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Grief Assessment: Relevance & Available Measures According to the DSM-IV-TR1, symptoms of bereavement are similar to symptoms characteristic of Major Depressive Episode and include sadness, insomnia, poor appetite and weight loss. All of these symptoms can vary depending on factors such as age, gender, social and cultural influences, social supports and provision of after-care services. Further, the isolation of the dying and the subsequent isolation of the bereaved by a society in which death is often a taboo topic may contribute to the intensity of concomitant psychological symptoms and complicate. One cross-sectional survey study focused on determining the rates of psychiatric illness in next of kin participants who served as primary decision-makers before the death of their loved one in the ICU2. Utilizing the Structured Clinical Interviews for DSM-IV and the Inventory of Complicated Grief-Revised (ICB) to assess for psychiatric disorder, a high prevalence of psychiatric illness was detected, especially major depressive disorder. Results suggest that 34% of the participants met criteria for at least one psychiatric illness: specifically, complicated grief disorder (5%), panic disorder (10%), generalized anxiety disorder (10%), and major depressive disorder (27%). These statistics highlight the importance of grief assessment to facilitate the provision of services to bereaved persons, who are clearly an “at risk” population for developing various psychiatric illnesses. To date, the ICB has been the most commonly used tool to assess grief (ICB;3). The ICB is a 19-item scale that assesses for symptoms of complicated grief. Specifically, items describe an emotional, cognitive, or behavioral state associated with complicated grief and respondents rate the frequency with which they experience each item on a 5-point scale, ranging from "never" to "always." However, over the years, as the definition and classification of grief has changed and become more refined, numerous other measures of bereavement have been developed and are summarized below. 10-Mile Mourning Bridge4 - a visual analogue scale ranging from 0 to 10, a self-assessed measure of progress through bereavement. "Mile 0" marks the point prior to grieving, and "mile 10" signifies the point at which grieving no longer is the primary focus of life. The intervening miles are not labeled to allow for individualized grieving processes. Anticipatory Grief Scale (AGS;5) - a 27-item self-report tool to assess the bereavement experience of women whose spouses have been diagnosed with dementia. Items are scored on a 5-point Likert-type scale, ranging from "strongly disagree" to "strongly agree." Bereavement Experience Questionnaire - Short-form (BEQ-24;6) - a 24-item measure to assess a variety of aspects of grief and bereavement in both clinical and research settings. Factor analysis reveals 3 sub-scales (existential loss/emotional needs, guilt/blame/anger, and preoccupation with thoughts of deceased). Items are coded on a 4-point response scale with anchors. Bereavement Phenomenology Questionnaire (BPQ;7) - a 22-item self-report measure to rate the frequency of bereavement phenomena in the prior 2 weeks. The BPQ is self-reported but has been administered by interviewers. Items are scored on a 4-point Likert-type scale (never, rarely, sometimes, and often). Bereavement Response Scale II (BR-II;8) - a 6-item measure to predict recovery from bereavement of the loss of a long-term partner (hetero- or homosexual). A guide for coding narrative data about the bereavement process to predict an outcome of the recovery process. Complicated Grief Symptoms Questions9– covers 30 possible symptoms of complicated grief divided into 3 clinically derived categories (avoidance, intrusion, and failure to adapt). These questions were added to an interviewer-rated assessment using the SCID-NP. Core Bereavement Items (CBI;10) - a 17-item questionnaire that measures the intensity and evolution of bereavement experiences among a variety of bereaved persons (e.g., spouses, adult children losing parents, parents losing children). Items are rated on 4-point scales and fit within 3 sub-scales (images and thoughts, acute separation, and grief). Hogan Grief Reactions Checklist11 - a 61-item measure assessing a range of topics related to the bereavement process. Topics include fears of loss of control, difficulty with concentration, culpability and survival guilt, panic attacks, and desire to die to be with the deceased person. Items are scored on a 5-pont scale, ranging from "does not describe me at all" to "describes me very well." Monologue Questionnaire12 - a 13-item questionnaire measuring unresolved grief and relating to an empty-chair monologue task undertaken before the completion of the questionnaire. Items are 5-point unipolar rating scales and address 5 domains (self-blame, helplessness, blame toward the deceased, non-acceptance, and being at peace). Revised Grief Experience Inventory (REGI;13) - a 22-item scale measuring 4 domains (existential concerns, depression, tension and guilt, and physical distress) of the grief experience of bereaved persons with a variety of relationships to the deceased. Responses are scored on a 6-point scale, ranging from slight disagreement to strong agreement. Satisfaction with Bereavement Experiences Questionnaire (SBEQ;14) - a 24-item self-report measure developed to assess family members’ satisfaction with bereavement experiences both before and after the death of a loved one in a critical care unit. Items are rated on a Likert-type scale, and factor analysis reveals 4 components (hospital experiences, personal experiences, ritual experiences, and post-hospital experiences). Semantic Representation of Others Scale (SROS;15) - a 16-item measure of interpersonal ambivalence. Respondents rate another person on 8 positive traits and 8 corresponding negative traits. The SROS has been used to examine the relationship between ambivalence during conjugal bereavement and prolonged grief. In addition to these measures for use in the general population, measures for use in special needs populations (i.e., intellectual disabilities) have also been developed16. Featured Course Bereavement: A Comprehensive Guide for Health Professionals (3 CEs) by Mirsad Serdarevic, Ph.D. “The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths.  These persons have an appreciation, a sensitivity and an understanding of life that fills them with compassions, gentleness, and a deep loving concern. Beautiful people do not just happen.” Elisabeth Kübler-Ross Globally, an estimated 53 million people die annually with upwards of 2 million of those annual deaths occurring in the United States17. An even greater number of persons survive them and live with grief from this loss. Unfortunately, death, coping with loss and bereavement remain relatively taboo topics making it challenging for the bereaved to get the support they need as well as making it challenging for those that care for them to provide that support. Yalom18 reminds all health professionals who may be working with bereaved individuals both about the importance of learning from the patients and the core issue associated with facing death: “The horror in learning of one’s sickness unto death, I learn from Paula, is intensified many times over by the withdrawal of others.” Not surprisingly, surviving family members often require support services to assist them with the grief process. Early intervention and provision of mental health and medical services to the bereaved may prevent “normal” grief from developing into complicated grief disorder, major depression, generalized anxiety disorders, suicide, and many other psychiatric illnessese.g., 19-23. However, despite efforts across health disciplines that have produced valuable evidence-based interventions for the treatment and support of the bereaved patient, there remains a gap in the training of health professionals in this domain. This course is a comprehensive overview of the current theory- and evidence-based research on bereavement treatment approaches and the roles health professionals play in this context. Discussions on grief stage theory, the distinction between normal and complicated grief, the importance of social support in the management of bereavement, various support group models, special considerations within the bereavement context, target populations of interest, multicultural issues, and ethical considerations in bereavement research are provided in an effort to educate health professionals and bridge the gap between empirical evidence and clinical application. In addition, the specialized information contained in this course will also reduce the burden for professionals working with the bereaved.

References

1. American Psychiatric Association (2000). Diagnostic and statistical manual of mental health disorders DSM-IV-TR Fourth Edition. Washington, DC: AmericanPsychiatric Association.  
2. Siegel, M.D., Hayes, E., Vanderwerker, L.C., Loseth, D., & Prigerson, H.G. (2008). Psychiatric Illness in the Next-of-Kin of Patients who Die in the Intensive Care Unit. Critical Care Medicine, 36(6), 1722-1728.
3. Prigerson, H.G., Maciejewski, P., Newson, J., Reynolds, C.F., Bierhals, A.J., Miller, M., et al. (1995). Inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research, 59, 65-79.
4. Huber R., & Bryant J. (1996). The 10-Mile Mourning Bridge and the Brief Symptom Inventory: Close Relatives? The Hospice Journal, 11, 31-46.
5. Theut, S.K., Jordan, L., Ross, L.A., & Deutsch, S.I. (1991). Caregiver's Anticipatory Grief in Dementia: A Pilot Study. International Journal of Aging and Human Development 33 (2), 113-118.
6. Guarnaccia, C.A., & Hayslip, B. (1998). Factor structure of the bereavement experience quesitonnaire: the BEQ-24, a revised short-form. Omega, 37 (4), 303-316.
7. Byrne, G.J.A., & Raphael B.A. (1994). Longitudinal study of bereavement phenomena in recently widowed elderly men. Psychological Medicine, 24, 411-421.
8. Weiss R.S., & Richards T.A. (1997). A scale for predicting quality of recovery following the death of a partner. Journal of Personality and Social Psychology, 72 (4), 885-891.
9. Horowitz, M.J., Siegel, B., Holen, A., Bonanno, G.A., Milbrath, C., & Stinson. C.H. (1997). Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry, 154 (7), 904-910.
10. Burnett P., Middleton W., Raphael B., & Martinek N. (1997). Measuring core bereavement phenomena. Psychological Medicine, 27, 49-57.
11. Hyrkas, K., Kaunonen, M., & Paunonen, M. (1997). Recovering from the death of a spouse. Journal of Advanced Nursing, 25, 775-779.
12. Field, N.P., & Horowitz M.J. (1998). Applying an empty-chair monologue paradigm to examine unresolved grief. Psychiatry, 61, 279-287.
13. Lev, E., Munro, B.H., & McCorkle, R. (1993). A shortened version of an instrument measuring bereavement. International Journal of Nursing Studies. 30 (3), 213-226.
14. Warren, N.A. (1998). Critical care family members’ satisfaction with bereavement experiences: Development and psychometric evaluation of a new instrument. Dissertation Abstracts International, 59 (3), 1049-B.
15. Bonanno, G.A., Wortman, C.B., & Nesse, R.M. (2004). Prospective patterns of resilience and maladjustment during widowhood. Psychology and Aging, 19, 260-271.
16. Dodd, P., Guerin, S., McEvoy, J., Buckley, S., Tyrrell, J., & Hillery J. (2008). A study of complicated grief symptoms in people with intellectual disabilities. Journal of Intellectual Disability Research, 52 (5), 415–425.
17. Central Intelligence Agency (2008). The 2008 World Factbookhttps://www.cia.gov/library/publications/the-world-factbook/geos/xx.html#People.
    Retrieved on February 18, 2009.
18. Yalom, I.D. (1999). Momma and the meaning of life: Tales of psychotherapy. New York, NY: Basic Books, Inc.
19. Cherlin, E.J., Barry, C.L., Prigerson, H.G., Schulman-Green, D., Johnson-Hurzeler, R., Kasl, S.V., & Bradley, E.H. (2007). Bereavement Services for Family Caregivers: Who Uses, Why and Why Not? Journal of Palliative Medicine, 10, 148-158.
20. Prigerson, H.G., Bierhals, A.J., Kasl, S.V., Reynolds, C.F., Shear, M.K., Day, N., Beery, L.C., Newsom, J.T., & Jacobs S. (1997). Traumatic grief as a risk factor for mental and physical morbidity. American Journal of Psychiatry, 154(5), 616-623.
21. Prigerson, H.G. (2003). Costs to society of family caregiving for patients with end-stage Alzheimer's disease. New England Journal of Medicine, 349(20), 1891-1893.
22. Latham, A.E., & Prigerson, H.G. (2004). Suicidality and Bereavement: Complicated Grief as Psychiatric Disorder Presenting Greatest Risk of Suicidality. Suicide and Life Threatening Behavior 34 (4), 350-363.
23. Mitchell, A.M., Kim Y., Prigerson, H.G., & Mortimer, M.K. (2005). Complicated grief and suicidal ideation in adult survivors of suicide. Suicide and Life Threatening Behaviors 35(5), 498-506.

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