The loss of a loved one is a negative life event that most individuals go through at some point in their lives. Although the majority of bereaved people psychologically recover with time, some may develop depression and/or prolonged grief disorder (Zisook & Kendler, 2007). Our recent study aimed to investigate the different correlates of depression and prolonged grief symptoms in a population-based sample.
Quantifying Loss
In Ankara, Turkey's capital, we examined the lifetime experiences of the loss of loved ones in a population-based sample. We asked them to select the loss that had the greatest impact on them, and based on that loss, we assessed the characteristics of the loss and the deceased, and also the characteristics of the bereaved. We screened for symptoms of depression and prolonged grief using the Beck Depression Inventory and the Inventory of Complicated Grief-Revised. We also used self-report questionnaires to assess the level of separation anxiety symptoms and anxiety sensitivity. We explored the correlations of depression and prolonged grief disorder symptom severity as separate dependent variables using linear regression analyses. We identified and discussed different predictors of depressive and prolonged grief symptoms. In addition, by repeating these analyses for each sex, we discussed the differences in these correlations between men and women.
Research Findings
We can group the study findings into three categories.
1) What is the prevalence of probable prolonged grief disorder in Ankara, Turkey?
2) What are the differentiating factors associated with symptom severity of depression and prolonged grief disorder after the loss of a loved one?
3) What are the differences between men and women in terms of these differentiating factors?
When the available data are examined, the prevalence of prolonged grief disorder has been reported to be slightly higher in Western societies than in Eastern societies (Kersting et al., 2011; Lundorff et al., 2017, Shevlin et al., 2023). We found a prevalence of 3.0% for probable prolonged grief disorder, which was higher than those found in Eastern and lower than Western societies, similar to findings regarding the prevalence of psychiatric disorders in Turkey compared to other countries (Steel et al., 2014).
Strikingly, although not surprisingly, the findings revealed that depression was more closely related to the features of bereaved individuals. The income level, separation anxiety score, anxiety sensitivity score, and total grief score of the bereaved were the significant correlates of depression. Variables related to the characteristics of the loss and of the deceased, on the other hand, were more closely related to prolonged grief. These variables were the number of lifetime losses the participant had experienced, the male sex of the deceased, felt closeness to the deceased, and the shorter time since the loss.
One of our major aims was to focus on sex differences. Lower education was associated with total grief scores in men, but not in women; whereas depression scores were associated with total grief scores in women, but not in men. Interestingly, male sex of the deceased predicted total grief scores in women, but not in men. We do not know whether this finding is culture-specific or not. We believe that the reasons underlying this finding call for sociological, as well as biological investigations.
Moving Forward
Our research's population-based nature may provide a substantial benefit. Most of the previous studies focused on specific risk groups (immigrants, the elderly, orphans, earthquake survivors, etc), or on individuals seeking help. However, it is unclear how many people seek treatment after bereavement; hence, population-based research is essential in the process of defining a disorder. Moreover, as accepted by current diagnostic criteria, norms relating to grief vary across cultures, which show the importance of cross-cultural studies. There has been no community-based grief research conducted in Turkey before. Considering the limitations of the study, the fact that the data is relatively old and can not permit an inference based on DSM-5-TR or ICD-11 criteria should not be ignored.
To conclude, grief appears to be more closely associated with the deceased, whereas depression appears to be associated with the one left behind. Further studies on representative population samples using recent measures aligned with DSM-5-TR and ICD-11 criteria will help resolve the inconsistency in the literature in terms of prevalence rates and predictors of PGD.
Read the full article here:
Bağcaz, A. & Kılıç, C. Differential correlates of prolonged grief and depression after bereavement in a population-based sample. Journal of Traumatic Stress.
Discussion Questions
1. How can the cultural criterion of prolonged grief be defined and introduced in grief research?
2. Are there specific cultural factors that facilitate or impede the grieving process?
3. How can prolonged grief studies be standardized to exclude the effects of different methodologies and provide a common understanding of both the prevalence and symptoms of pathological forms of grieving?
About the Authors
Arda Bağcaz, MD is an assistant professor of psychiatry at Başkent University, Faculty of Medicine, Ankara, Turkey, and a member of the Stress Assessment and Research Center (STAR) at Hacettepe University, Turkey. His current research focuses on prolonged grief disorder, grief after non-death losses, and the effects of chronic stress on the prognosis of psychiatric disorders. Dr. Bağcaz can be contacted at ardabagcaz@baskent.edu.tr and ardabagcaz@hotmail.com.
Cengiz Kılıç, MD is a professor of psychiatry at Hacettepe University, Faculty of Medicine, Ankara, Turkey, and also is the director of the Stress Assessment and Research Center (STAR) of the same university. His main clinical and research interests are in the area of anxiety disorders, traumatic stress, psychiatric assessment and psychiatric epidemiology. His recent work focuses on the mental health effects of earthquakes and mental health of refugee populations. He can be reached at cengizk@hacettepe.edu.tr.
References
Kersting, A., Brähler, E., Glaesmer, H., & Wagner, B. (2011). Prevalence of complicated grief in a representative population-based sample. Journal of Affective Disorders, 131(1–3), 339–343. https://doi.org/10.1016/j.jad.2010.11.032
Lundorff, M., Holmgren, H., & Zachariae, R. (2017). Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis. Journal of Affective Disorders, 212, 138–149. https://doi.org/10.1016/j.jad.2017.01.030
Shevlin, M., Redican, E., Hyland, P., Murphy, J., Karatzias, T., McBride, O., Bennett, K., Butter, S., Hartman, T. K., Vallières, F., & Bentall, R. P. (2023). Symptoms and levels of ICD-11 prolonged grief disorder in a representative community sample of UK adults. Social Psychiatry & Psychiatric Epidemiology, 58(10), 1535–1547.
https://doi.org/10.1007/s00127-023-02469-1
Steel, Z., Marnane, C., Iranpour, C., Chey, T., Jackson, J. W., Patel, V., & Silove, D. (2014) The global prevalence of common mental disorders: A systematic review and meta-analysis 1980–2013. International Journal of Epidemiology, 43(2), 476–493. https://doi.org/10.1093/ije/dyu038
Zisook, S., & Kendler, K. S. (2007). Is bereavement-related depression different than non-bereavement-related depression? Psychological Medicine, 37(6), 779–794. https://doi.org/10.1017/S0033291707009865