498 Suicide and Life-Threatening Behavior 35(5) October 2005 2005 The American Association of Suicidology

Complicated Grief and Suicidal Ideationin Adult Survivors of SuicideAnn M. Mitchell, PhD, RN, Yookyung Kim, PhD, Holly G. Prigerson, PhD,and Mary Kay Mortimer, PhD, RN

While the prevalence of complicated grief has been demonstrated to beelevated in survivors of suicide, the association between complicated grief andsuicidal ideation among adult suvivors of suicide has not been explored. The pur-pose of the present study is to examine the association between complicated griefand suicidal ideation in suicide survivors. The Inventory of Complicated Griefand the Beck Depression Inventory were administered to 60 adult survivors within1 month of a death by suicide of a family member or significant other. Compli-cated grief was associated with a 9.68 (CI: 1.036, 90.417) times greater likelihoodof suicidal ideation after controlling for depression, suggesting that syndromalcomplicated grief heightens vulnerability to suicidal ideation. Clinicians may pro-vide more comprehensive assessments by recognizing the possibility of suicidalideation in those with complicated grief.

Suicide, a major public health problem, oc- United States (American Association of Sui-cidology, 2001; DHHS, 2000), accountingcurs most frequently as a consequence of a

mental disorder (National Institute of Mental for about 30,000 deaths annually. For eachperson who commits suicide, as many as sixHealth [NIMH], 2003; U.S. Department of

Health and Human Services [DHHS], 1999). to ten survivors (persons close to the suicidevictim) remain to cope with the loss (Ameri-Suicide is the third leading cause of death in

young people between the ages of 15 and 24, can Association of Suicidology, 1999; Colt,1991), resulting in 180,000 to 300,000 newlyand the eleventh leading cause of death in the

Ann M.Mitchell is Assistant Professor of Nursing and Psychiatry in the Health and CommunitySystems Department at the University of Pittsburgh School of Nursing. Yookyung Kim is AssistantProfessor of Biostatistics, Center for Nursing Research, at the University of Pittsburgh School of Nurs-ing. Holly G. Prigerson is Associate Professor of Psychiatry at Brigham and Women’s Hospital, Har-vard Medical School, and the Division of Psychosocial Oncology and Palliative Care at Dana-FarberCancer Institute in Boston. Mary Kay Mortimer is Associate Professor of Nursing at the FranciscanUniversity of Steubenville in Ohio.

This work was made possible by the generous support of the American Foundation for SuicidePrevention, New York, NY, and the University of Pittsburgh Central Research Development Fund,Pittsburgh, PA. The authors wish to acknowledge the contributions of David Brent, MD, Departmentof Psychiatry, Pediatrics, and Epidemiology at the University of Pittsburgh School of Medicine andGraduate School of Public Health; Karen Evanczuk, PhD, CRNP, Family Nurse Practitioner, Depart-ment of Community Outreach, University of Pittsburgh Medical Center, UPMCMcKeesport; and SusanWesner, MSN, RN, Clinical Nurse Specialist, Services for Teens at Risk, Western Psychiatric Instituteand Clinic, Pittsburgh, PA.

Address correspondence to Ann M. Mitchell, PhD, RN, University of Pittsburgh, School of Nurs-ing, 415 Victoria Building, Pittsburgh, PA 15261; E-mail: ammi@pitt.edu

Mitchell et al. 499

bereaved suicide survivors annually. From a complicated grief was associated with a 5.08times greater likelihood of suicidal ideationpublic health perspective, suicide is a major

problem (DHHS, 1999, 2000) and for survi- after controlling for depression. Comorbidcomplicated grief and depression were notvors of suicide, their bereavement can nega-

tively influence their functioning and mental associated with a greater likelihood of sui-cidal ideation. Recently, Melhem and col-health, including their risk of complicated

grief reactions. leagues (2004) reported in a sample of 146friends and acquaintances of 26 individualsRecent studies have identified compli-

cated grief as an important distinct reaction who died by suicide, the occurrence of trau-matic grief symptoms was independent fromto bereavement that is separate from normal

grief and other psychiatric disorders, such as that of depression and Posttraumatic stressdisorder (PTSD), and that traumatic grief atbereavement-related depression and anxiety

disorders (Prigerson, Frank, et al., 1995; Prig- 6 months predicted the onset or course of de-pression and PTSD at subsequent assess-erson et al., 1997; Jacobs, Mazure, & Priger-

son, 2000). To develop complicated grief ments. These results suggest a long-lastingeffect of complicated grief on suicidality.symptom criteria empirically, data were de-

rived from a study group of 82 recently wid- Complicated grief also has been foundto be associated with a heightened risk of sui-owed elderly individuals recruited for an in-

vestigation of physiological changes in bereaved cidal ideation and thoughts among bereavedolder persons. Szanto, Prigerson, Houck,persons. Baseline data were collected 3 to 6

months after the deaths of the subjects’ Ehrenpreis, and Reynolds (1997) examinedwhether complicated grief predicted suicidalspouses, with follow-up data collected from

56 subjects 18 months after the baseline as- ideation during a depressive episode in 130elderly bereaved individuals who had lostsessments. Principal-components analysis re-

vealed a complicated grief factor and a be- their spouses within the past 2 years. Theyfound that 57% of the patients with highreavement-depression factor. The concept of

complicated grief as a new diagnostic cate- complicated grief scores were found to beideators during the follow-up time periodgory requires that certain criteria be met.

The proposed criteria, based on the work of versus 24% of the patients with low compli-cated grief scores. Latham and PrigersonPrigerson, Shear, et al. (1999), requires that

survivors of a significant loss have an intru- (2004) also examined the influence of com-plicated grief on suicidal thoughts or behav-sive and a distressing set of core symptoms

which includes: yearning and longing for the iors in 281 bereaved elders at an average of6.3 months post-loss. They found the risk ofdeceased, a sense of purposelessness, feelings

of futility, difficulty imagining a life without any suicidal thoughts or behaviors was 10.80times greater for subjects with complicatedthe deceased, numbness, detachment, feeling

stunned, dazed or shocked, feeling that life is grief and 7.10 times greater for subjects witha major depressive disorder compared to thoseempty or meaningless, feeling disbelief over

the loss, and excessive anger or bitterness re- who did not meet criteria for these disorders.There is an increased risk for suicidallated to the death.

Complicated grief has been found to ideation and behavior in families where therehas been a completed suicide (DHHS, 1999).be associated with a heightened risk of sui-

cidal thoughts and actions among young While complicated grief has been demon-strated to be high in survivors of suicideadult friends of adolescents who died by sui-

cide (Prigerson, Bridge, et al., 1999). Priger- (Mitchell, Kim, Prigerson & Mortimer-Stephens, 2004), the influence of compli-son, Bridge, et al. (1999) examined the influ-

ence of complicated grief on suicidal ideation cated grief symptoms on suicidal ideationamong adult survivors of suicide has not beenin 76 young adults who had a fried who died

by suicide at an average of 6.3 years after explored. The purpose of the present studyis to examine the main and interactive effectstheir friend’s suicide. Results indicated that

500 Complicated Grief

of complicated grief and depression on sui- 10–19; moderate to severe, 20–29; and se-vere, 30–66. Concurrent validity of the BDIcidal ideation in this group of individuals.to depression ratings by clinicians is well es-tablished in the literature. Test-retest reli-ability over 6 to 21 days was 0.86 for de-METHODSpressed, and 0.76 for nondepressed samples(Beck, Ward, Mendelson, Mock, & Erbaugh,Subjects and Design of the Study1961; Metcalfe & Goldman, 1965; Schwab,Pialow, & Holzer, 1967). The BDI demon-A cross-sectional design was used for

this exploratory, descriptive pilot study. Data strated high internal consistency in the pres-ent sample (Cronbach’s alpha = 0.95).were obtained from 60 adult survivors of sui-

cide (18 years of age or older) who completed Suicidal Ideation. Suicidal ideationwas determined by No = 0 on question 9 ofbaseline measures as part of a crisis interven-

tion study during the acute phase of bereave- the BDI and Yes = 1, 2, or 3 on question 9 ofthe BDI. In this sample, 16.7% (n = 10)ment. That study, which was conducted over

a 3-year period, examined the efficacy of a scored Yes on question 9 of the BDI. The in-ventory’s item assessing suicidal ideationmodified, family-focused critical incident

stress debriefing intervention for survivors (question 9) was then omitted from the sum-mary score. A BDI score greater than 10 waswithin 1 month of a death by suicide. Sub-

jects were recruited with the assistance of lo- selected as the cutoff point for “caseness” ofdepression in this study because this is thecal coroners’ offices, funeral homes, commu-

nity mental health centers, and other social established start point for the mild to moder-ate level of depression. In this sample, 50%service agencies within a 100 mile radius of a

tri-state area that included Southwestern (n = 30) scored above 10 on the BDI.The Inventory of Complicated Grief (ICG).Pennsylvania, Ohio, and West Virginia.

All data reported had been collected The ICG is an instrument developed to as-sess certain symptoms of grief known to pre-before any intervention was administered.

The study received Institutional Review Board dict long-term functional impairments (Prig-erson, Maciejewski, et al., 1995). It was(IRB) approval from a university-designated

committee comprised of members with mul- designed to measure symptoms that havebeen termed complicated grief. Subjects aretidisciplinary backgrounds and expertise es-

tablished to protect the rights and welfare of asked to report the frequency (Never = 0 toAlways = 4) with which they currently experi-human subjects participating in research ac-

tivities. All subjects consented to participate ence each of the behavioral, cognitive, andemotional symptoms described in the ICG.in the study.Respondents with ICG scores >25 were foundto be significantly more impaired in social,Measuresmental, and physical health functioning thanthose with ICG score ≤25. The instrumentThe 60 subjects completed the follow-

ing self-report measures at baseline, within 1 has been shown to have adequate psychomet-ric properties. Concurrent validity of themonth of the death by suicide of a family

member or significant other. ICG was assessed in relation to other scalesand showed a fairly high association with theThe Beck Depression Inventory (BDI),

Version I. The BDI is composed of 21 self- BDI (r = 0.67, p < 0.001) and the Grief Mea-surement Scale (r = 0.70, p < .0001). The in-administered, Likert-type items. Each of the

21 items is rated on a 4-point scale ranging ternal consistency of the 19-item ICG washigh (Cronbach’s alpha = 0.94). Test-retestfrom 0–3. The total BDI score (0–66) is ob-

tained by adding the score of all categories reliability was 0.80 when used with conju-gally bereaved elderly (Prigerson, Maciejew-and is matched with established degrees of

depression: minimal, 0–9; mild to moderate, ski, et al., 1995). The 19-item ICG demon-

Mitchell et al. 501

strated modest internal consistency in the Caucasian males (28%), with a mean age of43.3 years (range: 18–78 years) and was pre-present sample (Cronbach’s alpha = 0.66).

The cutoff point for “caseness” of dominately Catholic (67%) or Protestant(23%). In general, the subjects had a highcomplicated grief was an ICG score greater

than 25 given the prior work demonstrating school education (40%), technical/vocationaldiploma (13%), or bachelor’s degree (32%)the criterion validity of this cutpoint (Priger-

son, Maciejewski, et al., 1995). In this sample, and worked fulltime (65%) or parttime (33%).The sample consisted of 60 subjects43.3% (n = 26) scored above 25 on the ICG.

recently bereaved (within 1 month) by thesuicide of a family member, significant other,Data Analysesfriend, or coworker. Each subject belongedto one of 16 family networks, with the num-Preliminary descriptive analyses on de-

mographic and clinical variables and psycho- ber of subjects per family network rangingfrom 1 to 22. A family network consisted ofmetric analyses on the BDI and ICG were

conducted. Relationships between demo- those bereaved subjects who were survivorsof a particular individual’s suicide. Each fam-graphic variables (age, gender, religion, and

education) and suicidal ideation were exam- ily network included at least one spouse, par-ent, child, or sibling while the larger net-ined to identify significant covariates. Logis-

tic regression analyses (Agresti, 1990) were works also included in-laws, nieces/nephew,friends and/or co-workers. Although theperformed using the ICG scores, as well as

BDI scores as independent variables, and sui- family networks varied in size, the largestnetwork had members representing each ofcidal ideation as the dependent variable. Vari-

ables were examined to determine that there the relationship categories examined.Of the 16 deaths by suicide, 7 (44%)was not a problem with multicollinearity.

Multicollinearity is usually regarded as a were by gunshot, 4 (25%) were by hanging,3 (19%) were by carbon monoxide, followedproblem if bivariate correlation coefficients

between each pair of independent variables by 1 overdose (6%) and 1 suffocation (6%).However, of the 60 subjects associated withare greater than .80. Our results showed that

bivariate correlation between independent each of the 16 deaths, most subjects (n = 32,53%) were exposed to a death by hanging,variables was .471, indicating that multicol-

linearity is unlikely. The collinearity statistic with the next most frequent category beingdeath by gunshot (n = 15, 25%).(e.g., tolerance) of .778 further supports our

justification of using the current models for The demographic characteristics ofthe 60 subjects in terms of the two subgroupsdata analysis.

We employed binary logistic regres- of suicidal ideation (Yes vs. No) are presentedin Table 1. The groups were comparable withsion models to estimate the probability of an

individual reporting suicidal ideation (Yes vs. regard to age, gender, race, religion, and edu-cation with no significant statistical differ-No). Logistic regression models estimated

the main effect of syndromal complicated ences found between the two groups.grief on the likelihood of suicidal ideation,controlling for depression. Complicated Grief and Likelihood

of Suicidal Ideation

Multivariate logistic regression modelsRESULTSwere employed to estimate the probability ofan individual reporting suicidal ideation (YesSample Characteristicsvs. No) with two dichotomized grouping vari-ables of complicated grief (Yes vs. No) andA brief description of the investiga-

tion’s subjects follows. The sample was com- depression (Yes vs. No), with cutoff scoresdescribed in a previous section of this paper.prised of 43 Caucasian females (72%) and 17

502 Complicated Grief

TABLE 1Sample Demographics by Suicidal Ideation (SI) Group

SI Yes SI No(n = 10) (n = 50) t or χ2 P

Age .402 .689Mean ± SD 41.70 [12.63] 43.62 [13.99]

Gender .410 .522Male, n (%) 8 (80%) 35 (70%)Female, n (%) 2 (20%) 15 (30%)

Race — —White, n (%) 10 (100%) 50 (100%)

Religion 1.929 .381Catholic, n (%) 5 (50%) 35 (70%)Protestant, n (%) 4 (40%) 10 (20%)Other, n (%) 1 (10%) 5 (10%)

Education 5.862 .210Elem Sch, n (%) 1 (10%) 0 (0%)High Sch, n (%) 4 (40%) 20 (40.8%)Voc Sch, n (%) 2 (20%) 6 (12.2%)Undergrad, n (%) 2 (20%) 17 (34.7%)Graduate, n (%) 1 (10%) 6 (12.2%)

Table 2 depicts the multivariate logistic re- effect of syndromal complicated grief on thelikelihood of suicidal ideation, controlling forgression models for predicting suicide ide-

ation (predictor variable, unstandardized the effects of depression. As shown in Table2, complicated grief was significantly associ-regression coefficient, standard error, Wald-

test statistic, p value, adjusted odds ratio ated with suicidal ideation even after adjust-ing for the effect of depression in the model.[OR], and 95% confidence interval for OR).

In step 1, a logistic regression model first Subjects with syndromal levels of compli-cated grief were found to be approximatelytested the effect of depression on suicidal ide-

ation. The results showed that depression had ten times more likely to report suicidal ide-ation than were subjects with nonsyndromala significant effect on suicidal ideation (OR =

12.429, 95% CI = 1.461–105.737, p = .021). levels of complicated grief (OR = 9.680, 95%CI = 1.036–90.417, p = .046) when depres-In step 2, an additional logistic regres-

sion model was used to estimate the unique sion was in the model. The broad 95% confi-

TABLE 2Depression and Complicated Grief as Predictors of Suicidal Ideation in Survivors of Suicide

95% CI for OR

Step Predictor Variable B SE Wald df p OR Lower Upper

1 Depression 2.520 1.092 5.322 1 .021 12.429 1.461 105.7372 Depression 1.709 1.156 2.186 1 .139 5.524 .573 53.230

Complicated Grief 2.270 1.140 3.965 1 .046 9.680 1.036 90.417

Note. B = Unstandardized Regression Coefficient; SE = Standard Error; Wald = Wald-testStatistic; OR = Adjusted Odds Ratio.

Mitchell et al. 503

dence intervals for ORs indicate the effect mini, Gold, and Prigerson (2002) found thatin a 208-bed correctional facility for boys andwas small, although significant.

The model was statistically reliable girls, 60% of the detainees had experiencedthe violent death of a friend or family mem-(Chi-squared for model = 14.3, df = 2, p =

.001) and demonstrated a good fit to the data ber approximately 21⁄2 years earlier, and thatcomplicated grief was higher in those be-(Chi-squared for Hosmer-Lemeshow test

statistic = 3.11, df = 2, p = .211). The overall reaved by suicide (Prigerson, November 2004,personal communication). Rynearson et al. werepredictive success (correct classification) of

the model was 83.3%, indicating that com- evaluating a treatment group intervention,and although the pre- and post-interventionplicated grief was highly predictive of suicide

ideation in survivors of suicide, over and decrease in measures of distress (includingcomplicated grief) could have been associ-above the effects of depression.ated with change over time, it would seemunlikely that, given the high levels of death-related distress at 30 months since the violentDISCUSSIONdeath, a significant decrease would occurspontaneously.Syndromal levels of complicated grief

significantly increased the likelihood of sui- Although the present study utilizedcross-sectional data, longitudinal data hascidal ideation in this sample of adult survi-

vors of suicide. The significant effect of com- demonstrated that complicated grief and de-pression are preludes to suicidal ideation inplicated grief on suicidal ideation remained

even after depression was entered into the the spousally bereaved (Szanto et al., 1997).In a larger, community-based sample of re-model, suggesting that it is an independent

clinical correlate of suicidal ideation. Even cently bereaved blood relatives of the de-ceased, Latham and Prigerson (2004) foundthough there were no completed suicides re-

ported among the survivors of suicide within that bereaved elders who met criteria forcomplicated grief were at a significantlythe study observation period, prior suicidal

thoughts and gestures have been identified as heightened risk of suicidality that remainedafter controlling for depression. This sug-a leading predictor of subsequent suicide (Shaf-

fer, Garland, Gould, Fisher, & Trautman, gests that complicated grief is an indepen-dent and important clinical correlate of sui-1988). The results of the present study indi-

cate that complicated grief and depressive cidality, apart from a major depressive disorder.An important finding in the Lathamsymptoms independently heighten the risk of

suicidal ideation which may pose a risk for and Prigerson (2004) study involved the ex-amination of the prevalence of a prior psychi-subsequent suicide.

Although the present assessment of atric diagnosis. It could be postulated thatthose with a prior psychiatric history mightcomplicated grief was done within 1 month

of the death, when time from loss to mea- tend to be less successful at grieving the lossof a loved one. However, baseline character-surement of complicated grief has been con-

trolled, it has not had significant effects on istics in their sample demonstrated that priorpsychiatric history and complicated grief sta-levels of complicated grief. Furthermore,

Prigerson and others have found that the tus at baseline were not related. That is, thedeath of a loved one is an event that canpresence of complicated grief is higher and

more persistent in suicide bereavement than cause great mental distress in persons bothwith and without a prior psychiatric history,in other forms of death. Dyregrov, Nor-

danger, and Dyregrov (2003) have found the making both populations vulnerable for suf-fering from complicated grief.prevalence of complicated grief to be signifi-

cantly higher in parents bereaved by suicidal Furthermore, symptoms of compli-cated grief are not only associated with sui-and accidental deaths than by deaths from

SIDS. Recently, Rynearson, Favell, Belluo- cidal ideation but also with a number of other

504 Complicated Grief

negative physical and mental health outcomes. met criteria for PTSD, indicating the overlapwas not extremely high. When Silverman,Prigerson, Bierhals, et al. (1997) followed a

group of 150 widows and widowers at the Johnson, and Prigerson (2001) compared theinfluence of childhood and adulthood adver-time of their spouses hospitalization and at

6, 13, and 25-month follow-up time periods. sities on current diagnoses of major depres-sion, PTSD, and complicated grief among 85Using survival analysis and linear and logistic

regressions, the risk for adverse physical and recently widowed older adults, they foundadversities occurring in childhood were sig-mental health outcomes posed by the pres-

ence of complicated grief were assessed. The nificantly associated with complicated grief,and secondarily to depression, while adversi-presence of complicated grief at 6 months

after the death of their spouse predicted neg- ties occurring in adulthood were associatedwith PTSD. The tendency of childhood ad-ative health outcomes including cancer, heart

trouble, high blood pressure, changes in versity to predict complicated grief and adultadversities to predict PTSD remained signifi-eating habits, and suicidal ideation at 13- or

25-month follow-up time periods. These re- cant even after the clustering of adversity andcomorbidiy among psychiatric disorders wassults indicate that psychiatric sequelae, such

as complicated grief, may be of critical im- taken into account. The distinct etiologicalrisks for bereavement-related depression,portance in determining which individuals

will be at risk for long-term mental and phys- PTSD, and complicated grief suggest thattherapeutic interventions should be devel-ical health problems, rather than simply the

stress of bereavement (Prigerson, Bierhals, et oped and tailored to the particular symptomsand syndromes that are present.al., 1997).

More recently, Dyregrov and colleagues(2003) compared the predictors of psychoso- Limitationscial distress after a death by youth suicide,SIDS, and child accidents. Data were col- There are a number of limitations of

the current study, including a small and ho-lected from 140 families, representing 232parents. One and one-half years post-loss, mogeneous sample (e.g., all Caucasian and

primarily Catholic subjects from Western57–78% of the survivors scored above cut-off levels for complicated grief. Although Pennsylvania). There also may be sample se-

lection bias using participants who were will-they found no significant differences betweensurvivors of suicide and accidents, both groups ing to take part in a crisis intervention study.

We continue to need longitudinal analyses tohad significantly greater subjective distressthan the survivors of SIDS. These results draw conclusions about causality; and a larger

and more ethnically and geographically di-suggest that to lose a child suddenly and intraumatic circumstances can have a long-last- verse sample to draw conclusions that are

more generalizable. Finally, family networking impact. It may be that sudden and trau-matic death is a factor associated with com- effects (including the varying sizes of the net-

works) were not fully examined in this studyplicated grief and other posttraumatic reactions.It will be important to assess if the resultant because of the small sample size.risks of suicidal ideation in these bereavedadults are similar to what we have found insurvivors of suicide. CONCLUSIONS AND

RECOMMENDATIONSFurthermore, Callahan (2000) foundthat in a group of 210 survivors participatingin suicide support groups, one of the factors This study builds on previous work

that has been conducted on complicated griefaffecting their overall level of grief was post-traumatic reactions which increased their dis- with adolescents and the elderly, and broad-

ens the subjects to include numerous othertress. Latham and Prigerson (2004) foundthat 38.2% of those with complicated grief relationship categories (e.g., spouses, parents,

Mitchell et al. 505

children, siblings, in-laws, nieces/nephews, of suicide should examine not only symptomsof depression, PTSD, and other DSM diag-and friends or coworkers). The findings indi-

cate that survivors of suicide are vulnerable noses but also signs and symptoms of compli-cated grief and the comorbidity of thesenot only to complicated grief, but also to sui-

cidal ideation and possibly to suicide. Health among suicide survivors and other groups ofbereaved adults (e.g., from accidents, homi-care providers should be positioned to re-

sponsibly assess these areas and make appro- cides, and natural causes). Evidence is build-ing that confirms the nature and existence ofpriate follow-up referrals to prevent further

complications of grief and potentially self- complicated grief and the likelihood of co-morbid suicidal ideation. Continued researchharm in these populations.

Future research is needed to address is needed to identify those who are most vul-nerable to complicated grief as well as thecurrent limitations, including a larger and

more diverse sample. A larger and less self- predictors of complicated grief.Shear and colleagues (2001) reportselected into treatment sample will make

conclusions more generalizable to the target promising results from a pilot study utilizinga specific treatment program for traumaticgroup of survivors of suicide. Once we have a

larger sample we can then apply hierarchical grief which was based on the cognitive be-havioral therapy framework developed bylinear modeling (HLM) or multi-level analy-

ses to address the issue of interdependence of Foa (1997) for the treatment of posttraumaticstress disorder; however, further develop-subjects. Longitudinal studies will also allow

us to determine if long-term associations ment, refinement, and testing of interven-tions for both complicated grief and suicidalexist in suicide survivors as they do in non-

suicide survivors and to examine other factors ideation is needed to advance our under-standing and to reduce the risk of suicide inthat may influence complicated grief and sui-

cidal ideation. Future studies with survivors this highly vulnerable population.

REFERENCES

Agresti, A. (1990). Categorical data analysis. the trauma of rape: Cognitive-behavioral therapyfor PTSD. New York: Guilford Press.New York: Wiley.

Jacobs, S., Mazure, C., & Prigerson, H.American Association of Suicidology.(2000). Diagnostic criteria for traumatic grief.(1999). Facts about suicide. Retrieved SeptemberDeath Studies, 24, 185–99.20, 2004, from http://www.suicidology.org/display

Latham, A. E., & Prigerson, H. G.common.cfm(2004). Suicidality and bereavement: ComplicatedAmerican Association of Suicidology.grief as psychiatric disorder presenting greatest(2001). USA suicide: 2001 official final data. Re-risk for suicidality. Journal of Suicide and Life-trieved October 15, 2004, from http:www.suicidThreatening Behavior, 34, 350–363.ology.org/associations/2001datapage.pdf

Melhem, N. M., Day, N., Shear, M. K.,Beck, A. T., Ward, C. H., Mendelson,Day, R., Reynolds, C. F. III, & Brent, D.M., Mock, J., & Erbaugh, J. (1961). An inventory(2004). Traumatic grief among adolescents ex-for measuring depression. Archives of General Psy- posed to a peer’s suicide. American Journal of Psy-chiatry, 4, 561–571. chiatry, 161, 1411–1416.Callahan, J. (2000). Predictors and corre- Metcalfe, M., & Goldman, E. (1965).lates of bereavement in suicide support group par- Validation of an inventory for measuring depres-

ticipants. Suicide and Life-Threatening Behavior, sion. Journal of Clinical Psychology, 111, 240–242.30(2), 104–124. Mitchell, A. M., Kim, Y., Prigerson,

Colt, G. H. (1991). The enigma of suicide. H. G., & Mortimer-Stephens, M. K. (2004).New York: Simon & Schuster. Complicated grief in survivors of suicide. Crisis,

Dyregrov, K., Nordanger, D., & Dyre- 25, 12–18.grov, A. (2003). Predictors of psychosocial dis- National Institute of Mental Healthtress after suicide, SIDS and accidents. Death [NIMH]. (2003, April). In harms way: Suicide inStudies, 27, 143–165. America. Retrieved July 25, 2003, from http://www.

nimh.nih.gov/publicat/harmswayFoa, E., & Rothbaum, B. (1997). Treating

506 Complicated Grief

Prigerson, H. G., Bierhals, A. J., Kasl, C. E. (1967). A comparison of two rating scalesfor depression. Journal of Clinical Psychology, 23,S. V., Reynolds, C. F., Shear, M. K., Day, N.,

et al. (1997). Traumatic grief as a risk factor for 94–96.Shaffer, D., Garland, A., Gould, M.,mental and physical morbidity. American Journal

of Psychiatry, 154, 616–623. Fisher, P., & Trautman, P. (1988). Preventingteenage suicide: A critical review. In S. Chess &Prigerson, H. G., Bridge, J., Maciejew-

ski, P. K., Beery, L. C., Rosenheck, R. A., M. Hertzig (Eds.), Annual progress in child psychia-try and child development (pp. 401–428). Philadel-Jacobs, S. C., et al. (1999). Influence of traumatic

grief on suicidal ideation among young adults. phia: Brunner/Mazel.Shear, M. K., Frank, E., Foa, E., Cherry,American Journal of Psychiatry, 156, 1994–1995.

Prigerson, H. G., Frank, E., Kasl, S. V., C., Reynolds, C. F. III, Vander Bilt, J., et al.(2001). Traumatic grief treatment: A pilot study.Reynolds, C. F. III, Anderson, B., Zubenko, G.,

et al. (1995). Traumatic grief and bereavement- American Journal of Psychiatry, 158, 1506–1508.Silverman, G. K., Johnson, J. G., & Prig-related depression as distinct disorders: Prelimi-

nary empirical validation in elderly bereaved erson, H. P. (2001). Preliminary explorations ofthe effects of prior trauma and loss on risk for psy-spouses. American Journal of Psychiatry, 152, 22–30.

Prigerson, H. G., Maciejewski, P. K., chiatric disorders in recently widowed people. Is-rael Journal of Psychiatry, 38, 202–208.Newsom, J., Reynolds, C. F. III, Frank, E., Bier-

hals, E. J., et al. (1995). The inventory of com- Szanto, K., Prigerson, H., Houck, C.,Ehrenpreis, L., & Reynolds, C. F. III. (1997).plicated grief: A scale to measure certain maladap-

tive symptoms of loss. Psychiatry Research, 59, Suicidal ideation in elderly bereaved: The role ofcomplicated grief. Suicide and Life-Threatening Be-65–79.

Prigerson, H. G., Shear, M. K., Jacobs, havior, 27, 194–207.U.S. Department of Health and HumanS. C., Reynolds, C. F., Maciejewski, P. K.,

Davidson, J. R., et al. (1999). Consensus criteria Services. (1999). The Surgeon General’s call to ac-tion to prevent suicide. Washington, DC: Author.for traumatic grief: A preliminary empirical test.

British Journal of Psychiatry, 174, 67–73. U.S. Department of Health and HumanServices. (2000). Healthy People 2010, 2nd ed. WithRynearson, E. K., Favell, J. L., Belluo-

mini, V., Gold, R., & Prigerson, H. (2002). Be- understanding and improving health objectives for im-proving health. 2 vols. Washington DC: Author.reavement intervention with incarcerated youths.

Journal of the American Academy of Child and Ado-lescent Psychiatry, 41, 893. Manuscript Received: May 18, 2004

Revision Accepted: December 20, 2004Schwab, J. J., Pialow, M. R., & Holzer,