participants only. The risk screening might be based on higher levels of grief intensity but also on known risk factors for complicated grief such as: insecure attachment, preexisting mood and anxiety disorders, the nature of the relationship to the deceased, and the resources and support available following the death [ 36 ].

Considering all results, there seems to be a tendency for people bereaved by suicide to benefit from secondary intervention programs which is in line with evidence from meta-analyses and reviews for the bereaved in general that show either small positive effects for secondary interventions in the short term [ 8 , 69 ] or mixed results [ 47 ]. Surprisingly there is only a small number of intervention studies and none of them evaluated any tertiary interventions designed for individuals already suffering from complicated grief. Especially people bereaved by suicide are vulnerable to developing complicated grief [ 27 – 29 , 55 ] and the very is not only related to several negative mental and physical health outcomes [ 24 , 32 – 37 ], but is also a strong predictor of suicidal ideation and behavior [ 28 , 38 , 40 ].

Therefore, people bereaved by suicide are in need of and might be especially receptive to interventions aimed at reducing their grief. As Wilson and Marshall [ 44 ] showed, there is a significant gap between the need for support in people bereaved by suicide and the provision and quality of professional support services. Whereas 94% of the participants in their study indicated a need for help in managing their grief, less than half of them received help, and of those, only 40% felt satisfied with it. Our systematic review supports this result by showing that secondary interventions are rare and tertiary interventions are missing. Effective interventions for complicated grief [ 66 , 70 – 73 ] need to be adapted to and evaluated in suicide survivor populations.

Limitations of the included studies

There are some limitations of the included studies that must be taken into account when interpreting the results of our systematic review. First, overall methodological quality of the included studies was low as the two studies with the highest methodological quality [ 51 , 57 ] fulfilled only four of six quality criteria. The included studies were especially weak with regard to selection bias and blinding. Participants were not very likely to be representative of the population of suicide survivors because they had referred themselves for study participation. Additionally, two studies used a non-randomized study design [ 54 , 56 ]. Therefore, the generalizability of the results is limited. Furthermore, internal validity may be threatened due to the fact that, with the exception of the Kovac & Range [ 55 ] study, outcome assessors were not blinded. Only one study [ 57 ] used intention-to-treat analyses whereas all other studies based their analyses on completer analyses. This may have led to a biased estimate of treatment effects [ 74 ]. Overall the results should be considered exploratory since only two studies [ 55 , 57 ] have adjusted analysis for multiple testing. Moreover, because of the small sample sizes, it cannot be ruled out that small treatment effects were overseen due to the low power of the tests. Second, complicated grief was measured on a symptom level only. None of the two studies [ 51 , 57 ] using the Inventory of Traumatic Grief used cut-off values to separate participants with clinically relevant grief intensity from others even though such threshold values are available. Also, the functional impairment and time criteria that need to be fulfilled to diagnose complicated grief as a mental disorder [ 23 , 25 ] were not taken into account. Third, intervention duration was rather short in all of the studies, ranging from two weeks to four months, and all but one intervention [ 55 ] was implemented in a group setting. This may have led to smaller treatment effects as there is some evidence that a longer intervention duration and individual grief therapy might be more effective [ 75 ]. Furthermore, nearly all interventions were implemented within the first year after loss. Therefore, intervention effects may interfere with the "natural" grieving processes [ 47 ] making strong treatment effects less likely. Fourth, the results of this systematic review are limited to a white, female, middle-aged population with tight familiar relationships to the deceased. Interventions targeting children and adolescents as well as the elderly were missing completely. Younger and older people may experience more complications of their bereavement process [ 26 , 37 ] and may therefore be more difficult to treat [ 75 ]. Last, since long-term follow-up assessments were largely missing it remains unclear whether intervention effects remain stable over time.

Limitations of the systematic review

Searching for only English language articles may have led to the exclusion of relevant studies published in other languages. Also a broader search string might have led to more articles. Furthermore, including only studies published in peer-reviewed journals might have led to missing important knowledge from unpublished “gray” literature, which might result in publication bias. However, by including peer-reviewed articles a minimum of methodological quality was ensured. This systematic review was also not limited to RCT, which limits the level of evidence. Due to the small number of RCTs we decided to include all studies investigating any kind of intervention to gain as much insight as possible, thus providing directions for future research.

Implications for research and clinical practice

First, future research should focus on tertiary interventions, i.e. including participants diagnosed with complicated grief in clinical interviews, or at least screened for elevated symptoms of complicated grief with questionnaires providing cut-off values. Grief interventions which have already been shown to be effective in bereaved persons in general should be adapted to and investigated in this specific population. Second, because one promising study in our review showed that secondary interventions might be effective in preventing complicated grief if they are addressed to a subset of people at higher risk of complications of their bereavement process, future studies focusing on the prevention of complicated grief should include high risk participants only. Third, methodologically sound randomized controlled trials that adjust for multiple testing, conduct sample size calculations, intention-to-treat analyses, and long-term follow-up assessments are needed. Additionally, outcome assessors should be blinded and more effort should be made to include a representative sample of the population of suicide survivors.

People bereaved by suicide constitute a remarkable proportion of the population with an increased risk of experiencing complicated courses of grief. Untreated complicated grief might pose an independent risk factor for suicidal thoughts and action and could in turn contribute to the family transmission of suicidal behavior. General practitioners and mental health professionals, in particular, should screen patients who have lost a loved one to suicide for complicated grief and suicidal ideation. High-risk patients should then be referred to psychotherapists.

The aim of this systematic review was to evaluate the effects of interventions on grief for people bereaved by the suicide of a loved one. Studies investigating grief interventions for suicide survivors are rare and the results of these studies need to be interpreted with caution due to notable methodological limitations. Nevertheless, the preliminary results indicate some positive effects of interventions in reducing grief intensity and suicide-specific aspects of grief. Study results regarding complicated grief are less promising. Only one out of two studies found that a cognitive-behavioral intervention was effective in the prevention of complicated grief but only for a subset of participants with high levels of suicidal ideation at the beginning. This suggests that the effectiveness of a grief intervention might depend on the risk level of the participants. Further research is necessary in order to adapt and evaluate effective grief interventions for people bereaved by suicide that are in particular need of support.

Supporting information

S1 prisma checklist. prisma checklist..

https://doi.org/10.1371/journal.pone.0179496.s001

S1 File. List of excluded full-text articles.

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Acknowledgments

We acknowledge support from the German Research Foundation (DFG) and Universität Leipzig within the program of Open Access Publishing.

Author Contributions

• Conceptualization: KL JT JS MN AK.
• Formal analysis: KL JT.
• Investigation: KL JT JS.
• Methodology: KL JT MN.
• Project administration: AK.
• Resources: AK.
• Supervision: AK.
• Visualization: KL JT.
• Writing – original draft: KL JT.
• Writing – review & editing: KL JT JS MN AK.
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Guest Essay

We Will All Mourn, and We Will All Be Mourned

By Perri Klass, M.D.

Dr. Klass, a professor of journalism and pediatrics at New York University, is the author of the book “The Best Medicine: How Science and Public Health Gave Children a Future,” on how our world has been transformed by the radical decline of infant and child mortality.

After her 11-year-old son, Willie, died of typhoid, Mary Todd Lincoln’s “inconsolable” mourning brought on convulsions, her dressmaker and confidante, Elizabeth Keckly , wrote in an 1868 memoir .

As the first lady suffered one of her “paroxysms of grief” after losing the second of her children to illness, Abraham Lincoln reportedly drew her to the window and pointed out a “lunatic asylum,” telling his wife: “Try to control your grief, or it will drive you mad, and we may have to send you there.” Later, after the president was assassinated in his wife’s presence, Keckly described “the wails of a broken heart, the unearthly shrieks, the terrible convulsions, the wild, tempestuous outbursts of grief from the soul.”

The public found much to criticize in the widow’s public expressions of grief for her husband: She was faulted for her demonstrative emotions; for not attending her husband’s funeral and turning away sympathy callers; for choosing to wear only black for the rest of her life, well beyond the ritual widowhood mourning period of two and a half years.

I don’t bring this up to wade into the complex and much-reviewed history of Mrs. Lincoln’s mental and physical health, but to say that grief and mourning have always been influenced by and also judged according to the social and cultural norms of the time and place. The inclusion of “prolonged grief disorder” in the new edition of psychiatry’s compendium, the Diagnostic and Statistical Manual of Mental Disorders — which defines “prolonged” as lasting at least a year for adults — has set off another conversation about what is “normal” grief and what is “excessive.”

When should a grieving person be advised to seek psychiatric help or prescribed medication? Should we expect those who are grieving to keep to some timetable for returning to the business of life? How best to alleviate the suffering of those whose lives have been derailed by grief, while acknowledging that losing someone you love might very plausibly derail your life?

This discussion comes, of course, as we live through a time of great — and unequally distributed — grief, amid a pandemic that has killed more than a million Americans and as we contend also with relentless news of war and other horrors, including mass shootings like the one that leaves us grieving together this week for the children and teachers of Uvalde, Texas.

These days, few of us demonstrate our grief outwardly, with formal mourning clothes, death photos or bereavement jewelry incorporating locks of hair. But we will all mourn, and we will all eventually be mourned. Grief is personal, individual, idiosyncratic — but it is also public and universal. And public expression of grief is regulated and guided by every culture, every religion, with its particular rituals and timings.

Peculiarly, human universals seem to call forth judgment as well as fellow feeling; the same irresistible urge that makes pregnancy and parenthood such ready topics of community judgment, in person or online, comes into play in judging the grief of others, whether neighbors, strangers or celebrities. How much people grieve, how they show their grief, even the language of loss and mourning — all are sensitive subjects, areas where you can offend.

Grief can have physical as well as psychological effects , and shaming others for their grief can be corrosive. In an essay lamenting the “grief police,” the cognitive scientist Sian Beilock argues: “We need to give ourselves license to express positive emotions and affirm other aspects of ourselves that we value outside of the tragedy. Doing so means we will feel more in control and cope better down the line.”

Cultures around the world have explicit expectations of what grief should look like, Dr. Paul Rosenblatt, a professor emeritus of family social science at the University of Minnesota, told me. “If you grieve properly you support the cultural rules regarding grief and affirm everyone else who has grieved properly,” Dr. Rosenblatt, who co-founded the Grief and Families Focus Group of the National Council on Family Relations, wrote in an email.

But people are idiosyncratic, he told me, and grief is diverse from culture to culture, and even within cultures: “We have to be open to people being very different from what we expect in their grieving — but they may hide it if we’re going to be judgey.”

In today’s celebrity-obsessed culture, we watch and assess how the famous grieve. Look at the way, for example, Queen Elizabeth II was criticized when Diana, her former daughter-in-law, died, and Buckingham Palace did not initially issue a statement expressing grief or lower the flag. More recently, the queen’s grief at the loss of her husband was occasion for sympathy, but some commenters looked for a way to place some blame on Meghan Markle.

But even if you aren’t a celebrity, people expect you to get grief “right” and they take it personally when you don’t. When I wrote in these pages about missing my deceased parents and the recurring surprise of realizing over and over that they were gone, I was very sternly dressed down by commenters for referring to my then almost 60-year-old self (I had thought self-deprecatingly) as a very elderly orphan. Readers who had lost their parents in childhood felt that I had callously appropriated the word, and had thereby claimed a level of tragedy and suffering that was not properly mine.

We are also living through a time when certain losses and griefs that frequently used to go unacknowledged are being recognized. Younger people, in particular, are asserting the ways that the loss of friends , exes and relatives outside the nuclear family can cause powerful grief. And in a time of “parasocial” attachment , there has been a lot of discussion about the impact of celebrity deaths on fans .

Some are speaking up about griefs that previously they were expected to endure only in private, such as the grief many feel after a miscarriage . The model and social media influencer Chrissy Teigen wrote movingly about her pregnancy loss in a Medium post , and Ms. Markle shared her experience in a Times essay .

Judging others’ grief is a way we try to protect ourselves from it, explained Dr. Elena Lister, an associate professor of clinical psychiatry at Weill Cornell Medical College and co-author of the forthcoming book “Giving Hope: Conversations With Children About Illness, Death, and Loss.” “Grief makes us horribly uncomfortable; to see other people grieving reminds us we are mortal, we could die ourselves or lose people we love,” said Dr. Lister. “We need to distance ourselves, and one of the ways we distance ourselves from pain is by putting it down, judging — ‘you’re grieving too much,’ ‘you’re grieving too little.’ Either way you’re saying, ‘that’s not me.’”

Today, people often look to psychotherapists or books for advice on how to grieve . In the 19th century, when childhood death was much more common, there was a proliferation of “comfort books” for grieving parents and siblings, which sometimes relied heavily on assuring parents that the deceased child was in heaven and had escaped the vicissitudes and temptations of life on earth.

In her 1838 book, “Letters to Mothers,” the Connecticut writer Lydia Sigourney included a chapter on “Loss of Children,” which instructed the grieving mothers: “You will not then, become a prey to despondence, though loneliness broods over your dwelling, when you realize that its once cherished inmates have but gone a little in advance, to those mansions which the Saviour hath prepared for all who love him.”

The idea that beautiful and virtuous children, the angels on earth, were called early up to heaven, was meant to be a salve, of course — and it’s likely that it was for many. But it also placed grieving parents in the unfortunate position of feeling that sorrow — instead of joy at their child’s ascension — made them less than pious. The promise of comfort carried with it a rubric for grief, which, if you couldn’t abide by it, might leave you feeling that you weren’t doing it right.

In the public debate about the D.S.M. diagnosis , we hear from those who are horrified by the implied judgment of people who experience long and debilitating grief, and also from those seeking help because of their long and debilitating grief. Some argue that powerful and lengthy grief is an appropriate and proportional response to tragedy. That is true, and always has been.

Others describe being tortured by grief that does not abate , or by regrets, self-blame and second-guessing to a point where they need something more than sympathy in order to take care of themselves and the people who depend upon them. For them the hope is that the new D.S.M. diagnosis could make help more accessible.

The 18th-century poet Ann Eliza Bleecker described clinging to her own grief, not wishing for comfort. In the early years of the American Revolution, she had to flee her home near Albany with her two young daughters because British troops were approaching. Her baby, Abella, died of dysentery during the journey, and later, Bleecker’s mother and sister died as well. In her poem “Lines Written in the Retreat From Burgoyne,” she described her grief for Abella as a kind of companion:

The idol of my soul was torn away; Her spirit fled and left me ghastly clay! Then — then my soul rejected all relief, Comfort I wish’d not for, I lov’d my grief

Bleecker returned to the topic of her daughter’s death again and again as the central tragedy of her life, rejecting the resignation and Christian fortitude that was expected of her, the scholar Allison Giffen writes . Her surviving daughter, Margaretta Faugères, also a writer, commented in an introduction to her mother’s works that being reminded of the circumstances that led to Abella’s death “never failed to awaken all her sorrows; and she being naturally of a pensive turn of mind, too freely indulged them.”

You can hear the echoes across the centuries, the grief that cannot be healed because the departed child cannot be retrieved, the sorrow of the surviving daughter who feels that her mother’s persistent grief overshadowed her own childhood.

I have quoted here a poet whose subject is grief, but for me, when my father died suddenly and unexpectedly in 2001, one of the surprises was that the beautiful words of all the poets and novelists and playwrights didn’t seem particularly relevant. I don’t mean that they didn’t resonate with me; I just mean that the loss still felt unbearably shocking and terrible.

The whole history of humankind, all the other people who had lost their fathers, everything they had written down — none of it had really prepared me for this feeling. “I think we’re all beginners again and again with grieving,” Dr. Rosenblatt told me when I asked him about this.

It shouldn’t need to be said that there is no “right” way to grieve, that it’s a piece of living we each have to explore in a way that reflects the person you are and also the person you’ve lost. I have experienced aspects of grief that I wasn’t sure I could live with forever: intrusive, repetitive sleep-destroying thoughts about what could have been or should have been different, for example. And I was grateful for the possibility of therapy and counseling.

But is there not some way to take some judgment out of the equation, whether we’re judging someone for grieving too much, too little or too long; for using the wrong language; or for daring to suggest that grief can be profound even after what may seem like a lesser bereavement? People who are mourning a pregnancy that ended in a loss do not need to be told that it is harder to lose a 1-year-old; people who are grieving parents whom they loved don’t need to be reproached for causing pain to those who are estranged from their own parents.

There is always a greater grief. You can acknowledge the rich history of human sadness and still mourn your own loss. You can lean on the ones you love; you can turn to poetry; you can seek professional help if you need it. Perhaps there is even some comfort to glean from our tendency to measure and assess the grief of others, to pick apart what a loss is and what it should be. To observe and judge and parse the narratives of others, to mind one another’s business, is a part of being human.

We may each navigate the landscape of grief alone, but we also are all in this together. In the words of Jim Morrison, no one here gets out alive.

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Dr. Perri Klass is the author of the book “ The Best Medicine: How Science and Public Health Gave Children a Future ,” on how our world has been transformed by the radical decline of infant and child mortality. @ PerriKlass