Original Research
Differentiating Symptoms of Complicated Grief and Depression Among Psychiatric Outpatients
John S Ogrodniczuk, PhD1, William E Piper, PhD2, Anthony S Joyce, PhD3, Rene Weideman, PhD4, Mary McCallum, PhD5, Hassan F Azim, MD6, John S Rosie, MD7
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Objective: This study examined whether dimensions of complicated grief (CG) could be distinguished from dimensions of depression and whether these dimensions were differentially affected by group psychotherapy for CG.
Method: A total of 398 psychiatric outpatients who had experienced one or more significant death losses provided ratings on standard measures of grief and depression. Factor analysis of the 56 items from these measures was used to explore the possibility that grief and depression symptoms would form separate dimensions of distress. Subsamples of the patients also participated in 1 of 2 forms of short-term group therapy for CG. Repeated-measures analysis of variance and calculation of effect sizes were performed to examine changes in the dimensions following treatment.
Results: The grief items formed 3 distinct clusters representing different dimensions of CG. None of the depression items loaded highly on these grief dimensions. The depression items formed 2 distinct clusters. Two of the grief dimensions demonstrated the most improvement following group therapy that addressed CG. There was also evidence for differential effectiveness of the 2 forms of group therapy.
Conclusions: When assessing psychiatric patients who have death losses, clinicians should consider different types of grief reactions. Different types of grief reactions may be responsive to different treatments. In the absence of depressive symptoms, clinicians should not assume the absence of CG.
(Can J Psychiatry 2003;48:87–93)
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Clinical Implications
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Complicated grief is a multidimensional construct; thus, clinicians should attend to different areas of distress when assessing patients who have lost an important person through death.
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Symptoms of complicated grief and depression should be considered separately.
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Interpretive group therapy may be more effective than supportive group therapy for treating specific dimensions of complicated grief.
Limitations
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The cross-sectional design of the study did not allow us to determine the stability of the dimensions across time.
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Because other available grief symptom measures were not included, it is possible that other aspects of complicated grief reactions were not assessed.
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Principal components analysis is an exploratory factor analytic technique; thus, the results of the present study must be considered preliminary and require replication in a different sample using confirmatory factor analysis.
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Key Words: complicated grief, depression, symptom profile, response to treatment
Résumé : Différencier les symptômes du deuil complexe et de la dépression chez les patients psychiatriques externes
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Acute distress is normal following the loss of a loved one. In some cases, grief reactions reach intensities and durations that are extreme, are associated with complications (for example, physical ailments), and interfere with daily functioning. Such grief reactions are referred to as complicated grief (CG) (1). There is considerable interest in CG as a nosologic entity that is distinct from major depression, panic disorder, and posttraumatic stress disorder (2). However, there is still much debate concerning the operationalization and validation of CG.
Clinicians frequently find that loss issues underlie and sustain patients’ problems. Treatment interventions with these patients may need to focus on various aspects of CG (3). Robinson and Pickett recommended that measures of grief should cover multiple dimensions to elicit the most clinically useful material (4). They argued that complications may be restricted to specific symptoms rather than generalized distress. Uni-dimensional scales may fail to detect specific problems.
Several instruments have been developed to assess symptoms of CG (5). However, there have been no attempts to determine whether the different instruments measure unique aspects of grief or whether they address common features. Inability to clearly define the components of CG has contributed to its exclusion as a distinct diagnostic category from the major classification systems of mental disorders (1).
The debate over whether grief and depression are distinct constructs adds to the difficulty in clearly defining CG. Clayton defined CG as a “continued depressive symptom” (p 34, 6). Others have argued that CG is distinct from depression (7). Support for this argument comes from a study of older adults who had lost a spouse, which demonstrated that CG symptoms were empirically distinguishable from symptoms of depression and anxiety (8). This suggests that symptoms unique to CG may be overlooked if grief and depression are assumed to be part of the same condition.
Stroebe and others (1) argued that, despite many recent advances in bereavement research, there remains a need for greater clarity in defining CG, finer delineation of the overlap and distinction between grief and other symptoms such as depression, and further validation of the concept of CG. The present study addressed each of these issues. The study used data from 2 recently completed investigations of the prevalence (9) and treatment of CG (10). The samples were unique for 2 reasons. First, the subjects were psychiatric outpatients who had significant death losses. Second, the losses occurred at least 3 months ago, most well over 1 year ago. Nearly all previous investigations of dimensions of grief have used nonpsychiatric samples with recent losses. Although CG has been found to be prevalent among psychiatric outpatients (9,11), few researchers have studied symptoms of CG in patient samples. In addition, Prigerson and others (12) recommended that future studies of the signs and symptoms of grief and depression be conducted using individuals whose most significant death loss occurred at least 18 months ago.
Specifically, the present study had 2 objectives. The first was to determine whether symptoms conceptualized as dimensions of CG could be identified and distinguished from symptoms conceptualized as dimensions of depression. The second was to determine whether the dimensions of grief and depression would be differentially affected by group therapy for CG.
Method
Data Collection for the Present Study
To address the first objective of the present study, data from a large number of patients were required. Data from 398 patients were available from 2 previously conducted investigations (9,10) in which patients provided ratings on self-report measures of grief and depression. One of the previous investigations was a study of the prevalence of significant death losses and CG among psychiatric outpatients (9). The investigation involved collecting data from patients at 2 psychiatric outpatient clinics in Vancouver, British Columbia: the Assessment and Treatment Services, Department of Psychiatry, Lions Gate Hospital, and the Outpatient Psychiatry Program, Department of Psychiatry, Vancouver General Hospital. Data from 235 patients from the prevalence investigation were used in the present study to address the first objective. All these patients had at least 1 significant death loss. To determine whether they met criteria for CG, the patients completed 3 brief questionnaires. They included a set of Pathological Grief Items (PGI), adapted from work by Prigerson and others (13), the Impact of Events Scale (IES; 14), and the Social Adjustment Scale - Self Report (SAS-SR; 15). The PGI and IES were completed for the 1 or 2 most significant death losses in the patient’s life.
To meet criteria for CG, the patient had to have a score of 10 or higher on the PGI, or on the Intrusion Subscale of the IES, or on the Avoidance Subscale of the IES for at least 1 loss and a score of 2.0 or higher on 1 of the 6 subscales of the SAS-SR. The loss must have occurred at least 3 months before. These criteria were selected, after a review of previous studies, to include patients with at least moderate grief symptomatology and social role dysfunction and to rule out immediate grief reactions. Sixty percent of the 235 patients met criteria for CG. Most patients who met the criteria considerably exceeded the cut-off scores on the questionnaires.
The second investigation that provided data for the present study was a randomized clinical trial of 2 forms of time-limited, short-term group therapy for CG (10). The trial was conducted at the Psychiatric Treatment Clinic of the Department of Psychiatry, University of Alberta Hospital Site in Edmonton, Alberta. Pretherapy data from 163 patients in the trial were used in the present study to address the first objective. All these patients had at least 1 significant death loss and all met criteria for CG as described above. Most patients considerably exceeded the cut-off scores.
To address the second objective of the present study, data from 119 of the 163 patients from the Edmonton trial were available. These 119 patients completed group therapy for CG. The pretherapy and posttherapy data from these 119 patients were used to address the second objective.
Patients
The diagnostic, demographic, and loss information presented in this section describe the combined sample (n = 398) of patients from the 2 studies. Patients provided written informed consent before participating in the studies. The patients received DSM-IV diagnoses that were determined jointly by an intake interviewer and a psychiatrist. Almost all the patients (87%) received an Axis I diagnosis. The most frequent primary diagnoses were major depression (60%), dysthymia (15%), and substance abuse (9%). About one-half of the patients (48%) received one or more Axis II diagnoses. The most frequent of these diagnoses were obsessive–compulsive (29%), dependent (28%), avoidant (17%), and borderline (15%). Slightly more than one-third of the patients (39%) received both Axis I and Axis II diagnoses.
The average age of the patients was 42.3 years. Sixty-six percent were women. Thirty-six percent were married or living with a partner, 29% were separated or divorced, 9% were widowed, and 26% had never been married. Seventy percent had at least a high school education, and 53% were employed. The types of losses reported by the patients and their prevalence were parent (46.3%), partner (7.8%), sibling (8.1%), friend (9.6%), child (7.6%), grandparents (5.5%), and other (13.4%). The average time since the loss(es) was 9.7 years (SD 10.2, range 0.25 to 47.0). For approximately one-half of the patients, the time since the loss exceeded 5 years.
Measures
Three self-report questionnaires were used to assess CG symptoms. They included the PGI (13), the IES (14), and the 13-item Texas Revised Inventory of Grief (TRIG; 16). These measures were chosen because they purport to assess different aspects of an individual’s grief response and have been used in many research studies of grief. The PGI addresses symptoms of traumatic distress and separation distress. The IES focuses on 2 major aspects: the intrusion of thoughts, images, and feelings about the death and attempts to avoid such feelings and cognitions. The TRIG was designed to assess symptoms associated with separation distress. Patients in both studies completed the 3 grief measures for their 1 or 2 most significant death losses, following their initial visit to the outpatient clinics. For the present study, scores on the 3 grief measures for the most troublesome loss were used. This was identified as the loss with the highest intrusion or avoidance score from the IES.
Depressive symptoms were assessed using the Beck Depression Inventory-II (BDI-II; 17). This self-report measure reflects the diagnostic criteria for major depressive disorders as described in the DSM-IV. Patients in both studies completed the BDI-II upon their initial presentation to the outpatient clinics. Patients in the Edmonton outcome study also completed the 3 grief measures and the BDI-II a second time, following their completion of short-term group therapy for CG.
Therapies
Patients in the Edmonton outcome study were randomly assigned to either interpretive or supportive group therapy for CG. The therapies were guided by treatment manuals and differed as intended according to assessments of therapist adherence to the manuals. Patients were scheduled for weekly 90-minute sessions for 12 weeks. In interpretive therapy, the primary objective was to enhance the patients’ insight about repetitive conflicts (intrapsychic and interpersonal) and trauma that are associated with the losses and that were assumed to serve as impediments to experiencing a normal mourning process. In supportive therapy, the primary objective was to improve the patients’ immediate adaptation to their life situations. It was assumed that improvements in symptomatology and social (role) functioning could be achieved through the provision of support and problem solving.
Management of medication was conducted by 1 of 2 project psychiatrists. Fifty-seven percent of the therapy completers were prescribed psychotropic medication prior to the start of the therapy groups and were maintained on a constant dosage for the duration of the study. In nearly all cases (92.3%), the medication was an antidepressant (tricyclic, selective serotonin reuptake inhibitor, or other). In the remaining cases (7.7%), an anxiolytic, antipsychotic, or hypnotic was prescribed. Statistical analyses revealed no significant differences between the 2 forms of therapy in initial use or pattern of use during therapy.
Data Analyses
Data analyses proceeded in 2 parts. First, the 56 item scores from the 3 grief measures and the BDI-II that were provided by the 398 patients were subjected to a principal components analysis (PCA) with varimax rotation. The PCA was conducted to identify the dimensions underlying the grief and depression items. Dimensions had to have an eigenvalue of at least 1.0 to be retained, and Cattell’s (18) scree test was used to ascertain the number of dimensions to extract. Items were assigned to factors based on their highest loading (minimum acceptable loading of 0.40). The subject to variable ratio was 7:1. After the dimensions were identified, dimension scores were calculated and the correlations among the dimensions were examined using Pearson correlations. Reliability of the dimensions was examined using Cronbach’s alpha.
Second, to test the validity of the dimensions, we examined whether the dimension scores changed as a function of treatment for the 119 patients who completed therapy in the Edmonton outcome study. Treatment (interpretive vs supportive) by time (pretherapy vs posttherapy) repeated-measures analyses of variance (ANOVAs) were used to examine whether scores on the dimensions changed across the treatment period and whether there were any differences in change between the 2 forms of therapy. We also calculated effect sizes to determine the magnitude of change on the dimensions. Comparisons of the effect sizes were performed using paired-samples t-tests to determine which dimensions changed the most and least following group therapy for CG. As well, because about one-half of our sample were on psychotropic medication, we examined the effect of medication on change in the 5 dimensions. Repeated-measures ANOVAs were used to examine this issue.
Results
Defining Dimensions of Grief and Depression
The PCA of the 56 items generated 6 dimensions. Because the sixth dimension had only one item, it was discarded. The 5-dimension solution accounted for 52.9% of the variance in the item ratings (a table of the item loadings is available from the authors upon request). The first dimension accounted for 14.8%. Five of the 6 PGI items, all of the items from the Intrusion Subscale of the IES, and 1 item from the Avoidance Subscale of the IES loaded highly on this factor. The content of most items reflects intrusive grief symptoms such as distressful thoughts and feelings about the lost person, yearning, searching, and numbness or disbelief. These symptoms are most often associated with CG. Thus, we labelled this dimension grief symptoms. The second dimension accounted for 13% of the variance. Only the 13 items of the TRIG loaded highly on this dimension. Many of these items also reflect intrusive grief symptoms such as persistent emotional distress, rumination, and painful memories. In addition, several items reflect attitudes suggesting a lack of acceptance of the death. We labelled this dimension grief experiences and attitudes. The third dimension accounted for 11% of the variance and consisted of 12 of the 21 BDI-II items. Many items reflect self-blame and despair. We labelled this dimension depression-cognitive. The fourth dimension, accounting for 8.3% of the variance, consisted of 7 of the 8 items from the Avoidance Subscale of the IES. These items reflect an active quality of avoiding thoughts and feelings associated with the lost person. We labelled this dimension grief avoidance. The fifth dimension accounted for 6.8% of the variance. The remaining 9 items of the BDI-II loaded highly on this dimension. Many represent the somatic components of depression, notably fatigue and lack of energy. We labelled this dimension depression-somatic.
The reliability (alpha) coefficients for each dimension were high (ranging from 0.83 to 0.94), indicating that the dimensions of grief and depression are internally consistent. The correlations among the dimensions are presented in Table 1. The grief symptoms and grief experiences and attitudes dimensions shared much variance. This is not surprising considering the conceptual overlap between the 2. Similarly, the 2 depression dimensions shared much variance. In contrast, the correlations between the grief dimensions and the depression dimensions were low, thus providing evidence for their independence.
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Table 1 Correlations among the grief and depression dimensions
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Grief experiences and attitudes
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Grief avoidance
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Depression-cognitive
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Depression-somatic
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Grief symptoms
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0.75
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0.62
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0.19
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0.19
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Grief experiences and attitudes
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—
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0.54
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0.24
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0.22
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Grief avoidance
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—
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—
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0.21
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0.20
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Depression-
cognitive
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—
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—
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—
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0.69
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All correlations are significant at P < 0.001.
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