Bereavement care interventions: a systematic review

1472-684X-3-3 1472-684X Research article Bereavement care interventions: a systematic review Forte L Amanda forte@email.chop.edu Hill Malinda hillme@email.chop.edu Pazder Rachel rpazder@rosemont.edu Feudtner Chris feudtner@email.chop.edu

Pediatric Advanced Care Team and Pediatric Generalist Research Group, Division of General Pediatrics, The Children's Hospital of Philadelphia, PA, USA

Department of Social Work and Family Services, The Children's Hospital of Philadelphia, PA, USA

The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA

Center for Bioethics, University of Pennsylvania, Philadelphia, PA, USA

BMC Palliative Care 1472-684X 2004 3 1 3 http://www.biomedcentral.com/1472-684X/3/3 15274744 10.1186/1472-684X-3-3 20 2 2004 26 7 2004 26 7 2004 2004 Forte et al; licensee BioMed Central Ltd. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Bereavement intervention systematic review

Abstract

Background

Despite abundant bereavement care options, consensus is lacking regarding optimal care for bereaved persons.

Methods

We conducted a systematic review, searching MEDLINE, PsychINFO, CINAHL, EBMR, and other databases using the terms (bereaved or bereavement) and (grief) combined with (intervention or support or counselling or therapy) and (controlled or trial or design). We also searched citations in published reports for additional pertinent studies. Eligible studies had to evaluate whether the treatment of bereaved individuals reduced bereavement-related symptoms. Data from the studies was abstracted independently by two reviewers.

Results

74 eligible studies evaluated diverse treatments designed to ameliorate a variety of outcomes associated with bereavement. Among studies utilizing a structured therapeutic relationship, eight featured pharmacotherapy (4 included an untreated control group), 39 featured support groups or counselling (23 included a control group), and 25 studies featured cognitive-behavioural, psychodynamic, psychoanalytical, or interpersonal therapies (17 included a control group). Seven studies employed systems-oriented interventions (all had control groups). Other than efficacy for pharmacological treatment of bereavement-related depression, we could identify no consistent pattern of treatment benefit among the other forms of interventions.

Conclusions

Due to a paucity of reports on controlled clinical trails, no rigorous evidence-based recommendation regarding the treatment of bereaved persons is currently possible except for the pharmacologic treatment of depression. We postulate the following five factors as impeding scientific progress regarding bereavement care interventions: 1) excessive theoretical heterogeneity, 2) stultifying between-study variation, 3) inadequate reporting of intervention procedures, 4) few published replication studies, and 5) methodological flaws of study design.

Background

Give sorrow words; the grief that does not speak

Whispers the o'er fraught heart and bids it break.

Shakespeare, Macbeth IV, iii, 209

Grieving the death of a loved one has an ancient history: from time immemorial, cultures have provided the bereaved with advice and rituals to address – and express – the experience of grief 1. Over the past several decades, efforts to aid the bereaved have increasingly focused on the physical and psychological morbidity, and the spiritual suffering and social isolation associated with bereavement. The resulting plethora of intervention options, ranging from mutual-help support groups to prescribed pharmacotherapy and professionally led psychotherapy, is striking, as is the panoply of settings in which bereavement care can be found: hospitals, hospices, churches, palliative care units, community-based services, and bereavement-specific foundations all provide an array of bereavement care interventions. This welter of activity testifies to the broadly valued goal of decreasing the severity of bereavement-related symptoms.

Given the abundance of care options, what is the best way to care for a bereaved person? Numerous studies measuring the impact of bereavement interventions have been published in diverse journals, yet no consensus has emerged in the medical, mental health, or social work communities regarding whether one form of treatment is preferable to another 2345. We therefore have conducted a systematic review of bereavement care interventions. Our goal is to present a comprehensive yet coherent synthesis of the current literature that will promote the advancement in the quality of care and research on behalf of bereaved individuals.

Methods

Data sources

To identify studies in the traditional medical literature as well as the complementary and alternative medicine literature, we searched the following databases: MEDLINE; PsychINFO; Cumulative Index to Nursing and Allied Health (CINAHL); BIOSIS Previews; ISI Science Citation Index Expanded and Social Sciences Index; Evidence Based Medicine Reviews (EBMR), including the Cochrane Database of Systematic Reviews (DSR), the Cochrane Controlled Trial Registry (CCTR), Database of Abstracts of Reviews of Effectiveness (DARE), and the American College of Physicians' (ACP) Journal Club Review; Sociological Abstracts; Alt HealthWatch; and Wilson Web from 1966 to 2003. We identified all relevant articles on bereavement care interventions by using the primary search terms of "bereaved or bereavement" and "grief", combined with secondary descriptors of "intervention or support or counselling or therapy" and "controlled or trial or design".

Study selection

Our inclusion criteria specified that each study: 1) addressed the treatment of bereaved individuals, and 2) included an evaluation of a selected method of therapy aimed at reducing the grief reaction due to bereavement. We considered only articles written in the English language. We then reviewed the titles and abstracts of all articles we retrieved through our initial database search, and obtained the full texts of all applicable studies. We also reviewed the references in all applicable studies for additional pertinent studies.

Data extraction

The full articles of all studies that met inclusion criteria and passed subsequent title and abstract reviews were retrieved and examined independently by two of the authors. Each article was reviewed for measured outcomes, patient and decedent characteristics, and intervention characteristics. These measures included sample size, type of intervention, length of intervention, patient's relationship to the deceased, time since the bereaved death, and patient demographics. Data was extracted and any disagreements were resolved through discussion, clarification, and consensus within the research team.

Characteristics of reviewed studies

The initial literature search generated 737 citations. Elimination of duplicate citations yielded 340 references. 2 studies, written in Chinese and Spanish, were excluded. Reviewing the titles culled the sample to 243 citations, and a review of the abstracts found 87 of these to be potentially relevant. Of these, 9 were dissertations, 2 were irretrievable, 2 were duplicate publications of the same study, and 15 were ineligible because they did not meet our inclusion criteria. The resulting set of 74 articles was subject to review for data extraction. A list of all citations found, including those excluded from this analysis, is available [see Additional file 1].

Additional File 1

All citations. This file contains citations to all of the studies identified by our literature search and screened for inclusion in this review, as well as other scholarly works consulted during the conduct of this review.

Click here for file

Of the 74 studies that met inclusion criteria, almost 6,000 participants within these studies experienced a multitude of losses – of parents, spouses, children, and other loved ones who had died from a wide range of causes, both sudden and protracted. The therapies utilized and outcomes evaluated varied widely. Heterogeneity among both the outcomes and the measures used to assess similar outcomes precluded an effort to summarize data across studies, even in the form of generic effect-size measures. Furthermore, for a significant portion of the studies, concerns regarding the internal or external validity of the reported results cautioned against making quantitative summary statements regarding treatment effects.

Results

The 74 studies selected for detailed review evaluated diverse types of interventions designed to ameliorate the adverse physical and psychological outcomes associated with bereavement. These interventions can be classified according to various schemes, including their underlying theoretical framework (ranging from Freudian psychoanalysis to neurotransmitter imbalances), the format of the intervention (individual, group, family, marital), the timing of the intervention (acute, intermittent crisis, chronic), the tasks assigned to the bereaved (ranging from verbalizing feelings to taking medication), or the population targeted for the intervention (children, adults, seniors). We chose to organize this review on the basis of the social framework used to implement the intervention (that is, either personalized structured therapeutic relationships or less personal systems-level interventions), as this attribute of the interventions emerged as the most verifiable and salient measure.

Structured therapeutic relationship

Eight studies feature pharmacotherapy, but only four compared active therapy to non-pharmacotherapy controls, and only one study clearly reported their random allocation method (Table 1) 678910111213. These studies targeted adults and seniors, ranged in sample size from 10–80 subjects, and used a variety of drugs, including tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRI), buprioion, and benzodiazepines. Overall, these studies demonstrated a statistically significant beneficial effect of pharmacotherapy on ameliorating symptoms of depression and improving subjective sleep quality 6789101113. These benefits persisted only as long as the subjects continued to receive pharmacotherapy. Pharmacotherapy was found, however, to have a mixed effect on bereavement intensity as measured by symptoms of grief (i.e., Texas Revised Inventory of Grief, Inventory of Complicated Grief). For example, Warner and colleagues (2001) did not find evidence of an effect of benzodiazepines (diazepam) on bereavement-related grief intensity12. One study combined pharmacotherapy with psychotherapy in a 16-week double-blinded factorial design trial of nortriptyline (NT) and interpersonal psychotherapy 6. The 80 patients were randomly assigned to one of four treatment conditions: NT plus interpersonal psychotherapy, NT plus medication clinic (i.e., no interpersonal psychotherapy), placebo pill plus interpersonal psychotherapy, and placebo pill plus medication clinic (i.e., no interpersonal psychotherapy conditions). Details of the psychotherapy were not described. While the results displayed a statistically significant benefit of nortriptyline over placebo regarding remission of depression, none of the treatment conditions were associated with diminishment of grief.

Table 1

Pharmacotherapy Interventions

Medication

Pop

Num*

TSL (days)

Dose

DT (days)

Key Outcome Measures

Article

Nortriptyline

Senior

Y-NE

80/66

216–279

Steady-state plasma level: 50–120 ng/mL

112

Depression (HAM-D); Grief (TRIG)

Reynolds, Miller, et al, 1999**

Senior

Y-NE

27/27

210 (mean)

Steady-state plasma level: 79.9+/-28.3 ng/mL

Daily dose: 70.8+/-22.2 mg

<180

Sleep (PSQI); Depression (HAM-D, BDI)

Taylor, Reynolds, et al, 1999

Senior

30/24

276

Steady-state plasma level: 72.7 ng/mL

Daily dose: 53.0 mg

112

Sleep (PSQI)

Pasternak, Reynolds, et al, 1994

Senior

13/13

150–750

Daily dose: 49.2 mg

9–184

Depression (HAM-D, BDI, BSI); Grief (TRIG, JGI); Sleep (PSQI)

Pasternak, Reynolds, et al, 1991

Nortriptyline and Paroxetine

Adult

21/15

183–4158

PT Daily dose: 20–50 mg

NT Daily dose: 50–160 mg

120

Depression (HAM-D); Grief (ICG); Sleep (PSQI)

Zygmont, Prigerson, et al, 1998

Desipramine

Adult

10/9

Daily dose: 75–150 mg

Depression (HDRS, CGI, Raskin DS); Grief (Separation Distress)

Jacobs, Nelson, et al, 1987

Bupropion

Adult

22/14

42–56

Daily dose: 150–300 mg

Grief (TRIG, ICG); Depression (HAM-D)

Zisook, Schuchter, et al, 2001

Diazepam

Senior

35/30

<14

2 mg/pill, self-administered

<42

Bereavement (BPQ)

Warner, Metcalfe, et al, 2001

Notes: * All Ns are reported as (starting population of bereaved individuals/bereaved population completing all follow-ups), unless only study included only one assessment. ** Study also included psychotherapy condition. Legend: Pop, Target Population; CG, Control Group; RA, Random Assignment; Num, Number of subjects; TSL, Time Since Loss; DT, Duration of Trial; NA, Not Applicable; NR, Not Reported; UC, Unclear; Y, Yes; N, No; Y-NE, Randomization mentioned, but allocation method not explicitly stated; RS, Randomization Subverted.

Support groups or counselling constituted the intervention in 39 studies, of which 23 had control groups and 15 claimed random allocation, yet only three of these included clearly described allocation methods (Table 2) 141516171819202122232425262728293031323334353637383940414243444546474849505152. Ten of these were mutual/self-help, with the majority taking the form of informal group therapy. The remaining 29 studies were professionally led support groups targeting select subgroups including parentally bereaved children, college students, and seniors, as well as many specific adult populations. Program implementation across studies varied even further. This variation was found in terms of number of sessions (one to 25), whether the sessions proceeded with full-fledged patient-driven discussion or highly structured protocols, whether attendance was mandatory or individually motivated, as well as in the nature of the group leadership and the format (individual, group, or marital). Perhaps due to these or other differences in the interventions, some studies documented study treatment effects 2226293031333452 while other studies showed no effect 151727374651.

Table 2

Support/Counselling Interventions

Type

Format

Pop

Num

TSL (days)

Key Outcome Measures

Article

Mutual/Self-help

Individual

Adult

Y-NE

162/62

~30

Psychiatric Functioning (GHQ); Social Support/psychological and psychophysiological variables (author-created)

Vachon, Lyall, et al, 1980

Mutual/Self-help (included professionally-lead groups)

Group

Senior

339/295

30–60

56, 365 days

Self-Esteem (Rosenberg's Self-Esteem Scale); Life Satisfaction (LSI-A); Depression (GDS); Grief (TRIG)

Caserta & Lund, 1983

Mutual/Self-help

Group

Senior

34–474

21 days; 7 sessions

Domain Specific State Locus of Control (Zeigler-Reid State Locus of Control Measure); Trait Locus of Control (I-E); Distress (BSI, GSI)

McKibbin, Guarnaccia, et al, 1997

Mutual/Self-Help

Group

Adult

113/67

90–365

63 days; 9 sessions

Depression (GHQ, BDI); Anxiety (STAI); Social Functioning (SAS); Social Support (SSQ)

Tudiver, Hilditch, et al, 1992

Mutual/Self-help

Group

Adult

Y-NE

113/112

90–365

63 days

Healthcare visit rates (Family Physician, Specialist, Psychiatrist)

Tudiver, Permaul-Woods, et al, 1995

Mutual/Self-help

Group

Adult

38/21

90–750

70 days; 10 sessions

Treatment Expectancy (Expectancy Scale); Depression (BDI); Avoidance, Anxiety (Social Anxiety and Distress Scale); Enjoyability (Pleasant Events Scale); Life Satisfaction (Life Satisfaction Scale)

Walls & Meyers, 1985

Mutual/Self-help

Group

Adult

721/502

~1290

365 days; >3 sessions

Depression, Anxiety, Somatization (Hopkins Symptom Checklist); Self Esteem, Well-being, Mastery (Not reported)

Lieberman & Videka-Sherman, 1986

Mutual/Self-help

Group

Adult

667/391

365–1095

365 days

Depression, Anxiety, Somatization (Not reported); Self Esteem (Rosenberg 1965); Life Satisfaction, Mastery, Medication (Not reported); Social Functioning Parental Functioning Attitudes (BPQ)

Videka-Sherman & Lieberman, 1985

Mutual/Self-help

Group

Adult

Y-NE

61/55

120–1095

84 days; 12 sessions

Avoidance/Intrusion (IES); Stress Symptoms (SRRS); Depression (BDI); Mental Distress (BPRS, SCL-90); Social Functioning (SAS-SR); Overall Functioning (GAS)

Marmar, Horowitz, et al, 1988**

Mutual/Self-help

Group

Adult

53/33

<730

8 sessions, optional 4

Psychosomatic Symptoms (SCL-90 subscales: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism, GSI)

Rogers, Sheldon, et al, 1982

Professionally Lead

Individual

Adult

493/225

120

1 day; 1 session

Grief (HGRC)

Kaunonen, Tarkka, et al, 2000

Professionally Lead

Family

Adult

Y-NE

50/30

1–2

1–120 days; up to 8 sessions

General Health Questionnaire (self-rated); Anxiety, Depression (Leeds Scale)

Forrest, Standish, & Baum, 1982

Professionally Lead

Family

Adult

334/161*

<1–180

7–70 days; up to 10 sessions

Medical Illness (CMI, MMPI); Psychiatric Illness (Boston Bereavement, Mood Inventory); Family Functioning (Ferriera-Winter, Bodin Drawing); Crisis Coping (Intrapersonal, Family, Job/Financial, Social); Social Cost (Gross Income, Living Expenses, Absenteeism, Economic Loss)

Williams, Lee, & Polak, 1976 Polak, Egan, et al, 1975

Professionally Lead

Family

Adult

176/86*

<1–180

7–70 days; up to 10 sessions

Neurotic Symptoms Scale; Bodin Family Closeness; Crisis Coping Scale; Religious helping of others; Authoritarian Family Functioning; Depression; Monthly Income; Monthly Expenses; Social Costs; Bereavement Adjustment

Williams & Polak, 1979

Professionally Lead

Family

Adult

77/37*

>360 days

Personal and social phenomena of death (structured interview)

Oliver, Sturtevant, et al, 2001

Professionally Lead

Family

Child

Y-NE

72/55

<730

15 sessions

Depression (CDI, CBCL, PERI Demoralization Scale); Parental Warmth (CRPBI); Family Cohesion (Family Environment Scale); Parent perception of support (author-created scale); Family Coping (F-COPES)

Sandler, West, et al, 1992

Professionally Lead

Group

Senior

28/11

90–7300

<140 days; up to 20 sessions

Social Support (ASSIS); Affect/Mood (PANAS); Emotional/Social Loneliness (ESLI)

Stewart, Craig, et al, 2001

Professionally Lead

Group

Adult

197/166

<180

70 days; 10 sessions

Grief (TRIG, GRI); Distress (POMS); Depression and Anxiety (SIGH-AD)

Goodkin, Blaney, et al, 1999

Professionally Lead

Group

Adult

Y-NE

242/185

0–35

77 days; 3 sessions

Distress (POMS-TMD, Anxiety-tension, Depression-dejection, Anger-hostility, Confusion-bewilderment, Overall emotional disturbance); Self-Esteem (Rosenberg 1965 scale)

Swanson, 1999

Professionally Lead

Group

Adult

Y-NE

150/120

30–240

270 days

Depression (CES-D, BDI); Anxiety (A-Sta); Somatic Symptoms (SOM); Emotional Symptoms (EMOT); Life Satisfaction (Lsat, SelfAnch)

Kay, Guernsey de Zapien, et al, 1993

Professionally Lead

Group

Adult

Y-NE

119/119

<180

70 days; up to 10 sessions

Immunological measures (CD3+CD4+ cell count, CD3+CD8+ cell count, CD4/CD8 ratio, CD3+ cell count, CD4 cell count, Lymphocyte count, T-lymphocyte count); Neuroendocrine measure (Plasma cortisol level)

Goodkin, Feaster, et al, 1998

Professionally Lead

Group

Adult

Y-NE

110/80

~730

28 days; 8 sessions

Coping and Adaptation (TAT)

Balk, Lampe, et al, 1998

Professionally Lead

Group

Adult

Y-NE

36/36

<180

70 days; up to 10 sessions

Plasma Viral Load (HIV-1 RNA copy number)

Goodkin, Baldewicz, et al, 2001

Professionally Lead

Group

Adult

159/127

42–140

Up to 25 sessions

Social Support (SSES); Group Involvement (Liberman & Videka-Sherman, 1986); Depression (CES-D, POMS-D); Anger (POMS-A); Anxiety (POMS-T); Stress (IES)

Levy, Derby, et al, 1993

Professionally Lead

Group

Adult

121

30–4745

30–365 days

Grief (HGRC subscales: Despair, Panic behavior, Personal growth, Blame and Anger, Detachment, Disorganization)

DiMarco, Menke, & McNamara, 2001

Professionally Lead

Group

Adult

139/107

90–17155

84 days; 12 sessions

Avoidance/Intrusion (IES); Grief (TRIG); Interpersonal Distress (IIP); Social Functioning (SAS-SR); Depression (BDI); Anxiety (STAI); Mental Distress (BSI, GSI); Self-Esteem (SES); Physical Functioning (SF-36); Symptomatic Distress (SCL-90)

Piper, McCallum, et al, 2001**

Professionally Lead

Group

Adult

83/70

<30–8030

49 days; 7 sessions

Physical, Emotional, and Social Functioning (author created measures); Self Esteem (Rosenberg, 1962); Locus of Control (I-E); Life satisfaction (Neugarten, Havighurdt, & Tobin, 1961); Attitude Toward Women (Spence & Helmreich, 1972, Gump 1972)

Barrett, 1978

Professionally Lead

Group

Adult

392/77

56 days

Distress (BSI); Group Process and Satisfaction (author created questionnaire)

Glajchen & Magen, 1995

Professionally Lead

Group

Adult

174/138

780

730 days

Motives for joining (Lieberman 1979); Interpersonal relations (Porat 1987); Group leadership style (Porat 1987); Perceived contribution of treatment on recovery

Geron, Ginsberg, & Solomon, 2003

Professionally Lead

Group

Adult

21/21

70 days; up to 10 sessions

Perceived Social Support (PRQ); Perceived Stress (PSS)

Davis, Hoshiko, et al, 1992

Professionally Lead

Group

Adult

21/21

365–3650

52 days; up to 8 sessions

Depression (CDI); Anxiety (HSC-25); Knowledge of Death and Bereavement (KDBQ)

Stoddart, Burke, & Temple, 2002

Professionally Lead

Group

Adult

90–1095

<1095 days; unlimited sessions

Grief (TRIG); Social Network (SNM, SNG)

Forte, Barrett, & Campbell, 1996

Professionally Lead

Group

Adult

12/5

60–780

28 days; 8 sessions

Emotional Distress (EPI); Family Adjustment (FACES-III); Social Adjustment (SAS-SR)

Heiney, Ruffin, & Goon-Johnson, 1995

Professionally Lead

Group

Child

Y-NE

17/17

>730

42 days; 6 sessions

Self-Esteem (PH); Depression (CDI); Behavior (CBCL-TRF, CBCL-YSR)

Huss & Ritchie, 1999

Professionally Lead

Group

Child

38/29

<900

300 days; 12 sessions

Depression (BID); Attitude/ Conception of Death (ATCD)

Shilling, Koh, et al, 1992

Professionally Lead

Group

Child

18/18

<730

52 days; 8 sessions

Bereavement Survey (author created); Loss Resolution (LRS-Modified); Distress and Somatic Complaints (ALAC)

Opie, Goodwin, Finke, et al, 1992

Professionally Lead

Group

Child

6/6

240–1020

42 days; 6 sessions

Psychological measures (Lewis Counselling Inventory, IPAT)

Quarmby, 1993

Professionally Lead

Group

Child

4/4

<90

77 days; 11 sessions

Self-Esteem (Piers-Harris Self-Concept Scale); Descriptive (Risk Impact, Negative Chain Events, Opening Up Opportunities)

Zambelli & DeRosa, 1992

Professionally Lead

Couple/ Marital

Adult

Y-NE

57/31

Mean of 6 sessions

Grief (TRIG); Irritability, Depression, Anger (IDA)

Lilford, Stratton, et al, 1994

Notes: * Families, not individuals. ** Study also included psychotherapy condition. Legend: Type, Type of Intervention; Format, Format of Intervention; Pop, Target Population; CG, Control Group; RA, Random Assignment; Num, Number of subjects; TSL, Time Since Loss; DT, Duration of Trial; NA, Not Applicable; NR, Not Reported; UC, Unclear; Y, Yes; N, No; Y-NE, Randomization mentioned, but allocation method not explicitly stated; RS, Randomization Subverted.

Several studies documented substantial spontaneous improvements in bereavement symptomology in the control groups. Kay and others (1993) report a bereavement intervention for Mexican-American widows 33. They found that all widows improved on all depression scales, state anxiety, life satisfaction, and emotional and somatic symptom scales over the course of two years. However, those widows in the experimental support group exhibit significantly improved changes in these scores. Tudiver and colleagues (1992) conducted a mutual-help support group for recently bereaved widowers 17 that can be compared to Vachon and colleagues' (1980) and Barrett's (1978) widow studies 1439. Tudiver and others found significant improvement over time (baseline to eight months) for all widowers, but found no significant differences between those who received treatment and a comparison group of windowers who were on the wait list to receive treatment but had not.

Psychotherapy-based treatments, another form of psychological interventions, can be done in different formats (family, group, or individual), and via different approaches. Of the 25 studies that use psychotherapy as an intervention, approaches included cognitive-behavioral, psychodynamic, psychoanalytical, and interpersonal approaches, as well as combinations of these and modality and social support (Table 3)6192235385354555657585960616263646566676869707172. Seventeen of these studies utilized control groups, only 13 claimed randomization, and only five of these clearly stated their method of allocation.

Table 3

Psychotherapy Interventions

Type

Format

Pop

Num

TSL (days)

Key Outcome Measures

Article

Cognitive-behavioral

Individual

Senior

58/NR

120–180

70 days; 4 sessions

Mastery (Personal Mastery Scale); Well-being (MHI subscales, ABS Subscale, PERI self-esteem); Distress (PERI Demoralization Scales, MHI subscales)

Reich & Zautra, 1989

Individual

Senior

4/4

540–730

98 days; 14–18 sessions

Distress (SUDS); Grief (ICG); Depression (BDI); Anxiety (BAI)

Harkness, Shear, et al, 2002**

Individual

Adult

30/25

>90

35 days; 10 sessions

Avoidance/Intrusion (IES); Anxiety (SCL-90); Depression (SCL-90); Mood (POMS)

Lange, van de Ven, et al, 2001

Individual

Adult

Y-NE

26/14

180–7300

70 days; 6 sessions

Depression (Wakefield, BDI); Physical Symptoms (Mawson et al, 1981); Fear (FQ); Grief (TRIG); Avoidance (Bereavement Avoidance Tasks)

Sireling, Cohen, & Marks, 1988

Group

Adult

Y-NE

261/147

46–229

84 days; 8 sessions

Mental Distress (BSI, GSI); PTS Symptoms (TES); Grief (GES); Physical Health (HHB); Marital Strain (DAS)

Murphy, Johnson, et al, 1998 Murphy, 1997

Group

Adult

Y-NE

110/80

~730

28 days; 8 sessions

Coping and Adaptation (TAT)

Balk, Lampe, et al, 1998

Group

Adult

38/21

90–750

70 days; 10 sessions

Treatment Expectancy (Expectancy Scale); Depression (BDI); Avoidance, Anxiety (Social Anxiety and Distress Scale); Enjoyability (Pleasant Events Scale); Life Satisfaction (Life Satisfaction Scale)

Walls & Meyers, 1985

Group

Adult

8/8

>30

56 days; 8 sessions

Avoidance/Intrusion (IES); Depression (BDI, SCL-90-R); Anxiety (SCL-90-R, STAI); Grief (GRI); Distress (PERI Demoralization)

Sikkema, Kalichman, et al, 1995****

Group

Child

19/18

<730

Behavior (BRIC-S, BRIC-H); Depression (DSRS); Grief (BP)

Hilliard, 2001

Psycho-dynamic

Individual

Senior

228

~60

<180 days; Unlimited sessions

Number of Office Visits, Types of Illnesses

Gerber, Wiener, Battin, et al, 1975

Individual

Senior

Y-NE

33/30

90–1170

14 days; 4 sessions

Mental Distress (BSI); Depression (GDS); Hopelessness (GHS); Avoidance/Intrusion (IES); Mood (PANAS)

Segal, Bogaards, et al, 1999

Individual

Adult

66/56

<49

90 days; up to 9 sessions

General Health(general health questionnaire)

Raphael, 1977

Individual

Adult

72/63

60–462

12–20 sessions

Avoidance/Intrusion (IES-A, IES-I); Depression (SCL-90); Anxiety (SCL-90); Total Pathology (SCL-90); Stress-Intrusion (SRRS); Neurotic Symptoms (BPRS)

Horowitz, Weiss, et al, 1984

Individual

Adult

Y-NE

12/6

365–3650

196 days

Depression (Wakefield); Grief (TRIG) Phobic Avoidance (FQ); Hostility/Anger/Guilt (HAG); Attitude to self and deceased (author-created scales); Avoidance (Bereavement Avoidance Tasks); Physical Symptoms (Maddison & Viola, 1968); Compulsive Behavior (Compulsive Activity Checklist); Social Adjustment (Watson & Marks, 1971)

Mawson, Marks, et al, 1981

Individual

Adult

1/1

<180

112 days; 10 sessions

Grief (Grief Scale); Coping (CRI)

Orton, 1994

Group

Senior

150/117

<365–7300

540 days; 6 sessions

Depression (BDI); Socialization (RSAS)

Constantino, 1988*****

Psycho-dynamic

Group

Adult

Y-NE

56/53

120–330

8 sessions

Depression, Anxiety, Somatization (Hopkins Symptom Checklist); Grief Intensity, Preoccupation, Guilt, Anger (Lieberman & Videka-Sherman, 1986); Psychological Distress (Bradburn Affect Balance Scale); Locus of Control (Pearlman et al, 1981); Self-Esteem (Rosenberg scale, 1965); Social Adjustment (Pearlman et al, 1981, Lieberman & Videka-Sherman, 1986)

Lieberman & Yalom, 1992

Group

Adult

50/50

90 days; 14 sessions

Grief (TRIG)

Sabatini, 1988–89

Group

Adult

139/107

90–17155

84 days; 12 sessions

Piper, McCallum, et al, 2001*

Group

Adult

Y-NE

61/55

120–1095

84 days; 12 sessions

Avoidance/Intrusion (IES); Stress Symptoms (SRRS); Depression (BDI); Mental Distress (BPRS, SCL-90); Social Functioning (SAS-SR); Overall Functioning (GAS)

Marmar, Horowitz, et al, 1988**

Group

Child

16/16

30–365

56 days

Depression (CDI); Behavior (AP, AT); Grief (BP); Family alliance (TP); Grief, family relationship (TC)

Tonkins & Lambert, 1996

Group

Child

45/37

30–3650

70 days

Trauma (CPTSRI)

Salloum, Avery, & McClain, 2001

Psycho-analytic

Group

Adult

154/59

84 days; 12 sessions

Affect (author created); Psychodynamic Work (PWORS); Severity of objectives (author created)

McCallum, Piper, & Morin, 1993

Inter-personal

Individual

Senior

Y-NE

80/66

216–279

112 days; up to 16 sessions

Grief (TRIG)

Reynolds, Miller, et al, 1999***

Behavioral and Psycho-dynamic

Individual

Adult

83/83

<1825

15–20 sessions

Anger (State Trait Anger Inventory); Anxiety (STAI); Avoidance/Intrusion (IES); Somatic/psychoneurotic symptoms (SCL-90); (Locus of Control Scale)

Kleber & Brom, 1987

Notes: * Study also included support/counselling condition. ** Treatment also included aspects of interpersonal psychotherapy. *** Study also included pharmacotherapy condition. **** Treatment also included aspects of social support. ***** Study also included social activities condition. Legend: Type, Type of Intervention; Format, Format of Intervention; Pop, Target Population; CG, Control Group; RA, Random Assignment; Num, Number of subjects; TSL, Time Since Loss; DT, Duration of Trial; NA, Not Applicable; NR, Not Reported; UC, Unclear; Y, Yes; N, No; Y-NE Randomization mentioned, but allocation method not explicitly stated.

Cognitive-behavioral therapy was employed in nine trials, four of which used individual sessions while five studies used group sessions. Murphy and colleagues (1998) studied an intervention for parents bereaved by the violent death of their children 57. The results show no treatment effect between intervention and control groups over the five main tested outcome variables. The authors then proceeded with a post-hoc subgroup analysis, which identified mothers with high Global Severity Index scores and grief at baseline as potentially benefiting from intervention during the period, while fathers who received the intervention appeared to have more posttraumatic stress disorder (PTSD) symptoms at six-month follow-up.

Kleber and Brom (1987) conducted a comparative outcome study of three forms of short-term psychotherapy 69. They compared the results of 83 patients suffering from a major loss who had been randomized into hypnotherapy (behavioral), trauma desensitization (behavioral), psychodynamic therapy, and a delayed-treatment control group. They found all three therapies successful in improving patients' conditions, but did not find any particular therapy to be significantly more effective than another. While the control group showed slight recovery, over time the three therapies were more effective in reducing symptoms of the bereavement response.

Studies of psychodynamic therapy, which strives for the patient to understand and cope better with feelings by re-experiencing them and talking them through with the aid of the therapist, was found to be quite prevalent in the bereavement care literature. Overall, the results are mixed, with more support found in the group format of psychodynamic therapy than in individual therapy. Of the studies we evaluated as psychodynamic therapy, six were individual in format, seven had a group format, and eight employed control groups; five of these claimed random allocation (one additional study randomly assigned subjects to two experimental conditions but lacked a control group).

Psychoanalysis, as exemplified by Freud, proceeds with an inward investigation of unconscious mental processes and childhood experiences as the principal therapeutic procedure. Problematic measurement methodology beset the one study that utilized a group format to provide a psychoanalytic-based intervention (with no details regarding the tasks assigned to the patients)68. This study focused primarily on the relationship between the patient's personal affect (measured by an unvalidated affect assessment scale) and a favorable treatment outcome (measured again by an ad-hoc unvalidated measure).

Behavioral therapy uses learning principles (such as behavior modification, systematic desensitization, and aversion) to eliminate or reduce unwanted reactions to either external situations, one's thoughts and feelings, and bodily sensations or functions. Behavioral therapy was used in only one study, which compared traumatic desensitization to hypnotherapy and psychodynamic therapies 69. As described in the section on cognitive-behavioral therapies above, all three therapies resulted in significant improvements from pre- to post-treatment as compared to controls, and no one therapy was found to be more effective than the others in treating bereavement-related symptoms.

Interpersonal therapy aims to improve communication skills and increase self-esteem during a short time period by focusing on a patient's behaviors and social interactions with family and friends, directly teaching how better to relate to others. Only one study used interpersonal therapy as a bereavement care intervention, and this study found no effect on grief as the only measured outcome 6.

Systems-oriented interventions

Seven studies featured interventions that altered the manner in which the healthcare system interacted with patients, family, and friends prior to death, guided by an underlying (yet not fully explicated) notion that interactions experienced by loved ones prior to death can influence the subsequent bereavement process (Table 4) 73747576777879. Six of the seven interventions provided enhanced or augmented care, in the form of palliative care, hospice care, or care coordination. One intervention gave family members the option of witnessing resuscitation efforts 79. Overall, the studies that reported systems-oriented interventions produced mixed results of efficacy, with only three of the seven studies showing any treatment effect, mostly in long-term follow-up ranging from 60–365 days post-death. In fact, no study found significant treatment effects when measured during the intervention.

Table 4

Systems-Oriented Interventions

Intervention

Pop

Num

Time of Evaluation

Key Outcome Measures

Article

Care Coordination

Relative of cancer death

365 days pre-death

56 days post-death

Anxiety (HADA, Leeds Depression and Anxiety Scale); Depression (HADD, Leeds Depression and Anxiety Scale); Social Support (Family Apgar Scale)

Addington, MacDonald, et al, 1992

Emergency Room

Relative of Emergency Room Death

100/66

180–365 days post-death

Changes in satisfaction of care, information received (author-created questionnaire)

Adamowski, Dickinson, et al, 1993

Hospice Care

Relative of cancer death

Y-NE

42 days post-death

540 days post-death

Depression (CES-D); Anxiety (Rand Health Insurance Study); General Health (Rand Health Insurance Study); Social Functioning

Kane, Klein, et al, 1986

Palliative Care

Relative of cancer death

183

60–270 days pre-death

390 days post-death

Grief (TRIG2)

Ringdal, Jordhoy, et al, 2001

Relative of cancer death

119/49

0–60 days post-death

Anxiety, Depression, Mental Exhaustion ("observations and ratings")

Haggmark & Theorell, 1988

Relative of cancer death

49/37