Acceptability, feasibility and outcome of a screening programme for complicated grief in integrated primary and behavioural health care clinics

Acceptability, feasibility and outcome of a screening programme for complicated grief in... Abstract Background Complicated grief, a syndrome of persistent grief diagnosed >6 months following the loss of someone close is expected to be included in the 11th revision of the International Classification of Diseases as a new diagnosis called prolonged grief disorder. Complicated grief is associated with impaired functioning and health comorbidity and does not respond to treatments for depression. Individuals may seek help in primary care where providers need to be familiar with the syndrome. Objective This study examines the acceptability, feasibility and outcome of a screening programme for complicated grief among diverse adults receiving behavioural health services in integrated primary care. Methods Behavioural health providers (n = 14) administered the Brief Grief Questionnaire and the Inventory of Complicated Grief during routine assessment and completed an acceptability survey. Descriptive statistics described rates of complicated grief symptoms and sample demographics, health and service use. Results Most providers (71%) reported the Brief Grief Questionnaire to be a moderate to very useful assessment instrument and the Inventory of Complicated Grief moderate to very useful for developing a treatment plan (57%). Of the 2425 patients screened, 1015 reported a loss over 6 months ago. Of these 1015, 28% (n = 282) screened positive on the Brief Grief Questionnaire and 22% (n = 228) endorsed symptoms of complicated grief (Inventory of Complicated Grief score ≥25), considered at high risk for needing clinical care. Conclusions A screening programme for identifying complicated grief was acceptable to providers, feasible to implement and useful in identifying complicated grief in integrated primary care clinics. Federally qualified health centre, identify, prolonged grief disorder, protocol, provider, questionnaire Introduction Experiencing the death of a loved one is a universal part of human life. Most bereaved individuals experience acute grief that decreases in intensity over time. However, estimates suggest that about 11–15% of bereaved people suffer from a syndrome of persistent impairing grief here termed complicated grief (1,2). Complicated grief is characterized by maladaptive cognitions and behaviours that impede adaptation to loss and result in persistent yearning, longing and sorrow, preoccupation with thoughts and memories of the deceased and difficulty envisioning a meaningful future without the deceased (3). Complicated grief is associated with significant impairment in social and occupational functioning (4,5) and behavioural health comorbidity (5,6) and has been shown to increase the risk for health problems, including cardiovascular disease and cancer (7,8). Complicated grief is also associated with increased suicidal ideation (9–11) and its course is typically chronic and unremitting (12). The prevalence of complicated grief in the general population worldwide ranges from 0.9% to 9.8% (1,13,14). The prevalence appears to be higher among females, older adults and individuals of low income (1,14,15). Comorbidities that are associated with complicated grief include depression, anxiety and substance use (16). Two studies found that African Americans are 2.5 times more likely to develop complicated grief than Whites (17,18). Why is it important to screen for complicated grief in primary care? The most important reason to screen is that acute grief and major depression are often confused but they not the same. Complicated grief is a form of persistent impairing acute grief. Studies have shown it to differ from depression (19,20) and to show a low response to antidepressant medication (21) and efficacious psychotherapy for depression (22,23). These studies show that complicated grief can be effectively treated with a targeted short-term treatment. Bereaved people, especially older adults, often seek help from their primary care providers (18,24). In one study, ~50% of widowed older adults with complicated grief reported discussing grief with their primary care physicians (25). Yet to our knowledge, there have been no studies on the identification and prevalence of complicated grief in individuals attending primary care clinics or those seen in integrated primary and behavioural health care (mental health and substance use) settings in the USA. A simple, easily administered screening would help providers identify individuals with complicated grief. Clinician recognition of this syndrome will spare patients ineffective medication and enable them to seek efficacious treatment. We developed a partnership between a large network of integrated Federally Qualified Health Centers serving low-income populations in New York and a university-based research and training centre for complicated grief. We implemented a simple screening programme to include complicated grief assessment in a standard assessment programme among adults receiving behavioural health services in primary care. This study aims to (i) develop and implement a systematic screening programme for complicated grief in a network of integrated health care clinics, (ii) examine feasibility and acceptability of the screening programme among behavioural health providers and (iii) explore the frequency of positive complicated grief screens among adult patients at these clinics and describe the sample. The development of complicated grief screening programme was the first phase of a multiphase project to train behavioural health providers in the identification and treatment of individuals with complicated grief. Subsequent to the training in the screening programme, providers participated in training in the delivery of complicated grief therapy and supervision by expert complicated grief therapy–trained clinicians. Methods Setting The Institute for Family Health (the Institute) is a network of Federally Qualified Health Centers. A Federally Qualified Health Center is a community-based organization that provides comprehensive care, including health, dental and behavioural health services to persons of all ages, regardless of their ability to pay or health insurance status. Located in medically underserved areas, Federally Qualified Health Centers are a critical component of the health care safety net (26). The Institute operates 31 practices serving predominantly underserved populations in urban and rural regions of Manhattan, Mid-Hudson Valley and the Bronx. The Institute serves over 102000 patients who make ~593000 primary care, behavioural health care and dental visits annually. Six rural and urban primary care clinics with co-located behavioural health services were the research setting of this study. All procedures were approved by the Institute’s Institutional Review Board. Participants There were two samples in this study: first, primary care patients 18 years or older presenting with behavioural health problems at the Institute between September 2014 and March 2017; second, providers who completed a survey related to the acceptability of the screening programme. Procedures All participants presenting for behavioural health services in any of the six primary care clinics were screened for complicated grief as part of the routine psychosocial assessment. The psychosocial assessment is integrated into the Institute electronic health record and is administered by providers (master’s level or higher) when an individual presents for behavioural health treatment. The psychosocial assessment consists of a psychosocial interview, the mental status examination and selected screening tests including the Patient Health Questionnaire–9 (27), Generalized Anxiety Disorder–7 (28) and Screening, Brief Intervention, and Referral to Treatment (29). The major components of a psychosocial interview include patient sociodemographic characteristics, history of presenting problem, psychiatric history, medical/surgical history, medication list, alcohol and drug use, violence risk assessment, family/social history, occupational history, educational history, legal history, cultural assessment, coping skills and interests. A complicated grief assessment programme was developed and integrated into the psychosocial assessment portion of the Institute electronic health record for new or ongoing primary care patients with behavioural health needs at the six Institute sites. Complicated grief screening programme A screening programme was developed to (i) identify death of someone close and the time since loss, (ii) screen for complicated grief using the Brief Grief Questionnaire (30) and (iii) assess symptoms of complicated grief using the Inventory of Complicated Grief (31) among those who screened positive on the Brief Grief Questionnaire (≥5). Assessment of loss and time since loss During the psychosocial assessment, participants were assessed for loss of a loved one and the time since the person died. Participants were asked two questions: ‘Have you ever experienced the death of someone close to you?’ and ‘Did this happen more than 6 months ago?’ If they endorsed both, they were administered the Brief Grief Questionnaire. In line with other studies of complicated grief and the 11th revision of the International Classification of Diseases guideline (21,22,32), patients were included in the study if the loss occurred >6 months ago. Brief Grief Questionnaire The Brief Grief Questionnaire (30) is a five-item screening measure scored on a three-point Likert scale (0 = not at all, 1 = somewhat, 2 = a lot) that asks individuals to report on the extent of complicated grief symptoms they are currently experiencing. An example item is, ‘How much are you having trouble accepting the death of ____?’ The measure has good reliability (Cronbach’s alpha = .82) and discriminant validity (30,33). The responses are summed, and a total score of five or above is considered a positive screen for complicated grief. In this study, individuals who scored a five or above on the Brief Grief Questionnaire were then administered the Inventory of Complicated Grief. Inventory of Complicated Grief The Inventory of Complicated Grief (31) measures how often individuals experience cognitive, emotional and behavioural symptoms of complicated grief. The measure consists of 19 questions scored on a five-point Likert scale (0 = never, 4 = always). Scores on the items are summed, and a score of 25 or above is considered positive for complicated grief (31). This is also a well-validated clinical cut point; clients who score over 25 are considered at high risk for requiring clinical care (34). The measure has good internal consistency (Cronbach’s alpha = .92) and test–retest reliability (31). Both the Brief Grief Questionnaire and Inventory for Complicated Grief were administered and graded by a clinician during the course of a psychosocial assessment. Training providers in the screening programme to identify complicated grief Master’s-level behavioural health providers (n = 14) at the six participating institute sites were trained in the complicated grief screening programme via a 1.5-hour webinar training and a series of two ‘office hours’ calls with complicated grief experts to address provider’s questions and discuss experiences with the screening programme. The webinar training (conducted by authors SRP and NAS) provided background on diagnosing mental health disorders in the context of bereavement with case examples (major depressive disorder, post-traumatic stress disorder and complicated grief). Workflow of the electronic health record–integrated screening programme was also reviewed with providers. These providers were invited to complete an online survey regarding acceptability of the complicated grief screening programme. Data collection Data on the complicated assessment programme, demographics, health and service use factors were collected and extracted from the Institute electronic health records. Feasibility Feasibility was measured by the number of providers trained who administered the screening programme, the sites they represent and the number of individuals who were screened successively at each assessment point in the screening programme. Acceptability Providers trained in the complicated screening programme were invited to complete a nine-item survey via Survey Monkey. The first six questions in the survey focused on the extent to which the complicated grief screening programme helped the clinician to understand the patient’s problems, helped the patient feel better understood, how useful the providers found the Brief Grief Questionnaire and the Inventory of Complicated Grief as assessment instruments, how useful the Inventory of Complicated Grief was for developing a treatment formulation and how difficult the providers found the Brief Grief Questionnaire and Inventory of Complicated Grief to incorporate into patient care. These questions were scored on a five-point Likert scale. The next two questions were yes/no with the opportunity to expand via open-ended responses. The questions were (i) ‘Were there any questions that patients seemed to have difficulty answering?’ and (ii) ‘Were there any questions that you didn’t understand or that you thought were not asked clearly?’ The final question is open ended (iii) ‘What suggestions do you have as to how to administer the Brief Grief Questionnaire and the Inventory of Complicated Grief?’ Demographic variables Demographic variables were collected on patients using self-report as part of the psychosocial assessment and entered into the electronic health records system. These variables include gender, age, race, ethnicity, education, current relationship and marital status, employment status and public assistance status (defined as receiving or not social security disability, supplemental security income, food stamps, social security and/or HIV/AIDS service administration). Health and service use variables Health and service use variables were also collected during the psychosocial assessment. Clinician assessed behavioural health diagnoses that have overlapping symptoms with complicated grief; post-traumatic stress disorder, major depression, adjustment disorder and bipolar disorder were collected. Self-reported data on co-occurring chronic health conditions (asthma, diabetes and hypertension) and engagement in behavioural health treatment (treatment naïve or experienced), and whether or not they are currently receiving primary care services from the Institute were also collected. Suicidal ideation was assessed by using the question, ‘Over the last two weeks have you been bothered by thoughts that you were better off dead or of hurting yourself in some way?’ of the Patient Health Questionnaire–9 collected as part of the routine psychosocial assessment at the Institute. Statistical analysis All data analyses were conducted using SPSS version 23. Descriptive statistics were conducted to describe acceptability survey data and demographic, health and service characteristics of the complicated grief sample. Results Feasibility All providers who were trained in the complicated grief screening programme used the programme for at least one psychosocial assessment across all six sites included in this study. Figure 1 presents the flow diagram of the complicated grief assessment programme. We found a low attrition rate (4–5%) between each step in the multi-step screening programme demonstrating good uptake and administration, indicating that it was feasible for providers to use. Of the patients screened (n = 2425), 63% (n = 1530) reported that they had lost someone close to them. Of those, 66% (n = 1015) reported a loss >6 months ago. These individuals (n = 1015) were administered the Brief Grief Questionnaire, and 28% (n = 282) scored a five or higher, a positive screen for complicated grief. Those who screened positive on the Brief Grief Questionnaire (n = 282) were administered the Inventory of Complicated Grief. Of those who screened positive on the Brief Grief Questionnaire, 81% endorsed a score of 25 or greater on the Inventory of Complicated Grief. Figure 1. View largeDownload slide Complicated grief assessment workflow diagram Figure 1. View largeDownload slide Complicated grief assessment workflow diagram Acceptability Broadly, providers found the complicated grief screening programme acceptable (Table 1). Most providers (64%) found that patients did not have trouble understanding the grief-related questions and 86% reported there were not any questions they personally did not understand or thought were not asked clearly. In addition, 71% of the providers found the Brief Grief Questionnaire moderately to very useful as an assessment instrument, 64% found the Inventory of Complicated Grief moderately to very useful as an assessment instrument, and just over half thought the Inventory of Complicated Grief was useful for developing a treatment plan. Seventy-one per cent of providers reported that the screening programme helped them to understand the patient’s problem at least moderately better and 100% reported that the patient felt slightly to moderately better understood as a result of the complicated grief screening programme. Thirty-six percent of clinicians reported that patients did have difficulty answering the questions on the Brief Grief Questionnaire or Inventory for Complicated Grief, citing that, “some patients do not have great verbal comprehension regarding emotions.” Table 1. Provider (n = 14) acceptability ratings of complicated grief screening programme at the Institute for Family Health between 2014 and 2017 Question Not at all n (%) Slightly n (%) Moderately n (%) Very n (%) Understanding 1. How much did the grief interview questions help you to understand the patient’s problems you assessed? 0 (0.0) 4 (28.6) 10 (71.4) 0 (0.0) 2. How much do you think the patient you interviewed felt better understood as a result of the interview? 0 (0.0) 8 (57.1) 6 (42.9) 0 (0.0) Usefulness 3. How useful do you think the BGQ is as an assessment instrument? 1 (7.1) 3 (21.4) 7 (50.0) 3 (21.4) 4. How useful do you think the ICG is as an assessment instrument? 0 (0.0) 5 (35.7) 7 (50.0) 2 (14.3) 5. How useful do you think the ICG is for developing a treatment formulation? 1 (7.1) 5 (35.7) 8 (57.1) 0 (0.0) Difficulty 6. How difficult was it to incorporate the BGQ and ICG into your care of patients? 3 (21.4) 7 (50.0) 4 (28.6) 0 (0.0) Question Not at all n (%) Slightly n (%) Moderately n (%) Very n (%) Understanding 1. How much did the grief interview questions help you to understand the patient’s problems you assessed? 0 (0.0) 4 (28.6) 10 (71.4) 0 (0.0) 2. How much do you think the patient you interviewed felt better understood as a result of the interview? 0 (0.0) 8 (57.1) 6 (42.9) 0 (0.0) Usefulness 3. How useful do you think the BGQ is as an assessment instrument? 1 (7.1) 3 (21.4) 7 (50.0) 3 (21.4) 4. How useful do you think the ICG is as an assessment instrument? 0 (0.0) 5 (35.7) 7 (50.0) 2 (14.3) 5. How useful do you think the ICG is for developing a treatment formulation? 1 (7.1) 5 (35.7) 8 (57.1) 0 (0.0) Difficulty 6. How difficult was it to incorporate the BGQ and ICG into your care of patients? 3 (21.4) 7 (50.0) 4 (28.6) 0 (0.0) BGQ, Brief Grief Questionnaire; ICG, Inventory for Complicated Grief; PCP, Primary Care Physician. View Large Table 1. Provider (n = 14) acceptability ratings of complicated grief screening programme at the Institute for Family Health between 2014 and 2017 Question Not at all n (%) Slightly n (%) Moderately n (%) Very n (%) Understanding 1. How much did the grief interview questions help you to understand the patient’s problems you assessed? 0 (0.0) 4 (28.6) 10 (71.4) 0 (0.0) 2. How much do you think the patient you interviewed felt better understood as a result of the interview? 0 (0.0) 8 (57.1) 6 (42.9) 0 (0.0) Usefulness 3. How useful do you think the BGQ is as an assessment instrument? 1 (7.1) 3 (21.4) 7 (50.0) 3 (21.4) 4. How useful do you think the ICG is as an assessment instrument? 0 (0.0) 5 (35.7) 7 (50.0) 2 (14.3) 5. How useful do you think the ICG is for developing a treatment formulation? 1 (7.1) 5 (35.7) 8 (57.1) 0 (0.0) Difficulty 6. How difficult was it to incorporate the BGQ and ICG into your care of patients? 3 (21.4) 7 (50.0) 4 (28.6) 0 (0.0) Question Not at all n (%) Slightly n (%) Moderately n (%) Very n (%) Understanding 1. How much did the grief interview questions help you to understand the patient’s problems you assessed? 0 (0.0) 4 (28.6) 10 (71.4) 0 (0.0) 2. How much do you think the patient you interviewed felt better understood as a result of the interview? 0 (0.0) 8 (57.1) 6 (42.9) 0 (0.0) Usefulness 3. How useful do you think the BGQ is as an assessment instrument? 1 (7.1) 3 (21.4) 7 (50.0) 3 (21.4) 4. How useful do you think the ICG is as an assessment instrument? 0 (0.0) 5 (35.7) 7 (50.0) 2 (14.3) 5. How useful do you think the ICG is for developing a treatment formulation? 1 (7.1) 5 (35.7) 8 (57.1) 0 (0.0) Difficulty 6. How difficult was it to incorporate the BGQ and ICG into your care of patients? 3 (21.4) 7 (50.0) 4 (28.6) 0 (0.0) BGQ, Brief Grief Questionnaire; ICG, Inventory for Complicated Grief; PCP, Primary Care Physician. View Large Data were mixed regarding how difficult providers found it to be to incorporate the Brief Grief Questionnaire and Inventory of Complicated Grief into patient care, with the majority (71%) reporting it was not at all (21%) or slightly (50%) difficult. The remaining 29% found it moderately difficult. Open-ended responses on acceptability indicate that at least one clinician found the programme difficult to administer when the patient had experienced multiple losses due to the patient not being able to identify which loss was most impactful. Another clinician felt that including both the Brief Grief Questionnaire and the Inventory of Complicated Grief into the psychosocial assessment programme was too laborious, and perhaps the Inventory of Complicated Grief should be completed upon the second visit with the clinician. See Table 1 for these results. Rate and sample description Overall, among the 1015 patients who had experienced the death of someone close <6 months ago, 22% (n = 228) endorsed scores of 25 or greater on the Inventory of Complicated Grief. This proportion is in line with mental health clinics (16). Table 2 presents descriptive statistics of this sample. A majority of the sample was middle aged (M = 41 years) female (72%) and about half were unemployed (58%) or receiving public assistance (46%). The sample was diverse compared to previous studies on complicated grief in western and non-western samples, with Black (31%), White (25%) and some other race (25%) and one-third of the respondents (36%) self-identified as Hispanic. Almost half of the sample (47%) had up to a high school level of education, and approximately one-quarter had some college or a college degree. About half (52%) reported being single/never married. Approximately half (47%) of the sample were referred to behavioural health from co-located primary care and half were already receiving behavioural health services. Compared with the behavioural health populations across these clinics, this sample had more females (P = 0.00) and African Americans (P = 0.00). Table 2. Characteristics of individuals (n = 228) with Inventory of Complicated Grief Scores ≥25 at the Institute for Family Health between 2014 and 2017 Demographics n (%) Gender (female) 164 (71.9) Age (M, SD) 41.29 (13.4) Education <12th grade 63 (27.6) High school/GED 44 (19.3) Some college 10 (4.4) College graduate 48 (21.1) Race Asian 6 (2.6) Black 71 (31.1) Some other race 57 (25.0) White 58 (25.4) Ethnicity Hispanic 83 (36.4) Non-Hispanic 121 (53.1) Employment Employed 51 (22.4) Unemployed 131 (57.5) Public assistance Receives some public assistance 105 (46.1) Receives no public assistance 79 (34.6) Marital status Single/never married 118 (51.8) Married 25 (11.0) Divorced/separated 29 (12.7) Widowed 8 (3.5) Current relationship status In a relationship 75 (32.9) Not in a relationship 105 (46.1) Health Comorbid behavioural health diagnosis a. PTSD 36 (15.8) b. Major depressive disorder 88 (38.6) e. Adjustment disorder 95 (41.7) f. Suicidal ideation 31 (13.6) g. Bipolar 13 (5.7) Co-occurring chronic health conditions Asthma 46 (20.2) Diabetes 19 (8.3) Hypertension 29 (12.7) Service use Engagement in behavioural health treatment Treatment naïve 60 (26.3) Treatment experienced: past diagnosis (self-report) 122 (53.5) Primary care at IFH (yes) 126 (55.3) Demographics n (%) Gender (female) 164 (71.9) Age (M, SD) 41.29 (13.4) Education <12th grade 63 (27.6) High school/GED 44 (19.3) Some college 10 (4.4) College graduate 48 (21.1) Race Asian 6 (2.6) Black 71 (31.1) Some other race 57 (25.0) White 58 (25.4) Ethnicity Hispanic 83 (36.4) Non-Hispanic 121 (53.1) Employment Employed 51 (22.4) Unemployed 131 (57.5) Public assistance Receives some public assistance 105 (46.1) Receives no public assistance 79 (34.6) Marital status Single/never married 118 (51.8) Married 25 (11.0) Divorced/separated 29 (12.7) Widowed 8 (3.5) Current relationship status In a relationship 75 (32.9) Not in a relationship 105 (46.1) Health Comorbid behavioural health diagnosis a. PTSD 36 (15.8) b. Major depressive disorder 88 (38.6) e. Adjustment disorder 95 (41.7) f. Suicidal ideation 31 (13.6) g. Bipolar 13 (5.7) Co-occurring chronic health conditions Asthma 46 (20.2) Diabetes 19 (8.3) Hypertension 29 (12.7) Service use Engagement in behavioural health treatment Treatment naïve 60 (26.3) Treatment experienced: past diagnosis (self-report) 122 (53.5) Primary care at IFH (yes) 126 (55.3) GED, General Education Diploma; IFH, Institute for Family Health; PTSD, post-traumatic stress disorder. View Large Table 2. Characteristics of individuals (n = 228) with Inventory of Complicated Grief Scores ≥25 at the Institute for Family Health between 2014 and 2017 Demographics n (%) Gender (female) 164 (71.9) Age (M, SD) 41.29 (13.4) Education <12th grade 63 (27.6) High school/GED 44 (19.3) Some college 10 (4.4) College graduate 48 (21.1) Race Asian 6 (2.6) Black 71 (31.1) Some other race 57 (25.0) White 58 (25.4) Ethnicity Hispanic 83 (36.4) Non-Hispanic 121 (53.1) Employment Employed 51 (22.4) Unemployed 131 (57.5) Public assistance Receives some public assistance 105 (46.1) Receives no public assistance 79 (34.6) Marital status Single/never married 118 (51.8) Married 25 (11.0) Divorced/separated 29 (12.7) Widowed 8 (3.5) Current relationship status In a relationship 75 (32.9) Not in a relationship 105 (46.1) Health Comorbid behavioural health diagnosis a. PTSD 36 (15.8) b. Major depressive disorder 88 (38.6) e. Adjustment disorder 95 (41.7) f. Suicidal ideation 31 (13.6) g. Bipolar 13 (5.7) Co-occurring chronic health conditions Asthma 46 (20.2) Diabetes 19 (8.3) Hypertension 29 (12.7) Service use Engagement in behavioural health treatment Treatment naïve 60 (26.3) Treatment experienced: past diagnosis (self-report) 122 (53.5) Primary care at IFH (yes) 126 (55.3) Demographics n (%) Gender (female) 164 (71.9) Age (M, SD) 41.29 (13.4) Education <12th grade 63 (27.6) High school/GED 44 (19.3) Some college 10 (4.4) College graduate 48 (21.1) Race Asian 6 (2.6) Black 71 (31.1) Some other race 57 (25.0) White 58 (25.4) Ethnicity Hispanic 83 (36.4) Non-Hispanic 121 (53.1) Employment Employed 51 (22.4) Unemployed 131 (57.5) Public assistance Receives some public assistance 105 (46.1) Receives no public assistance 79 (34.6) Marital status Single/never married 118 (51.8) Married 25 (11.0) Divorced/separated 29 (12.7) Widowed 8 (3.5) Current relationship status In a relationship 75 (32.9) Not in a relationship 105 (46.1) Health Comorbid behavioural health diagnosis a. PTSD 36 (15.8) b. Major depressive disorder 88 (38.6) e. Adjustment disorder 95 (41.7) f. Suicidal ideation 31 (13.6) g. Bipolar 13 (5.7) Co-occurring chronic health conditions Asthma 46 (20.2) Diabetes 19 (8.3) Hypertension 29 (12.7) Service use Engagement in behavioural health treatment Treatment naïve 60 (26.3) Treatment experienced: past diagnosis (self-report) 122 (53.5) Primary care at IFH (yes) 126 (55.3) GED, General Education Diploma; IFH, Institute for Family Health; PTSD, post-traumatic stress disorder. View Large Among those with an Inventory of Complicated Grief score of 25 and greater, the most commonly documented comorbid behavioural health diagnoses were adjustment disorder (42%), major depression (39%), post-traumatic stress disorder (16%) and bipolar disorder (6%). Thus, while high rates of comorbidity between major depression and complicated grief exist, 61% of patients with complicated grief did not have depression in this sample. Approximately 14% of the sample reported suicidal ideation as defined by the one-item question of the Patient Health Questionnaire–9. Suicidal thinking is well documented in association with complicated grief (8,9). Among the 31 patients with complicated grief and suicidal ideation, 19 (61%) had a comorbid diagnosis of major depression, bipolar disorder and/or post-traumatic stress disorder and 12 (39%) had no comorbid health diagnosis. With regard to treatment, approximately half of the sample was receiving their primary care treatment at the Institute (55%) and reported having received a behavioural health diagnosis and treatment in the past (53%). Discussion To our knowledge, this study is the first in the USA to implement a screening programme for complicated grief in a diverse medically underserved population in integrated health care settings. There are four main findings. First, we learned that this complicated grief screening programme was feasible and acceptable to providers working in an integrated primary and behavioural health care setting. Second, we learned that in the identification of complicated grief in this sample, a short five-item screener for complicated grief, the Brief Grief Questionnaire performed about as well as the Inventory of Complicated Grief as indicated by a high rate of identifying individuals with a score on the Inventory of Complicated Grief >25 and by being easier and shorter to administer. Third, in a sample of underserved or safety net population of racially and ethnically diverse outpatients referred for behavioural health in primary care, the estimated rate of complicated grief is 22%. Fourth, we found that complicated grief is associated with high rates of suicidal thinking in this population, similar to elevated rates in mental health treatment and community settings (10,11). Through the implementation of the complicated grief screening programme in the electronic health record, we learned that the Brief Grief Questionnaire is an easily administered and effective screening tool. Given that many individuals may turn to primary care providers when bereaved, primary care providers can administer the Brief Grief Questionnaire to efficiently identify and refer individuals with complicated grief to behavioural health. The behavioural health providers in this sample found the Brief Grief Questionnaire and Complicated Grief acceptable to implement noting that it informed their understanding of the patient’s problem and useful assessments that were used to inform treatment formulation. Some providers noted suggestion to further improve the screening programme to accommodate the time and workflow of their psychosocial assessment procedures. One clinician suggested the Brief Grief Questionnaire be first administered by a primary care provider similar to how the Patient Health Questionnaire nine-item screening tool for depression is used in the collaborative care for depression programme (35). Integrated care settings seeking to implement a complicated grief screening programme may consider embedding their programme in an electronic health record (if available) to facilitate administration. Providers would need initial training and ongoing support to maximize administration of the screening programme and recognize differences between complicated grief and other common behavioural health disorders seen in primary care. This study found that the prevalence of complicated grief in medically underserved populations referred for behavioural health in primary care is comparable to that of psychiatric populations (16,36) and higher than community samples (1,14). While not all patients referred to behavioural health from primary care receive a psychiatric diagnosis, these individuals were being referred for behavioural health and the estimated prevalence should be interpreted within this context. There may be several other reasons for this elevated prevalence rate in this population including a higher rate of traumatic loss in low-income communities, community violence and chronic illness comorbidity (37–39). Our findings are consistent with the previous research showing that individuals with complicated grief report suicidal ideation (10,11) Front-line providers in integrated settings may benefit from an awareness of the association between suicidality and complicated grief for timely intervention (23). Although this is the first study of a screening programme to identify complicated grief in behavioural health outpatients in primary care, our study has some limitations. First, these data were collected as part of routine clinical assessment in an electronic health record and do not represent rigorous data collection as part of a research study. While this enhances the real-world applicability and aligns with most psychiatric research that relies on self-report and clinician assessment, our findings should be interpreted within this data collection context. Second, the clinics participating in this study serve a segment of the population and are not representative of all primary care patients experiencing grief. Third, we did not collect sufficient information on whether these individuals were seeking help for grief, the nature of the loss [e.g. relationship to deceased and cause of death (sudden, illness, suicide)] which may allow for greater understanding of the factors associated with complicated grief. Conclusions Integrated primary and behavioural health care settings are well positioned to identify individuals with complicated grief. This is the first study to develop and assess acceptability, feasibility and outcome of a systematic screening programme for complicated grief among an underserved, racially and ethnically diverse safety net primary care population in an integrated care setting. It provides an example of how to develop, embed a screening programme into an electronic health record to facilitate implementation and train providers to administer the programme in a real-world setting. Declaration Funding: The study was funded by institutional resources. Ethical approval: This research was approved by the institutional review board at which the research was conducted. Conflict of interest: The authors have no conflicts of interest to report. References 1. Lundorff M , Holmgren H , Zachariae R , Farver-Vestergaard I , O’Connor M . Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis . J Affect Disord 2017 ; 212 : 138 – 49 . Google Scholar CrossRef Search ADS PubMed 2. Kersting A , Brahler E , Glaesmer H , Wagner B . Prevalence of complicated grief in a representative population-based sample . J Affect Disord 2011 ; 31 : 339 – 43 . Google Scholar CrossRef Search ADS 3. Shear MK . Grief and mourning gone awry: pathway and course of complicated grief . Dialogues Clin Neurosci 2012 ; 14 : 119 – 28 . Google Scholar PubMed 4. Bonanno GA , Kaltman S . The varieties of grief experience . Clin Psychol Rev 2001 ; 21 : 705 – 34 . Google Scholar CrossRef Search ADS PubMed 5. Simon NM , Shear KM , Thompson EH , et al. The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief . Compr Psychiatry 2007 ; 48 : 395 – 9 . Google Scholar CrossRef Search ADS PubMed 6. Bonanno GA , Neria Y , Mancini A , et al. Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity . J Abnorm Psychol 2007 ; 116 : 342 – 51 . Google Scholar CrossRef Search ADS PubMed 7. Prigerson HG , Bierhals AJ , Kasl SV , et al. Traumatic grief as a risk factor for mental and physical morbidity . Am J Psychiatry 1997 ; 154 : 616 – 23 . Google Scholar CrossRef Search ADS PubMed 8. Lannen PK , Wolfe J , Prigerson HG , Onelov E , Kreicbergs UC . Unresolved grief in a national sample of bereaved parents: impaired mental and physical health 4 to 9 years later . J Clin Oncol 2008 ; 26 : 5870 – 6 . Google Scholar CrossRef Search ADS PubMed 9. Dell’osso L , Carmassi C , Rucci P , et al. Complicated grief and suicidality: the impact of subthreshold mood symptoms . CNS Spectr 2011 ; 16 : 1 – 6 . Google Scholar CrossRef Search ADS PubMed 10. Szanto K , Shear MK , Houck PR , et al. Indirect self-destructive behavior and overt suicidality in patients with complicated grief . J Clin Psychiatry 2006 ; 67 : 233 – 9 . Google Scholar CrossRef Search ADS PubMed 11. Latham AE , Prigerson HG . Suicidality and bereavement: complicated grief as psychiatric disorder presenting greatest risk for suicidality . Suicide Life Threat Behav 2004 ; 34 : 350 – 62 . Google Scholar CrossRef Search ADS PubMed 12. Shear MK . Clinical practice. Complicated grief . N Engl J Med 2015 ; 372 : 153 – 60 . Google Scholar CrossRef Search ADS PubMed 13. Fujisawa D , Miyashita M , Nakajima S , et al. Prevalence and determinants of complicated grief in general population . J Affect Disord 2010 ; 127 : 352 – 8 . Google Scholar CrossRef Search ADS PubMed 14. He L , Tang S , Yu W , et al. The prevalence, comorbidity and risks of prolonged grief disorder among bereaved Chinese adults . Psychiatry Res 2014 ; 219 : 347 – 52 . Google Scholar CrossRef Search ADS PubMed 15. Newson RS , Boelen PA , Hek K , Hofman A , Tiemeier H . The prevalence and characteristics of complicated grief in older adults . J Affect Disord 2011 ; 132 : 231 – 8 . Google Scholar CrossRef Search ADS PubMed 16. Sung SC , Dryman MT , Marks E , et al. Complicated grief among individuals with major depression: prevalence, comorbidity, and associated features . J Affect Disord 2011 ; 134 : 453 – 8 . Google Scholar CrossRef Search ADS PubMed 17. Goldsmith B , Morrison RS , Vanderwerker LC , Prigerson HG . Elevated rates of prolonged grief disorder in African Americans . Death Stud 2008 ; 32 : 352 – 65 . Google Scholar CrossRef Search ADS PubMed 18. Boerner K , Schulz R . Caregiving, bereavement and complicated grief . Bereave Care 2009 ; 28 : 10 – 3 . Google Scholar CrossRef Search ADS PubMed 19. Zisook S , Simon NM , Reynolds CF III , et al. Bereavement, complicated grief, and DSM, part 2: complicated grief . J Clin Psychiatry 2010 ; 71 : 1097 – 8 . Google Scholar CrossRef Search ADS PubMed 20. Zisook S , Iglewicz A , Avanzino J , et al. Bereavement: course, consequences, and care . Curr Psychiatry Rep 2014 ; 16 : 482 . Google Scholar CrossRef Search ADS PubMed 21. Shear MK , Reynolds CF III , Simon NM , et al. Optimizing treatment of complicated grief: a randomized clinical trial . JAMA Psychiatry 2016 ; 73 : 685 – 94 . Google Scholar CrossRef Search ADS PubMed 22. Shear MK , Wang Y , Skritskaya N , et al. Treatment of complicated grief in elderly persons: a randomized clinical trial . JAMA Psychiatry 2014 ; 71 : 1287 – 95 . Google Scholar CrossRef Search ADS PubMed 23. Shear K , Frank E , Houck PR , Reynolds CF III . Treatment of complicated grief: a randomized controlled trial . JAMA 2005 ; 293 : 2601 – 8 . Google Scholar CrossRef Search ADS PubMed 24. Caserta MS , Lund DA . Bereaved older adults who seek early professional help . Death Stud 1992 ; 16 : 17 – 30 . Google Scholar CrossRef Search ADS PubMed 25. Ghesquiere A , Shear MK , Duan N . Outcomes of bereavement care among widowed older adults with complicated grief and depression . J Prim Care Community Health 2013 ; 4 : 256 – 64 . Google Scholar CrossRef Search ADS PubMed 26. Doty MM , Abrams MK , Hernandez SE , Stremikis K , Beal AC. Enhancing the Capacity of Community Health Centers to Achieve High Performance: Findings from the 2009 Commonwealth Fund. National Survey of Federally Qualified Health Centers . The Commonwealth Fund , 2010 . 27. Kroenke K , Spitzer RL , Williams JB . The PHQ-9: validity of a brief depression severity measure . J Gen Intern Med 2001 ; 16 : 606 – 13 . Google Scholar CrossRef Search ADS PubMed 28. Spitzer RL , Kroenke K , Williams JB , Lowe B . A brief measure for assessing generalized anxiety disorder: the GAD-7 . Arch Intern Med 2006 ; 166 : 1092 – 7 . Google Scholar CrossRef Search ADS PubMed 29. Office of National Drug Control Policy . Screening, Brief Intervention, and Referral to Treatment (SBIRT) . Washington, DC : Office of National Drug Control Policy (ONDCP), Substance Abuse and Mental Health Services Administration (SAMHSA) , 2012 . 30. Shear KM , Jackson C , 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 : 1291 – 7 . Google Scholar CrossRef Search ADS PubMed 31. Prigerson HG , Maciejewski PK , Reynolds CF III , et al. Inventory of complicated grief: a scale to measure maladaptive symptoms of loss . Psychiatry Res 1995 ; 59 : 65 – 79 . Google Scholar CrossRef Search ADS PubMed 32. ICD 11 Beta Draft (Morbidity and Mortality Statistics) Prolonged Grief Disorder , 2018 . https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1183832314 (accessed on 23 May 2018) . 33. Ito M , Nakajima S , Fujisawa D , et al. Brief measure for screening complicated grief: reliability and discriminant validity . PLoS One 2012 ; 7 : e31209 . Google Scholar CrossRef Search ADS PubMed 34. American Psychological Association . Inventory of Complicated Grief , 2017 . http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/complicated-grief.aspx (accessed on 23 May 2018) . 35. Unützer J , Katon W , Callahan CM , et al. ; IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment . Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial . JAMA 2002 ; 288 : 2836 – 45 . Google Scholar CrossRef Search ADS PubMed 36. Simon NM , Pollack MH , Fischmann D , et al. Complicated grief and its correlates in patients with bipolar disorder . J Clin Psychiatry 2005 ; 66 : 1105 – 10 . Google Scholar CrossRef Search ADS PubMed 37. Hooyman NR , Kramer BJ. Living Through Loss: Interventions Across the Life Span . New York, NY : Columbia University Press ; 2006 . 38. Jenkins EJ , Wang E , Turner L . Beyond community violence: loss and traumatic grief in African American elementary school children . J Child Adolesc Trauma 2014 ; 7 : 27 – 36 . Google Scholar CrossRef Search ADS 39. Saltzman WR , Pynoos RS , Layne CM , Steinberg AM , Aisenberg E . Trauma- and grief-focused intervention for adolescents exposed to community violence: results of a school-based screening and group treatment protocol . Group Dyn 2001 ; 5 : 291 – 303 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Acceptability, feasibility and outcome of a screening programme for complicated grief in integrated primary and behavioural health care clinics

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Oxford University Press
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0263-2136
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10.1093/fampra/cmy050
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Abstract

Abstract Background Complicated grief, a syndrome of persistent grief diagnosed >6 months following the loss of someone close is expected to be included in the 11th revision of the International Classification of Diseases as a new diagnosis called prolonged grief disorder. Complicated grief is associated with impaired functioning and health comorbidity and does not respond to treatments for depression. Individuals may seek help in primary care where providers need to be familiar with the syndrome. Objective This study examines the acceptability, feasibility and outcome of a screening programme for complicated grief among diverse adults receiving behavioural health services in integrated primary care. Methods Behavioural health providers (n = 14) administered the Brief Grief Questionnaire and the Inventory of Complicated Grief during routine assessment and completed an acceptability survey. Descriptive statistics described rates of complicated grief symptoms and sample demographics, health and service use. Results Most providers (71%) reported the Brief Grief Questionnaire to be a moderate to very useful assessment instrument and the Inventory of Complicated Grief moderate to very useful for developing a treatment plan (57%). Of the 2425 patients screened, 1015 reported a loss over 6 months ago. Of these 1015, 28% (n = 282) screened positive on the Brief Grief Questionnaire and 22% (n = 228) endorsed symptoms of complicated grief (Inventory of Complicated Grief score ≥25), considered at high risk for needing clinical care. Conclusions A screening programme for identifying complicated grief was acceptable to providers, feasible to implement and useful in identifying complicated grief in integrated primary care clinics. Federally qualified health centre, identify, prolonged grief disorder, protocol, provider, questionnaire Introduction Experiencing the death of a loved one is a universal part of human life. Most bereaved individuals experience acute grief that decreases in intensity over time. However, estimates suggest that about 11–15% of bereaved people suffer from a syndrome of persistent impairing grief here termed complicated grief (1,2). Complicated grief is characterized by maladaptive cognitions and behaviours that impede adaptation to loss and result in persistent yearning, longing and sorrow, preoccupation with thoughts and memories of the deceased and difficulty envisioning a meaningful future without the deceased (3). Complicated grief is associated with significant impairment in social and occupational functioning (4,5) and behavioural health comorbidity (5,6) and has been shown to increase the risk for health problems, including cardiovascular disease and cancer (7,8). Complicated grief is also associated with increased suicidal ideation (9–11) and its course is typically chronic and unremitting (12). The prevalence of complicated grief in the general population worldwide ranges from 0.9% to 9.8% (1,13,14). The prevalence appears to be higher among females, older adults and individuals of low income (1,14,15). Comorbidities that are associated with complicated grief include depression, anxiety and substance use (16). Two studies found that African Americans are 2.5 times more likely to develop complicated grief than Whites (17,18). Why is it important to screen for complicated grief in primary care? The most important reason to screen is that acute grief and major depression are often confused but they not the same. Complicated grief is a form of persistent impairing acute grief. Studies have shown it to differ from depression (19,20) and to show a low response to antidepressant medication (21) and efficacious psychotherapy for depression (22,23). These studies show that complicated grief can be effectively treated with a targeted short-term treatment. Bereaved people, especially older adults, often seek help from their primary care providers (18,24). In one study, ~50% of widowed older adults with complicated grief reported discussing grief with their primary care physicians (25). Yet to our knowledge, there have been no studies on the identification and prevalence of complicated grief in individuals attending primary care clinics or those seen in integrated primary and behavioural health care (mental health and substance use) settings in the USA. A simple, easily administered screening would help providers identify individuals with complicated grief. Clinician recognition of this syndrome will spare patients ineffective medication and enable them to seek efficacious treatment. We developed a partnership between a large network of integrated Federally Qualified Health Centers serving low-income populations in New York and a university-based research and training centre for complicated grief. We implemented a simple screening programme to include complicated grief assessment in a standard assessment programme among adults receiving behavioural health services in primary care. This study aims to (i) develop and implement a systematic screening programme for complicated grief in a network of integrated health care clinics, (ii) examine feasibility and acceptability of the screening programme among behavioural health providers and (iii) explore the frequency of positive complicated grief screens among adult patients at these clinics and describe the sample. The development of complicated grief screening programme was the first phase of a multiphase project to train behavioural health providers in the identification and treatment of individuals with complicated grief. Subsequent to the training in the screening programme, providers participated in training in the delivery of complicated grief therapy and supervision by expert complicated grief therapy–trained clinicians. Methods Setting The Institute for Family Health (the Institute) is a network of Federally Qualified Health Centers. A Federally Qualified Health Center is a community-based organization that provides comprehensive care, including health, dental and behavioural health services to persons of all ages, regardless of their ability to pay or health insurance status. Located in medically underserved areas, Federally Qualified Health Centers are a critical component of the health care safety net (26). The Institute operates 31 practices serving predominantly underserved populations in urban and rural regions of Manhattan, Mid-Hudson Valley and the Bronx. The Institute serves over 102000 patients who make ~593000 primary care, behavioural health care and dental visits annually. Six rural and urban primary care clinics with co-located behavioural health services were the research setting of this study. All procedures were approved by the Institute’s Institutional Review Board. Participants There were two samples in this study: first, primary care patients 18 years or older presenting with behavioural health problems at the Institute between September 2014 and March 2017; second, providers who completed a survey related to the acceptability of the screening programme. Procedures All participants presenting for behavioural health services in any of the six primary care clinics were screened for complicated grief as part of the routine psychosocial assessment. The psychosocial assessment is integrated into the Institute electronic health record and is administered by providers (master’s level or higher) when an individual presents for behavioural health treatment. The psychosocial assessment consists of a psychosocial interview, the mental status examination and selected screening tests including the Patient Health Questionnaire–9 (27), Generalized Anxiety Disorder–7 (28) and Screening, Brief Intervention, and Referral to Treatment (29). The major components of a psychosocial interview include patient sociodemographic characteristics, history of presenting problem, psychiatric history, medical/surgical history, medication list, alcohol and drug use, violence risk assessment, family/social history, occupational history, educational history, legal history, cultural assessment, coping skills and interests. A complicated grief assessment programme was developed and integrated into the psychosocial assessment portion of the Institute electronic health record for new or ongoing primary care patients with behavioural health needs at the six Institute sites. Complicated grief screening programme A screening programme was developed to (i) identify death of someone close and the time since loss, (ii) screen for complicated grief using the Brief Grief Questionnaire (30) and (iii) assess symptoms of complicated grief using the Inventory of Complicated Grief (31) among those who screened positive on the Brief Grief Questionnaire (≥5). Assessment of loss and time since loss During the psychosocial assessment, participants were assessed for loss of a loved one and the time since the person died. Participants were asked two questions: ‘Have you ever experienced the death of someone close to you?’ and ‘Did this happen more than 6 months ago?’ If they endorsed both, they were administered the Brief Grief Questionnaire. In line with other studies of complicated grief and the 11th revision of the International Classification of Diseases guideline (21,22,32), patients were included in the study if the loss occurred >6 months ago. Brief Grief Questionnaire The Brief Grief Questionnaire (30) is a five-item screening measure scored on a three-point Likert scale (0 = not at all, 1 = somewhat, 2 = a lot) that asks individuals to report on the extent of complicated grief symptoms they are currently experiencing. An example item is, ‘How much are you having trouble accepting the death of ____?’ The measure has good reliability (Cronbach’s alpha = .82) and discriminant validity (30,33). The responses are summed, and a total score of five or above is considered a positive screen for complicated grief. In this study, individuals who scored a five or above on the Brief Grief Questionnaire were then administered the Inventory of Complicated Grief. Inventory of Complicated Grief The Inventory of Complicated Grief (31) measures how often individuals experience cognitive, emotional and behavioural symptoms of complicated grief. The measure consists of 19 questions scored on a five-point Likert scale (0 = never, 4 = always). Scores on the items are summed, and a score of 25 or above is considered positive for complicated grief (31). This is also a well-validated clinical cut point; clients who score over 25 are considered at high risk for requiring clinical care (34). The measure has good internal consistency (Cronbach’s alpha = .92) and test–retest reliability (31). Both the Brief Grief Questionnaire and Inventory for Complicated Grief were administered and graded by a clinician during the course of a psychosocial assessment. Training providers in the screening programme to identify complicated grief Master’s-level behavioural health providers (n = 14) at the six participating institute sites were trained in the complicated grief screening programme via a 1.5-hour webinar training and a series of two ‘office hours’ calls with complicated grief experts to address provider’s questions and discuss experiences with the screening programme. The webinar training (conducted by authors SRP and NAS) provided background on diagnosing mental health disorders in the context of bereavement with case examples (major depressive disorder, post-traumatic stress disorder and complicated grief). Workflow of the electronic health record–integrated screening programme was also reviewed with providers. These providers were invited to complete an online survey regarding acceptability of the complicated grief screening programme. Data collection Data on the complicated assessment programme, demographics, health and service use factors were collected and extracted from the Institute electronic health records. Feasibility Feasibility was measured by the number of providers trained who administered the screening programme, the sites they represent and the number of individuals who were screened successively at each assessment point in the screening programme. Acceptability Providers trained in the complicated screening programme were invited to complete a nine-item survey via Survey Monkey. The first six questions in the survey focused on the extent to which the complicated grief screening programme helped the clinician to understand the patient’s problems, helped the patient feel better understood, how useful the providers found the Brief Grief Questionnaire and the Inventory of Complicated Grief as assessment instruments, how useful the Inventory of Complicated Grief was for developing a treatment formulation and how difficult the providers found the Brief Grief Questionnaire and Inventory of Complicated Grief to incorporate into patient care. These questions were scored on a five-point Likert scale. The next two questions were yes/no with the opportunity to expand via open-ended responses. The questions were (i) ‘Were there any questions that patients seemed to have difficulty answering?’ and (ii) ‘Were there any questions that you didn’t understand or that you thought were not asked clearly?’ The final question is open ended (iii) ‘What suggestions do you have as to how to administer the Brief Grief Questionnaire and the Inventory of Complicated Grief?’ Demographic variables Demographic variables were collected on patients using self-report as part of the psychosocial assessment and entered into the electronic health records system. These variables include gender, age, race, ethnicity, education, current relationship and marital status, employment status and public assistance status (defined as receiving or not social security disability, supplemental security income, food stamps, social security and/or HIV/AIDS service administration). Health and service use variables Health and service use variables were also collected during the psychosocial assessment. Clinician assessed behavioural health diagnoses that have overlapping symptoms with complicated grief; post-traumatic stress disorder, major depression, adjustment disorder and bipolar disorder were collected. Self-reported data on co-occurring chronic health conditions (asthma, diabetes and hypertension) and engagement in behavioural health treatment (treatment naïve or experienced), and whether or not they are currently receiving primary care services from the Institute were also collected. Suicidal ideation was assessed by using the question, ‘Over the last two weeks have you been bothered by thoughts that you were better off dead or of hurting yourself in some way?’ of the Patient Health Questionnaire–9 collected as part of the routine psychosocial assessment at the Institute. Statistical analysis All data analyses were conducted using SPSS version 23. Descriptive statistics were conducted to describe acceptability survey data and demographic, health and service characteristics of the complicated grief sample. Results Feasibility All providers who were trained in the complicated grief screening programme used the programme for at least one psychosocial assessment across all six sites included in this study. Figure 1 presents the flow diagram of the complicated grief assessment programme. We found a low attrition rate (4–5%) between each step in the multi-step screening programme demonstrating good uptake and administration, indicating that it was feasible for providers to use. Of the patients screened (n = 2425), 63% (n = 1530) reported that they had lost someone close to them. Of those, 66% (n = 1015) reported a loss >6 months ago. These individuals (n = 1015) were administered the Brief Grief Questionnaire, and 28% (n = 282) scored a five or higher, a positive screen for complicated grief. Those who screened positive on the Brief Grief Questionnaire (n = 282) were administered the Inventory of Complicated Grief. Of those who screened positive on the Brief Grief Questionnaire, 81% endorsed a score of 25 or greater on the Inventory of Complicated Grief. Figure 1. View largeDownload slide Complicated grief assessment workflow diagram Figure 1. View largeDownload slide Complicated grief assessment workflow diagram Acceptability Broadly, providers found the complicated grief screening programme acceptable (Table 1). Most providers (64%) found that patients did not have trouble understanding the grief-related questions and 86% reported there were not any questions they personally did not understand or thought were not asked clearly. In addition, 71% of the providers found the Brief Grief Questionnaire moderately to very useful as an assessment instrument, 64% found the Inventory of Complicated Grief moderately to very useful as an assessment instrument, and just over half thought the Inventory of Complicated Grief was useful for developing a treatment plan. Seventy-one per cent of providers reported that the screening programme helped them to understand the patient’s problem at least moderately better and 100% reported that the patient felt slightly to moderately better understood as a result of the complicated grief screening programme. Thirty-six percent of clinicians reported that patients did have difficulty answering the questions on the Brief Grief Questionnaire or Inventory for Complicated Grief, citing that, “some patients do not have great verbal comprehension regarding emotions.” Table 1. Provider (n = 14) acceptability ratings of complicated grief screening programme at the Institute for Family Health between 2014 and 2017 Question Not at all n (%) Slightly n (%) Moderately n (%) Very n (%) Understanding 1. How much did the grief interview questions help you to understand the patient’s problems you assessed? 0 (0.0) 4 (28.6) 10 (71.4) 0 (0.0) 2. How much do you think the patient you interviewed felt better understood as a result of the interview? 0 (0.0) 8 (57.1) 6 (42.9) 0 (0.0) Usefulness 3. How useful do you think the BGQ is as an assessment instrument? 1 (7.1) 3 (21.4) 7 (50.0) 3 (21.4) 4. How useful do you think the ICG is as an assessment instrument? 0 (0.0) 5 (35.7) 7 (50.0) 2 (14.3) 5. How useful do you think the ICG is for developing a treatment formulation? 1 (7.1) 5 (35.7) 8 (57.1) 0 (0.0) Difficulty 6. How difficult was it to incorporate the BGQ and ICG into your care of patients? 3 (21.4) 7 (50.0) 4 (28.6) 0 (0.0) Question Not at all n (%) Slightly n (%) Moderately n (%) Very n (%) Understanding 1. How much did the grief interview questions help you to understand the patient’s problems you assessed? 0 (0.0) 4 (28.6) 10 (71.4) 0 (0.0) 2. How much do you think the patient you interviewed felt better understood as a result of the interview? 0 (0.0) 8 (57.1) 6 (42.9) 0 (0.0) Usefulness 3. How useful do you think the BGQ is as an assessment instrument? 1 (7.1) 3 (21.4) 7 (50.0) 3 (21.4) 4. How useful do you think the ICG is as an assessment instrument? 0 (0.0) 5 (35.7) 7 (50.0) 2 (14.3) 5. How useful do you think the ICG is for developing a treatment formulation? 1 (7.1) 5 (35.7) 8 (57.1) 0 (0.0) Difficulty 6. How difficult was it to incorporate the BGQ and ICG into your care of patients? 3 (21.4) 7 (50.0) 4 (28.6) 0 (0.0) BGQ, Brief Grief Questionnaire; ICG, Inventory for Complicated Grief; PCP, Primary Care Physician. View Large Table 1. Provider (n = 14) acceptability ratings of complicated grief screening programme at the Institute for Family Health between 2014 and 2017 Question Not at all n (%) Slightly n (%) Moderately n (%) Very n (%) Understanding 1. How much did the grief interview questions help you to understand the patient’s problems you assessed? 0 (0.0) 4 (28.6) 10 (71.4) 0 (0.0) 2. How much do you think the patient you interviewed felt better understood as a result of the interview? 0 (0.0) 8 (57.1) 6 (42.9) 0 (0.0) Usefulness 3. How useful do you think the BGQ is as an assessment instrument? 1 (7.1) 3 (21.4) 7 (50.0) 3 (21.4) 4. How useful do you think the ICG is as an assessment instrument? 0 (0.0) 5 (35.7) 7 (50.0) 2 (14.3) 5. How useful do you think the ICG is for developing a treatment formulation? 1 (7.1) 5 (35.7) 8 (57.1) 0 (0.0) Difficulty 6. How difficult was it to incorporate the BGQ and ICG into your care of patients? 3 (21.4) 7 (50.0) 4 (28.6) 0 (0.0) Question Not at all n (%) Slightly n (%) Moderately n (%) Very n (%) Understanding 1. How much did the grief interview questions help you to understand the patient’s problems you assessed? 0 (0.0) 4 (28.6) 10 (71.4) 0 (0.0) 2. How much do you think the patient you interviewed felt better understood as a result of the interview? 0 (0.0) 8 (57.1) 6 (42.9) 0 (0.0) Usefulness 3. How useful do you think the BGQ is as an assessment instrument? 1 (7.1) 3 (21.4) 7 (50.0) 3 (21.4) 4. How useful do you think the ICG is as an assessment instrument? 0 (0.0) 5 (35.7) 7 (50.0) 2 (14.3) 5. How useful do you think the ICG is for developing a treatment formulation? 1 (7.1) 5 (35.7) 8 (57.1) 0 (0.0) Difficulty 6. How difficult was it to incorporate the BGQ and ICG into your care of patients? 3 (21.4) 7 (50.0) 4 (28.6) 0 (0.0) BGQ, Brief Grief Questionnaire; ICG, Inventory for Complicated Grief; PCP, Primary Care Physician. View Large Data were mixed regarding how difficult providers found it to be to incorporate the Brief Grief Questionnaire and Inventory of Complicated Grief into patient care, with the majority (71%) reporting it was not at all (21%) or slightly (50%) difficult. The remaining 29% found it moderately difficult. Open-ended responses on acceptability indicate that at least one clinician found the programme difficult to administer when the patient had experienced multiple losses due to the patient not being able to identify which loss was most impactful. Another clinician felt that including both the Brief Grief Questionnaire and the Inventory of Complicated Grief into the psychosocial assessment programme was too laborious, and perhaps the Inventory of Complicated Grief should be completed upon the second visit with the clinician. See Table 1 for these results. Rate and sample description Overall, among the 1015 patients who had experienced the death of someone close <6 months ago, 22% (n = 228) endorsed scores of 25 or greater on the Inventory of Complicated Grief. This proportion is in line with mental health clinics (16). Table 2 presents descriptive statistics of this sample. A majority of the sample was middle aged (M = 41 years) female (72%) and about half were unemployed (58%) or receiving public assistance (46%). The sample was diverse compared to previous studies on complicated grief in western and non-western samples, with Black (31%), White (25%) and some other race (25%) and one-third of the respondents (36%) self-identified as Hispanic. Almost half of the sample (47%) had up to a high school level of education, and approximately one-quarter had some college or a college degree. About half (52%) reported being single/never married. Approximately half (47%) of the sample were referred to behavioural health from co-located primary care and half were already receiving behavioural health services. Compared with the behavioural health populations across these clinics, this sample had more females (P = 0.00) and African Americans (P = 0.00). Table 2. Characteristics of individuals (n = 228) with Inventory of Complicated Grief Scores ≥25 at the Institute for Family Health between 2014 and 2017 Demographics n (%) Gender (female) 164 (71.9) Age (M, SD) 41.29 (13.4) Education <12th grade 63 (27.6) High school/GED 44 (19.3) Some college 10 (4.4) College graduate 48 (21.1) Race Asian 6 (2.6) Black 71 (31.1) Some other race 57 (25.0) White 58 (25.4) Ethnicity Hispanic 83 (36.4) Non-Hispanic 121 (53.1) Employment Employed 51 (22.4) Unemployed 131 (57.5) Public assistance Receives some public assistance 105 (46.1) Receives no public assistance 79 (34.6) Marital status Single/never married 118 (51.8) Married 25 (11.0) Divorced/separated 29 (12.7) Widowed 8 (3.5) Current relationship status In a relationship 75 (32.9) Not in a relationship 105 (46.1) Health Comorbid behavioural health diagnosis a. PTSD 36 (15.8) b. Major depressive disorder 88 (38.6) e. Adjustment disorder 95 (41.7) f. Suicidal ideation 31 (13.6) g. Bipolar 13 (5.7) Co-occurring chronic health conditions Asthma 46 (20.2) Diabetes 19 (8.3) Hypertension 29 (12.7) Service use Engagement in behavioural health treatment Treatment naïve 60 (26.3) Treatment experienced: past diagnosis (self-report) 122 (53.5) Primary care at IFH (yes) 126 (55.3) Demographics n (%) Gender (female) 164 (71.9) Age (M, SD) 41.29 (13.4) Education <12th grade 63 (27.6) High school/GED 44 (19.3) Some college 10 (4.4) College graduate 48 (21.1) Race Asian 6 (2.6) Black 71 (31.1) Some other race 57 (25.0) White 58 (25.4) Ethnicity Hispanic 83 (36.4) Non-Hispanic 121 (53.1) Employment Employed 51 (22.4) Unemployed 131 (57.5) Public assistance Receives some public assistance 105 (46.1) Receives no public assistance 79 (34.6) Marital status Single/never married 118 (51.8) Married 25 (11.0) Divorced/separated 29 (12.7) Widowed 8 (3.5) Current relationship status In a relationship 75 (32.9) Not in a relationship 105 (46.1) Health Comorbid behavioural health diagnosis a. PTSD 36 (15.8) b. Major depressive disorder 88 (38.6) e. Adjustment disorder 95 (41.7) f. Suicidal ideation 31 (13.6) g. Bipolar 13 (5.7) Co-occurring chronic health conditions Asthma 46 (20.2) Diabetes 19 (8.3) Hypertension 29 (12.7) Service use Engagement in behavioural health treatment Treatment naïve 60 (26.3) Treatment experienced: past diagnosis (self-report) 122 (53.5) Primary care at IFH (yes) 126 (55.3) GED, General Education Diploma; IFH, Institute for Family Health; PTSD, post-traumatic stress disorder. View Large Table 2. Characteristics of individuals (n = 228) with Inventory of Complicated Grief Scores ≥25 at the Institute for Family Health between 2014 and 2017 Demographics n (%) Gender (female) 164 (71.9) Age (M, SD) 41.29 (13.4) Education <12th grade 63 (27.6) High school/GED 44 (19.3) Some college 10 (4.4) College graduate 48 (21.1) Race Asian 6 (2.6) Black 71 (31.1) Some other race 57 (25.0) White 58 (25.4) Ethnicity Hispanic 83 (36.4) Non-Hispanic 121 (53.1) Employment Employed 51 (22.4) Unemployed 131 (57.5) Public assistance Receives some public assistance 105 (46.1) Receives no public assistance 79 (34.6) Marital status Single/never married 118 (51.8) Married 25 (11.0) Divorced/separated 29 (12.7) Widowed 8 (3.5) Current relationship status In a relationship 75 (32.9) Not in a relationship 105 (46.1) Health Comorbid behavioural health diagnosis a. PTSD 36 (15.8) b. Major depressive disorder 88 (38.6) e. Adjustment disorder 95 (41.7) f. Suicidal ideation 31 (13.6) g. Bipolar 13 (5.7) Co-occurring chronic health conditions Asthma 46 (20.2) Diabetes 19 (8.3) Hypertension 29 (12.7) Service use Engagement in behavioural health treatment Treatment naïve 60 (26.3) Treatment experienced: past diagnosis (self-report) 122 (53.5) Primary care at IFH (yes) 126 (55.3) Demographics n (%) Gender (female) 164 (71.9) Age (M, SD) 41.29 (13.4) Education <12th grade 63 (27.6) High school/GED 44 (19.3) Some college 10 (4.4) College graduate 48 (21.1) Race Asian 6 (2.6) Black 71 (31.1) Some other race 57 (25.0) White 58 (25.4) Ethnicity Hispanic 83 (36.4) Non-Hispanic 121 (53.1) Employment Employed 51 (22.4) Unemployed 131 (57.5) Public assistance Receives some public assistance 105 (46.1) Receives no public assistance 79 (34.6) Marital status Single/never married 118 (51.8) Married 25 (11.0) Divorced/separated 29 (12.7) Widowed 8 (3.5) Current relationship status In a relationship 75 (32.9) Not in a relationship 105 (46.1) Health Comorbid behavioural health diagnosis a. PTSD 36 (15.8) b. Major depressive disorder 88 (38.6) e. Adjustment disorder 95 (41.7) f. Suicidal ideation 31 (13.6) g. Bipolar 13 (5.7) Co-occurring chronic health conditions Asthma 46 (20.2) Diabetes 19 (8.3) Hypertension 29 (12.7) Service use Engagement in behavioural health treatment Treatment naïve 60 (26.3) Treatment experienced: past diagnosis (self-report) 122 (53.5) Primary care at IFH (yes) 126 (55.3) GED, General Education Diploma; IFH, Institute for Family Health; PTSD, post-traumatic stress disorder. View Large Among those with an Inventory of Complicated Grief score of 25 and greater, the most commonly documented comorbid behavioural health diagnoses were adjustment disorder (42%), major depression (39%), post-traumatic stress disorder (16%) and bipolar disorder (6%). Thus, while high rates of comorbidity between major depression and complicated grief exist, 61% of patients with complicated grief did not have depression in this sample. Approximately 14% of the sample reported suicidal ideation as defined by the one-item question of the Patient Health Questionnaire–9. Suicidal thinking is well documented in association with complicated grief (8,9). Among the 31 patients with complicated grief and suicidal ideation, 19 (61%) had a comorbid diagnosis of major depression, bipolar disorder and/or post-traumatic stress disorder and 12 (39%) had no comorbid health diagnosis. With regard to treatment, approximately half of the sample was receiving their primary care treatment at the Institute (55%) and reported having received a behavioural health diagnosis and treatment in the past (53%). Discussion To our knowledge, this study is the first in the USA to implement a screening programme for complicated grief in a diverse medically underserved population in integrated health care settings. There are four main findings. First, we learned that this complicated grief screening programme was feasible and acceptable to providers working in an integrated primary and behavioural health care setting. Second, we learned that in the identification of complicated grief in this sample, a short five-item screener for complicated grief, the Brief Grief Questionnaire performed about as well as the Inventory of Complicated Grief as indicated by a high rate of identifying individuals with a score on the Inventory of Complicated Grief >25 and by being easier and shorter to administer. Third, in a sample of underserved or safety net population of racially and ethnically diverse outpatients referred for behavioural health in primary care, the estimated rate of complicated grief is 22%. Fourth, we found that complicated grief is associated with high rates of suicidal thinking in this population, similar to elevated rates in mental health treatment and community settings (10,11). Through the implementation of the complicated grief screening programme in the electronic health record, we learned that the Brief Grief Questionnaire is an easily administered and effective screening tool. Given that many individuals may turn to primary care providers when bereaved, primary care providers can administer the Brief Grief Questionnaire to efficiently identify and refer individuals with complicated grief to behavioural health. The behavioural health providers in this sample found the Brief Grief Questionnaire and Complicated Grief acceptable to implement noting that it informed their understanding of the patient’s problem and useful assessments that were used to inform treatment formulation. Some providers noted suggestion to further improve the screening programme to accommodate the time and workflow of their psychosocial assessment procedures. One clinician suggested the Brief Grief Questionnaire be first administered by a primary care provider similar to how the Patient Health Questionnaire nine-item screening tool for depression is used in the collaborative care for depression programme (35). Integrated care settings seeking to implement a complicated grief screening programme may consider embedding their programme in an electronic health record (if available) to facilitate administration. Providers would need initial training and ongoing support to maximize administration of the screening programme and recognize differences between complicated grief and other common behavioural health disorders seen in primary care. This study found that the prevalence of complicated grief in medically underserved populations referred for behavioural health in primary care is comparable to that of psychiatric populations (16,36) and higher than community samples (1,14). While not all patients referred to behavioural health from primary care receive a psychiatric diagnosis, these individuals were being referred for behavioural health and the estimated prevalence should be interpreted within this context. There may be several other reasons for this elevated prevalence rate in this population including a higher rate of traumatic loss in low-income communities, community violence and chronic illness comorbidity (37–39). Our findings are consistent with the previous research showing that individuals with complicated grief report suicidal ideation (10,11) Front-line providers in integrated settings may benefit from an awareness of the association between suicidality and complicated grief for timely intervention (23). Although this is the first study of a screening programme to identify complicated grief in behavioural health outpatients in primary care, our study has some limitations. First, these data were collected as part of routine clinical assessment in an electronic health record and do not represent rigorous data collection as part of a research study. While this enhances the real-world applicability and aligns with most psychiatric research that relies on self-report and clinician assessment, our findings should be interpreted within this data collection context. Second, the clinics participating in this study serve a segment of the population and are not representative of all primary care patients experiencing grief. Third, we did not collect sufficient information on whether these individuals were seeking help for grief, the nature of the loss [e.g. relationship to deceased and cause of death (sudden, illness, suicide)] which may allow for greater understanding of the factors associated with complicated grief. Conclusions Integrated primary and behavioural health care settings are well positioned to identify individuals with complicated grief. This is the first study to develop and assess acceptability, feasibility and outcome of a systematic screening programme for complicated grief among an underserved, racially and ethnically diverse safety net primary care population in an integrated care setting. It provides an example of how to develop, embed a screening programme into an electronic health record to facilitate implementation and train providers to administer the programme in a real-world setting. Declaration Funding: The study was funded by institutional resources. Ethical approval: This research was approved by the institutional review board at which the research was conducted. Conflict of interest: The authors have no conflicts of interest to report. References 1. Lundorff M , Holmgren H , Zachariae R , Farver-Vestergaard I , O’Connor M . Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis . J Affect Disord 2017 ; 212 : 138 – 49 . Google Scholar CrossRef Search ADS PubMed 2. Kersting A , Brahler E , Glaesmer H , Wagner B . Prevalence of complicated grief in a representative population-based sample . J Affect Disord 2011 ; 31 : 339 – 43 . Google Scholar CrossRef Search ADS 3. Shear MK . Grief and mourning gone awry: pathway and course of complicated grief . Dialogues Clin Neurosci 2012 ; 14 : 119 – 28 . Google Scholar PubMed 4. Bonanno GA , Kaltman S . The varieties of grief experience . Clin Psychol Rev 2001 ; 21 : 705 – 34 . Google Scholar CrossRef Search ADS PubMed 5. Simon NM , Shear KM , Thompson EH , et al. The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief . Compr Psychiatry 2007 ; 48 : 395 – 9 . Google Scholar CrossRef Search ADS PubMed 6. Bonanno GA , Neria Y , Mancini A , et al. Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity . J Abnorm Psychol 2007 ; 116 : 342 – 51 . Google Scholar CrossRef Search ADS PubMed 7. Prigerson HG , Bierhals AJ , Kasl SV , et al. Traumatic grief as a risk factor for mental and physical morbidity . Am J Psychiatry 1997 ; 154 : 616 – 23 . Google Scholar CrossRef Search ADS PubMed 8. Lannen PK , Wolfe J , Prigerson HG , Onelov E , Kreicbergs UC . Unresolved grief in a national sample of bereaved parents: impaired mental and physical health 4 to 9 years later . J Clin Oncol 2008 ; 26 : 5870 – 6 . Google Scholar CrossRef Search ADS PubMed 9. Dell’osso L , Carmassi C , Rucci P , et al. Complicated grief and suicidality: the impact of subthreshold mood symptoms . CNS Spectr 2011 ; 16 : 1 – 6 . Google Scholar CrossRef Search ADS PubMed 10. Szanto K , Shear MK , Houck PR , et al. Indirect self-destructive behavior and overt suicidality in patients with complicated grief . J Clin Psychiatry 2006 ; 67 : 233 – 9 . Google Scholar CrossRef Search ADS PubMed 11. Latham AE , Prigerson HG . Suicidality and bereavement: complicated grief as psychiatric disorder presenting greatest risk for suicidality . Suicide Life Threat Behav 2004 ; 34 : 350 – 62 . Google Scholar CrossRef Search ADS PubMed 12. Shear MK . Clinical practice. Complicated grief . N Engl J Med 2015 ; 372 : 153 – 60 . Google Scholar CrossRef Search ADS PubMed 13. Fujisawa D , Miyashita M , Nakajima S , et al. Prevalence and determinants of complicated grief in general population . J Affect Disord 2010 ; 127 : 352 – 8 . Google Scholar CrossRef Search ADS PubMed 14. He L , Tang S , Yu W , et al. The prevalence, comorbidity and risks of prolonged grief disorder among bereaved Chinese adults . Psychiatry Res 2014 ; 219 : 347 – 52 . Google Scholar CrossRef Search ADS PubMed 15. Newson RS , Boelen PA , Hek K , Hofman A , Tiemeier H . The prevalence and characteristics of complicated grief in older adults . J Affect Disord 2011 ; 132 : 231 – 8 . Google Scholar CrossRef Search ADS PubMed 16. Sung SC , Dryman MT , Marks E , et al. Complicated grief among individuals with major depression: prevalence, comorbidity, and associated features . J Affect Disord 2011 ; 134 : 453 – 8 . Google Scholar CrossRef Search ADS PubMed 17. Goldsmith B , Morrison RS , Vanderwerker LC , Prigerson HG . Elevated rates of prolonged grief disorder in African Americans . Death Stud 2008 ; 32 : 352 – 65 . Google Scholar CrossRef Search ADS PubMed 18. Boerner K , Schulz R . Caregiving, bereavement and complicated grief . Bereave Care 2009 ; 28 : 10 – 3 . Google Scholar CrossRef Search ADS PubMed 19. Zisook S , Simon NM , Reynolds CF III , et al. Bereavement, complicated grief, and DSM, part 2: complicated grief . J Clin Psychiatry 2010 ; 71 : 1097 – 8 . Google Scholar CrossRef Search ADS PubMed 20. Zisook S , Iglewicz A , Avanzino J , et al. Bereavement: course, consequences, and care . Curr Psychiatry Rep 2014 ; 16 : 482 . Google Scholar CrossRef Search ADS PubMed 21. Shear MK , Reynolds CF III , Simon NM , et al. Optimizing treatment of complicated grief: a randomized clinical trial . JAMA Psychiatry 2016 ; 73 : 685 – 94 . Google Scholar CrossRef Search ADS PubMed 22. Shear MK , Wang Y , Skritskaya N , et al. Treatment of complicated grief in elderly persons: a randomized clinical trial . JAMA Psychiatry 2014 ; 71 : 1287 – 95 . Google Scholar CrossRef Search ADS PubMed 23. Shear K , Frank E , Houck PR , Reynolds CF III . Treatment of complicated grief: a randomized controlled trial . JAMA 2005 ; 293 : 2601 – 8 . Google Scholar CrossRef Search ADS PubMed 24. Caserta MS , Lund DA . Bereaved older adults who seek early professional help . Death Stud 1992 ; 16 : 17 – 30 . Google Scholar CrossRef Search ADS PubMed 25. Ghesquiere A , Shear MK , Duan N . Outcomes of bereavement care among widowed older adults with complicated grief and depression . J Prim Care Community Health 2013 ; 4 : 256 – 64 . Google Scholar CrossRef Search ADS PubMed 26. Doty MM , Abrams MK , Hernandez SE , Stremikis K , Beal AC. Enhancing the Capacity of Community Health Centers to Achieve High Performance: Findings from the 2009 Commonwealth Fund. National Survey of Federally Qualified Health Centers . The Commonwealth Fund , 2010 . 27. Kroenke K , Spitzer RL , Williams JB . The PHQ-9: validity of a brief depression severity measure . J Gen Intern Med 2001 ; 16 : 606 – 13 . Google Scholar CrossRef Search ADS PubMed 28. Spitzer RL , Kroenke K , Williams JB , Lowe B . A brief measure for assessing generalized anxiety disorder: the GAD-7 . Arch Intern Med 2006 ; 166 : 1092 – 7 . Google Scholar CrossRef Search ADS PubMed 29. Office of National Drug Control Policy . Screening, Brief Intervention, and Referral to Treatment (SBIRT) . Washington, DC : Office of National Drug Control Policy (ONDCP), Substance Abuse and Mental Health Services Administration (SAMHSA) , 2012 . 30. Shear KM , Jackson C , 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 : 1291 – 7 . Google Scholar CrossRef Search ADS PubMed 31. Prigerson HG , Maciejewski PK , Reynolds CF III , et al. Inventory of complicated grief: a scale to measure maladaptive symptoms of loss . Psychiatry Res 1995 ; 59 : 65 – 79 . Google Scholar CrossRef Search ADS PubMed 32. ICD 11 Beta Draft (Morbidity and Mortality Statistics) Prolonged Grief Disorder , 2018 . https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1183832314 (accessed on 23 May 2018) . 33. Ito M , Nakajima S , Fujisawa D , et al. Brief measure for screening complicated grief: reliability and discriminant validity . PLoS One 2012 ; 7 : e31209 . Google Scholar CrossRef Search ADS PubMed 34. American Psychological Association . Inventory of Complicated Grief , 2017 . http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/complicated-grief.aspx (accessed on 23 May 2018) . 35. Unützer J , Katon W , Callahan CM , et al. ; IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment . Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial . JAMA 2002 ; 288 : 2836 – 45 . Google Scholar CrossRef Search ADS PubMed 36. Simon NM , Pollack MH , Fischmann D , et al. Complicated grief and its correlates in patients with bipolar disorder . J Clin Psychiatry 2005 ; 66 : 1105 – 10 . Google Scholar CrossRef Search ADS PubMed 37. Hooyman NR , Kramer BJ. Living Through Loss: Interventions Across the Life Span . New York, NY : Columbia University Press ; 2006 . 38. Jenkins EJ , Wang E , Turner L . Beyond community violence: loss and traumatic grief in African American elementary school children . J Child Adolesc Trauma 2014 ; 7 : 27 – 36 . Google Scholar CrossRef Search ADS 39. Saltzman WR , Pynoos RS , Layne CM , Steinberg AM , Aisenberg E . Trauma- and grief-focused intervention for adolescents exposed to community violence: results of a school-based screening and group treatment protocol . Group Dyn 2001 ; 5 : 291 – 303 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Family PracticeOxford University Press

Published: Jun 1, 2018

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