Journal of Affective Disorders 127 (2010) 352–358

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Journal of Affective Disorders

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Brief report

Prevalence and determinants of complicated grief in general population

Daisuke Fujisawa a,b,c,⁎, Mitsunori Miyashita d, Satomi Nakajima e, Masaya Ito e,f,Motoichiro Kato b, Yoshiharu Kim e

a Psycho-oncology Division, National Cancer Center East, Japanb Department of Neuropsychiatry, Keio University School of Medicine, Japanc Division of Palliative Care, Keio University Hospital, Japand Department of Palliative Nursing, Health Science, Tohoku University Graduate School of Medicine, Japane National Institute of Mental Health, National Center of Neurology and Psychiatry, Japanf Research Fellow of the Japan Society for the Promotion of Science, Japan

a r t i c l e i n f o

⁎ Corresponding author. Psycho-oncology Division, NEast, Japan. 6-5-1 Kashiwanoha, Kashiwa-shi, Chiba, Ja7013; fax: +81 4 7134 7026.

E-mail address: dai_fujisawa@yahoo.co.jp (D. Fujis

0165-0327/$ – see front matter © 2010 Elsevier B.V.doi:10.1016/j.jad.2010.06.008

a b s t r a c t

Article history:Received 27 December 2009Accepted 3 June 2010Available online 1 July 2010

Background: Few epidemiological studies have examined complicated grief in the generalpopulation, especially in Asian countries. Therefore, this study aimed to explore the prevalenceand predictors of complicated grief among community dwelling individuals in Japan.Methods: A questionnaire survey regarding grief and related issues was conducted oncommunity dwelling individuals aged 40–79 who were randomly sampled from census tracts.Complicated grief was assessed using the Brief Grief Questionnaire. Stepwise logistic regressionanalysis was conducted in order to identify predictors of complicated grief.Results: Data from 969 responses (response rate, 39.9%) were subjected to analysis. The analysisrevealed 22 (2.4%) respondents with complicated grief and 272 (22.7%) with subthresholdcomplicated grief. Respondents whowere found to be at a higher risk for developing complicatedgrief had lost their spouse, lost a loved one unexpectedly, lost a loved one due to stroke or cardiacdisease, lost a loved one at a hospice, care facility or at home, or spent time with the deceasedeveryday in the last week of life.Limitations: Limitations of this study include the small sample size, the use of self-administeredquestionnaire, and the fact that the diagnoses of complicated grief were not based on robustdiagnostic criteria.Conclusions: The point prevalence of complicated grief within 10 years of bereavement was 2.4%.Complicated grief wasmaintainedwithout significant decrease up to 10 years after bereavement.When subthreshold complicated grief is included, the prevalence of complicated grief boosts up toa quarter of the sample, therefore, routine screening for complicated grief among the bereaved isdesired. Clinicians should pay particular attention to the bereaved families with abovementionedrisk factors in order to identify people at risk for future development of complicated grief.

© 2010 Elsevier B.V. All rights reserved.

Keywords:PrevalenceDeterminantComplicated griefGeneral populationEpidemiologyCancer

1. Background

Grief, or the emotional reaction to bereavement, is a normal,natural human experience.Most peoplemanage to come termswith grief over time. Nevertheless, it is associatedwith a period

ational Cancer Centerpan. Tel.: +81 4 7134

awa).

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of intense suffering, and for some individuals, the grievingprocess is disturbed and/or prolonged, which leads to a state ofcomplicated grief.

Complicated grief has been defined as a deviation from thenormal grief experience in terms of either the time course,intensity, or both. It is associatedwith increased risk of negativehealth consequences, including various physical symptoms,depression, higher alcohol consumption, greater use ofmedicalservices, higher functional impairment, decreased social par-ticipation, and higher mortality due to suicide and other

353D. Fujisawa et al. / Journal of Affective Disorders 127 (2010) 352–358

physical conditions (Ott, 2003; Prigerson et al., 1996; Stroebeet al., 2007; Szanto et al., 1997; Utz et al., 2002).

Complicated grief resembles depression, but it does notrespond well to treatments that are effective for depression(Reynolds et al., 1999). However, treatments designed specif-ically for complicated grief have been shown to be effective(Schut and Stroebe, 2005; Shear et al., 2005). The known riskfactors for complicated grief include the circumstances sur-roundingdeath (the cause, place andunexpectednessof death),the quality of the lost relationship, pre-bereavement caregiverburden, the characteristics of the bereaved (religion, quality ofsocial support, personality, coping style), and concurrentsocioeconomic stressors (Stroebe et al., 2007). Therefore,identification of complicated grief and its predictors is essential.

To date, epidemiological studies have demonstrated thatprolonged grief occurs in about 9–20% of a population(Prigerson and Jacobs, 2001; Raphael et al., 2001), but theprevalence rate shows wide variation depending upon thesocial, cultural, and clinical background. Among clinicalsamples, the prevalence rate has been reported as 18.6%among hospitalized patients with unipolar depression at 16.4(SD=14.1) years after significant loss (Kersting et al., 2009),24.3% among bipolar disorder patients at a mean of 12.3(SD=11.3) years after a loss (Simon et al., 2005), and 31.1%among a mixed sample of psychiatric outpatients at a mean of10.4 (SD=9.7) years since a loss (Piper et al., 2001). On theother hand, relatively few epidemiological studies have beenconducted on non-clinical populations, and the majority ofthesehavebeen limited to shorter periods of time. For example,Chiu et al. assessed bereaved family of cancer patients at meantime of 8.9 months after bereavement and reported a 24.6%prevalence of complicated grief (Chiu et al., 2009). Middletonalso reported a 9.2% prevalence of chronic grief at 14 monthsfrom bereavement in a community-based sample (Middletonet al., 1996).

Epidemiological studies on complicated grief have mostlybeen conducted in Western cultures, while some preliminaryresearch has been conducted in Asia (Chiu et al., 2009;Ghaffari-Nejad et al., 2007; Prigerson et al., 2002; Senanayakeet al., 2006). However, these data were mostly collected fromspecific populations, such as victims of natural disasters(Ghaffari-Nejad et al., 2007; Shear et al., 2006) or psychiatricpatients, with or without specific diagnoses such as unipolardepression and bipolar disorders (Kersting et al., 2009; Piperet al., 2001).

The present study aimed to explore the prevalence andpredictors of complicated grief in the general population.Therefore, a questionnaire survey regarding bereavementand related issues was conducted on community dwellingindividuals.

2. Methods

2.1. Participants

The participants were community dwelling individualsaged 40–79 years who had experienced bereavement withinthe past ten years. Since a diagnosis of complicated brief cannotbe given within six month after bereavement (Prigerson et al.,2009), those who had experienced bereavement within thepast six months were excluded. Furthermore, those who had

experienced the loss of a childwere also excluded because griefover a child's death has been consistently reported to beprolonged, and the diagnostic reliability of complicated griefamong bereaved parents remains unclear (Dyregrov et al.,2003; Stroebe et al., 2007).

2.2. Procedure

An anonymous questionnaire was mailed to a sample ofthe general Japanese population. We identified four targetareas (Tokyo, the capital city; Miyagi prefecture, in easternJapan; Shizuoka prefecture, in central Japan; and Hiroshima,in eastern Japan) in order to obtain a wide geographicdistribution for the nationwide sample. The four areasincluded an urban metropolis (Tokyo) and mixed urban-rural areas (others). We initially identified 5000 subjectsusing a stratified two-stage random sampling method ofresidents from the four areas. We randomly selected 50census tracts in each area and then selected 25 individualswithin each census tract, thus identifying 1250 individuals foreach area. In June 2009, questionnaires were mailed to thesepotential participants and a reminder postcard was sent2 weeks later. The protocol of this study was approved by theinstitutional review board of the University of Tokyo.

2.3. Questionnaire

The questionnaire included items regarding the respon-dents' demographic background (age and gender), the timesince the most recent bereavement, the relationship with thedeceased, the cause and place of death of the deceased, andthe number of days in which the respondent spent time withthe deceased during the last week of life.

Complicated grief was assessed using the Brief GriefQuestionnaire (BGQ) (Shear et al., 2006). The BGQ is a five-item, self-administered questionnaire that evaluates troubleaccepting the death, interference of grief in their life, troublingimages or thoughts of the death, avoidance of things related tothe person who died, and feeling cut off or distant from otherpeople. Responseswere rated as 0, not at all; 1, somewhat; or 2,a lot. A previous report suggests that a total score of 8 or higheron the BGQ indicated that a respondent was likely to developcomplicated grief, while a score ranging from 5 to 7 indicatedsubthreshold complicated grief and a score of less than 5indicated a respondent was unlikely to develop complicatedgrief (Shear et al., 2006).

2.4. Statistical analysis

The presence of complicated grief was defined using thepreviously established cutoff score described above (Shearet al., 2006). The chi-square test and Fisher's exact test wereused to identify factors possibly correlated with the presenceof complicated grief. Subsequently, a stepwise binary logisticregression analysis (backward selection) was performedwithpresence of complicated grief as the dependent variable andfactors with significant relationships identified by the above-mentioned analysis as predictor variables. All p values weretwo-tailed, and the level of statistical significance was set atpb0.05. All statistical analyses were performed using SPSSversion 16.0J software (SPSS Inc., Chicago, IL, USA).

354 D. Fujisawa et al. / Journal of Affective Disorders 127 (2010) 352–358

3. Results

Of 5000 questionnaires that were distributed, 44 werereturned as undeliverable and 1970 responses were received(response rate: 39.9 ). Of these, 63 were excluded because ofsignificantmissing data. Among the remaining responses, 808were excluded because the respondents had not experiencedbereavement within the past ten years, 117 were excludedbecause of bereavement within the past six months, and 7were excluded because they had experienced the loss of achild. Finally, a total 969 of responses were subjected toanalysis. The demographic data of the sample is shown inTable 1.

The results of the BGQ are presented in Table 2 accordingto severity of grief and sociodemographic variables. Amongall participants, 22 respondents (2.4%) had scores of 8 orhigher on the BGQ, andwere thus considered too complicatedgrief, and 272 respondents (22.7%) scored between 5 and 7,and were considered to be suffering from some symptoms ofcomplicated grief (subthreshold complicated grief). Using thechi-square test, significant differences in BGQ score wereobserved for gender, relationship with the deceased, whether

Table 1Demographic data of the participants.

n %

Gender Male 405 41.8Female 564 58.2

Age 40–49 225 23.250–59 354 36.560–69 379 39.170–79 11 1.1

Relationship with the deceased Spouse 61 6.3Parent(s) 468 48.3Parent(s)-in-law 247 25.5Sibling(s) 96 9.9Others 97 10.0

Primary caregiver Yes 462 47.7No 507 52.3

Time from bereavement 6–12 months 112 11.61–2 years 138 14.22–3 years 138 14.23–4 years 120 12.44–5 years 88 9.15–6 years 85 8.86–7 years 102 10.57–8 years 62 6.48–9 years 49 5.19–10 years 75 7.7

Cause of death Cancer 357 36.8Stroke 99 10.2Cardiac disease 108 11.1Others 405 41.8

Place of death Home 181 18.7General hospital 654 67.5Hospice/PCU 34 3.5Care facility 62 6.4Others 38 3.9

Expected death Expected death 546 56.3Unexpected death 423 44.6

Days spent with the deceasedduring the end-of-life period

Everyday 207 21.44–6 day/week 92 9.51–3 day/week 216 22.3None 335 34.6Missing data 119 12.3

the respondent was the primary caregiver or not, cause andplace of death, whether the death was expected or unex-pected, and days spent with the deceased during the end-of-life period.

Binary stepwise logistic regression analysis, with theabovementioned determinant variables entered as predictorvariables, and the presence of complicated grief as thedependent variable, demonstrated that relationship withthe deceased, the type of illness, the place of death, theunexpectedness of death, and time spent with the deceasedduring the end-of-life period were significant predictors forcomplicated grief (Table 3).

Comparedwith bereavement following the loss of a spouse,bereavement following the loss of a parent or parent-in-law contained a smaller risk for complicated grief (odds ratio(OR)=0.13, 95% confidence interval (CI)=0.05–0.35; OR=0.19, 95%CI=0.06–0.62, respectively). Those who lost a lovedone due to stroke or cardiac disease were more likely toexperience complicated grief than those who lost a loved onedue to cancer (OR=2.42, 95%CI=1.10–5.32). Familymembersof people who died in general hospitals were significantly lesslikely to experience complicated grief than family members ofpeople who died at home (OR=0.38, 95% CI=0.16–0.92).Those who did not spent time with the deceased during theend-of-life period were significantly less likely to experiencecomplicated grief, compared with those who spent time withthe deceased everyday during the same period (OR=0.07;95% C.I.=0.02–0.21).

4. Discussion

The results of the present study indicated that the pointprevalence of complicated grief within 10 years of bereave-ment is 2.4% among the general population. This figure iscomparable with that for major depressive disorder (2.1%),and higher than the figure for anxiety disorders (0.4–0.9%) inJapan (Kawakami et al., 2005).

In comparison with figures from studies conducted in othercountries, this prevalence is somewhat smaller. In Australiannon-clinical samples, theprevalencehas been reported to rangefrom 8.8% to 9.2% at 13 months post-bereavement (Byrne andRaphael, 1994) (Middleton et al., 1996). Among Taiwanesecaregiverswho lost a loved one due to cancer, the prevalence ofcomplicated grief was 24.6% at a mean of 8.9 months post-bereavement (Chiu et al., 2009). These differences can beattributed to both cultural differences and the employment ofdifferent criteria for diagnosing complicated grief. Stringentdiagnostic criteria for complicated grief have not yet beenestablished, and the prevalence of complicated grief variesdependingonwhichdiagnostic criteria are used. For example, asubstantial discrepancy in the prevalence rate of complicatedgrief had been noted in a general elderly sample, with a 0.9%prevalence observed using Prigerson's criteria and a 4.2%prevalence observed using Horowitz's criteria (Forstmeierand Maercker, 2007). The former criteria include items relatedto separation distress, traumatic distress, duration ofmore than6 months, and disturbance that causes clinically significantimpairment (Prigerson et al., 1999); while the latter criteriainclude grief-related intrusions, behaviors that avoid grief-related emotional stress, difficulties in adapting to the loss, andduration of more than 14 months with disturbance of daily

Table 2Prevalence and severity of complicated grief.

Subthreshold complicated grief (%) Complicated grief (%) p

Total 207 22.7 22 2.4Gender Male 79 20.6 4 1.0 0.02

Female 128 24.2 18 3.4Age 40–49 44 20.5 6 2.8 0.48

50–59 77 23.0 7 2.160–69 82 23.3 8 2.370–79 4 40.0 1 10.0

Relationship with the deceased Spouse 29 50.0 5 8.6 b0.001Parent(s) 108 24.5 11 2.5Parent(s)-in-law 30 12.9 2 0.9Sibling(s) 24 27.6 3 3.4Others 16 16.8 1 1.1

Primary caregiver Yes 128 29.7 13 3.0 b0.001No 77 16.1 9 1.9

Time from bereavement 6–12 months 30 28.3 2 1.9 0.191–2 years 39 28.9 3 2.22–3 years 26 19.8 2 1.53–4 years 23 20.5 1 0.94–5 years 14 16.5 5 5.95–6 years 13 16.7 2 2.66–7 years 22 23.4 1 1.17–8 years 9 15.8 3 5.38–9 years 12 25.5 0 0.09–10 years 19 28.4 3 4.5

Cause of death Cancer 94 28.2 9 2.7 b0.01Stroke 18 19.6 5 5.4Cardiac disease 30 28.6 3 2.9Others 64 16.8 5 1.3

Place of death Home 35 20.6 2 1.2 0.04General hospital 142 23.0 16 2.6Hospice/PCU 11 35.5 1 3.2Care facility 9 15.3 0 0.0Others 10 29.4 3 8.8

Expected death Expected 116 21.6 8 1.5 0.05Unexpected 75 25.1 11 3.7

Days spent with the deceased duringthe end-of-life period

Everyday 63 31.0 10 4.9 b0.0014–6 days/week 31 34.4 3 3.31–3 days/week 41 19.1 1 0.5None 56 17.1 5 1.5

PCU: palliative care unit.* pb0.05.

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functioning (Horowitz et al., 1997). The BGQ, the instrumentused in the present study, contains items derived from bothcriteria (“trouble accepting the death” fromHorowitz's criteria,and “avoidance”, “intrusive thoughts” and “feeling distant fromother people” from Prigerson's criteria. Therefore, the itemstructure of the BGG could explain why the prevalence ofcomplicated grief observed in the present study lies betweenthose measured using the criteria of Horowitz and Prigerson.

When subthreshold complicated grief is included, theprevalence of complicated grief rises to as high as 25.1%,implying that approximately a quarter of all bereaved peopleare at risk for developing complicated grief.

One of the most important findings in the present study isthat the prevalence of complicated grief does not show asignificant decline in the years after bereavement. Beforeconducting this study, we hypothesized that the prevalence ofcomplicated grief declines over time, but our results contra-dicted our hypothesis. This finding implies that complicatedgrief, for individuals who suffer from it, is maintained for manyyears and does not resolve spontaneously. Among thepopulation with psychiatric morbidity, complicated grief has

been observed a remarkably long time after bereavement(prevalence range, 18.6–31.1%; range of time after bereave-ment, 10.4–16.4 years) (Kersting et al., 2009; Piper et al., 2001;Simon et al., 2005). Our study demonstrated that long-standingcomplicated grief is observed even among the generalpopulation. However, further study is needed in order toinvestigate whether the maintenance of complicated grief ismediated by the presence of other psychiatric conditions.

The relationship with the deceased, type of illness, place ofdeath, unexpectedness of death, and time spent with thedeceased during the end-of-life period were extracted assignificant predictors for complicated grief. Concerning therelationshipwith the deceased, bereavement following the lossof a spouse contained the highest risk when compared withbereavement following the loss of a sibling, parentor parent-in-law. It has generally been considered in Eastern cultures thatthe parent-offspring relationship is more cherished thanspousal relationships, whereas the inverse is true in Westerncultures (Bernard and Guarnaccia, 2003). Contrary to thisgeneral perception, among the present sample, complicatedgrief was more frequently seen in spousal relationships. This

Table 3Binary logistic regression analysis of predictive variables for presence of complicated grief.

Beta S.D. Wald d.f. p Exp (B) 95% C.I.

Lower Upper

Gender −0.3 0.3 0.8 1 0.37 0.74 0.38 1.43Relationship (vs. spouse) 51.6 4 b0.001

Parents −2.0 0.5 16.6 1 b0.001 0.13 0.05 0.35Parents-in-law −1.7 0.6 7.6 1 b0.01 0.19 0.06 0.62Siblings 0.7 0.6 1.3 1 0.25 2.02 0.61 6.77Others 0.7 0.6 1 0.43 1.72 0.44 6.66

Primary carer 0.2 0.4 0.2 1 0.68 1.19 0.52 2.74Type_of_Illness (vs cancer) 26.5 3 b0.001

Stroke 1.3 0.5 6.1 1 0.01 3.58 1.31 9.79Cardiac 1.2 0.5 5.5 1 0.02 3.35 1.22 9.19Others −1.0 0.5 4.2 1 0.04 0.36 0.13 0.95

Place_of_Death (vs. home) 125.0 4 b0.001General hospital −1.0 0.4 4.7 1 b0.05 0.38 0.16 0.92Hospice 2.7 0.6 18.5 1 b0.001 14.73 4.32 50.18Care facility 2.7 0.7 15.7 1 b0.001 15.61 4.01 60.80Others 3.0 0.6 22.2 1 b0.001 19.84 5.72 68.76

Unexpected death 0.9 0.4 4.9 1 0.03 2.42 1.10 5.32Days spent with the deceased duringend-of-life period (vs. everyday)

39.0 3 b0.001

4–6 days/week 0.8 0.5 2.5 1 0.11 2.13 0.84 5.421–3 days/week −0.6 0.5 1.5 1 0.21 0.53 0.20 1.44None −2.7 0.6 21.1 1 b0.001 0.07 0.02 0.21

S.D.: standard deviation.d.f.: degree of freedom.C.I.: confidence interval.

356 D. Fujisawa et al. / Journal of Affective Disorders 127 (2010) 352–358

may be the result of recent changes in familial structure inJapan, which is becoming increasingly Westernized. Cliniciansshould note that cultural difference exists among Asiancountries, and shouldnot viewpatients in termsof theoversim-plified model of “Eastern vs. Western”.

The respondents who lost a loved one due to stroke orcardiac disease were more likely to experience complicatedgrief than those who lost a loved one due to cancer. This maybe because stroke and cardiac disease are more likely to occurunexpectedly, which leads to an increased likelihood ofcomplicated grief.

The place of death is another predictor of complicatedgrief. Family members of people who died in generalhospitals are significantly less likely to experience compli-cated grief than the family members of people who died athome. The burden of care before bereavement has beendemonstrated to have negative effect on subsequent compli-cated grief; therefore, it can be speculated that the familymembers of people who died at home may have experiencedhigher caregiver burden, whichmight lead to poor adaptationto bereavement (Rossi Ferrario et al., 2004; Schulz et al.,2001). Surprisingly, those who lost a loved one in a hospice ora care facility were found to be more likely to experiencecomplicated grief than those who lost a loved one at home. Itis possible that bereaved family members might be dissatis-fiedwith the care provided in the facilities and feel regret thatthey could not personally provide care. In fact, a past surveydemonstrated that the quality of care did not meet theexpectations of most bereaved families (Sanjo et al., 2008).The timing of referral to a hospice is also associated withsatisfaction with end-of-life care, and up to 50% of bereavedfamilies who used a palliative care unit felt that the timing of

the referral to the palliative care unit was either too early ortoo late (Morita et al., 2009). Furthermore, transferring aloved one from a hospital to a hospice or a care facility causedfeelings of guilt among family members, because such anaction was perceived as a withdrawal from active participa-tion in treatment and even as “turning their back” on theirloved one. Preferences for end-of-life care vary betweenindividuals, meaning that some prefer to spend their end-of-life period at home, while others prefer hospitals. It has beenreported that those who are of relatively older age, those whoprefer ‘unawareness of death’ and ‘pride and beauty’ in theirconcept of “good death” are more likely to hope to die in ageneral hospital than in a hospice (Sanjo et al., 2007).Potential discordance between the preference of the be-reaved and that of the deceased may have caused dissatis-faction and/or feelings of guilt concerning the place of death.In Japanese clinical settings, the family's approval has thestrongest influence on the final decision (Sato et al., 2008).Poor communication with the physician may have contrib-uted to the negative feelings about transferring the patientsto hospice (Morita et al., 2004). Toward the end-of-lifeperiod, the patient's family is expected to play a central role inmedical decision making, therefore, the family is faced withincreasing burden regarding end-of-life care, which maycontribute to the higher prevalence of subsequent griefamong those who used a hospice.

Respondents who spent time with the deceased everydayduring the end-of-life period were significantly more likely toexperience complicated grief, compared with those who didnot spend timewith the deceased during the same period.Wepresume that the time spent together during this period is anindicator of the quality of the bond between the respondent

357D. Fujisawa et al. / Journal of Affective Disorders 127 (2010) 352–358

and the deceased, meaning that those who had strong bondwith the deceased spent more time with the deceased duringthe end-of-life period and were, therefore, more likely toexperience complicated grief. Another possible interpretationis that those who spend every day with the deceased duringthe last week of life experienced heavier caregiver burden,which lead to an increased risk of subsequent complicatedgrief (Rossi Ferrario et al., 2004; Schulz et al., 2001).

This study contains some limitations. First, the response ratewas low, although the rate was acceptable for a mail-basedsurvey conducted on the general population. Second, thebackground variables of the non-respondents are unknown;therefore,we cannot rule out that thedemographic distributionof the sample was skewed. However, the distributions of thecause and place of death are quite similar to the nationalstatistics. For example, the proportion of deaths in Japan due tocancer, stroke and cardiac disease are 30.0%, 15.9%, and 11.1%,respectively, and place of death is 12.7% for home, 81.1% forhospital, and 3.9% for care facility (JapanMinistry of Health andLabor). Third, the reliability of the data was compromisedbecause the data solely depended on the participants' self-reports. Finally, the diagnostic reliability of complicated grief isrelatively weak as definite diagnostic criteria for complicatedgrief have yet to been established, although more stringentcriteria are currently under consideration (Forstmeier andMaercker, 2007; Prigerson et al., 2009).

Despite these limitations, our results are noteworthybecause this is the first epidemiological study to investigatethe prevalence and risk factors of complicated grief in thegeneral population in Japan. In consideration of the fact thatcomplicated grief is highly influenced by cultural background,our report should be considered pioneering research oncomplicated grief in Asia.

In conclusion, our population-based study revealed thatpoint prevalence of complicated grief within 10 years ofbereavement is 2.4%, which is comparable with other commonmental disorders. Complicated grief seems to bemaintained fora long time, without decrease even 10 years after bereavement.The spouse of a patient, those who have lost a loved oneunexpectedly, due to stroke or cardiac disease, those who havelost one in a hospice, care facility or at home, and those whospent time with the deceased everyday in the last week of lifeare at higher risk for complicated grief. Clinicians should payparticular attention to these predictors in order to identifypeople at risk for future development of complicated grief.When subthreshold complicated grief is included, the preva-lence of complicated grief boosts up to a quarter of the sample,therefore, routine screening for complicated grief among thebereaved is desired. Further study implication includes prev-alence study using the more stringent criteria that have beenproposed forDSM-Vand ICD-11andassessing other psychiatricmorbidities.

Role of funding sourceThis study was fully supported by the Grant-in-Aid for Cancer Research

endowed to M.M from the Ministry of Health, Labor and Welfare, Japan(MHLW); the MHLW had no further role in study design; in the collection,analysis and interpretation of data; in the writing of the report; and in thedecision to submit the paper for publication.

Conflict of InterestAll the authors declare no conflicting interests.

Acknowledgements

The authors express gratitude to Rieko Kimura, R.N. forcoordinating the study.

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