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The impact of complicated grief on mental and physical

health at various points in the bereavement process

Article  in  Death Studies · April 2003

DOI: 10.1080/07481180390137044

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Death Studies, 27: 2497272, 2003
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DOI: 10.1080/07481180390137044

????????????????????????????????????????????????????

THE IMPACT OF COMPLICATED GRIEF ON MENTAL

AND PHYSICAL HEALTH AT VARIOUS POINTS IN THE
BEREAVEMENT PROCESS
????????????????????????????????????????????????????

CAROL H. OTT
University of Wisconsin7Milwaukee,Wisconsin, USA

The purpose of this cohort sequential study was to determine whether the presence of com-
plicated grief (CG) measured at various points in the spousal bereavement process is asso-
ciated with an increase in mental and physical health problems 18 months later. One
hundred twelve participants provided data at four points in time. CG was measured with
the Inventory of Complicated Grief (ICG), and mental health was measured with the
Integra OutpatientTracking Assessment, Mental Health Index (MHI), and illnesses by
self-report.Twenty-nine participants were identified as experiencing CG. Beginning at
6 months after the death, MHI scores were significantly lower for the CG group and those
results were persistent.The CG group experienced more additional life stressors, perceived
less social support, and achieved less clinically significant change in MHI than the NCG
group. Identification of CG at any point at 6 months or later in bereavement indicates a
need for professional intervention. Implications for establishing CG as a DSM diagnosis
are discussed.

Each year approximately1million people in the United States experi-

encethe deathof a spouse, withthe majoritybeing women (National Cen-
ter for Health Statistics, 2000). The death of a spouse is considered to be
one of life’s most intense stresses and one that exposes the bereaved person
to a higher risk for physical and mental health problems (Gallagher-
Thompson, Futterman, Farberow,Thompson, & Peterson,1993; Holmes
& Rahe, 1967; Shuchter & Zisook, 1993; W. Stroebe & Stroebe M.S.,
1987). Previous research has established that as many as 20% to 30%

Received 8 July 2002; accepted 9 October 2002.

Address correspondence to Carol H. Ott, Ph.D., School of Nursing, University of Wisconsin7
Milwaukee, P.O. Box 413, Milwaukee,Wisconsin, 53203. E-mail: carolott@uwm.edu

249
250 C. H. Ott

of bereaved spouses experience complications of grief with many seek-

ing assistance from health care providers (Lund, Caserta, & Dimond,
1993; Raphael & Nunn, 1988; W. Stroebe & M.S. Stroebe, 1993).
Bereavement has been shown to increase the risk for mental health
problems, such as depressive symptoms and major depressive episodes
( Jacobs, Hansen, Berkman, Kasl, & Ostfeld, 1989; Pasternak et al.,
1993; W. Stroebe & M.S. Stroebe, 1993; Zisook, Shuchter, Sledge,
Paulus, & Judd, 1994) and anxiety-related disorders (Jacobs, Hansen,
Kasl, Ostfeld, Berkmann, & Kim 1990; Schut, deKeijser,Van den Bout,
& Dykhius, 1991; Zisook, Mulvihill, & Shuchter, 1990). Other studies
have identified increased mortality rates from causes such as heart dis-
eases, accidents, suicide, and cirrhosis of the liver (Gallagher-Thompson
et al.,1993; M.S. Stroebe & W. Stroebe,1993).These complications take a
toll not only in terms of personal suffering, but also in terms of the family,
social network, workplace, health care system, and the community.

Complicated Grief

In addition to the mental health and mortality consequences of bereave-

ment described above, some characterize complications of bereavement
as ‘‘pathological’’ with subtypes of inhibited, delayed, and prolonged
(Bowlby, 1980/1981; Horowitz, Wilner, Marmar, & Krupnick, 1980;
Middleton, Raphael, Martinek, & Misso, 1993; Parkes, 1965; Worden,
1991). Recent attention has focused on a variant of prolonged grief now
termed complicated grief (CG). This condition was formerly referred to as
traumatic grief but recent trends in the literature have favored the com-
plicated grief terminology to avoid confusion with post-traumatic stress
disorder (PTSD). Until the development of the Inventory of Compli-
cated Grief (ICG; Prigerson, Frank et al., 1995) consensus criteria for
identifying this condition were not available. CG is defined as a‘‘disorder
that occurs after the death of a significant other. Symptoms of separation
distress are the core of the disorder and amalgamate with bereavement
specific symptoms of being devastated and traumatized by the death’’
(Jacobs, 1999, p. 24).
The etiology of CG is thought to be due to insecure childhood attach-
ments resulting from a history of abuse, conflict, inconsistent parenting
or neglect, and/or death of a parent (Beery et al., 1997; Jacobs, 1999;
Prigerson, Shear et al., 1997; Silverman, Johnson, & Prigerson, 2001).
Developmental attachment deficits in combination with a personality
 Complicated Grief 251

style characterized by poor affect modulation lead to enmeshed adult

relationships characterized by dependency or compulsive care giving.
For such people, loss of a relationship that was stabilizing and relatively
exclusive can result in intense separation anxiety and psychological
trauma, even if the loss itself did not occur under traumatic circum-
stances (van Doorn, Kasl, Beery, Jacobs, & Prigerson, 1998).
There is a debate in the literature about when to assess for CG. In a
number of studies, symptoms of CG assessed 6 months after the death of
a spouse were shown to predict mental and physical health problems 18
to 25 months later (Chen et al., 1999; Prigerson, Bierhals et al., 1997). In
contrast, Horowitz et al. (1997) believe that CG should only be assessed
a year after the spouse’s death. The issue of precisely when symptoms of
CG can be identified has not been resolved. The purpose of this study is
to identify whether the presence of CG symptoms measured in six
cohort groups beginning at 3 months in the bereavement process is asso-
ciated with an increase in mental and physical health problems 18
months later.

Study Aims

The present study had three aims: (a) to classify the sample of bereaved
spouses by criteria for CG, (b) to examine the differences in outcomes
over time for the two groups, and (c) to describe the clinical significance
of the findings.
This study is part of a larger study based on the psychotherapy phase
model (Howard, Lueger, Maling, & Martinovich,1993), which describes
the pattern of change in mental health following spousal bereavement in
the domains of overall mental health, subjective well-being, current
symptoms, and current life functioning (Ott & Lueger, 2002). Results
from that analysis with an additional wave of data 1 year later will be
briefly summarized in the Results section.The focus of this analysis is on
the impact of CG symptoms on mental and physical health outcomes.

Method

Participants
The sample of 96 widows and 24 widowers was recruited from a number
ofcommunitysources includingchurches, hospice programs, amortician,
252 C. H. Ott

and support groups in a large Midwestern metropolitan area (see Ott &
Lueger, 2002, for a complete description of the participants). Agency
directors identified all participants from the churches and community
agencies who had experienced the death of a spouse between 3 and 18
months prior. These potential participants received a letter from the
agency director and from the researcher describing the study. Those
interested in participating in the study were instructed to return a post-
card expressing an interest. Of the 421 potential participants contacted
by letter, 29% of the total pool volunteered for the study. Upon receipt of
the postcard, participants were contacted by phone to arrange for a
home visit. This study includes the first 120 surviving spouses who met
the study criteria (i.e., recent death of a spouse and no major self-
reported mental health diagnosis except depression and/or anxiety).
There was no way to determine whether those who chose to participate
in the study were different from those who decided not to participate.
The study group was primarily Caucasian (97%), well educated
(M ¼14.17 years of education, SD ¼ 2.11), and from a relatively high
socioeconomic status (M ¼ 4.05, SD ¼ 2.11) as measured on a 5-point
scale (Hollingshead, 1975; reversed scale numbering). The ages of the
participants ranged from 27 to 87 with a mean of 60.65 years
(SD ¼12.76). More spousal deaths were categorized by the participant
as expected (59%) than unexpected (41%). Those who stated that the
death was expected mainly identified the cause of death as occurring
from natural causes, primarily cancer and heart disease. Unexpected
deaths were primarily attributable to heart attacks, accidents, and neuro-
logical causes. Sixteen percent of participants who categorized the
death as unexpected (n ¼ 8)identified the cause of death from a chronic
illness such as diabetes, heart failure, or complications of cancer. Of the
120 participants who initially joined the study, 118 (98%) remained in
the study at the 6-month assessment and112 (93%) completed the study
and comprised the sample for this study. Those who dropped out of the
study did not differ significantly in characteristics from those who com-
pleted the study. Reasons given for dropping out of the study included a
busy work schedule, too old, and a lack of interest in continuing.

Design and Procedure

The following options for the study design were considered: cross sec-
tional, longitudinal, or cohort sequential. By combining aspects of both
 Complicated Grief 253

TABLE 1 Data Collection Sequence for Six Cohort Groups

Months bereaved
Cohort
group 1.5a 3 6 9 12 15 18 21 24 27 30 33 36

Cohort 3 X X X X X
Cohort 6 X X X X X
Cohort 9 X X X X X
Cohort 12 X X X X X
Cohort 15 X X X X X
Cohort 18 X X X X X
a
This measure was a retrospective self-rating on the Mental Health Index obtained about
the first three months of bereavement. No significant differences found between cohort groups,
F(5, 101) ¼ 1.73, p ¼ .134.

cross-sectional and longitudinal designs, the cohort sequential design

goes beyond a cross-sectional approach by assessing change over an 18-
month time frame. Although a longitudinal design would increase con-
fidence in the differences between those in the CG and NCG groups, the
cohort sequential design enabled the researcher to examine the impact
of CG identified at various points in bereavement.
Table 1 illustrates the cohort sequential design used in this study. As
participants volunteered for the study, they were grouped into the time
frame closest to the death: 3, 6, 9, 12, 15, and 18 months. The sample size
in each cohort group ranged from 13 to 27. Data were collected four
times: at entrance into the study, 3 months later, 6 months later, and a
year later.
Each participant provided actual data over an 18-month time frame.
Each participant also contributed a retrospective mental health mea-
surement representing the time during the first 3 months of bereave-
ment. Questionnaires were administered individually to study
participants; the first set of questionnaires was administered during a
home visit and future questionnaires were sent and returned by mail.

Measures
Data for this report were collected from a battery of paper-and-pencil
questionnaires having established reliability and validity and a socio-
demographic questionnaire developed by the investigator.
254 C. H. Ott

Sociodemographic Measures and Self-Reported Physical and

Mental Health Diagnoses
Sociodemographic information was obtained including age, gender,
education, race, socioeconomic status (SES), whether the death was
expected, mode of death, and additional life stressors in addition to the
spouse’s death. Data were obtained on participation in professional
counseling, attendance at a support group, and the presence of any diag-
nosed physical or mental health condition for which they were currently
being treated. To determine whether any new medical or psychiatric
diagnoses were made during the study, participants were asked to record
any new physical or mental health conditions for which they were
receiving treatment during the three subsequent data collection points.

ICG
The ICG (Prigerson, Maciejewski, Newsom, Reynolds, & Frank,
1995) was administered to assess symptoms of CG.The ICG is a 19-item
self-report questionnaire used to measure symptoms of traumatic dis-
tress (i.e., feelings of disbelief, being stunned, avoidance, anger, shock)
and separation distress (i.e., yearning and searching for the deceased,
excessive loneliness, preoccupation with thoughts of the deceased, per-
sonal guilt, auditory and visual hallucinations).The questions are scored
on a 5-point fixed response scale ranging from 0 (never) to 4 (always).
Possible scores range from 0776.
The internal consistency of the ICG is reported as .94 and test7retest
reliability is .80 over 6 months of bereavement (Prigerson, Maciejewski
et al., 1995). Cronbach’s alpha in this study was .92. Concurrent validity
is reported as .67 with the Beck Depression Inventory (Beck, Ward,
Mendelson, Mock, & Erbaugh,1961) and .87 withTexas Revised Instru-
ment of Grief (TRIG) Part II (Fauschingbauer, 1981) with the ICG bet-
ter discriminating good from poor grief outcomes.The ICG is associated
with lower quality of life, global functioning, mood, sleep quality, and
self-esteem 18 months after spousal loss (Prigerson, Maciejewski et al.,
1995). Elevated scores 6 months after the loss predicted an elevated risk
of cancer, high blood pressure, heart trouble, smoking, and eating pro-
blems 1to 2 years later (Prigerson, Bierhals et al.,1997).
ICG was assessed three times: at entrance into the study and at 3 and
6 months later. Participants having ICG scores elevated on three waves
or an elevated score on at least two data waves and a third score within 2
points of the cutoff score of 5 32 were categorized as CG. Of this
 Complicated Grief 255

sample, 26% (n ¼ 29) met the above criteria for CG, which was within
the range of the percentage of bereaved spouses in other studies who
develop complications of bereavement. A score of 525 distinguished
between CG and noncomplicated (NCG) groups in Prigerson, Frank
et al.’s (1995) original study, but these researchers cautioned that the
validity of an ICG score of 525 needed to be further evaluated in future
studies (Prigerson, Maciejewski et al., 1995). In this study a score of
532 was a more stringent criterion and more clearly separated those
participants who were more distressed from those who were not.

Mental Health Inventory

The 68-item self-report Integra Outpatient Tracking Assessment,
Mental Health Inventory (MHI; Howard, Brill, Lueger, O’Mahoney,
& Grissom, 1993) was used to assess overall mental health status. The
MHI is a combination of three scales: subjective well being (SWB), cur-
rent mental health symptoms (CS), and current life functioning (CLF).
Questions have a 5- or 6-point fixed response scale. Scores on the MHI
and subscales are reported asTscores with a mean of 50 and a standard
deviation of 10. Higher mean scores represent a more positive overall
mental health status. The mean is based on a sample of over 16,000
outpatients seeking mental health services at the beginning of treatment.
ATscore of 60 separates the patient from the non-patient group and a
score of 70 indicates the norm for a healthy population. The internal
consistency of the MHI was .87, and the three-to-four week test7retest
stability was .82. In this study Cronbach’s alpha for the total MHI and
the subscales ranged from .90 to .92. The MHI was administered five
times: during the initial interview, at two subsequent 3-month intervals,
and then a year later. A retrospective measure (i.e., regarding mental
health status during the first 3 months of bereavement) was administered
at the second data collection and reflects the fifth administration of the
MHI.Thus, each participant completed the MHI for 5 points in time.
The SWB scale includes four questions related to measures of distress,
energy and health, emotional and psychological adjustment, and life
satisfaction. Correlations with other recognized well-being scales
(Dupuy, 1977; Stewart, Hayes, & Ware, 1988; Ware & Sherbourne,
1992; Watson & Tellegen, 1985) ranged from .70 to .79. The CS scale
consist of 40 items representing 7 diagnostic categories of the revised
3rd edition Diagnostic and Statistical Manual for Mental Disorders (DSM-
III7R; American Psychiatric Association,1987).These diagnoses include
256 C. H. Ott

(a) adjustment disorder, (b) anxiety, (c) depression, (d) bipolar disorder,
(e) obsessive-compulsive disorder, (f ) phobia, and (g) substance use.
Internal consistency scores of .94, and test7retest correlations over a 3-
to 4-week period of .85 were reported. This scale correlates positively
with the abbreviated Symptom Checklist-907R (r ¼.91; Derogatis,
1977); the CES-D (r ¼.68; Radloff, 1977), and the Beck Depression
Inventory (r ¼.87; Beck et al., 1961).
The CLF scale contains 24-items that assess the extent to which
emotional problems interfere with the ability to function in major areas
of life: (a) family, (b) intimacy, (c) social, (d) health, (e) work, and
(f ) self-management roles. The test7retest correlation is reported as
.76 and internal consistency of .93.

Social Support
Social support was measured with the 6-item Three Mile Island
Social Support Scale (Fleming, Baum, Gisriel, & Gatchel, 1982) at
entrance into the study and at two additional times each three months
apart. Items are rated on a 7-point Likert scale.Two items from the scale
include ‘‘I don’t know anyone I can confide in’’and ‘‘I often meet and talk
with family or friends.’’ Cronbach’s alpha for social support was .74 in
this study. In the validation study, social support was validated with
symptom self-report measures, performance tasks, and biochemical
assessments of stress.
Data Analysis
Measurements of CG, mental health status, and the existence or devel-
opment of new physical and/or mental diagnoses were assessed. Partici-
pants were categorized as CGs based on ICG scores. Chi square analysis
was used to compare the CG and NCG groups on sociodemographic
measures, participation in professional counseling, and attendance at
grief support groups. Social support was compared for both groups
using t tests. A repeated-measures analysis of variance (ANOVA) was
used to compare mean MHI T scores for each time frame for the CG
and the NCG groups. Clinically significant change was computed for
both groups and comparisons were made (Jacobson & Truax, 1991).
A Pearson’s correlation was calculated to assess the relationship between
total MHI and subscale scores and CG status.The pattern of participant
ICG scores was examined to determine if time since bereavement is pre-
dictive of mental and physical health problems.
 Complicated Grief 257

Results

Prior to addressing differences in the pattern of change for those partici-

pants categorized as CGs and NCGs, the typical pattern of change in
mental health status for the total group over 36 months of bereavement
was examined (see Figure 1). Table 2 presents the MHI means and stan-
dard deviations of each cohort for each of the four observed MHI scores
and the retrospectively reported MHI (RMHI). Three cohort groups
contributed to the mean scores at 9,12,15, 18, and 21months; two groups
contributed to the mean score at 6 and 24 months; and one group con-
tributed to mean scores at 3, 27, 30, 33, and 36 months. All participants
completed a retrospective MHI about how they were coping during the
first 3 months after the spouse’s death and this score was used as the
initial measure (seeTable 2). An ANOVA examining the effect of length
of time since bereavement on the retrospective MHI measure (i.e., first
3 months of bereavement) indicated no significant difference between
cohort groups at each point in time, F(5, 100) ¼ 1.73, p ¼1. The change
in MHI scores appeared to be most dramatic during the first 3 months of
bereavement and continued to improve until 15 months when scores
tended to plateau (see Ott & Lueger, 2002, for a complete description

FIGURE 1. Pattern of improvement in mental health over time.

 TABLE 2 Retrospective MHI (RMHI) and Observed MHI Mean Scores over 36 Months of Bereavement in Cohort Sequential Design

Cohort RMHI Months since spousal death and means scores for each time frame
Group
(N ¼112) 1.5 3 6 9 12 15 18 21 24 27 30 33 36

3 (n ¼15)
M 51.23 56.94 60.01 60.79 59.36
SD 3.13 6.45 7.13 8.29 5.40
6 (n ¼ 20)
M 50.14 57.15 60.70 62.02 63.33
SD 3.56 9.43 8.52 7.30 6.70
9 (n ¼ 25)
M 49.30 58.74 60.78 62.78 64.40
SD 4.77 9.97 8.05 6.70 5.67
12 (n ¼19)
M 51.28 61.44 64.40 64.57 63.72
SD 3.67 8.57 8.65 7.58 6.81
15 (n ¼13)
M 49.29 61.82 61.49 62.17 64.51
SD 4.66 8.97 9.99 10.28 5.89
18 (n ¼ 20)
M 47.79 61.63 61.10 62.07 64.54
SD 4.73 8.23 9.72 9.73 7.41
Overall (n ¼112)
M 49.78 56.94 58.38 59.91 61.37 63.11 62.67 60.85 62.70 64.40 63.72 64.51 64.54
SD 4.25 8.84 8.53 9.00 7.87 7.85 8.44 8.67 8.27 6.70 6.81 5.89 7.41
N 112 15 35 60 64 57 52 48 40 25 19 13 20

Note: Means of columns do not equal the means of the items in the columns because the overall mean was computed based on the means of all participants in

258
the time frame and not the mean of the groups.
 Complicated Grief 259

of the patterns of change in MHI). Thirty-six months after the spouse’s

death the group mean had not reached a score of 70, the norm for the
healthy population.

Comparison of CG and NCG Groups on Sociodemographic Measures

Twenty-nine participants (25.89%) met the criteria for CG at all three
time frames when the ICG was administered. A comparison of the CG
and NCG groups on measures of sociodemographic status indicated no
significant difference for age, gender, education, employment status,
SES, and perceptions of whether the death was expected or unexpected.
There was a significant difference between groups on the number of
life stressors in addition to the spouse’s death, t(110) ¼ 2.24, p ¼ .027
(two-tailed). Those in the CG group indicated more stressors
(M ¼ 2.38, SD ¼1.65) than those in the NCG group (M ¼1.67,
SD ¼1.38). Examples of additional life stressors given by the participants
included demands of single parenting, financial burdens resulting from a
long terminal illness, changes in residence, new diagnoses, and changes
in personal and work relationships.
Fifty-four percent of the respondents participated in a grief support
group and 30% of the total group sought professional counseling.There
was not a significant difference between CG and NCG groups on reports
of participation in professional counseling or in grief support groups,
w2 ¼ 2.67, p ¼ .083; w2 ¼ 3.28, p ¼ .083, respectively. Forty-one percent
of those in the CG group sought professional counseling compared with
25% in the NCG group. Sixty-nine percent of those categorized as CG
participated in a grief support group compared with 48% in the NCG
group.
There was a significant difference between groups on the perception
of the role of social support, t(110) ¼ 5.09; p < .001 (two-tailed). The
mean of the CG group was 10.75 (SD ¼ 4.04) compared with a mean of
14.10 (SD ¼ 2.61) for the NCG group. The CG group perceived less sup-
port than the NCG group.

Clinical Significance
According to Kazdin (1992), a major criterion for evaluating change in
clinical research should be whether the improvement enhances the per-
son’s everyday functioning (Kazdin, 1992). To address the research aim
260 C. H. Ott

about identifying differences in the type of change experienced by TGs

and NTGs and whether the type of change was meaningful for the
bereaved participants, clinical significance was determined (Jacobson,
Follette, & Revenstorf, 1984). First, reliable change scores were calcu-
lated for each participant as recommended by Jacobson and Truax
(1991) for psychotherapy outcome assessment. The criterion for reliable
improvement for the MHI is a 5 T-score improvement. In addition to a
change score of 5 Ton the MHI, the criterion for clinically significant
change includes the achievement of a score of 60 T, which is a standard
for return to a non-patient status meaning that the participant is not
likely to need mental health treatment (Howard, Brill et al.,
1993). To determine if there was clinically significant improvement in
the participants at the completion of the study, the difference score
between the retrospective MHI score (i.e., status during the first 3
months of bereavement) and the end point of measurement was
calculated.
Twelve percent (n ¼13) of the total group did not improve, 20%
(n ¼ 21) achieved reliable improvement but not clinically significant
change, and 68% (n ¼ 73) met the criteria for clinically significant
change. The CG group achieved significantly less improvement than
the NCG group over the 18 months of the study; w2 ¼ 23.81, df ¼ 2,
p < .001. A comparison of those meeting the criteria for CG compared
with those who did not indicated that 82% of the NCG group achieved
clinically significant change, whereas only 32% of the CG group
achieved this type of change (see Table 2). Twelve percent of the NCG
group and 46% of the CG group achieved reliable but not clinically sig-
nificant change. Twenty-one percent of the CG group did not meet the
criteria for improvement (i.e., 5 T-score improvement on the MHI),
whereas only 6% of the NCG group did not improve.

Pattern of Change in MHI for CG and NCG Groups

There is a significant difference between the CG and NCG groups in
their overall MHI scores, subjective well-being (SWB), current mental
health symptoms (CS), and current life functioning (CLF). Four sepa-
rate repeated-measures ANOVAs were performed, one for each of the
mental health measures (i.e., MHI, SWB, CS, & CLF), comparing the
CG group and NCG group scores over time. The retrospective MHI is
 Complicated Grief 261

FIGURE 2. Comparison of clinically significant change in mental health status*

from baseline to last data collection point for complicated and non-complicated
grievers.

not included in this analysis. The CG group scored significantly lower

than those categorized as NCG in overall MHI at each point in time,
F(1, 100) ¼ 33.72, p < .001. In terms of the SWB scale, the CG group
scored significantly lower than NCG group, F(1, 100) ¼ 59.8, p < .001.
Those participants in the CG group had a significantly lower level of
well-being compared with those in the NCG group. Differences in the
CS scale were also significantly different between the two groups, F(1,
100) ¼ 83.15, p < .001]. The CG group experienced more mental health
symptoms (i.e., depression, bipolar disorder, anxiety, phobia, adjust-
ment disorder, obsessive compulsive disorder, and substance abuse)
overall than the NCG group. In terms of the CLF scale, the difference
between the two groups was also significant; indicating more problems
in work/homemaker roles, social, family, health, and self-management
roles in the CG group, F(1,100) ¼ 48.98, p < .001.The CG group experi-
enced a significant decrease in mental health, a decreased sense of well-
being, an increase in problematic symptoms and a decreased level of
functioning in life roles as compared with the NCG group.
262 C. H. Ott

FIGURE 3. A comparison of mental health scores of non-complicated grievers

compared to complicated grievers by cohort.

Comparisons examining the difference between those categorized as

CG and NCG at each point in time indicated no significant difference in
MHI at 3 months for the CG and NCG group. At 6 months of bereave-
ment the CG group displayed significantly more distress than the NCG
group and continued to be significantly more distressed for the 18
months of the study (all p < .05). Figure 3 shows a graphic comparison
of MHI mean scores at the 4 data points (i.e., entrance to the study,
3 months later, 3 months from second data point, and 12 months later)
for each cohort group of those in the CG group and the NCG group.

Relationship Between Inventory of Complicated Grief (ICG) Scores and

Total Mental Health Index (MHI) Scores
At each point in time beginning at 6 months after the death of the
spouse, the ICG scores were significantly inversely correlated to the
MHItotal score. Correlations of total MHI and ICG scores ranged from

.590 to
.844.The higher the ICG (i.e., measure of CG), the lower the
total MHI. The SWB and CS scales of the MHI were also significantly
inversely correlated to ICG scores at each point in time. Correlations
with ICG and SWB ranged from
.604 to
.864 and correlations with
ICG and the CS ranged from
.709 to
.571.
 Complicated Grief 263

Self-Reported Physical and Mental Health Diagnoses

Although the age range in this study was 27 to 87 years old, 75% of the
sample was over 52 years of age with a median age of 61. No significant
age differences were found in the CG group and the NCG group,
t(110) ¼.907, p ¼ .36. The mean age of the cohorts ranged from 58.3 to
63.7 years of age. There were no significant differences in age between
cohort groups, F(5, 106) ¼.510, p ¼ .77. At entrance into the study, 44%
(n ¼ 49) of the 112 participants indicated that they were currently being
treated for a wide range of physical illnesses (e.g., hypertension, heart
disease, arthritis, high cholesterol, migraine headaches, asthma, emphy-
sema, bronchitis, diabetes mellitus, gastrointestinal problems, and can-
cer) and 15% (n ¼17) indicated being treated for depression, anxiety, or
a combination of depression and anxiety. By the fourth data collection
point, 23% (n ¼ 26) of the participants self-reported a new physical ill-
ness and 15% (n ¼17) self-reported a new mental health problem (i.e.,
12% depression, 2% anxiety, and 2% suicide attempts). New physical
diagnoses included pneumonia, stomach ulcer, migrane headache,
hypothyroidism, vascular insufficiency, heart failure, cancer, and glau-
coma. Over the 18 months of the study, there were no significant differ-
ences between the CG and NCG group on the prevalence of physical
illnesses, w2(1, N ¼110) ¼ 1.12, df 1, p ¼ .29, or the prevalence of depres-
sion, w2(1, N ¼110) ¼.07, p ¼ .79. Because of the small number of cases no
comparisons were made.

Discussion

Four observations can be made from these data: (a) those bereaved in
the CG group did not differ from the NCG group on sociodemographic
measures or participation in professional counseling or grief support
groups; (b) the CG group identified significantly more additional life
stressors and perceived less social support than those in the NCG group;
(c) the CG group scored lower on total MHI, SWB, CLF, and higher on
CS (current symptoms) than those in the NCG group beginning at 6
months after the spouse’s death and remained significantly different for
the 18 months of the study; and (d) there was no significant difference in
the prevalence of self-reported physical or mental health illnesses
between CG and NCG groups.
264 C. H. Ott

Limitations
Because of the volunteer nature of the recruitment process from a
variety of community sources, it is possible that these bereaved
spouses may not be representative of the ‘‘typical’’ griever. However,
the self-reported incidence of a new depressive disorder over 18
months of the study (e.g., 12%) is not atypical of other bereaved
samples ( Jacobs et al., 1989; W. Stroebe & M.S. Stroebe, 1993;
Zisook et al., 1994). The participation rate of those who were con-
tacted by letter to join the study was low (29%). However, once
recruited, 93% completed the study. Bereavement research indicates
that samples tend to include an over-representation of women,
which is reflective of the demographics of those who are widowed
(Levy, Derby, & Martinkowski, 1992; M.S. Stroebe & W. Stroebe,
1989). Although data are lacking on those who decided not to parti-
cipate in this study, Levy et al. (1992) found that refusers in bereave-
ment research were not significantly different than participants except
that participants tended to be younger than refusers. The characteris-
tics of this convenience sample were consistent with this finding with
an uneven distribution of age, gender, limited ethnic, and SES. A
greater percentage of participants in this study were in support
groups and receiving professional counseling than is reported in the
literature. A trend in the community where the study took place is to
offer support groups through numerous agencies including hospitals,
funeral homes, churches, and community mental health services. The
cohort sequential design is a limitation in that waves of data do not
reflect a uniform time from loss and conclusions about causality stand
on weaker ground (i.e., participants entered the study at different
points after the spouse’s death ranging from 3 months to 18 months
after the spouse’s death). At entrance to the study participants were
asked if they currently had a health problem. They were not asked
when the problem developed. Therefore, it was not possible to deter-
mine if the health problem existed prior to or after the spouse’s death.
The study design lacked power to determine if a relationship existed
between CG status and the development of new self-reported physical
and mental health diagnoses. The self-report method of identifying
new mental and physical health problems may have resulted in an
under-reporting of new diagnoses. Sample characteristics should be
taken into account when making generalizations from these results.
 Complicated Grief 265

Pattern of Change in MHI Status for theTotal Group

The pattern of change in mental health status for the bereaved partici-
pants in this study indicated consistent improvement in mental health,
especially in the first 3 to 6 months, which peaked at 15 months and then
showed very little variation for the next 21 months. Thirty-six months
after the death of a spouse MHI scores were still .5 SD below the norm
for a healthy population.The significance of this finding is unclear as the
MHI was normed on a younger population representative of those seek-
ing outpatient mental health treatment. The length of time to cope with
the death of a spouse is consistent with other research indicating the pro-
tracted nature of the grieving process (Gallagher-Thompson et al.,1993;
Shuchter & Zisook,1993;W. Stroebe & M.S. Stroebe,1993). Shuchterand
Zisook comment that ‘‘some aspects of grief work may never end for a
significant proportion of otherwise normal bereaved individuals’’ (p. 25).

Clinical Significance
Identifying statistically significant differences between groups does not
address the issue of whether the difference is practically significant. In
this study the issue of clinically significant change was examined for the
CG and NCG groupsby using the norms of mental health functioning for
a patient and a nonpatient population.The majority of those in the NCG
group (81%) achieved the type of change indicating enhanced function-
ing (i.e., movement to a nonpatient population norm, MHI score of 60 T
and a 5 T-score change), whereas only a minority of those in the CG
group achieved this type of change (32%). Less than half (46%) of the
CG group achieved the criterion for reliable change (i.e., a 5 T increase
in MHI score but not a 60 Tscore) indicating they had achieved some
improvement but still would be in need of mental health services. Addi-
tionally, almost a quarter of the CG group (21%) did not show any signs
of improvement.Taken together these results indicate that the majority of
the CG group did not experience the type of improvement that could be
classified as ‘‘an enhanced level of functioning’’ (Kazdin,1992).

Assessment
In this study the Integra Compas MHI (Howard, Brill, Lueger,
O’Mahoney, & Grissom,1993) was sensitive to changes in mental health
status over time in the domains of overall mental health, subjective well
266 C. H. Ott

being, distressing symptoms and resumption of functioning in current

life roles. The CG group scored consistently lower than the NCG group
in all four domains of mental health throughout 18 months of the study.
From a practitioner’s perspective, the MHI can be helpful in identifying
secondary symptoms and evaluating progress in therapy. Having results
reported in theTscore format allows for ease in calculation of clinically
significant change. Neimeyer and Hogan (20 01) cautioned
against using these types of mental health scales alone without a specific
grief measure.
The 19-item ICG was useful in identifying and predicting mental
health consequences in both the CG and NCG group as measured by
MHI but was not predictive of identifying differences in new self-
reported physical and mental health diagnoses between the groups.This
may be due to the lack of power in the cohort sequential design. A pro-
spective design would be necessary to determine if participants in the
later cohort groups had developed the documented diagnoses in the
beginning months of their bereavement or prior to the death. Determin-
ing the validity of using the ICG cutoff score of 525 as recommended
by Prigerson, Frank et al. (1995) was an issue. In this study a score of
532 more clearly separated those participants who were more dis-
tressed from those who were not. Further research is needed to deter-
mine a more standardized cutoff score.
This analysis may heighten awareness of helping professionals to cri-
tical periods in the bereavement process when assessment and interven-
tion for CG may prevent the development of more serious mental and
physical health problems. Prigerson, Bierhals et al. (1997) found that
the 6-month assessment was the earliest time frame to intervene,
whereas Horowitz et al. (1997) recommended waiting until 12 months
after the death. Findings from this study are supportive of the 6-month
recommendation because ICG scores were initially high in both the CG
group and the NCG group and differences were not significant at 3
months of bereavement. Starting at 6 months of bereavement, CG
symptoms assessed in each cohort group (i.e., 3, 6, 9,12,15, & 18 months)
were predictive of lower mental health scores over the 18 months of the
study. The CG group experienced significantly lower overall mental
health, subjective well being, functioning ability, and more distressing
mental health symptoms. New findings from this study indicate that
assessment at other times besides 6 months after the death (i.e., 9, 12, 15,
& 18 months or later) are important because when CG status was
 Complicated Grief 267

identified, mental health was significantly decreased a year and a half

later. Taken together these results would indicate the need for interven-
tion when CG is identified any time at 6 months or after. The ICG has
since been renamed the ICG Revised and has changed from 19 items to
34 items with a structured clinical interview available from the author
(Prigerson & Jabobs, 2001). Some of the new items include impairments
in social, occupational, or other areas of functioning and sleep difficul-
ties. These additions should increase the sensitivity of the tool.
In summary, use of the ICG Revised can assist the practitioner to
identify complicated grief at 6 months or later in the bereavement pro-
cess. The addition of the Integra Compas MHI (Howard, Brill et al.,
1993) can be helpful in monitoring mental health status over time.

Professional Counseling and Grief Support Group Interventions

In this study, 41% of those in the CG group sought professional counsel-
ing and 69% participated in a grief support group.The CG group experi-
enced significantly more additional stressors and perceived less social
support from family and friends than those in the NCG group. Because
of the study design it is not possible to know whether the perceived lack of
support and increased stressors were because of presence of CG symp-
toms or whether increased stressors and lack of support contribute to the
development of CG. Nevertheless, it would appear that the CG group
sought additional support from professional counselors and grief
support groups. Despite this help-seeking behavior, MHI results suggest
that the help received by the CG group may have lacked specificity.

Complicated Grief as a DSM Diagnosis

Currently there is a debate about whether CG should be considered a
separate diagnostic category in the DSM and whether it can reliably
be distinguished from other forms of disordered grief (M. Stroebe,
Hannson, Stroebe, & Schut, 2001). Some contend that the syndrome
can be accommodated under existing diagnostic criteria such as adjust-
ment disorder, depression, anxiety, and PTSD (Bonanno & Kaltman,
2001). Some (e.g., M. Stroebe et al., 2001) contend that the overlap
between CG symptoms and other disorders such as depression, anxiety,
and PTSD would indicate that further research is needed to determine
the etiology of CG.
268 C. H. Ott

Others believe there is a need to have CG included in the DSM diag-

nostic classification system (Prigerson & Jacobs, 2001). Prigerson and
Jacobs asserted that evidence supports CG as a unified syndrome with
symptoms that are distinct from those of bereavement-related depres-
sion and anxiety (Prigerson et al., 1996; Prigerson, Frank et al., 1995;
Prigerson, Shear et al., 1996). Prigerson and Jacobs believe that the
acceptance of CG as separate diagnostic entity would lead to better
identification of the syndrome in bereaved populations and also encou-
rage the development and testing of efficacious treatments specifically
directed at the syndrome. Horowitz et al. (1997) also recommended an
additional DSM diagnostic label for CG but disagreed about the etiol-
ogy of the disorder. They believed CG is a stress-related disorder with
elements of avoidance behavior. Results of this study would lend support
for continued efforts to delineate specific criteria for CG.

Conclusion

The current investigation added several new notable findings to the

empirical base on CG. Once identified, the majority of CGs did not
achieve clinically significant change in mental health during 18 months
of the study and in fact almost 20% did not show any signs of improve-
ment. Given the limitations of the sample and the research design, the
identification of CG symptoms at any point at 6 months or later in the
bereavement process would indicate a need for professional interven-
tion.
The significance of the CG group experiencing significantly more
additional life stressors and less social support needs to be clarified in
future studies. The majority of participants in the CG group were
involved in professional counseling and support groups. Recent studies
provide preliminary evidence that therapy for CG should be targeted
specifically to the disorder, namely through cognitive/behavioral inter-
ventions and possibly medications (Reynolds et al., 1999; Shear et al.,
2001). The theory and empirical research base on CG is broadening.
Further studies need to be conducted to validate the etiology of the
disorder. As more research is accumulating on CG it seems more clear
that CG should be considered for inclusion in the DSM diagnostic
nomenclature. This would provide a better avenue for diagnosis and
efficacious treatment for those who suffer from this disorder. Professional
 Complicated Grief 269

counselors and therapists may want to consider adding the revised ICG
assessment tool to their intake and evaluation procedures with bereaved
clients. The finding that participants in the CG group experienced sig-
nificant mental health distress should alert clinicians to assess for com-
plicated grief symptoms.

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