CRD summary

The authors concluded that treatment interventions can effectively diminish complicated grief symptoms among bereaved adults, but preventive interventions did not appear to be effective. There was some uncertainty regarding the robustness of the results due the small number of studies that reported follow-up data for treatment interventions, variability between studies and some limitations in the included studies.

Authors' objectives

To determine the short-term and long-term effect of both preventive and treatment interventions on complicated grief.

Searching

Web of Science and PsycARTICLES were searched for peer-reviewed articles published between 1990 and 2007. Search terms were provided. It was unclear whether any language restrictions were applied. Bibliographies of review articles were searched.

Study selection

Randomised controlled trials (RCTs) that evaluated a specific grief intervention to prevent or treat complicated grief in adults (≥18 years) who had lost a loved one through death were included. The grief intervention had to be compared to a control condition or a non-specific intervention used for a variety of disorders and report grief symptoms pre and post or as a follow-up measure using a quantitative standardised questionnaire. A preventive grief intervention was defined as an intervention for bereaved individuals in general designed to reduce the probability of developing complicated grief. A treatment intervention was defined as an intervention to reduce the severity of the grief symptoms for bereaved individuals who experienced complicated grief.

Preventive interventions in the included studies were mainly targeted at high-risk groups such as spouses and suicide survivors. Treatment interventions were targeted at a broader range of people. Group and individual therapy sessions were used. The number of sessions ranged from one to 12 for preventive interventions and 10 to 16 for treatment interventions. Most of the participants in the included studies were female. Mean age was 41 years (range 20 to 57 years). For all studies except two, outcomes were assessed at the end of treatment. Approximately two thirds of studies assessed outcomes at follow-up. Follow-up ranged from six weeks to 13 months after bereavement. Studies used different self-report instruments to measure outcomes.

The authors did not state how many reviewers performed study selection.

Assessment of study quality

Studies were assessed for description of assignment to study arms, method of randomisation, concealment of allocation, whether groups were balanced at baseline, proportion completing the study, sample size, use of reliable and valid outcome measures and use of intention-to-treat analysis. The authors recorded whether studies used a treatment protocol or manual and whether the consistency of intervention delivery was assessed.

The authors did not state how many reviewers undertook the quality assessment.

Data extraction

Data were extracted to enable calculation of the standardised mean difference (SMD) and 95% confidence interval (CI) for each study using outcome data for participants who completed the study.

The authors did not state how many reviewers extracted data.

Methods of synthesis

Studies were pooled using a random-effects meta-analysis where there was statistically significant heterogeneity and a fixed-effect model otherwise. Studies were stratified by type of intervention and time of outcome assessment. Within and between group heterogeneity was assessed using Χ² (p<0.1 was considered statistically significant).

Results of the review

Fourteen RCTs were included (n=1,655 participants): nine of preventive interventions and five of treatment interventions. Full details of the quality assessment for each study were provided in the paper. Six of the 14 studies reported the method of randomisation. Three studies reported concealment of allocation. Three studies used an intention-to-treat analysis. The proportion of people who did not complete the studies ranged from 5% to 35%. Most studies reported use of a treatment manual. All studies used an outcome measure known to be reliable and valid.

Preventive interventions: There was no statistically significant difference between preventive grief interventions and control post intervention (SMD -0.03, 95% CI -0.18 to 0.11) and at follow-up (SMD 0.13, 95% CI -0.08 to 0.33). Statistically significant heterogeneity was present in the analysis of follow-up data (p=0.07).

Treatment interventions: There was a statistically significant benefit with a complicated grief treatment intervention compared to control post-intervention (SMD -0.53, 95% CI -1.00 to -0.07) and at follow-up (SMD -1.38, 95% CI -2.08 to -0.68). Statistically significant heterogeneity was present in the analysis of post-intervention data (p=0.009).

The difference between the pooled standardised mean differences of the preventive and treatment interventions was statistically significant and in favour of treatment interventions at post intervention and at follow-up.

Authors' conclusions

Treatment interventions can effectively diminish complicated grief symptoms, but preventive interventions do not appear to be effective.

CRD commentary

The review contained explicitly stated inclusion criteria. Relevant sources were searched for studies. Relevant studies may have been missed as unpublished studies were not sought. The authors did not state whether appropriate methods were used to assess error and bias in the review processes. Quality was assessed and reported in detail. There was limited discussion of the implications of the quality of the included studies for the robustness of the results. The approach to the analysis seemed appropriate. Heterogeneity was assessed. The small number of studies limited the statistical opportunities for exploration of the sources of the heterogeneity present; possible sources were discussed in some detail in the paper.

The authors' overall conclusions reflected the evidence presented. But, as outlined in their discussion, there were methodological limitations in the included studies and these suggest some caution should be taken in interpreting the pooled results. Methodological issues, risk of publication bias, the small number of studies that reported follow-up data for treatment interventions (one study with 23 patients) and heterogeneity in most of the analyses result in some uncertainty regarding the robustness of the results.

Implications of the review for practice and research

Practice: The authors stated that the findings confirmed the proposition that professional assistance was indicated only for those who showed the onset of complicated grief reactions.

Research: The authors stated that further studies to evaluate treatment interventions for complicated grief should be undertaken and these should use larger samples and long-term follow-up periods.

Funding

Funded by Go for Happiness.

Bibliographic details

Wittouck C, Van Autreve S, De Jaegere E, Portzky G, van Heeringen K. The prevention and treatment of complicated grief: a meta-analysis. Clinical Psychology Review 2011; 31(1): 69-78. [PubMed: 21130937]

Original Paper URL

http://dx.doi.org/10.1016/j.cpr.2010.09.005

Indexing Status

Subject indexing assigned by NLM

MeSH

Bereavement; Humans; Psychotherapy

AccessionNumber

12011000189

Database entry date

02/11/2011

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.