Clinical Psychology Review 31 (2011) 69–78 Contents lists available at ScienceDirect Clinical Psychology Review The prevention and treatment of complicated grief: A meta-analysis Ciska Wittouck ⁎, Sara Van Autreve, Eva De Jaegere, Gwendolyn Portzky, Kees van Heeringen Unit for Suicide Research, Department of Psychiatry and Medical Psychology, University Hospital, Ghent, Belgium a r t i c l e i n f o Article history: Received 10 February 2010 Received in revised form 12 September 2010 Accepted 14 September 2010 Keywords: Meta-analysis Complicated grief Grief interventions Prevention Treatment a b s t r a c t Background: Bereaved individuals are at increased risk of mental and physical disorders, and prevention and treatment of complicated grief is indicated. Earlier quantitative reviews have not focused on the effect of bereavement interventions on (complicated) grief. Therefore the main objective of this meta-analysis was to determine the short-term and long-term effect of both preventive and treatment interventions on complicated grief. Methods: Randomized controlled trials for prevention or treatment of complicated grief were identified through a systematic literature search. Electronic databases and reference lists of earlier review articles served as data sources. Data were analyzed with REVMAN 5.0.14. Results: Fourteen randomized controlled trials met the inclusion criteria. Study quality differed among the trials. Contrary to preventive interventions, treatment interventions yielded significant pooled standardized mean differences in favor of the (specific) grief intervention at post-test and follow-up. During the follow-up period, the positive effect of treatment interventions for complicated grief even increased. Conclusions: Treatment interventions can effectively diminish complicated grief symptoms. Preventive interventions, on the other hand, do not appear to be effective. Limitations of the meta-analysis and future research options are discussed. © 2010 Elsevier Ltd. All rights reserved. Contents 1. 2. Introduction . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . 2.1. Inclusion criteria . . . . . . . . . . 2.2. Search strategy . . . . . . . . . . . 2.3. Data analysis . . . . . . . . . . . . 3. Results . . . . . . . . . . . . . . . . . . 3.1. Identification of studies . . . . . . . 3.2. Study quality . . . . . . . . . . . . 3.3. Meta-analyses . . . . . . . . . . . . 3.3.1. Preventive interventions . . 3.3.2. Treatment interventions. . . 3.3.3. Prevention versus treatment. 4. Discussion . . . . . . . . . . . . . . . . . Acknowledgement . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ⁎ Corresponding author. Unit for Suicide Research, Dept of Psychiatry and Medical Psychology, University Hospital, De Pintelaan 185, 9000 Ghent, Belgium. Tel.: + 32 9 332 43 30; fax: + 32 9 332 49 89. E-mail addresses: [email protected] (C. Wittouck), [email protected] (S. Van Autreve), [email protected] (E. De Jaegere), [email protected] (G. Portzky), [email protected] (K. van Heeringen). URL: http://www.unitforsuicideresearch.be (C. Wittouck). 0272-7358/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2010.09.005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 70 70 70 71 71 71 71 74 74 74 74 74 77 77 1. Introduction Losing a loved one through death is a common life event. A mourning process commonly follows such a loss, and most bereaved individuals go through this process without severe mental or physical problems (Middleton, Burnett, Raphael, & Martinek, 1996; Bonanno et al., 2002; 70 C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78 Bonanno, Wortman, & Nesse, 2004). Over time, mourners usually find a way to cope with the loss and its consequences, therefore they are not in need of grief interventions (Raphael, Minkov, & Dobson, 2001; Bonanno et al., 2004; Zhang, El-Jawahri, & Prigerson, 2004; Stroebe, Schut, & Stroebe, 2007). Nevertheless, a relationship between grief and the development of poor mental and physical health is well documented (Stroebe & Stroebe, 1993; Woof & Carter, 1997; Stroebe, Stroebe, & Abakoumkin, 2005; de Groot, de Keijser, & Neeleman, 2006; Onrust & Cuijpers, 2006; Miyabayashi & Yasuda, 2007; Stroebe et al., 2007). It is estimated that about 9% of adults experiencing a loss develop complicated grief reactions (Middleton et al., 1996; Raphael & Minkov, 1999). Complicated grief (CG) is not (yet) an officially recognized (DSM)diagnosis, although the addition of CG as a diagnostic category to DSM-V has received much support, (Horowitz, Bonanno, & Holen, 1993; Prigerson & Jacobs, 2001; Lichtenthal, Cruess, & Prigerson, 2004; Simon et al., 2007; Boelen & van den Bout, 2008; Dillen, Fontaine, & Verhofstadt-Denève, 2008). In the late nineties two research teams independently published a set of diagnostic criteria to assess CG (Horowitz et al., 1997; Prigerson, Shear, et al., 1999). Recently, these two diagnostic entities were integrated and the concept of CG was renamed as Prolonged Grief Disorder (PGD). This debilitating disorder is defined as a combination of separation distress and cognitive, emotional and behavioral symptoms that can develop after the death of a significant other. The symptoms must last for at least 6 months and cause significant impairment in social, occupational and other important areas of functioning (Prigerson, Vanderwerker, & Maciejewski, 2008). The term CG instead of PGD will be used throughout this paper to improve readability. CG is associated with several mental and physical health problems, e.g., depression, hypertension and cardiac problems, work and social impairment, psychotropic drug use, and reduced quality of life (Prigerson et al., 1997; Prigerson, Bridge, et al., 1999; Silverman et al., 2000; Latham & Prigerson, 2004; Boelen & Prigerson, 2007; Bonanno et al., 2007; Neria et al., 2007; Simon et al., 2007). In addition, bereaved individuals are at increased risk of suicide and suicidal behavior (Prigerson, Bridge, et al., 1999; Latham & Prigerson, 2004; Agerbo, 2005; Stroebe, Stroebe, & Abakoumkin, 2005; Stroebe et al., 2007). CG thus clearly warrants prevention and treatment. However, literature reviews and meta-analyses of studies of the effects of bereavement interventions show only limited results. With regard to preventive interventions, effects may indeed be limited or absent (Neimeyer, 2000; Schut, Stroebe, van den Bout, & Terheggen, 2001; Currier, Neimeyer, & Berman, 2008). In addition, some studies even show negative results, although treatment-induced-deteriorationeffects may be due to questionable statistical techniques (Neimeyer, 2000; Schut et al., 2001; Larson & Hoyt, 2007). Recent studies of preventive interventions show more positive results, which may be due to methodological differences, as participants are commonly selfreferred and the intervention is offered later in the bereavement process. Interventions may indeed interfere with natural grieving processes if they are implemented soon after the loss (Schut & Stroebe, 2005). Interventions appear to be most effective when grief is more complicated or when the risk of complications is higher, and when the bereaved are self-referred (Allumbaugh & Hoyt, 1999; Jacobs & Prigerson, 2000; Neimeyer, 2000; Schut et al., 2001; Jordan & Neimeyer, 2003; Schut & Stroebe, 2005; Currier et al., 2008). To our knowledge, there have been three previous meta-analytic investigations of bereavement interventions for adults (Allumbaugh & Hoyt, 1999; Kato & Mann, 1999; Currier et al., 2008). The meta-analyses of Allumbaugh and Hoyt (1999) and Kato and Mann (1999) were published a decade ago. Since then, meta-analytic techniques have highly evolved, and the methodological quality of trials regarding grief interventions has improved. In addition, these meta-analyses only addressed the effect of grief interventions immediately after treatment completion. Allumbaugh and Hoyt (1999) included controlled but also non-controlled studies. Currier et al. (2008) analyzed the effect of controlled bereavement interventions at post-test and follow-up, included random as well as non-random studies, and investigated various research questions in their meta-analysis. None of these three quantitative reviews specifically focused on the effect of bereavement interventions on (complicated) grief. Therefore, use of stringent inclusion criteria (such as the inclusion of only randomized controlled trials, RCT's) and limitation of the outcome variable to (complicated) grief measures in the current meta-analysis can contribute to the overall understanding of the effects of preventive and treatment grief interventions. The main objective of the current meta-analysis is therefore to determine the short-term (i.e., immediately after the intervention) and long-term (i.e., follow-up) effect of specific grief interventions for adults. Hereby, the aim of the interventions (prevention versus treatment) is taken into consideration. 2. Method 2.1. Inclusion criteria We included RCT's in which a specific grief intervention (i.e., an intervention or technique specifically designed to treat or prevent CG) was offered to individuals aged 18 years or older who had lost a loved one through death. This experimental, grief specific, intervention had to be compared to either a control condition or an a-specific intervention (i.e., an intervention that is used for a variety of disorders), and assessments had to include pre- and post- or follow-up-measurements. A preventive grief intervention is defined as any technique or any more extensive intervention for bereaved individuals in general designed to reduce the probability of the development of CG. A treatment grief intervention is defined as any technique or any more extensive intervention for bereaved individuals suffering complicated grief designed to reduce the severity of complicated grief symptoms. Furthermore, (complicated) grief had to be an outcome variable, to be measured with a quantitative standardized questionnaire. Only studies published in a peer-reviewed journal were considered, in order to provide a degree of quality control in the selection of studies. Not included were case studies, studies of interventions specifically developed for other loss-related diagnoses than CG, interventions for children, adolescents, caregivers or individuals with intellectual disabilities as survivors, studies of interventions for loss of a pet, studies of interventions initiated before the loss (palliative care), and psychopharmacological interventions. 2.2. Search strategy Two strategies were used to identify relevant studies. First, the electronic databases Web of Science (WOS) and PsycArticles were consulted with the use of the following search terms and Boolean operators: (bereave* OR mourning OR grief OR survivor OR widow*) AND (psychotherapy OR therapy OR intervention OR treatment OR managing OR counselling OR counselling OR support OR help). For Web of Science the ‘title only’ option was marked, and no refinements for document types were made. To search PsycArticles, a shortened list of terms was used (bereavement, bereaved, mourning, grief, survivor, & widow). The second strategy consisted of searching eligible studies within the reference lists of large-scale review articles concerning interventions for the bereaved (these articles are marked with an • in the reference list of this paper). As the theoretical basis of the treatment and prevention of grief and its related concepts has changed considerably during the past decades, and this study aimed to provide an up-to-date review, only studies published between 1990 and 2007 were included. C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78 2.3. Data analysis Data were analyzed with REVMAN 5.0.14. A random effect model was used if heterogeneity was found, while a fixed effect model was used in case of homogeneity (a p-value of b0.10 for the chi-squared test for heterogeneity was considered significant). The standardized mean difference (SMD) was used as the summary statistic in the metaanalysis, because different self-report instruments to measure (complicated) grief ((C)G) were used in the studies (Higgins & Green, 2008). Since only two studies reported the complete results of intention-totreat analyses, the meta-analysis was performed with outcome data on study completers. 3. Results 3.1. Identification of studies After the study selection process (see Fig. 1 for details), 14 studies met the inclusion criteria (these articles are markes with an * in the reference list of this paper). Table 1 provides an overview of included studies, according to aim of intervention (prevention versus treatment), and characteristics of participants, interventions, trials, and follow-up periods. In total, 1655 subjects initially participated in the included studies, of which 910 were in the specific grief intervention condition and 745 were in the control or a-specific grief intervention condition. A total of 344 subjects was lost to follow-up. Males were underrepresented in the study groups as an average of 70% was female (range from 0% to 92%). Mean age of participants was 41 years (range from 20 to 57 years). Preventive interventions mostly targeted high risk groups (such as spouses and suicide survivors) for CG, while treatment interventions made no differentiations regarding mode of death or kinship. With respect to intervention aim, nine studies examined preventive grief interventions. Three of these studies reported moderately positive results with regard to (C)G of which two offered a cognitive-behavioral oriented preventive intervention. Five studies examined treatment grief 71 interventions. Positive results with respect to (C)G were reported in four of these studies. All of these four treatment interventions employed cognitive-behavioral techniques. In eight studies the specific grief intervention was compared with a control condition (of which seven were preventive interventions and one a treatment intervention) and in six studies with an a-specific grief intervention (of which four were treatment interventions). A group format was used in eight studies, while in the remaining six studies individual therapy sessions were offered. Number of sessions differed substantially among studies, with one to twelve sessions in preventive interventions and ten to sixteen sessions in treatment interventions. All but two studies (both preventive interventions) assessed participants at post-test and in five studies (of which four were treatment interventions) a follow-up measurement was absent. A few remarks concerning five studies should be made. Boelen, de Keijser, van den Hout, and van den Bout (2007) described two different cognitive-behavioral trials in a cross-over design (cognitive restructuring (CR) + exposure therapy (ET) and ET + CR), which were compared to a supportive condition. These trials were considered as two separate studies designated as a (CR + ET) and b (ET + CR). Murphy et al. (1998) reported results separately for male and female participants, which were included in the analysis as two separate studies, designated as a (mothers) and b (fathers). Piper, Ogrodniczuk, Joyce, Weideman, and Rosie (2007) reported the combined scores on the outcome variables for the different intervention groups. Upon request the authors kindly provided their post-data separately for the different intervention groups. The results of the study of Range, Kovac, and Marion (2000) were only included in the follow-up analyses, because the number of participants per group was not reported for post-data and the authors had no longer access to the required information. Finally, in the study by Sikkema et al. (2006) follow-up data were provided for three different time points. The 8-month follow-up data were used to increase comparability with the follow-up data of the other studies. 3.2. Study quality Assessment of quality of the included studies was based on the criteria, which were developed by McDaid, Trowman, Golder, Hawton, Potentially relevant papers identified through the three search strategies and screened on the basis of title (references from reference lists) and on the basis of title and abstract (WOS & PsycArticles) (n= 806) Papers excluded due to duplicates, irrelevant subject, presence of an exclusion criteria, study design (descriptive studies) (n= 680) Potentially relevant papers retrieved for more detailed evaluation (n= 126) Papers excluded as not meeting the inclusion criteria (n= 7), other reasons for exclusion were absence of a control group (n= 11), absence of a randomisation procedure (n= 11), descriptive study (n= 24), qualitative or retrospective study (n= 21), absence of a standardized grief measure or grief measure could not be used (n= 11), duplicate paper (n= 19), irrelevant subject (n= 5), unobtainable data (n= 2), unobtainable publication (n= 1) Citations included in the meta analysis (n= 14) Fig. 1. Flow diagram of study selection process. 72 Table 1 Characteristics of participants, interventions, trials, and follow-up periods of the included studies. Study Details of participants Goodkin et al. (1999)¹ Kovac and Range (2000) Lieberman & Yalom (1992), Yalom & Vinogradov (1988) Murphy et al. (1998)² Nikčević et al. (2007) O'Connor et al. (2003) Homosexual HIV-seropositive and HIV-seronegative men who lost a close friend or intimate partner to AIDS within the prior 6 months; mean time since loss not reported; 100% male; 63% Caucasian & 24% Hispanic American, mean age 38 years Undergraduate students who lost a loved one to suicide within the past 2 years; participants had to be close to the deceased and had to be upset by the death, mean time since loss 12 months; 79% female, 88% Caucasian, mean age 24 years Spouses who lost their partner to cancer within the prior 4 to 10 months; mean time since loss not reported; 72% female, 100% Caucasian, mean age 57 years Parents who lost their 12- to 28-year-old children due to accidents, homicide or suicide within the prior 2 to 7 months; mean time since loss 4 months; 65% female, 86% Caucasian, mean age 45 years Women who were attending for a routine scan at 10–14 weeks of gestation and found to have a missed miscarriage; mean time since loss not reported; 100% female, 95% Caucasian, mean age 35 years Bereaved family members whose relatives died up to 1 year previously; mean time since loss 9 months; 71% female; ethnicity not reported; mean age 57 years Initial number of participants (number lost to follow-up) Post-test Follow-up period Experimental: A family based, cognitive behaviour counselling programme (psycho-education and cognitive restructuring) of 4 sessions (of 2 h) with a trained psychiatric nurse counsellor between 3 and 6 months after the suicide 134 (12) No 13 months after the suicide 197 (31) Yes No 42 (12) Yes 6 weeks 56 (3) No 1 year after entering group therapy 261 (45) Yes 6 months 80 (14) Yes, 2 weeks after session 9 weeks 69 (24) Yes, 2 weeks after session 6 weeks Control: care as usual Experimental: A bereavement support group intervention (combination of cognitive-behavioral and social support group interventions, stressor-support-coping model) of 10 weekly sessions (of 90 min) led by 2 experienced co-therapists Control: community standard-of-care control condition Specific: a profound writing condition (Pennebaker's experimental writing paradigm, participants were asked to write about the events and emotions surrounding the loss of your loved one, writing about traumatic events, emotional events) of 4 writing assignments (of 15 min) over 2 weeks alone at the lab room. A-specific: a trivial writing condition (participants were asked to write about a different trivial topic for each assignment, writing about innocuous topics, objective topics) of 4 writing assignments (of 15 min) over 2 weeks alone at the lab room Experimental: A brief group psychotherapy (focus on interpersonal and existential issues) of 8 weekly group sessions (of 80 min) led by an experienced male–female co-therapy team. Control: control condition Experimental: a preventive broad-spectrum group intervention (two-dimensional approach, consisted of information-giving and skill-building support followed by emotion-focused support) of 10 weekly sessions (of 2 h) led by men-women pairs of group leader-clinicians who were psychologists, nurses, or family therapist. Control: a 3-session delayed intervention control condition Experimental: an individual psychological counselling intervention (based on the cognitive therapy framework) of 1 session (of 50 min) after a medical counselling session, 5 weeks after the diagnosis, offered by a psychologist Control: control condition with only a medical counselling session Experimental: a 1-day writing therapy workshop (Pennebaker's paradigm, participants are supported, rather than guided to develop a coherent narrative about the death of their loved one, to explore feelings and to examine positive aspects of the event(s) alongside negative thoughts and feelings), led by a writing facilitator with extensive experience in running groups Control: a delayed intervention control condition C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78 Studies regarding the prevention of complicated grief de Groot et al. First degree relatives (aged N 15 years) and (2007) spouses of suicide victims, bereaved since 2 to 3 months (at study entry); mean time since loss not reported; 68% female; ethnicity not reported, mean age 43 years Interventions Range et al. (2000) Undergraduate students who lost a loved one to a sudden unintentional accidental or homicidal death, mean time since loss 14 months; 80% female; ethnicity not reported; mean age 20 years Sikkema et al. (2006), Sikkema, Hansen, Kochman, Tate, & Difranceisco (2004) HIV-positive or AIDS-diagnosed men and women who lost a loved one to AIDS within the prior 2 years (but not less than 1 month ago); mean time since loss not reported; 35% female, 54% African American and 27% Caucasian, mean age 40 years Piper et al. (2007) Bereaved individuals suffering complicated grief who lost a loved one at least 3 months ago, mean time since loss 8.4 years; 79% female, 84% Caucasian, mean age 45.2 years Shear et al. (2005) Bereaved individuals suffering complicated grief who lost a loved one to violent or non-violent causes at least 6 months ago, mean time since loss not reported (median 2.1 and 2.5 years); 87% female, 53% Caucasian, mean age 48 years Wagner et al. (2006) Bereaved individuals suffering complicated grief who lost a loved one at least 14 months ago, mean time since loss 4.6 years; 92% female, ethnicity not reported, mean age 37 years Specific: an individual cognitive-behavioral therapy (exposure therapy & cognitive restructuring) of 12 weekly manual-based sessions (of 45 min) led by trained therapists A-specific: an individual supportive counseling intervention (focus on practical difficulties and problem solving) ) of 12 weekly manual-based sessions (of 45 min) offered by a trained therapist Specific: an interpretive, time-limited, short-term group therapy (focus on enhancement of patients' insight about repetitive conflicts and trauma that are associated with the losses) of 12 weekly sessions (of 90 min) led by experienced group therapists A-specific: a supportive , time-limited, short-term group therapy (focus on improvement of the patients' immediate adaptation to their life situations) of 12 weekly sessions (of 90 min) Specific: an interpretive, time-limited, short-term group therapy (focus on enhancement of patients' insight about repetitive conflicts and trauma that are associated with the losses) of 12 weekly sessions (of 90 min) led by experienced group therapists A-specific: a supportive , time-limited, short-term group therapy (focus on improvement of the patients' immediate adaptation to their life situations) of 12 weekly sessions (of 90 min) Specific: an individual complicated grief treatment (a form of cognitivebehavioral therapy combined with aspects of interpersonal therapy) of 16 sessions over a 16- to 20-week period offered by an experienced and licensed therapist A-specific: an individual interpersonal therapy (IPT) of 16 sessions over a 16- to 20-week period offered by an experienced and licensed therapist Experimental: an internet-based cognitive-behavioral therapy of two weekly writing assignments (of 45 min) conducted by trained psychologists Control: delayed intervention control condition/waiting list control condition 64 (20) Yes 6 weeks 267 (74) Yes 8 months 54 (15) Yes 6 months 139 (32) Yes No 135 (25) Yes No 102 (33) Yes No 55 (4) Yes No C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78 Studies regarding the treatment of complicated grief Boelen et al. Bereaved individuals suffering complicated grief (2007) who lost a loved one to violent and non-violent causes at least 2 months ago (this was during the study changed to 6 months), mean time since loss 45 months; 74% female, ethnicity not reported, mean age 44 years Piper et al. Bereaved individuals suffering complicated grief (2001) who lost a loved one (cause of death not reported) at least 3 months ago, mean time since loss 9 years; 77% female, 90% Caucasian, mean age 43 years Specific: profound writing condition (Pennebaker's paradigm, participants were asked to write about the events and emotions surrounding the loss of their loved one) of 4 daily writing assignments (of 15 min) alone at the lab room A-specific: trivial writing condition (participants were asked to write about a different trivial topic for each assignment) of 4 daily writing assignments (of 15 min) alone at the lab room. Experimental: a cognitive-behavioral group intervention (combined elements of cognitive theory of stress and coping with models of coping with grief and bereavement) of 12 weekly sessions (of 90 min) led by 2 experienced co-therapists. Control: minimal treatment condition (individual therapy (up to 12 sessions) on request comparison condition) (individual mental health and psychiatric services outside the project protocol on request and whenever needed) 73 74 C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78 and Sowden (2008) using three tools: the Centre for Reviews and Dissemination's guidance for undertaking systematic reviews (Khan, ter Riet, Glanville, Sowden, & Kleijnen, 2001), a report on evaluating nonrandomised studies (Deeks et al., 2003), and the Quality Assessment Tool for Quantitative Studies (Effective Public Health Practice Project, 2003). For seven of the 14 included studies the procedure of assignment to study arms was described (Goodkin et al., 1999; Shear, Frank, Houck, & Reynolds, 2005; Sikkema et al., 2006; Wagner, Knaevelsrud, & Maercker, 2006; Boelen et al., 2007; de Groot et al., 2007; Nikčević, Kuczmierczyk, & Nicolaides, 2007). In the remaining studies the authors did not explicitly report the assignment procedure (Lieberman & Yalom, 1992; Murphy et al., 1998; Kovac & Range, 2000; Range et al., 2000; Piper, McCallum, Joyce, Rosie, & Ogrodniczuk, 2001; O'Connor, Nikoletti, Kristjanson, Loh, & Willcock, 2003; Piper et al., 2007). The method of randomisation was described in six studies (Goodkin et al., 1999; Shear et al., 2005; Wagner et al., 2006; Boelen et al., 2007; de Groot et al., 2007; Nikčević et al., 2007). Concealment of treatment allocation was secured in three studies (Goodkin et al., 1999; Shear et al., 2005; Nikčević et al., 2007). In one study an attempt at concealment was made (de Groot et al., 2007). For the remaining studies it was unclear whether treatment allocation was concealed (Lieberman & Yalom, 1992; Murphy et al., 1998; Kovac & Range, 2000; Range et al., 2000; Piper et al., 2001; O'Connor et al., 2003; Sikkema et al., 2006; Wagner et al., 2006; Boelen et al., 2007; Piper et al., 2007). The experimental and control groups were balanced with regard to potential confounds in eight studies (Murphy et al., 1998; Piper et al., 2001; O'Connor et al., 2003; Shear et al., 2005; Wagner et al., 2006; Boelen et al., 2007; Nikčević et al., 2007; Piper et al., 2007). Of the five studies in which imbalances among study groups at baseline were reported (Lieberman & Yalom, 1992; Kovac & Range, 2000; Range et al., 2000; Sikkema et al., 2006; de Groot et al., 2007), one reported adequate adjustment for baseline differences (de Groot et al., 2007). For one study it was not reported if the study groups were balanced for potential confounds, but adjustments for possible imbalances were made (Goodkin et al., 1999). Proportion of study completion varied between 65% (O'Connor et al., 2003) and 95% (Lieberman & Yalom, 1992). There was great variability among the studies regarding sample size, ranging from 42 (Kovac & Range, 2000) to 267 participants (Sikkema et al., 2006). All studies used subjective outcome measures to assess (C)G. These data collection tools were known or shown to be reliable and valid in all but one study (Range et al., 2000). Intention-to-treat (ITT) analyses were performed and reported in three studies (performed on total randomization sample) (Piper et al., 2001; Shear et al., 2005; Boelen et al., 2007). A majority of studies (n = 11) reported the use of a treatment protocol or manual (Murphy et al., 1998; Goodkin et al., 1999; Kovac & Range, 2000; Range et al., 2000; Piper et al., 2001; Shear et al., 2005; Sikkema et al., 2006; Wagner et al., 2006; Boelen et al., 2007; de Groot et al., 2007; Piper et al., 2007). In the remaining three studies treatment content was described (Lieberman & Yalom, 1992; O'Connor et al., 2003; Nikčević et al., 2007). In half of the studies (n = 7) an assessment of the intervention consistency was reported (Lieberman & Yalom, 1992; Goodkin et al., 1999; Kovac & Range, 2000; Range et al., 2000; O'Connor et al., 2003; Wagner et al., 2006; Nikčević et al., 2007). 3.3. Meta-analyses 3.3.1. Preventive interventions The meta-analysis of the interventions aiming at prevention of CG yielded a pooled standardized mean difference (SMD) of −0.03 (95% CI: −0.18−0.11; Z = 0.47; p = 0.64) at post-test and of 0.13 (95% CI: −0.08−0.33; Z = 1.21; p = 0.23) at follow-up. With regard to the outcome variable, studies were homogeneous in the post-test analysis (p = 0.12) and heterogeneous in the follow-up analysis (p = 0.07). The difference among the pooled SMD's of preventive interventions at post-test and at follow-up was not significant (χ² = 2.41; df = 1; p = 0.12). Heterogeneity among the studies was found (p = 0.03) (see Fig. 2). 3.3.2. Treatment interventions The meta-analysis of the interventions aiming at treatment of CG yielded a pooled SMD of −0.53 (95% CI: −1.00−−0.07; Z = 2.23; p = 0.03) at post-test and of −1.38 (95% CI: −2.08 to −0.68; Z = 3.87; p = 0.0001) at follow-up. With respect to the outcome variable, studies were heterogeneous (p = 0.009) in the post-test analysis and homogeneous (p = 0.87) in the follow-up analysis. The difference of the pooled SMD's among post-test and follow-up of treatment interventions was significant in favor of the effect at follow-up (χ² = 8.65; df = 1; p = 0.003). Heterogeneity among the studies was found (p = 0.0001) (see Fig. 3). 3.3.3. Prevention versus treatment The difference among the pooled SMD's of preventive and treatment interventions at post-test was significant in favor of treatment interventions (χ² = 3.71; df= 1; p = 0.05). Heterogeneity among the studies was found (p = 0.0006) (see Fig. 4). The difference among the pooled SMD's of preventive and treatment interventions at follow-up was significant in favor of the treatment interventions (χ² = 17.09; df = 1; p b 0.0001). Heterogeneity among the studies was found (p = 0.0005) (see Fig. 5). 4. Discussion Results of this meta-analysis of prevention and treatment studies of CG among persons who were bereaved through death of a loved one can be summarized as follows. The results from preventive grief intervention studies provide inconsistent support for their effectiveness. The lack of a significant effect of preventive interventions on (C)G observed immediately after the intervention evolves to a rather negative, though also non-significant effect at follow-up. Treatment interventions, on the other hand, appear to be efficacious in the short-term and long-term alleviation of CG symptoms. Contrary to preventive interventions, the positive effect of treatment interventions increases significantly over time. Prior to a discussion of the implications of these findings for prevention and treatment of CG some methodological limitations have to be addressed. First, at the moment CG is not recognized as an official (DSM-) diagnosis. Nevertheless, CG-symptoms have shown to be different from other symptoms and disorders, such as normal grief reactions (Boelen & van den Bout, 2008; Dillen et al., 2008), mood disorders (Boelen & van den Bout, 2005; Bonanno et al., 2007; Lichtenthal et al., 2004; Silverman et al., 2000), and anxiety disorders (Boelen & van den Bout, 2005), such as Post Traumatic Stress Disorder (PTSD) (Bonanno et al., 2007; Lichtenthal et al., 2004; Silverman et al., 2000). These findings were corroborated across different subgroups of mourners, e.g., violent and non-violent deaths, male and female survivors (Boelen & van den Bout, 2005, 2007). Moreover, the same set of criteria is indicative for CG irrespective of time since loss (Boelen & van den Bout, 2007). Second, due to ethical reasons not all included studies used a nonintervention control group, and some of the bereavement interventions were compared to more general (a-specific) interventions. In this context it is important to note that Allumbaugh and Hoyt (1999) found no difference in effect size among studies using ‘placebo’ treatment groups and control groups. Third, this meta-analysis of bereavement interventions investigated the effect of interventions on CG. The performed analyses could thus have yielded different results with other outcome measures. For instance, Piper et al. (2001), compared interpretive therapy (specific grief therapy) to supportive therapy (non-specific grief therapy), and observed a similar C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78 75 Fig. 2. Short term and long term effect of preventive interventions on (complicated) grief. effect size for both study groups with respect to CG, while interpretive therapy yielded a larger effect size concerning anxiety and depression. Fourth, only a small number of papers were available for this metaanalysis, which is due to the use of stringent inclusion criteria and data sources (for example, gray literature was not searched). Fifth, there were differences among the preventive and treatment interventions concerning the instruments to assess (C)G. The preventive interventions often utilized general grief measures, while the treatment interventions assessed CG. Therefore, the comparability of the results of both interventions is limited. Sixth, preventive interventions mostly focused on specific risk groups for the development of CG (such as parents, suicide survivors, and widows), but used general grief measures. Such measurements may not have been sufficiently sensitive to adequately represent grief reactions after a specific loss (e.g., kinship and mode of death). For example, in a study with students who lost a loved one to suicide, no significant difference was observed among the study groups with respect to general grief, contrary to suicidal grief (Kovac & Range, 2000). Seventh, it is important to note that only one study (Boelen et al., 2007) examined the long-term effect of treatment interventions on Fig. 3. Short term and long term effect of treatment interventions on complicated grief. 76 C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78 Fig. 4. Difference in short term effect of preventive and treatment interventions on (complicated) grief. CG, in which two specific treatment groups were compared to a supportive counselling group. For the current analysis, this single study was divided in two separate studies, which could possibly have biased the reliability of the result. Eighth, studies in this meta-analysis investigated consequences of deaths due to a wide range of violent and non-violent causes, but may not have included deaths due to particular circumstances such as military service. Further study is needed to investigate effects of interventions following death due to such circumstances. Finally, 70% of study participants in the included studies are female. The predominance of females may be due to a number of factors including a comparatively greater effect of loss (Stroebe et al., 2007), a more common perception that help is useful (De Groot, Van der Meer, & Burger, 2009), and more help seeking behavior (Stead, Shanahan, & Neufeld, 2010) among women than men. The predominant representation of females in the studies may limit the generalization of results to men. It is not clear whether differences among interventions can be attributed to the interventions. More particularly, lack of effect of preventive interventions as demonstrated in this review may be due to, first, the interventions per se, second, to the problem of complicated grief, or, third, to other factors including characteristics of study participants and other types of support received by participants. First, Fig. 5. Difference in long term effect of preventive and treatment interventions on (complicated) grief. C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78 the lack of effect of preventive interventions can theoretically be due to the fact that some interventions may show impressive effectiveness while others may show little benefit or even negative effects. This review has shown that effects of preventive interventions indeed may be positive or negative, though all but one not significant. Negative outcomes may thereby be due to improved adjustment among participants not receiving the intervention, while positive outcomes may be due to deterioration among controls. Based on their review, Neimeyer and Currier (2009) could however not find any support for the latter interpretation. Second, demonstrated lack of effect of preventive interventions may be due to the possibility that prolonged grief cannot be prevented, which is supported by the finding that interventions aiming at (primary) prevention have no effect on the outcome among people who suffered a loss (Neimeyer & Currier, 2009). Third, characteristics of study participants may have influenced the outcome of this review. While factors such as gender, age and relationship to the deceased may not have such an effect (Neimeyer & Currier, 2009), study participants may have constituted subgroups based on unidentified other moderating characteristics, which may respond differently to different interventions. Despite these limitations, the results of this meta-analysis offer a quantification of earlier and rather qualitative findings regarding grief interventions. The findings confirm the proposition that professional assistance is indicated for only a subgroup of the bereaved, namely those who show (the onset of) CG reactions (Jacobs & Prigerson, 2000; Neimeyer, 2000; Schut et al., 2001; Jordan & Neimeyer, 2003; Bonanno et al., 2004; Schut & Stroebe, 2005; Stroebe et al., 2007). Prigerson et al. (1997) conclude: “it may not be the stress of bereavement per se that puts individuals at risk for long-term mental and physical health impairments. Rather, it appears that the manifestation of psychiatric sequelae, specifically traumatic grief, is of critical importance” (p. 622). In addition, our results suggest that CG can be treated but not prevented. This does however not necessarily mean that interventions aimed at the prevention of CG do not have any value. First, the absence or limited effects of preventive grief interventions does not necessarily reflect a lack of effect at an individual level. Measures of improvement often are quantitative measures of (C)G, anxiety, and depression, and the effect of preventive grief interventions may not be situated in these areas, but rather on a qualitative level, such as feeling supported in their mourning process by co-mourners or a grief counsellor. Currier et al. (2008) point out the importance of assessing protective factors (as coping skills) and practical benefits (as reducing health-care costs) over several years in studies focusing on preventive interventions. Second, if bereaved individuals feel the need for grief counselling (either individually or in group), irrespective of whether their grief reactions are to be regarded as normal or complicated, they may very well benefit from a counselling program. A preventive intervention study by Kang and Yoo (2007), which was not included in this metaanalysis due to the absence of randomisation, indeed provides support for this assumption. Participants were allowed to choose themselves to which study arm (bereavement group versus control condition) they were assigned. Bereavement group participants significantly improved over time in comparison with control group participants on the grief scale. This was not the case in the preventive studies included in the current analysis. Third, preventive interventions may accelerate the adjustment process after a significant loss (Currier et al., 2008). Fourth, the finding that the results of preventive intervention studies reveal inconsistent support for their effectiveness may be due to the possibility that such studies are more problematic to conduct. Finally, it should be noted that the preventive grief interventions often were techniques rather than comprehensive interventions. Further study into the treatment and prevention of CG is needed. First, although interventions aimed at the treatment of CG appear to 77 be effective, effect sizes may be smaller than those of treatments for other psychiatric disorders (Allumbaugh & Hoyt, 1999). The aim of CG treatment is to adjust CG reactions into normal grief reactions, which are themselves almost always accompanied by some kind of distress and therefore result in higher scores on self-report measures. Second, the most adequate treatment for CG may not have been developed yet. According to O'Connor et al. (2003), a universal treatment for CG may not exist as grief can be viewed as a multidimensional construct (O'Connor et al., 2003). An integrative risk factor framework for the prediction of bereavement outcome is described by Stroebe, Folkman, Hansson, and Schut (2006). In this model it is postulated that adaptation to bereavement is influenced by bereavement-related stressors (loss-oriented stressors such as type of loss and mode of death, and restoration-oriented stressors such as work problems and economic changes), appraisal and coping (cognitive-behavioral processes and mechanisms, emotion regulation and oscillation between confrontation and avoidance of bereavement-related stressors), interpersonal risk factors (these factors originate within the social or environmental context and are external to the bereaved person, such as social support, intervention programs and family dynamics), intrapersonal risk factors (these factors are intrinsic to the bereaved person, such as sociodemographic variables, personality, attachment style, and predisposing vulnerabilities) and by interactions among these risk factors (Stroebe et al., 2006). Thus, each person may grieve in a unique way. Therefore treatment protocols may have to be adaptable to individual needs. Third, the aim and content of preventive interventions should be reconsidered, and outcome measures of general grief should be refined considering background variables as kinship and mode of death. Results of this meta-analysis clearly point at a difference among the short-term and long-term effects of preventive and treatment strategies for CG, in favor of the latter. Recent treatment interventions for CG have been designed more adequately and have proved to be efficacious. Nevertheless, taking into account the common prevalence of potentially devastating consequences of CG, treatment studies should be replicated using larger samples and long-term follow-up periods. Acknowledgement This study was supported by a grant from “Go for Happiness”. References Agerbo, E. (2005). 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