Journal of Affective Disorders 127 (2010) 352358

Contents lists available at ScienceDirect

Journal of Affective Disorders

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d

Brief report

Prevalence and determinants of complicated grief in general population

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

Psycho-oncology Division, National Cancer Center East, Japan

Department of Neuropsychiatry, Keio University School of Medicine, Japan
Division of Palliative Care, Keio University Hospital, Japan
d
Department of Palliative Nursing, Health Science, Tohoku University Graduate School of Medicine, Japan
e
National Institute of Mental Health, National Center of Neurology and Psychiatry, Japan
f
Research Fellow of the Japan Society for the Promotion of Science, Japan
b
c

a r t i c l e

i n f o

Article history:
Received 27 December 2009
Accepted 3 June 2010
Available online 1 July 2010
Keywords:
Prevalence
Determinant
Complicated grief
General population
Epidemiology
Cancer

a b s t r a c t
Background: Few epidemiological studies have examined complicated grief in the general
population, especially in Asian countries. Therefore, this study aimed to explore the prevalence
and predictors of complicated grief among community dwelling individuals in Japan.
Methods: A questionnaire survey regarding grief and related issues was conducted on
community dwelling individuals aged 4079 who were randomly sampled from census tracts.
Complicated grief was assessed using the Brief Grief Questionnaire. Stepwise logistic regression
analysis was conducted in order to identify predictors of complicated grief.
Results: Data from 969 responses (response rate, 39.9%) were subjected to analysis. The analysis
revealed 22 (2.4%) respondents with complicated grief and 272 (22.7%) with subthreshold
complicated grief. Respondents who were found to be at a higher risk for developing complicated
grief had lost their spouse, lost a loved one unexpectedly, lost a loved one due to stroke or cardiac
disease, lost a loved one at a hospice, care facility or at home, or spent time with the deceased
everyday in the last week of life.
Limitations: Limitations of this study include the small sample size, the use of self-administered
questionnaire, and the fact that the diagnoses of complicated grief were not based on robust
diagnostic criteria.
Conclusions: The point prevalence of complicated grief within 10 years of bereavement was 2.4%.
Complicated grief was maintained without signicant decrease up to 10 years after bereavement.
When subthreshold complicated grief is included, the prevalence of complicated grief boosts up to
a quarter of the sample, therefore, routine screening for complicated grief among the bereaved is
desired. Clinicians should pay particular attention to the bereaved families with abovementioned
risk factors in order to identify people at risk for future development of complicated grief.
2010 Elsevier B.V. All rights reserved.

1. Background
Grief, or the emotional reaction to bereavement, is a normal,
natural human experience. Most people manage to come terms
with grief over time. Nevertheless, it is associated with a period

Corresponding author. Psycho-oncology Division, National Cancer Center

East, Japan. 6-5-1 Kashiwanoha, Kashiwa-shi, Chiba, Japan. Tel.: +81 4 7134
7013; fax: +81 4 7134 7026.
E-mail address: dai_fujisawa@yahoo.co.jp (D. Fujisawa).
0165-0327/$ see front matter 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2010.06.008

of intense suffering, and for some individuals, the grieving

process is disturbed and/or prolonged, which leads to a state of
complicated grief.
Complicated grief has been dened as a deviation from the
normal grief experience in terms of either the time course,
intensity, or both. It is associated with increased risk of negative
health consequences, including various physical symptoms,
depression, higher alcohol consumption, greater use of medical
services, higher functional impairment, decreased social participation, and higher mortality due to suicide and other

D. Fujisawa et al. / Journal of Affective Disorders 127 (2010) 352358

physical conditions (Ott, 2003; Prigerson et al., 1996; Stroebe

et al., 2007; Szanto et al., 1997; Utz et al., 2002).
Complicated grief resembles depression, but it does not
respond well to treatments that are effective for depression
(Reynolds et al., 1999). However, treatments designed specifically for complicated grief have been shown to be effective
(Schut and Stroebe, 2005; Shear et al., 2005). The known risk
factors for complicated grief include the circumstances surrounding death (the cause, place and unexpectedness of death),
the quality of the lost relationship, pre-bereavement caregiver
burden, the characteristics of the bereaved (religion, quality of
social support, personality, coping style), and concurrent
socioeconomic stressors (Stroebe et al., 2007). Therefore,
identication of complicated grief and its predictors is essential.
To date, epidemiological studies have demonstrated that
prolonged grief occurs in about 920% of a population
(Prigerson and Jacobs, 2001; Raphael et al., 2001), but the
prevalence rate shows wide variation depending upon the
social, cultural, and clinical background. Among clinical
samples, the prevalence rate has been reported as 18.6%
among hospitalized patients with unipolar depression at 16.4
(SD = 14.1) years after signicant loss (Kersting et al., 2009),
24.3% among bipolar disorder patients at a mean of 12.3
(SD = 11.3) years after a loss (Simon et al., 2005), and 31.1%
among a mixed sample of psychiatric outpatients at a mean of
10.4 (SD = 9.7) years since a loss (Piper et al., 2001). On the
other hand, relatively few epidemiological studies have been
conducted on non-clinical populations, and the majority of
these have been limited to shorter periods of time. For example,
Chiu et al. assessed bereaved family of cancer patients at mean
time of 8.9 months after bereavement and reported a 24.6%
prevalence of complicated grief (Chiu et al., 2009). Middleton
also reported a 9.2% prevalence of chronic grief at 14 months
from bereavement in a community-based sample (Middleton
et al., 1996).
Epidemiological studies on complicated grief have mostly
been conducted in Western cultures, while some preliminary
research has been conducted in Asia (Chiu et al., 2009;
Ghaffari-Nejad et al., 2007; Prigerson et al., 2002; Senanayake
et al., 2006). However, these data were mostly collected from
specic populations, such as victims of natural disasters
(Ghaffari-Nejad et al., 2007; Shear et al., 2006) or psychiatric
patients, with or without specic diagnoses such as unipolar
depression and bipolar disorders (Kersting et al., 2009; Piper
et al., 2001).
The present study aimed to explore the prevalence and
predictors of complicated grief in the general population.
Therefore, a questionnaire survey regarding bereavement
and related issues was conducted on community dwelling
individuals.
2. Methods
2.1. Participants
The participants were community dwelling individuals
aged 4079 years who had experienced bereavement within
the past ten years. Since a diagnosis of complicated brief cannot
be given within six month after bereavement (Prigerson et al.,
2009), those who had experienced bereavement within the
past six months were excluded. Furthermore, those who had

353

experienced the loss of a child were also excluded because grief

over a child's death has been consistently reported to be
prolonged, and the diagnostic reliability of complicated grief
among bereaved parents remains unclear (Dyregrov et al.,
2003; Stroebe et al., 2007).
2.2. Procedure
An anonymous questionnaire was mailed to a sample of
the general Japanese population. We identied four target
areas (Tokyo, the capital city; Miyagi prefecture, in eastern
Japan; Shizuoka prefecture, in central Japan; and Hiroshima,
in eastern Japan) in order to obtain a wide geographic
distribution for the nationwide sample. The four areas
included an urban metropolis (Tokyo) and mixed urbanrural areas (others). We initially identied 5000 subjects
using a stratied two-stage random sampling method of
residents from the four areas. We randomly selected 50
census tracts in each area and then selected 25 individuals
within each census tract, thus identifying 1250 individuals for
each area. In June 2009, questionnaires were mailed to these
potential participants and a reminder postcard was sent
2 weeks later. The protocol of this study was approved by the
institutional review board of the University of Tokyo.
2.3. Questionnaire
The questionnaire included items regarding the respondents' demographic background (age and gender), the time
since the most recent bereavement, the relationship with the
deceased, the cause and place of death of the deceased, and
the number of days in which the respondent spent time with
the deceased during the last week of life.
Complicated grief was assessed using the Brief Grief
Questionnaire (BGQ) (Shear et al., 2006). The BGQ is a veitem, self-administered questionnaire that evaluates trouble
accepting the death, interference of grief in their life, troubling
images or thoughts of the death, avoidance of things related to
the person who died, and feeling cut off or distant from other
people. Responses were rated as 0, not at all; 1, somewhat; or 2,
a lot. A previous report suggests that a total score of 8 or higher
on the BGQ indicated that a respondent was likely to develop
complicated grief, while a score ranging from 5 to 7 indicated
subthreshold complicated grief and a score of less than 5
indicated a respondent was unlikely to develop complicated
grief (Shear et al., 2006).
2.4. Statistical analysis
The presence of complicated grief was dened using the
previously established cutoff score described above (Shear
et al., 2006). The chi-square test and Fisher's exact test were
used to identify factors possibly correlated with the presence
of complicated grief. Subsequently, a stepwise binary logistic
regression analysis (backward selection) was performed with
presence of complicated grief as the dependent variable and
factors with signicant relationships identied by the abovementioned analysis as predictor variables. All p values were
two-tailed, and the level of statistical signicance was set at
p b 0.05. All statistical analyses were performed using SPSS
version 16.0J software (SPSS Inc., Chicago, IL, USA).

354

D. Fujisawa et al. / Journal of Affective Disorders 127 (2010) 352358

3. Results
Of 5000 questionnaires that were distributed, 44 were
returned as undeliverable and 1970 responses were received
(response rate: 39.9 ). Of these, 63 were excluded because of
signicant missing data. Among the remaining responses, 808
were excluded because the respondents had not experienced
bereavement within the past ten years, 117 were excluded
because of bereavement within the past six months, and 7
were excluded because they had experienced the loss of a
child. Finally, a total 969 of responses were subjected to
analysis. The demographic data of the sample is shown in
Table 1.
The results of the BGQ are presented in Table 2 according
to severity of grief and sociodemographic variables. Among
all participants, 22 respondents (2.4%) had scores of 8 or
higher on the BGQ, and were thus considered too complicated
grief, and 272 respondents (22.7%) scored between 5 and 7,
and were considered to be suffering from some symptoms of
complicated grief (subthreshold complicated grief). Using the
chi-square test, signicant differences in BGQ score were
observed for gender, relationship with the deceased, whether

Table 1
Demographic data of the participants.

Gender
Age

Relationship with the deceased

Primary caregiver
Time from bereavement

Cause of death

Place of death

Expected death
Days spent with the deceased
during the end-of-life period

Male
Female
4049
5059
6069
7079
Spouse
Parent(s)
Parent(s)-in-law
Sibling(s)
Others
Yes
No
612 months
12 years
23 years
34 years
45 years
56 years
67 years
78 years
89 years
910 years
Cancer
Stroke
Cardiac disease
Others
Home
General hospital
Hospice/PCU
Care facility
Others
Expected death
Unexpected death
Everyday
46 day/week
13 day/week
None
Missing data

405
564
225
354
379
11
61
468
247
96
97
462
507
112
138
138
120
88
85
102
62
49
75
357
99
108
405
181
654
34
62
38
546
423
207
92
216
335
119

41.8
58.2
23.2
36.5
39.1
1.1
6.3
48.3
25.5
9.9
10.0
47.7
52.3
11.6
14.2
14.2
12.4
9.1
8.8
10.5
6.4
5.1
7.7
36.8
10.2
11.1
41.8
18.7
67.5
3.5
6.4
3.9
56.3
44.6
21.4
9.5
22.3
34.6
12.3

the respondent was the primary caregiver or not, cause and

place of death, whether the death was expected or unexpected, and days spent with the deceased during the end-oflife period.
Binary stepwise logistic regression analysis, with the
abovementioned determinant variables entered as predictor
variables, and the presence of complicated grief as the
dependent variable, demonstrated that relationship with
the deceased, the type of illness, the place of death, the
unexpectedness of death, and time spent with the deceased
during the end-of-life period were signicant predictors for
complicated grief (Table 3).
Compared with bereavement following the loss of a spouse,
bereavement following the loss of a parent or parent-inlaw contained a smaller risk for complicated grief (odds ratio
(OR) = 0.13, 95% condence interval (CI) = 0.050.35; OR=
0.19, 95%CI = 0.060.62, respectively). Those who lost a loved
one due to stroke or cardiac disease were more likely to
experience complicated grief than those who lost a loved one
due to cancer (OR = 2.42, 95% CI = 1.105.32). Family members
of people who died in general hospitals were signicantly less
likely to experience complicated grief than family members of
people who died at home (OR = 0.38, 95% CI = 0.160.92).
Those who did not spent time with the deceased during the
end-of-life period were signicantly less likely to experience
complicated grief, compared with those who spent time with
the deceased everyday during the same period (OR = 0.07;
95% C.I.= 0.020.21).
4. Discussion
The results of the present study indicated that the point
prevalence of complicated grief within 10 years of bereavement is 2.4% among the general population. This gure is
comparable with that for major depressive disorder (2.1%),
and higher than the gure for anxiety disorders (0.40.9%) in
Japan (Kawakami et al., 2005).
In comparison with gures from studies conducted in other
countries, this prevalence is somewhat smaller. In Australian
non-clinical samples, the prevalence has been reported to range
from 8.8% to 9.2% at 13 months post-bereavement (Byrne and
Raphael, 1994) (Middleton et al., 1996). Among Taiwanese
caregivers who lost a loved one due to cancer, the prevalence of
complicated grief was 24.6% at a mean of 8.9 months postbereavement (Chiu et al., 2009). These differences can be
attributed to both cultural differences and the employment of
different criteria for diagnosing complicated grief. Stringent
diagnostic criteria for complicated grief have not yet been
established, and the prevalence of complicated grief varies
depending on which diagnostic criteria are used. For example, a
substantial discrepancy in the prevalence rate of complicated
grief had been noted in a general elderly sample, with a 0.9%
prevalence observed using Prigerson's criteria and a 4.2%
prevalence observed using Horowitz's criteria (Forstmeier
and Maercker, 2007). The former criteria include items related
to separation distress, traumatic distress, duration of more than
6 months, and disturbance that causes clinically signicant
impairment (Prigerson et al., 1999); while the latter criteria
include grief-related intrusions, behaviors that avoid griefrelated emotional stress, difculties in adapting to the loss, and
duration of more than 14 months with disturbance of daily

D. Fujisawa et al. / Journal of Affective Disorders 127 (2010) 352358

355

Table 2
Prevalence and severity of complicated grief.

Total
Gender
Age

Relationship with the deceased

Primary caregiver
Time from bereavement

Cause of death

Place of death

Expected death
Days spent with the deceased during
the end-of-life period

Male
Female
4049
5059
6069
7079
Spouse
Parent(s)
Parent(s)-in-law
Sibling(s)
Others
Yes
No
612 months
12 years
23 years
34 years
45 years
56 years
67 years
78 years
89 years
910 years
Cancer
Stroke
Cardiac disease
Others
Home
General hospital
Hospice/PCU
Care facility
Others
Expected
Unexpected
Everyday
46 days/week
13 days/week
None

Subthreshold complicated grief

(%)

Complicated grief

(%)

207
79
128
44
77
82
4
29
108
30
24
16
128
77
30
39
26
23
14
13
22
9
12
19
94
18
30
64
35
142
11
9
10
116
75
63
31
41
56

22.7
20.6
24.2
20.5
23.0
23.3
40.0
50.0
24.5
12.9
27.6
16.8
29.7
16.1
28.3
28.9
19.8
20.5
16.5
16.7
23.4
15.8
25.5
28.4
28.2
19.6
28.6
16.8
20.6
23.0
35.5
15.3
29.4
21.6
25.1
31.0
34.4
19.1
17.1

22
4
18
6
7
8
1
5
11
2
3
1
13
9
2
3
2
1
5
2
1
3
0
3
9
5
3
5
2
16
1
0
3
8
11
10
3
1
5

2.4
1.0
3.4
2.8
2.1
2.3
10.0
8.6
2.5
0.9
3.4
1.1
3.0
1.9
1.9
2.2
1.5
0.9
5.9
2.6
1.1
5.3
0.0
4.5
2.7
5.4
2.9
1.3
1.2
2.6
3.2
0.0
8.8
1.5
3.7
4.9
3.3
0.5
1.5

p
0.02
0.48

b 0.001

b 0.001
0.19

b 0.01

0.04

0.05
b 0.001

PCU: palliative care unit.

* p b 0.05.

functioning (Horowitz et al., 1997). The BGQ, the instrument

used in the present study, contains items derived from both
criteria (trouble accepting the death from Horowitz's criteria,
and avoidance, intrusive thoughts and feeling distant from
other people from Prigerson's criteria. Therefore, the item
structure of the BGG could explain why the prevalence of
complicated grief observed in the present study lies between
those measured using the criteria of Horowitz and Prigerson.
When subthreshold complicated grief is included, the
prevalence of complicated grief rises to as high as 25.1%,
implying that approximately a quarter of all bereaved people
are at risk for developing complicated grief.
One of the most important ndings in the present study is
that the prevalence of complicated grief does not show a
signicant decline in the years after bereavement. Before
conducting this study, we hypothesized that the prevalence of
complicated grief declines over time, but our results contradicted our hypothesis. This nding implies that complicated
grief, for individuals who suffer from it, is maintained for many
years and does not resolve spontaneously. Among the
population with psychiatric morbidity, complicated grief has

been observed a remarkably long time after bereavement

(prevalence range, 18.631.1%; range of time after bereavement, 10.416.4 years) (Kersting et al., 2009; Piper et al., 2001;
Simon et al., 2005). Our study demonstrated that long-standing
complicated grief is observed even among the general
population. However, further study is needed in order to
investigate whether the maintenance of complicated grief is
mediated by the presence of other psychiatric conditions.
The relationship with the deceased, type of illness, place of
death, unexpectedness of death, and time spent with the
deceased during the end-of-life period were extracted as
signicant predictors for complicated grief. Concerning the
relationship with the deceased, bereavement following the loss
of a spouse contained the highest risk when compared with
bereavement following the loss of a sibling, parent or parent-inlaw. It has generally been considered in Eastern cultures that
the parent-offspring relationship is more cherished than
spousal relationships, whereas the inverse is true in Western
cultures (Bernard and Guarnaccia, 2003). Contrary to this
general perception, among the present sample, complicated
grief was more frequently seen in spousal relationships. This

356

D. Fujisawa et al. / Journal of Affective Disorders 127 (2010) 352358

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

Gender
Relationship (vs. spouse)
Parents
Parents-in-law
Siblings
Others
Primary carer
Type_of_Illness (vs cancer)
Stroke
Cardiac
Others
Place_of_Death (vs. home)
General hospital
Hospice
Care facility
Others
Unexpected death
Days spent with the deceased during
end-of-life period (vs. everyday)
46 days/week
13 days/week
None

Beta

S.D.

Wald

d.f.

0.3

0.3

2.0
1.7
0.7
0.7
0.2

0.5
0.6
0.6
0.6
0.4

1.3
1.2
1.0

0.5
0.5
0.5

1.0
2.7
2.7
3.0
0.9

0.4
0.6
0.7
0.6
0.4

0.8
51.6
16.6
7.6
1.3
1
0.2
26.5
6.1
5.5
4.2
125.0
4.7
18.5
15.7
22.2
4.9
39.0

1
4
1
1
1
0.43
1
3
1
1
1
4
1
1
1
1
1
3

0.37
b0.001
b0.001
b0.01
0.25
1.72
0.68
b0.001
0.01
0.02
0.04
b0.001
b0.05
b0.001
b0.001
b0.001
0.03
b0.001

0.8
0.6
2.7

0.5
0.5
0.6

1
1
1

0.11
0.21
b0.001

2.5
1.5
21.1

Exp (B)

95%

C.I.

Lower

Upper

0.74

0.38

1.43

0.13
0.19
2.02
0.44
1.19

0.05
0.06
0.61
0.52

0.35
0.62
6.77
6.66
2.74

3.58
3.35
0.36

1.31
1.22
0.13

9.79
9.19
0.95

0.38
14.73
15.61
19.84
2.42

0.16
4.32
4.01
5.72
1.10

0.92
50.18
60.80
68.76
5.32

2.13
0.53
0.07

0.84
0.20
0.02

5.42
1.44
0.21

S.D.: standard deviation.

d.f.: degree of freedom.
C.I.: condence interval.

may be the result of recent changes in familial structure in

Japan, which is becoming increasingly Westernized. Clinicians
should note that cultural difference exists among Asian
countries, and should not view patients in terms of the oversimplied model of Eastern vs. Western.
The respondents who lost a loved one due to stroke or
cardiac disease were more likely to experience complicated
grief than those who lost a loved one due to cancer. This may
be because stroke and cardiac disease are more likely to occur
unexpectedly, which leads to an increased likelihood of
complicated grief.
The place of death is another predictor of complicated
grief. Family members of people who died in general
hospitals are signicantly less likely to experience complicated grief than the family members of people who died at
home. The burden of care before bereavement has been
demonstrated to have negative effect on subsequent complicated grief; therefore, it can be speculated that the family
members of people who died at home may have experienced
higher caregiver burden, which might lead to poor adaptation
to bereavement (Rossi Ferrario et al., 2004; Schulz et al.,
2001). Surprisingly, those who lost a loved one in a hospice or
a care facility were found to be more likely to experience
complicated grief than those who lost a loved one at home. It
is possible that bereaved family members might be dissatised with the care provided in the facilities and feel regret that
they could not personally provide care. In fact, a past survey
demonstrated that the quality of care did not meet the
expectations of most bereaved families (Sanjo et al., 2008).
The timing of referral to a hospice is also associated with
satisfaction with end-of-life care, and up to 50% of bereaved
families who used a palliative care unit felt that the timing of

the referral to the palliative care unit was either too early or
too late (Morita et al., 2009). Furthermore, transferring a
loved one from a hospital to a hospice or a care facility caused
feelings of guilt among family members, because such an
action was perceived as a withdrawal from active participation in treatment and even as turning their back on their
loved one. Preferences for end-of-life care vary between
individuals, meaning that some prefer to spend their end-oflife period at home, while others prefer hospitals. It has been
reported that those who are of relatively older age, those who
prefer unawareness of death and pride and beauty in their
concept of good death are more likely to hope to die in a
general hospital than in a hospice (Sanjo et al., 2007).
Potential discordance between the preference of the bereaved and that of the deceased may have caused dissatisfaction and/or feelings of guilt concerning the place of death.
In Japanese clinical settings, the family's approval has the
strongest inuence on the nal decision (Sato et al., 2008).
Poor communication with the physician may have contributed to the negative feelings about transferring the patients
to hospice (Morita et al., 2004). Toward the end-of-life
period, the patient's family is expected to play a central role in
medical decision making, therefore, the family is faced with
increasing burden regarding end-of-life care, which may
contribute to the higher prevalence of subsequent grief
among those who used a hospice.
Respondents who spent time with the deceased everyday
during the end-of-life period were signicantly more likely to
experience complicated grief, compared with those who did
not spend time with the deceased during the same period. We
presume that the time spent together during this period is an
indicator of the quality of the bond between the respondent

D. Fujisawa et al. / Journal of Affective Disorders 127 (2010) 352358

and the deceased, meaning that those who had strong bond
with the deceased spent more time with the deceased during
the end-of-life period and were, therefore, more likely to
experience complicated grief. Another possible interpretation
is that those who spend every day with the deceased during
the last week of life experienced heavier caregiver burden,
which lead to an increased risk of subsequent complicated
grief (Rossi Ferrario et al., 2004; Schulz et al., 2001).
This study contains some limitations. First, the response rate
was low, although the rate was acceptable for a mail-based
survey conducted on the general population. Second, the
background variables of the non-respondents are unknown;
therefore, we cannot rule out that the demographic distribution
of the sample was skewed. However, the distributions of the
cause and place of death are quite similar to the national
statistics. For example, the proportion of deaths in Japan due to
cancer, stroke and cardiac disease are 30.0%, 15.9%, and 11.1%,
respectively, and place of death is 12.7% for home, 81.1% for
hospital, and 3.9% for care facility (Japan Ministry of Health and
Labor). Third, the reliability of the data was compromised
because the data solely depended on the participants' selfreports. Finally, the diagnostic reliability of complicated grief is
relatively weak as denite diagnostic criteria for complicated
grief have yet to been established, although more stringent
criteria are currently under consideration (Forstmeier and
Maercker, 2007; Prigerson et al., 2009).
Despite these limitations, our results are noteworthy
because this is the rst epidemiological study to investigate
the prevalence and risk factors of complicated grief in the
general population in Japan. In consideration of the fact that
complicated grief is highly inuenced by cultural background,
our report should be considered pioneering research on
complicated grief in Asia.
In conclusion, our population-based study revealed that
point prevalence of complicated grief within 10 years of
bereavement is 2.4%, which is comparable with other common
mental disorders. Complicated grief seems to be maintained for
a long time, without decrease even 10 years after bereavement.
The spouse of a patient, those who have lost a loved one
unexpectedly, due to stroke or cardiac disease, those who have
lost one in a hospice, care facility or at home, and those who
spent time with the deceased everyday in the last week of life
are at higher risk for complicated grief. Clinicians should pay
particular attention to these predictors in order to identify
people at risk for future development of complicated grief.
When subthreshold complicated grief is included, the prevalence of complicated grief boosts up to a quarter of the sample,
therefore, routine screening for complicated grief among the
bereaved is desired. Further study implication includes prevalence study using the more stringent criteria that have been
proposed for DSM-V and ICD-11 and assessing other psychiatric
morbidities.
Role of funding source
This study was fully supported by the Grant-in-Aid for Cancer Research
endowed to M.M from the Ministry of Health, Labor and Welfare, Japan
(MHLW); the MHLW had no further role in study design; in the collection,
analysis and interpretation of data; in the writing of the report; and in the
decision to submit the paper for publication.
Conict of Interest
All the authors declare no conicting interests.

357

Acknowledgements
The authors express gratitude to Rieko Kimura, R.N. for
coordinating the study.

References
Bernard, L.L., Guarnaccia, C.A., 2003. Two models of caregiver strain and
bereavement adjustment: a comparison of husband and daughter
caregivers of breast cancer hospice patients. Gerontologist 43, 808816.
Byrne, G.J., Raphael, B., 1994. A longitudinal study of bereavement phenomena
in recently widowed elderly men. Psychol. Med. 24, 411421.
Chiu, Y.W., Huang, C.T., Yin, S.M., Huang, Y.C., Chien, C.H., Chuang, H.Y., 2009.
Determinants of complicated grief in caregivers who cared for terminal
cancer patients. Support Care Cancer.
Dyregrov, K., Nordanger, D., Dyregrov, A., 2003. Predictors of psychosocial
distress after suicide, SIDS and accidents. Death Stud. 27, 143165.
Forstmeier, S., Maercker, A., 2007. Comparison of two diagnostic systems for
complicated grief. J. Affect. Disord. 99, 203211.
Ghaffari-Nejad, A., Ahmadi-Mousavi, M., Gandomkar, M., Reihani-Kermani,
H., 2007. The prevalence of complicated grief among Bam earthquake
survivors in Iran. Arch. Iran. Med. 10, 525528.
Horowitz, M.J., Siegel, B., Holen, A., Bonanno, G.A., Milbrath, C., Stinson, C.H.,
1997. Diagnostic criteria for complicated grief disorder. Am. J. Psychiatry
154, 904910.
Japan Ministry of Health and Labor. Japan Ministry of Health and Labor
database system for statistics. [http://www.e-stat.go.jp/] (last accessed
2010/06/15).
Kawakami, N., Takeshima, T., Ono, Y., Uda, H., Hata, Y., Nakane, Y., Nakane, H.,
Iwata, N., Furukawa, T.A., Kikkawa, T., 2005. Twelve-month prevalence,
severity, and treatment of common mental disorders in communities in
Japan: preliminary nding from the World Mental Health Japan Survey
20022003. Psychiatry Clin. Neurosci. 59, 441452.
Kersting, A., Kroker, K., Horstmann, J., Ohrmann, P., Baune, B.T., Arolt, V.,
Suslow, T., 2009. Complicated grief in patients with unipolar depression.
J. Affect. Disord. 118, 201204.
Middleton, W., Burnett, P., Raphael, B., Martinek, N., 1996. The bereavement
response: a cluster analysis. Br. J. Psychiatry 169, 167171.
Morita, T., Akechi, T., Ikenaga, M., Kizawa, Y., Kohara, H., Mukaiyama, T.,
Nakaho, T., Nakashima, N., Shima, Y., Matsubara, T., Fujimori, M.,
Uchitomi, Y., 2004. Communication about the ending of anticancer
treatment and transition to palliative care. Ann. Oncol. 15, 15511557.
Morita, T., Miyashita, M., Tsuneto, S., Sato, K., Shima, Y., 2009. Late referrals to
palliative care units in Japan: nationwide follow-up survey and effects of
palliative care team involvement after the Cancer Control Act. J. Pain
Symptom Manage. 38, 191196.
Ott, C.H., 2003. The impact of complicated grief on mental and physical
health at various points in the bereavement process. Death Stud. 27,
249272.
Piper, W.E., Ogrodniczuk, J.S., Azim, H.F., Weideman, R., 2001. Prevalence of
loss and complicated grief among psychiatric outpatients. Psychiatr.
Serv. 52, 10691074.
Prigerson, H., Jacobs, S., 2001. Traumatic grief as a distinct disorder: a
rationale, consensus criteria, and a preliminary empirical test. In:
Stroebe, M.S., Hansson, R.O., Stroebe, W., Schut, H. (Eds.), Handbook of
bereavement research: consequences, coping and care. American
Psychological Association, Washington, pp. 613645.
Prigerson, H.G., Bierhals, A.J., Kasl, S.V., Reynolds III, C.F., Shear, M.K.,
Newsom, J.T., Jacobs, S., 1996. Complicated grief as a disorder distinct
from bereavement-related depression and anxiety: a replication study.
Am. J. Psychiatry 153, 14841486.
Prigerson, H.G., Shear, M.K., Jacobs, S.C., Reynolds III, C.F., Maciejewski, P.K.,
Davidson, J.R., Rosenheck, R., Pilkonis, P.A., Wortman, C.B., Williams, J.B.,
Widiger, T.A., Frank, E., Kupfer, D.J., Zisook, S., 1999. Consensus criteria for
traumatic grief. A preliminary empirical test. Br. J. Psychiatry 174, 6773.
Prigerson, H., Ahmed, I., Silverman, G.K., Saxena, A.K., Maciejewski, P.K.,
Jacobs, S.C., Kasl, S.V., Aqeel, N., Hamirani, M., 2002. Rates and risks of
complicated grief among psychiatric clinic patients in Karachi, Pakistan.
Death Stud. 26, 781792.
Prigerson, H.G., Horowitz, M.J., Jacobs, S.C., Parkes, C.M., Aslan, M., Goodkin,
K., Raphael, B., Marwit, S.J., Wortman, C., Neimeyer, R.A., Bonanno, G.,
Block, S.D., Kissane, D., Boelen, P., Maercker, A., Litz, B.T., Johnson, J.G.,
First, M.B., Maciejewski, P.K., 2009. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med.
6, e1000121.
Raphael, B., Minkov, C., Dobson, M., 2001. Psychotherapeutic and pharmacological intervention for bereaved peersons. In: M.S., S., Hansson, R.O.,

358

D. Fujisawa et al. / Journal of Affective Disorders 127 (2010) 352358

Stroebe, W., Schit, H. (Eds.), Handbook of bereavement research:

Consequences, coping and care. American Psychological Association,
Washington DC, pp. 587612.
Reynolds III, C.F., Miller, M.D., Pasternak, R.E., Frank, E., Perel, J.M., Cornes, C.,
Houck, P.R., Mazumdar, S., Dew, M.A., Kupfer, D.J., 1999. Treatment of
bereavement-related major depressive episodes in later life: a controlled
study of acute and continuation treatment with nortriptyline and
interpersonal psychotherapy. Am. J. Psychiatry 156, 202208.
Rossi Ferrario, S., Cardillo, V., Vicario, F., Balzarini, E., Zotti, A.M., 2004.
Advanced cancer at home: caregiving and bereavement. Palliat. Med. 18,
129136.
Sanjo, M., Miyashita, M., Morita, T., Hirai, K., Kawa, M., Akechi, T., Uchitomi, Y.,
2007. Preferences regarding end-of-life cancer care and associations
with good-death concepts: a population-based survey in Japan. Ann.
Oncol. 18, 15391547.
Sanjo, M., Miyashita, M., Morita, T., Hirai, K., Kawa, M., Ashiya, T., Ishihara, T.,
Miyoshi, I., Matsubara, T., Nakaho, T., Nakashima, N., Onishi, H., Ozawa, T.,
Suenaga, K., Tajima, T., Hisanaga, T., Uchitomi, Y., 2008. Perceptions of
specialized inpatient palliative care: a population-based survey in Japan.
J. Pain Symptom Manage. 35, 275282.
Sato, K., Miyashita, M., Morita, T., Sanjo, M., Shima, Y., Uchitomi, Y., 2008.
Quality of end-of-life treatment for cancer patients in general wards and
the palliative care unit at a regional cancer center in Japan: a
retrospective chart review. Support. Care Cancer 16, 113122.
Schulz, R., Beach, S.R., Lind, B., Martire, L.M., Zdaniuk, B., Hirsch, C., Jackson, S.,
Burton, L., 2001. Involvement in caregiving and adjustment to death of a

spouse: ndings from the caregiver health effects study. JAMA 285,
31233129.
Schut, H., Stroebe, M.S., 2005. Interventions to enhance adaptation to
bereavement. J. Palliat. Med. 8 (Suppl 1), S140147.
Senanayake, H., de Silva, D., Premaratne, S., Kulatunge, M., 2006. Psychological reactions and coping strategies of Sri Lankan women carrying fetuses
with lethal congenital malformations. Ceylon Med. J. 51, 1417.
Shear, K., Frank, E., Houck, P.R., Reynolds III, C.F., 2005. Treatment of
complicated grief: a randomized controlled trial. JAMA 293, 26012608.
Shear, K.M., Jackson, C.T., Essock, S.M., Donahue, S.A., Felton, C.J., 2006.
Screening for complicated grief among Project Liberty service recipients
18 months after September 11, 2001. Psychiatr. Serv. 57, 12911297.
Simon, N.M., Pollack, M.H., Fischmann, D., Perlman, C.A., Muriel, A.C., Moore,
C.W., Nierenberg, A.A., Shear, M.K., 2005. Complicated grief and its correlates
in patients with bipolar disorder. J. Clin. Psychiatry 66, 11051110.
Stroebe, M., Schut, H., Stroebe, W., 2007. Health outcomes of bereavement.
Lancet 370, 19601973.
Szanto, K., Prigerson, H., Houck, P., Ehrenpreis, L., Reynolds III, C.F., 1997.
Suicidal ideation in elderly bereaved: the role of complicated grief.
Suicide Life Threat. Behav. 27, 194207.
Utz, R.L., Carr, D., Nesse, R., Wortman, C.B., 2002. The effect of widowhood on
older adults' social participation: an evaluation of activity, disengagement, and continuity theories. Gerontologist 42, 522533.