18Bereavement: universally applied structured psychological interventions – adults

Q18. For bereaved adults without a mental disorder, do universally applied structured psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?

Background on the scoping question

Bereavement is referred to here as the event of a loss of a loved one. In this document, grief refers to the psychological reactions in response to bereavement. Loss of loved ones is a common occurrence in life, which for most people will not lead to mental disorder. For a small minority, bereavement and grief may be associated with prolonged symptomatology and impairment in functioning. This scoping question focuses on adults who do not meet criteria for a mental disorder, i.e. on interventions that are offered to all bereaved individuals independent of whether or not people score above certain threshold levels of symptoms.

Primary care practitioners often encounter bereaved individuals in their practice, with seemingly little consistency in applied interventions. 49 The increased popularity of “grief work” and bereavement interventions makes this a relevant scoping question.

The scoping question refers to “structured psychological” interventions, i.e. psychological interventions that go beyond general application of psychological principles that are part of health and social care, such as good communication and mobilizing and providing social support (cf. the mhGAP Intervention Guide (2010), p.6). Examples of structural interventions include psychotherapy or a grief counselling intervention involving a series of sessions that encompass psycho-education, efforts to improve coping skills, understanding of death and grief, talking about the deceased and expression of grief-related feelings.

The scoping question focuses on “universally applied” interventions, i.e. interventions applied to all bereaved individuals regardless of the existence of a mental disorder (i.e. delivery without identification). 50

PART 1. EVIDENCE REVIEW

Population/intervention/comparison/outcome (PICO)
  • Population: Bereaved adults who do not meet criteria for a mental disorder
  • Interventions: All universally applied psychological and psychosocial interventions
  • Comparison: Treatment as usual or no treatment/waitlist
  • Outcomes:
    -

    Symptom severity (mainly sub-threshold symptoms) post-intervention and at follow-up

    -

    Functioning/quality of life post-intervention and at follow-up

    -

    Presence of mental disorder post-intervention and at follow-up

    -

    Adverse effects (including tolerability).

List of systematic reviews identified by the search process

The search was conducted in week 28 of 2011 in the following databases: Cochrane Database of Systematic Reviews, PubMed (clinical queries), the Campbell Collaboration, LILACS, psycINFO, Embase and PILOTS. As keywords we used “bereavement” OR “grief” OR “mourning” AND “systematic review”. In databases that allowed specifically for selection of systematic reviews and meta-analyses (e.g. PubMed, psycINFO and Embase) we selected this option. We included studies if they were systematic reviews of treatment studies published from 2001 onwards that included studies with adults (>18 years). In addition, we searched for clinical practice guidelines through Google, the National Guideline Clearinghouse and NICE. Appraisal of quality of systematic reviews was conducted with the use of the Oxford Centre for Evidence-based Medicine's checklist.

INCLUDED IN GRADE TABLES OR FOOTNOTES
  • Wittouck C, Van Autreve S, De Jaegere E, Portzky G, van Heeringen G. The prevention and treatment of complicated grief: A meta-analysis. Clinical Psychology Review. 2011;31:69–78. COMMENT: this review covers both prevention and treatment studies. The prevention studies are relevant to the PICO question. [PubMed: 21130937]
EXCLUDED FROM GRADE TABLES AND FOOTNOTES
  • Currier JM, Neimeyer RA, Berman JS. The effectiveness of psychotherapeutic interventions for bereaved persons: A comprehensive quantitative review. Psychological Bulletin. 2008;134(5):648–661. REASON FOR EXCLUSION: older than two years. [PubMed: 18729566]
  • Currier JM, Holland JM, Neimeyer RA. Do CBT-based interventions alleviate distress following bereavement? A review of the current evidence. International Journal of Cognitive Therapy. 2010;3(1):77–93. REASON FOR EXCLUSION: focused only on CBT interventions.
  • Forte AL, Hill M, Pazder R, Feudtner C. Bereavement care interventions: a systematic review. BMC Palliative Care. 2004;3(3) REASON FOR EXCLUSION: older than two years. [PMC free article: PMC503393] [PubMed: 15274744] [Cross Ref]
  • Harvey S, Snowdon C, Elbourne D. Effectiveness of bereavement interventions in neonatal intensive care: A review of the evidence. Seminars in Fetal and Neonatal Medicine. 2008;13:341–356. REASON FOR EXCLUSION: older than two years, and focused on a specific sub-group of parents bereaved of a baby in neonatal care. [PubMed: 18514602]
  • McDaid C, Trowman R, Golder S, Hawton K, Sowden A. Interventions for people bereaved through suicide: A systematic review. British Journal of Psychiatry. 2008;193:438–443. REASON FOR EXCLUSION: older than two years, and focused on a specific sub-group of people bereaved through suicide. [PubMed: 19043143]
  • Nagraj S, Barclay S. Bereavement care in primary care: A systematic review and narrative synthesis. British Journal of General Practice. 2011 REASON FOR EXCLUSION: does not review evaluations of interventions, but UK primary care practices. [PMC free article: PMC3020071] [PubMed: 21401990] [Cross Ref]
  • Rowa-Dewar N. Do interventions make a difference to bereaved parents? A systematic review of controlled studies. International Journal of Palliative Nursing. 2002;8(9):452–457. REASON FOR EXCLUSION: older than two years, and methodological limitations in retrieval of evidence. [PubMed: 12362126]
  • Stroebe M, Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007;370:1960–1973. REASON FOR EXCLUSION: older than two years, and review methodology not systematically described. [PubMed: 18068517]
  • Szumilas M, Kutcher S. Post-suicide intervention programs: A systematic review. Canadian Journal of Public Health. 2011;102(1):18–29. REASON FOR EXCLUSION: focused on a specific sub-group of those bereaved through suicide. [PubMed: 21485962]
  • United Kingdom Department of Health. Bereavement Care Services: A Synthesis of the Literature. London, UK: DoH; REASON FOR EXCLUSION: no formal meta-analysis conducted, wide inclusion criteria (also studies focusing on service need/provision issues) and databases searched.
PICO table
Serial no.Intervention/comparisonOutcomesSystematic reviews used for GRADEExplanation
1Universal psychological interventions vs. no treatment/controlSymptom severity (mainly sub-threshold)Wittouck et al.(2011)Wittouck et al.(2011) is a recent thorough review comparing prevention with no intervention.
FunctioningNo data
Presence of disorderNo data
Adverse effectsNo data
Narrative description of the studies that went into analysis

Wittouck and colleagues' (2011) study identified 14 randomized controlled trials (RCTs), through searching Web of Science and PsycArticles, focused on (a) prevention (nstudies=9) and (b) treatment of complicated grief (nstudies=5). As this scoping question concerns adults without a mental disorder, only the studies focused on prevention are discussed here. Treatment studies were defined as studies aimed at reducing symptoms of people with pronounced complicated grief.

The nine prevention studies contained preventive interventions ranging from one to 12 sessions. All studies were conducted in high-income countries (five in the USA, one UK, one Australia, one Netherlands, one not reported). These interventions included cognitive-behavioural (individual, family and group) interventions (n=4), writing therapy (n=3), information giving and emotional support (n=1) and brief psychotherapy (n=1). All studies used subjective outcome measures to assess complicated grief, which were shown reliable in all but one of the nine studies, and studies were included if they compared a grief intervention with a control condition or non-specific intervention (i.e. non-grief-focused). Sample size ranged from 42 to 276 participants.

NOTE: Currier et al.'s (2008) review was excluded because it was older than two years, in accordance with the WHO Handbook on Guidelines Development. This systematic review included a larger number of studies, and comes to a similar conclusion: “Overall, analyses showed that interventions had a small effect at posttreatment but no statistically significant benefit at follow-up. However, interventions that exclusively targeted grievers displaying marked difficulties adapting to loss had outcomes that compare favorably with psychotherapies for other difficulties. Other evidence suggested that the discouraging results for studies failing to screen for indications of distress could be attributed to a tendency among controls to improve naturally over time. The findings of the review underscore the importance of attending to the targeted population in the practice and study of psychotherapeutic interventions for bereaved persons” (p.648).

NOTE: Szumilas & Kutcher (2011) focuses on interventions with people bereaved through suicide. Given that this review focuses on a specific population sub-group it was not included in the GRADE table. It is noted, however, that this systematic review leads to similar conclusions as the other systematic reviews. It identified three RCTs, but only one of these compared treatment to a control group. The latter study evaluated a 10-week broad-spectrum intervention for parents bereaved of children through violent deaths, and found no effects with fathers. Regarding effects found with mothers, it concluded that, “The intervention appeared to be the most beneficial for mothers most distressed at baseline.”

GRADE table

Author(s): Corrado Barbui, Wietse Tol

Date: 2012-02-24

Question: Should universal psychological or psychosocial interventions vs treatment as usual or no treatment/waitlist be used for bereaved adults who do not meet criteria for a mental disorder?

Bibliography: Wittouck et al. (2011)

Quality assessmentNo. of patientsEffectQualityImportance
No. of studiesDesignRisk of biasInconsistencyIndirectnessImprecisionOther considerationsUniversal psychological or psychosocial interventionsTreatment as usual or no treatment/waitlistRelative (95% CI)Absolute
Symptom severity: post-intervention (better indicated by lower values)
81Randomized trialsSerious2No serious inconsistencyNo serious indirectnessNo serious imprecisionNone442334SMD 0.0 lower (0.19 lower to 0.19 higher)MODERATEIMPORTANT
Symptom severity: follow-up (better indicated by lower values)
93Randomized trialsSerious4No serious inconsistencyNo serious indirectnessNo serious imprecisionNone440329SMD 0.07 higher (0.08 lower to 0.21 higher)MODERATEIMPORTANT
Functioning (better indicated by lower values)
0No evidence availableNone0MD 0 higher (0 to 0 higher)IMPORTANT
Prevention of disorder (better indicated by lower values)
0No evidence availableNone0MD 0 higher (0 to 0 higher)IMPORTANT
Adverse effects (better indicated by lower values)
0No evidence availableNone0MD 0 higher (0 to 0 higher)IMPORTANT
1

A total of nine studies assessed the efficacy of preventive grief interventions (p.71 of Wittouck et al., 2011). Of these, eight comparisons were included in the analysis of effect immediately after the intervention (Figure 2 of Wittouck et al., 2011).

2

Drop-out rates exceeded 30% in one study (O'Connor 2003); in two other studies drop-outs rates were nearly 30% (Kovac & Range, 2000; Sikkema, 2006). In addition, it is unclear if outcome assessment was performed by masked raters.

3

A total of nine studies assessed the efficacy at follow-up of preventive grief interventions (p.71 of Wittouck et al., 2011 and Figure 2 of Wittouck et al., 2011).

4

Drop-out rates exceeded 30% in two studies (O'Connor, 2003 and Range, 2000); in two other studies drop-outs rates were nearly 30% (Kovac & Range, 2000; Sikkema, 2006). In addition, it is unclear if outcome assessment was performed by masked raters.

PART 2. FROM EVIDENCE TO RECOMMENDATION(S)

Evidence to recommendation table
BenefitsThere is evidence suggesting that universally applied psychological interventions have no effect on grief-related symptoms in bereaved adults. The confidence in estimate is MODERATE.

There is no systematic review of evidence on presence of disorder and functioning for universally applied psychological interventions in bereaved adults.
HarmsThere is no systematic review of evidence of potential negative consequences from universally applied psychological interventions in bereaved adults.
Value and preferences
In favourUniversally applied psychological interventions that involve the delivery of common-sense strategies in people with psychological symptoms (but no mental disorder) in response to bereavement (e.g. providing (a) emotional support through empathic listening with a respectful and non-judgemental attitude and (b) problem-solving) may be low-risk strategies in people who seek help for bereavement-related complaints.
AgainstIt is inappropriate to offer an intervention that has been subject to study but which lacks a positive evidence base. Interventions may contribute to medicalization.
Feasibility (including economic consequences)Most staff in PHC in LMIC have not received extensive training in communication skills and basic emotional support. Any additional training in more complex psychological interventions would require some resources, including supervision.

Psychological interventions require time to be delivered, which is important in the context of constrained human resources.
Judgements to inform the decision on the strength of the recommendation
FactorDecision
Is there high- or moderate-quality evidence?
The higher the quality of evidence, the more likely is a strong recommendation.
Yes X
No
Is there certainty about the balance of benefits versus harms and burdens?
In the case of positive recommendations (a recommendation to do something), do the benefits outweigh harms?
In the case of negative recommendations (a recommendation not to do something), do the harms outweigh benefits?
Yes X
No
Are the expected values and preferences clearly in favour of the recommendation?Yes X
No
Is there certainty about the balance between benefits and resources being consumed?
In the case of positive recommendations (recommending to do something) is there certainty that the benefits are worth the costs of the resources being consumed?
In the case of negative recommendations (recommending not to do something) is there certainty that the costs of the resources being consumed outweigh any benefit gained?
Yes
No X
Final recommendation by the guideline panel

Recommendation 18

Structured psychological interventions should not be offered universally to (all) bereaved adults who do not meet the criteria for a mental disorder.

Strength of recommendation: strong

Quality of evidence: moderate

Remarks

General principles of care, as reported in the WHO (2010) mhGAP Intervention Guide (particularly principles on communication, mobilizing and providing social support, and attention to overall well-being) and the principles of psychological first aid should be considered. Encourage participation in culturally appropriate mourning.

49

Nagraj S, Barclay S. Bereavement care in primary care: A systematic review and narrative synthesis. British Journal of General Practice. 2011 [PMC free article: PMC3020071] [PubMed: 21401990] [Cross Ref].

50

Advice for recently bereaved people meeting criteria for moderate or severe depression can be found in the depression module of mhGAP (p.10), which advises that antidepressants or psychotherapy should not be considered as first-line treatment of depression if there is recent bereavement or other major loss in the prior two months, but to consider discussion and support of culturally appropriate mourning and reactivation of social networks. This is consistent with the raised concerns about medicalization of normal grief responses (see Friedman, R.A. (2012). Grief, depression and the DSM-5. New England Journal of Medicine, 366(20), 1855-7). Also, there has been an ongoing discussion on a separate mental disorder category for prolonged grief disorder, traumatic grief disorder, or complicated bereavement disorder, etc. The category prolonged grief disorder (disabling grief occurring more than six months after the loss) is currently under consideration for inclusion in the ICD-11.

From: Annex 5, Evidence Profiles

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