WHOLE HEALTH: CHANGE THE CONVERSATION

Advancing Skills in the Delivery of Personalized, Proactive, Patient-Driven Care

This document has been written for clinicians. The content was developed by the Integrative Medicine

Program, Department of Family Medicine, University of Wisconsin-Madison School of Medicine and Public

Health in cooperation with Pacific Institute for Research and Evaluation, under contract to the Office of

Patient Centered Care and Cultural Transformation, Veterans Health Administration.

Information is organized according to the diagram above, the Components of Proactive Health and Well-Being.

While conventional treatments may be covered to some degree, the focus is on other areas of Whole Health

that are less likely to be covered elsewhere and may be less familiar to most readers. There is no intention to

dismiss what conventional care has to offer. Rather, you are encouraged to learn more about other

approaches and how they may be used to complement conventional care. The ultimate decision to use a

given approach should be based on many factors, including patient preferences, clinician comfort level,

efficacy data, safety, and accessibility. No one approach is right for everyone; personalizing care is of

fundamental importance.

Screening for Complicated Grief Clinical Tool

VHA Office of Patient Centered Care and Cultural Transformation

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WHOLE HEALTH: CHANGE THE CONVERSATION Screening for Complicated Grief

Clinical Tool

Deviations from “typical” (i.e., acute) grief that require more aggressive intervention were described as early as 1944.1 In complicated grief, symptoms are long-lasting and may intensify over time; the person has trouble accepting the death and resuming life. Something is getting in the way of the grief process and not allowing the person to adequately adapt to the loss.2 Some bereaved individuals who experience complicated grief do not recognize that their behavior and symptoms are related to a previous loss.2

More attention has been focused on complicated grief recently. Estimates of the prevalence of complicated grief vary widely. An estimate published in 2011 indicates that 7% of those bereaved in the general public experience complicated grief.3 It is possible that this statistic may be higher for Veterans, who are at risk for disenfranchised (hidden) grief. For example, a study of 114 Vietnam-era combat Veterans admitted to a post-traumatic stress disorder (PTSD) inpatient rehabilitation unit identified that 70% scored higher (i.e., worse) on standardized measures of grief symptoms related to friends lost in combat 30 years previous than did spouses who were bereaved in the past six months.4 Complicated grief, identified as Persistent Complex Bereavement Disorder, has been added to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) published in 2013.5 It is in Section III, which contains conditions that are in need of further research. For diagnosis, grief symptoms must persist to a “clinically significant degree” for at least 12 months (6 months for children) following the death of someone close and be “out of proportion or inconsistent with cultural, religious, or age-appropriate norms.” A similar classification, Prolonged Grief Disorder, has been proposed for the eleventh version of the International Classification of Diseases and Related Health Problems (ICD-11) to be approved in 2015.6

For someone who has had a significant loss and whose symptoms are ongoing, differentiating “typical” grief from the more debilitating “complicated grief” or from clinical depression can be tricky. It may best be accomplished via referral to a mental health professional experienced in the area of grief for further assessment and facilitation/ support of mourning. Patients can experience grief reactions coincidentally with anxiety, depression, and PTSD.

Note: This clinical tool focuses on grief related to a death loss. A focus on other types of losses is beyond the scope of this module, although you may find this clinical tool helpful when working with a Veteran who has experienced a loss other than death.

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Screening for Complicated Grief

VHA Office of Patient Centered Care and Cultural Transformation Page 2 of 3

The Brief Grief Questionnaire developed by M. Katherine Shear MD and Susan Essock PhD7 is an efficient tool to screen for complicated grief in health care settings.8 A copy is on the next page. To help screen for complicated grief…

Ask the five questions in the Brief Grief Questionnaire during a patient’s appointment.

Use with adults bereaved for at least 12 months and children at least 6 months. Screen all bereaved individuals who seek treatment for suicide risk, mood, and

anxiety disorders as well. These conditions may require treatment earlier than 6-12 months post bereavement.

Brief Grief Questionnaire*7

1. How much are you having trouble accepting the death of ______________? Not at all............... 0 Somewhat..............1 A lot...................... 2 2. How much does your grief still interfere with your life?

Not at all............... 0 Somewhat..............1 A lot...................... 2 3. How much are you having images or thoughts of _____________ when s/he died or

other thoughts about the death that really bother you? Not at all............... 0 Somewhat..............1 A lot...................... 2

4. Are there things you used to do when ______ was alive that you don’t feel comfortable doing anymore, that you avoid? Like going somewhere you went with him/her, or doing things you used to enjoy together? Or avoiding looking at pictures or talking about _________? How much are you avoiding these things? Not at all............... 0 Somewhat..............1 A lot...................... 2

5. How much are you feeling cut off or distant from other people since _________ died, even people you used to be close to like family or friends? Not at all............... 0 Somewhat..............1 A lot...................... 2

A score of 4 or more suggests an individual may have complicated grief.

(M.K. Shear, personal communication, January 2014). Refer the individual to a grief specialist for further evaluation.

* Developed by M. Katherine Shear MD and Susan Essock Ph.D. Included with permission.

WHOLE HEALTH: CHANGE THE CONVERSATION Clinical Tool: Screening for Complicated Grief

VHA Office of Patient Centered Care and Cultural Transformation Page 3 of 3

This clinical tool was written by Charlene Luchterhand MSSW, LCSW, Education and Research Coordinator, Integrative Medicine Program, Department of Family Medicine, University of Wisconsin-Madison School of Medicine and Public Health.

References

1. Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry. 1944;101:141-148.

2. Worden, JW. Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner (4th Edition). New York: Springer Publishing Company; 2009.

3. Kersting A, Brahler E, Glaesmer H, Wagner B. Prevalence of complicated grief in a representative population-based sample. J Affect Disord. 2011;131:339-343.

4. Pivar IL, Field NP. Unresolved grief in combat veterans with PTSD. Anxiety Disorders. 2004;18:745-755.

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington DC:American Psychiatric Publishing; 2013.

6. Maercker A, Brewin CR, Bryant RA, et al. Diagnosis and classification of disorders specifically associated with stress: Proposals for ICD-11. World Psychiatry. 2013;12:198-206.

7. Shear KM, Jackson CT, Essock SM, Donahue SA, Felton CJ. Screening for complicated grief among Project Liberty service recipients 18 months after September 11, 2001. Psychiatr Serv. 2006;57(9):1291-1297.

8. Simon NM. Treating complicated grief. JAMA. 2013;310(4):416-423.