DEPRESSION AND ANXIETY 28:648–657 (2011)
COMPLICATED GRIEF ASSOCIATED WITH HURRICANE
M. Katherine Shear, M.D.,1?Katie A. McLaughlin, Ph.D.,2Angela Ghesquiere, M.S.W.,1Michael J. Gruber, M.S.,3
Nancy A. Sampson, B.A.,3and Ronald C. Kessler, Ph.D.3
Background: Although losses are important consequences of disasters, few
epidemiological studies of disasters have assessed complicated grief (CG) and none
assessed CG associated with losses other than death of loved one. Methods: Data
come from the baseline survey of the Hurricane Katrina Community Advisory
Group, a representative sample of 3,088 residents of the areas directly affected by
Hurricane Katrina. A brief screen for CG was included containing four items
consistent with the proposed DSM-V criteria for a diagnosis of bereavement-related
adjustment disorder. Results: Fifty-eight and half percent of respondents reported a
significant hurricane-related loss: Most-severe losses were 29.0% tangible, 9.5%
interpersonal, 8.1% intangible, 4.2% work/financial, and 3.7% death of loved one.
Twenty-six point one percent respondents with significant loss had possible CG and
7.0% moderate-to-severe CG. Death of loved one was associated with the highest
conditional probability of moderate-to-severe CG (18.5%, compared to 1.1–10.5%
conditional probabilities for other losses), but accounted for only 16.5% of
moderate-to-severe CG due to its comparatively low prevalence. Most moderate-
to-severe CG was due to tangible (52.9%) or interpersonal (24.0%) losses.
Significant predictors of CG were mostly unique to either bereavement
(racial–ethnic minority status, social support) or other losses (prehurricane history
of psychopathology, social competence.). Conclusions: Nonbereavement losses
accounted for the vast majority of hurricane-related possible CG despite risk of
CG being much higher in response to bereavement than to other losses. This result
argues for expansion of research on CG beyond bereavement and alerts clinicians to
the need to address postdisaster grief associated with a wide range of losses.
Depression and Anxiety 28:648–657, 2011.
r 2011 Wiley-Liss, Inc.
Key words: bereavement; complicated grief; disaster mental health; grief; loss;
Published online in Wiley Online Library (wileyonlinelibrary.com).
Received for publication 28 April 2011; Revised 9 June 2011;
Accepted 13 June 2011
?Correspondence to: M. Katherine Shear, Columbia University
School of Social Work, 1255 Amsterdam Avenue, New York, NY
10027. E-mail: firstname.lastname@example.org
Dr. Kessler has been a consultant for GlaxoSmithKline Inc.,
Kaiser Permanente, Pfizer Inc., Sanofi-Aventis, Shire Pharma-
ceuticals, and Wyeth-Ayerst; has served on advisory boards for
Eli Lilly & Company and Wyeth-Ayerst; and has had research
support for his epidemiological studies from Bristol-Myers Squibb,
Eli Lilly & Company, GlaxoSmithKline, Johnson & Johnson
Pharmaceuticals, Ortho-McNeil Pharmaceuticals Inc., Pfizer
Inc., and Sanofi-Aventis. The remaining authors, M. Katherine
Shear, Katie A. McLaughlin, Angela Ghesquiere, Michael J.
Gruber, and Nancy A. Sampson, report nothing to disclose.
1Columbia University School of Social Work and Columbia
University College of Physicians and Surgeons, New York,
2Division of General Pediatrics, Children’s Hospital Boston
and Harvard Medical School, Boston, Massachusetts
3Department of Health Care Policy, Harvard Medical School,
The authors disclose the following financial relationships within the
past 3 years: Contract grant sponsor: NIH; Contract grant numbers:
R01 MH070884-01A2; R01 MH081832; Contract grant sponsors:
Office of the Assistant Secretary of Planning and Evaluation; The
Federal Emergency Management Agency; The Administration for
Children and Families; National Institute of Mental Health (NIMH);
Contract grant numbers: R01MH070741; R01MH06078.
rrrr 2011 Wiley-Liss, Inc.
Death of a loved one is one of the many types of loss
caused by natural disasters.[1–16]Until very recently,
though, loss was evaluated in epidemiological studies of
the psychiatric consequences of disaster only as a
stressor that might trigger PTSD or depression.[10,11]
There is now growing awareness of the clinical
significance of complicated grief (CG)with recog-
nition of its potential importance following disas-
ters.[18–20]Uncomplicated acute grief is often intense
and disruptive shortly after the occurrence of a loss,
but typically becomes more muted and less impairing
over time.For people with CG, though, this
transformation does not occur and acute grief symp-
toms (e.g., strong feelings of longing/yearning, pre-
occupation with thoughts/memories of the deceased,
withdrawal, loss of interest) persist longer. Research
has documented that CG is impairing,[23–25]distin-
guishable from major depression and posttraumatic
stress disorder,[23–27]and profits from psychotherapy
that focuses on CG symptoms rather than on depres-
sion[28,29]or on general support.
A DSM-V workgroup has proposed that CG be
added to DSM-V as a new diagnosis of bereavement-
related adjustment disorder, which is described as
including intense yearning, difficulty accepting, and
anger over the death of a loved one along with a feeling
that life is empty or meaningless.Although this
proposal stipulates that these symptoms occur follow-
ing the loss of a loved one, evidence exists that grief
symptoms also often occur after nonbereavement
losses, such as job loss,loss of a home,loss of
the ability to function,[34,35]receiving a diagnosis of a
fatal disease,[36–38]and caring for a loved one with
dementia.[39,40]Grief symptoms associated with these
nonbereavement losses appear to be similar to those
associated with bereavement.Yet, we are aware of no
disaster research on CG associated with these non-
This report presents preliminary data on this issue
from a brief screening scale of CG collected in a survey
with the Hurricane Katrina Community Advisory
Group (CAG), a representative sample of prehurricane
residents of the areas in Alabama, Louisiana, and
Mississippi directly affected by Hurricane Katri-
na.[41–44]Hurricane Katrina was one of the most
devastating natural disasters in U.S. historyand
was associated with substantial losses of life, property,
income, and community,[41,46]providing an excellent
opportunity to examine the prevalence and correlates
of CG associated with a range of disaster-related losses.
The CAG is a representative sample of 3,088 English-speaking
adults (Z18 years old) recruited from random-digit-dial telephone
calls of households in the FEMA-defined disaster area affected by
Hurricane Katrina and from random selection of families applying for
American Red Cross assistance. The baseline CAG interviews, the
focus of this report, were carried out with separate samples of
respondents in three waves: January–March 2006 (5–7 months
posthurricane) n51,043; April–June 2006 (7–10 months posthurri-
cane) n5723; December 2006–April 2007 (15–19 months posthurri-
cane) n51,322. Interviews were carried out in these three waves based
on added funding that allowed baseline sample size to increase on two
different occasions after the first wave. The 3,088 total respondents
had a low (35.2%) cooperation rate (i.e., the survey completion rate
among predesignated respondents who were successfully traced to
their current residence at the time of interview) due to the requirement
that respondents make a long-term commitment to remain in the CAG
(and provide contact information for an informant who would know
their whereabouts if they moved), as we aimed to use the CAG to track
the progress of posthurricane recovery over time.
A nonresponse survey found that CAG nonrespondents were
similar to respondents on sociodemographic variables, but had
somewhat higher hurricane-related stress on a 0–10 scale (where 0
meant ‘‘no stress at all’’ and 10 meant ‘‘the most stress you can
imagine’’) and more psychological distress (assessed with a short
series of questions about common anxiety/mood symptoms scored on
a 0–10 scale) than respondents. The median and interquartile range
(IQR: 25th–75th percentiles) of hurricane-related stress were 8.0
(6.0–10.0) among nonrespondents and 7.0 (5.0–9.0) among respon-
dents. The median and IQR of psychological distress were 2.9
(1.2–4.4) among nonrespondents and 1.7 (0.6–3.5) among respon-
dents. A weight was applied to the baseline CAG data to adjust for
these response biases. No data were collected from nonrespondents,
though, on specific hurricane-related losses. A within-household
probability of selection weight and poststratification weight were also
used to adjust for residual discrepancies between the CAG and the
2000 Census population on a range of sociodemographic and
prehurricane housing variables. The consolidated CAG sample
weight was then trimmed to increase design efficiency.
questions regarding exposure to hurricane-related stressors. Cate-
gories of stressors sufficiently common to be analyzed in subgroup
analyses were serious risk of death, death of a family member or close
friend, victimization due to lawlessness after the storm (e.g., robbery
or physical assault), victimization of a loved one, physical illness or
injury caused or exacerbated by the storm, extreme physical adversity
(e.g., sleeping in a church basement, difficulty obtaining food or
clothing), extreme psychological adversity (e.g., living in distressing
circumstances, such as having to use the toilet or change clothes
without adequate privacy), major property or income loss, and
ongoing difficulties associated with housing (e.g., experiencing
multiple moves or living in substantially worse posthurricane than
Respondents were asked to nominate and rate
their one ‘‘most significant hurricane-related loss’’ on a 0–10 scale
(where 0 meant ‘‘no loss’’ and 10 meant ‘‘the greatest loss you can
imagine’’). Only respondents who rated their loss 31 were
administered the grief questions described below. These losses were
coded as death of loved one, work/financial losses, other tangible
losses (e.g., home, possessions, memorabilia), intangible losses (e.g.,
quality of life, sense of well-being, control, security, way of life), and
interpersonal losses (e.g., separations from family or friends, reduced
quality of relationships with family or friends). A small proportion of
respondents did not respond to this question (1.2%) or provided
uncodeable responses (2.7%).
Respondents were asked 30
649Research Article: Complicated Grief and Hurricane Katrina
Depression and Anxiety
questions about grief in the past 30 days associated with their most
significant loss: (1) How often have you found yourself longing or yearning
for the people or things you lost? (2) How bitter do you feel over your loss?
(3) How empty or meaningless do things seem since your loss? and (4) How
difficult is it for you to accept your loss or to believe that it’s real? Response
options were coded 0–4 (almost all, most, some, a little, and none of the
time for the first question; and not at all, a little, some, a lot, and
extremely for the other three questions). Principal axis factor analysis
found one meaningful factor with an unrotated eigenvalue of 2.7
compared to 0.5 for the second factor and factor loadings of .771 for
all items. A composite measure of grief was created by reflecting
responses to the first question and then summing the four responses
to create a 0–16 scale. A preliminary categorical classification was
made with the following categories: severe CG (15–16), moderate CG
(13–14), mild CG (8–12), subthreshold grief (5–7), and no–minimal grief
(0–4). These cut-points were based on an analysis of sensitivity–spe-
cificity of responses to a similar subset of questions in reproducing
diagnoses of CG based on a widely utilized CG scalein a large
clinical dataset.The fact that these interviews took place 5–19
months after the hurricane suggests that the majority of cases had
symptoms for more than 6 months, which is the minimum duration
typically specified for CG.[49,50]
symptoms with age, sex, race/ethnicity (Non-Hispanic White versus
Other), education, marital status, family income in the year before the
hurricane (low/low-to-middle versus high-to-middle/high), health
insurance status, and prehurricane location of residence (New
Orleans Metropolitan Area versus elsewhere). Low/low-to-middle
family income was defined as less than or equal to the population
median on the ratio of pretax income to a number of family members,
whereas high/middle-to-high income was defined as greater than the
median on this ratio.
Respondents completed short screening scales
of prehurricane lifetime history of major depressive episode, anxiety
disorders (panic disorder, generalized anxiety disorder, posttraumatic
stress disorder), substance use disorders (alcohol or drug abuse with
or without dependence), intermittent explosive disorder, and
suicidality. These scales were adapted from the Family History
Research Diagnostic Criteria interviewand its extensions.
The questions about suicidality were taken from the Self-Injurious
Thoughts and Behaviors Interview.The K6 scale of nonspecific
psychological distresswas used to screen for DSM-IV Serious
Mental Illness (SMI) in the 30 days before interview. Validation
studies have found an area under the receiver operating characteristic
curve of 0.86–0.89 of the K6 predicting clinical diagnoses of
SMI.[54–56]K6 scores of 13–24 were classified probable SMI. A small
K6 clinical reappraisal study (n515) in the CAG selected eight
respondents with K6 scores in the clinical range and seven below that
range, and blindly administered the Structured Clinical Interview for
DSM-IV (SCID).Sensitivity and specificity were perfect in
predicting SMI. Suicidal ideation in the 12 months before interview
was assessed with a question that asked respondents whether they had
seriously thought about killing themselves in the past year.
Functional social supportwas assessed
with one question that asked respondents about the number of
people in their county/parish who they could speak to about their
private feelings without embarrassment. Social competence was
assessed with a 12-item scalerating such abilities as staying
calm in a crisis, getting along with people, being persuasive, staying
out of trouble in dangerous situations, staying in control of
emotions when necessary, and keeping a sense of humor in tense
situations. The internal consistency reliability (Cronbach’s a) of this
scale was .87.
Respondents with losses rated 31 were asked four
Prevalence of grief symptoms associated with each type of loss and
co-occurrence of CG with SMI suicidality were examined with cross-
tabulations. Predictive associations of sociodemographics, hurricane-
related stressors, and prehurricane history of psychopathology with
CG were examined with logistic regression analysis. Logistic
regression coefficients and their standard errors were exponentiated
to create odds ratios (ORs) and 95% confidence intervals (CIs). The
Taylor series linearization method was used to calculate design-based
significance tests. Statistical significance was consistently evaluated
using two-sided .05-level tests.
ESTIMATED PREVALENCE OF
The estimated prevalence of CG in the CAG was
15.3%, representing 26.1% of respondents with a
significant loss (Table 1). The majority of CG (73%)
was rated mild, compared to 14.5% moderate and
12.5% severe. Only 4.1% of respondents in the total
sample (7.0% of those with a significant loss) were
estimated to have moderate (2.2%) or severe (1.9%)
DISTRIBUTION OF GRIEF BY TYPE OF LOSS
Only 3.7% of respondents reported that death of a
loved one was their most significant hurricane-related
loss. Other types of loss were more common, with
58.5% of respondents reporting some type of loss rated
31 on the 0–10 loss severity scale (Table 2). The most
(29.0%), interpersonal losses (9.5%), intangible losses
(8.1%), and work/financial losses (4.2%). The distribu-
tion across the five substantive loss categories did not
differ significantly among respondents interviewed 5–6,
7–12, and 13–19 months after the hurricane (w2
TABLE 1. Estimated prevalence of grief among adults
exposed to Hurricane Katrina (n53,088)
Complicated grief (CG)b
aScores in the range 0–2 on the 0–10 scale assessing severity of
hurricane-related loss. Grief reactions were assessed only among
respondents with scores in the range 3–10 on this scale.
bThe grief scale was scored in the range 0–16. Scale ranges were
defined as 0–4 no–minimal grief, 5–7 subthreshold griefs, 8–12 mild CG,
13–14 moderate CG, and 15–16 severe CG.
650Shear et al.
Depression and Anxiety
Bereavement had the highest conditional probability
of grief symptoms (68.9%) and CG (18.9%) (Table 3;
Part I). Grief symptoms were less prevalent among
(52.5%) or tangible (50.5%). Moderate-to-severe CG
was also lower in these subsamples (10.6% interperso-
nal, 7.6% tangible). Moderate-to-severe CG was least
common among respondents whose main loss was
intangible (1.3%) or work/financial (1.1%). Differences
in prevalence of CG by type of most significant loss did
not differ among respondents in the three survey waves
(i.e., interviewed 5–6, 7–12, and 13–19 months post-
P5.09 moderate-to-severe CG).
Despite the much higher risk of CG among
respondents whose most significant loss was bereave-
ment than other types of loss, only 16.5% of all
moderate-to-severe CG was associated with bereave-
ment (Table 3; Part II). This proportion did not vary
markedly depending on whether respondents were
interviewed 5–6 (15.8%), 7–12 (23.2%), or 13–19
(14.2%) months after the hurricane. The highest
proportions of moderate-to-severe CG were associated
with tangible (52.9%) and interpersonal (24.0%) losses.
8510.3, P5.25 total CG; w2
CO-OCCURRENCE OF COMPLICATED
GRIEF WITH SERIOUS MENTAL ILLNESS
AND SUICIDAL IDEATION
The vast majority of respondents with severe CG
(83.9%) met criteria for either the 30-day SMI or the
12-month suicidal ideation (Table 4). ORs between
severe CG (compared to no hurricane-related loss) and
these outcomes are in the range of 24.0–97.5.
Prevalence of SMI or suicidal ideation were consider-
ably lower among respondents with moderate (41.7%)
or mild (38.3%) CG (ORs57.8–13.3). Prevalence of
SMI or suicidal ideation were lower still among
respondents with no–minimal or subthreshold grief
symptoms (21.4%), but with elevated ORs (5.1–6.9)
compared to people who had no hurricane-related
TABLE 2. Distribution of self-reported most significant
Work or financial
Death of a loved one
aRespondents who reported hurricane-related losses in the range 3–10
on the 0–10 severity-of-loss scale were asked to describe their most
significant loss. Open-ended responses were coded into the categories
reported in this table. Tangible losses include such things as loss of a
home, possessions, or memorabilia. Interpersonal losses (other than
death of a loved one) include separations from family or friends as well
as decreases in quality of relationships with family or friends.
Intangible losses include such things as loss of quality of life, sense
of well being, control, security, or way of life. Work/financial losses
include any mention of job, money, finance, income, or business losses.
TABLE 3. Estimated prevalence and severity of complicated grief (CG) according to type of lossa
I. Percentage by rows% SE% SE% SE% SE% SE% SE(n)
I. Percentage by rows
Death of a loved one
II. Percentage by columns
Death of a loved one
aThe 2,183 respondents in this table consist of all those who reported hurricane-related losses in the range 3–10 on the 0–10 severity-of-loss scale.
The subsample n’s do not correspond to the proportions in Tables 1 and 2 due to the fact that those proportions are based on weighted data,
whereas the n’s reported in the current table are unweighted.
651Research Article: Complicated Grief and Hurricane Katrina
Depression and Anxiety
loss. Prevalence of SMI or suicidal ideation among
respondents who had no hurricane-related loss, finally,
PREDICTORS OF COMPLICATED GRIEF
We examined associations of sociodemographics,
hurricane-related stressors, prehurricane history of
psychopathology, and posthurricane resiliency factors
with moderate-to-severe CG among respondents who
experienced hurricane-related loss. None of the socio-
demographic variables was a significant predictor after
controlling type of loss. This is striking given that
sociodemographics typically are associated with more
general measures of anxiety and mood disorders in
community epidemiological surveys.[60,61]Access to
health insurance, an indirect indicator of socioeco-
nomic status, was also unrelated to moderate-to-severe
CG, as was residential location before the hurricane
(the New Orleans Metropolitan Area versus the
remainder of the areas affected by the hurricane).
Two presumed stress buffers, social support and
social competence, were also insignificant predictors of
moderate-to-severe CG. However, the remaining two
predictors, number of hurricane-related stressors re-
ported by respondents and prehurricane history of
psychopathology, were both significant. Number of
hurricane-related stressors were coded in the range
1–10 (with 1 being the lowest score rather than 0,
because all respondents in the loss subsample reported
exposure to at least one hurricane-related stressor),
where a score of 10 represents reporting exposure to 10
or more of the 30 stressors assessed in the survey.
(Scores were truncated at 10, because only a very small
number of respondents reported exposure to more than
10 of the 30 stressors.) The 1.7 OR associated with
hurricane-related stressors consequently represents the
relative odds of moderate-to-severe CG associated with
an increase of one stressor. More detailed analyses
(results available on request) showed that the implicit
assumption of a linear association between number of
stressors and log odds of moderate-to-severe CG is
consistent with the data; that is, the OR of having been
exposed to 3 stressors versus 1 is roughly equal to
1.7252.9; of having been exposed to 4 stressors versus
1 equal to 0 1.7354.9, etc. Further analysis also
supported the model assumption that types of stressors
could be considered equivalent for purposes of
predicting this outcome (Table 5).
Prehurricane history of psychopathology was coded
as a 0–7 count of number of prior lifetime mental
disorders assessed in the survey. The OR of 1.2
associated with this predictor consequently represents
the association of an increase in one point on this scale.
More detailed analyses (results available on request)
showed that the implicit assumption of a linear
association between number of disorders and log odds
of CG is consistent with the data; that is, the OR
history of two prior mental disorders versus 0 is
roughly 1.2251.4, of having three prior disorders
versus 0 is roughly 1.2351.7, etc. Further analysis also
supported the model assumption that types of disorders
are not significant predictors of CG once number of
disorders is controlled. This means that the vulner-
ability associated with history of psychopathology is
relatively general rather than linked to any particular
subset of disorders.
Decomposition showed that the ORs of the pre-
dictors taken as a set are significantly different across
subsamples defined by type of loss (w2
P5.011). However, the only individual predictor for
which the ORs are significantly different across
subsamples is social competence (w2
Social competence (standardized to a mean of 0 and
variance of 1) has a statistically significant 0.3 OR
predicting moderate-to-severe CG associated with
interpersonal loss, but is not significant in predicting
moderate-to-severe CG associated with other types of
loss (0.8–0.9). Most other significant specifications
involved predictors only of CG associated with
bereavement, including elevated ORs associated with
non-White race (6.9), low education (8.6), and social
support (2.3). However, caution is needed in interpret-
ing these specifications, as none of the ORs differs
TABLE 4. Co-occurrence of complicated grief (CG) with 30-day serious mental illness (SMI) and 12-month suicidal
12-month suicidal ideationSMI or suicidal ideation
% SE OR(95% CI)% SE OR (95% CI)% SEOR (95% CI)
No hurricane-related loss
dichotomous outcome are: SMI w2
4tests for the association between level of grief (no loss, no–minimal/subthreshold grief, mild CG, moderate CG, severe CG) and each
45135.7, Po.001, suicidal ideation w2
4526.3, Po.001, SMI or suicidal ideation w2
652Shear et al.
Depression and Anxiety
TABLE 5. Multivariate associations of sociodemographics, hurricane-related stressors, prehurricane history of psychopathology,
and posthurricane resiliency factors with moderate-to-severe complicated grief (CG) among respondents with any hurricane-
related loss and separately among respondents with the hurricane-related losses most strongly associated with CGa
Any loss Death of a loved oneTangible losses Interpersonal losses
OR (95% CI)OR (95% CI)OR (95% CI) OR(95% CI)
Education (in years)
New Orleans metro
3.2 0.4 1.5 1.9
0.0 2.6 0.1 0.4
2.0 2.40.2 0.0
1.53.6 2.7 0.8
1.2 (0.9–1.7) 2.3?
0.7(0.6–1.0) 0.8(0.5–1.3) 0.9(0.6–1.4) 0.3?
Prehurricane history of psychopathologyd
?Significant at the .05 level, two-sided test.
aMultivariate logistic regression models predicting moderate-to-severe complicated grief among respondents who reported hurricane-related
losses in the range 3–10 on the 0–10 severity-of-loss scale.
bThe hurricane-related stressors scale is a count of number of hurricane-related stressors out of the 30 assessed. The scale is scored in the range 1–10 in
this subsample. The lowest score is 1 because all respondents with significant loss reported at least one hurricane-related stressor. The highest score is 10
because the small number of respondents who reported more than 10 hurricane-related stressors were coded 10 due to the rarity of higher exposures.
cThe social support and social competence scales are standardized to have a mean of 0.0 and a variance of 1.0 in the total sample.
dPrehurricane history of psychopathology is coded in the range 0–7 and represents the number of lifetime disorders the respondent reported having
before the hurricane. These seven include major depressive episode, panic disorder, generalized anxiety disorder, posttraumatic stress disorder,
intermittent explosive disorder, substance abuse with or without dependence, and suicide ideation.
653 Research Article: Complicated Grief and Hurricane Katrina
Depression and Anxiety
significantly from the nonsignificant ORs for these
predictors inthe total
P5.17–.34), raising the possibility that significant
subsample associations might be due to chance
fluctuations in the large number of subsample replica-
tions. The only other noteworthy specification is that
history of psychopathology does not predict CG
associated with bereavement, whereas it does predict
CG associated with other types of loss.
The CAG is one of the largest disaster-related
surveys that screened CG and the first to investigate
CG associated with nonbereavement disaster-related
losses. More than half of respondents reported a
disaster-related loss, with types similar to those
described after other disasters.[15,62]More than one-
fourth of respondents with a significant loss reported at
least some grief symptoms, with moderate-to-severe
CG reported by 3.9% of respondents. Although CG
was significantly associated with SMI and suicidal
ideation, the majority of respondents with mild or
moderate CG did not have SMI.
CG was most prevalent following bereavement
(conditional prevalence of moderate-to-severe CG of
18.9% compared to 1.1–10.6% for other losses). These
differences were quite consistent across subsamples of
respondents that differed in length of time between the
hurricane and the time of baseline interview.
Prevalence estimates of CG in other postdisaster
studies that assessed CG related to bereavement[18–20]
and other studies of death of a loved one due to a
variety of causes[49,63]vary widely (10–76%). The
18.9% CAG estimate is at the lower end of this range.
Caution is needed in interpreting this comparison,
though, as each study so far has used a different rating
instrument and the CAG estimate was based on a very
short screening measure. No other study asked
respondents to rate a range of losses and to identify
which was most severe.
We are unaware of any previous disaster study that
estimated CG associated with nonbereavement loss.
Interestingly, because of the comparatively low pre-
valence of bereavement, other types of loss accounted
for the vast majority of CG (83.5%). Property loss was
the most common cause of CG (accounting for 52.9%
of all CG cases), with interpersonal losses other than
death accounting for an additional 24.0%. However, as
a result of the high conditional risk of CG among
respondents with bereavement, the proportion of CG
due to bereavement (16.5%) was a considerably higher
proportion than one would expect by chance given that
only 6.4% of all respondents who reported a loss said
that bereavement was their most significant loss.
The finding of high co-occurrence of CG with both
tion[66–69]is consistent with previous research, and
was particularly common (more than 80%) among
and suicidal idea-
individuals with severe CG. In addition, we found that
exposure to hurricane-related stressors was strongly
related to CG. This, too, is consistent with previous
research.[18,64]However, our finding that CG from
nonbereavement loss was largely unrelated to socio-
demographics is inconsistent with evidence from
previous studies that bereavement-related CG is
generally more common among women, minorities,
the unmarried, and people with socioeconomic dis-
advantage.[18,25,64]This failure to find strong socio-
demographic correlates of CG is part of a larger
pattern in the CAG for sociodemographics to be much
less strongly related either to trauma exposure or to
psychopathology (PTSD or SMI) than in other natural
disaster samples.[41,43]We suggested in a previous
report that these weak associations are due to the
enormity of the devastation caused by Katrina, which
overwhelmed the protective effects typically provided
by sociodemographic advantage, leading to a wider
distribution of psychopathological reactions than in
more typical natural disasters.
Another CAG finding consistent with previous
research is that prehurricane history of psychopathol-
CG.[27,64,70]The finding that number of rather than
type of prior disorders predicted CG is consistent with
accumulating evidence that CG is a unique syndrome,
not best described as a form of depression or PTSD as
many have done,[1–16]although it is important to be
clear that this finding is certainly not definitive in
arguing that CG is a unique syndrome. Indeed, one of
the weakest aspects of this sample is that it did not
include a comprehensive assessment of other disorders
with which CG might be confounded.
A series of specifications showed that low education,
minority race/ethnic status and social support pre-
dicted bereavement-related CG but not other CG,
whereas prehurricane history of psychopathology and
social competence predicted only nonbereavement-
related CG. The stability of these specifications is
uncertain and requires replication in independent
datasets. The possibility of specificity, paired with the
high prevalence of grief symptoms among those with
nonbereavement losses, points to the importance of
future studies examining patterns and predictors of
grief among individuals who experienced losses other
than death of a loved one.
Several observations can be made about these
specificities. The finding that markers of disadvantaged
social status (minority race/ethnic status, low educa-
tion) predicted only bereavement-related CG might be
taken to suggest that social ties are especially important
for people in socially disadvantaged than advantaged
positions. Evidence consistent with such a specification
exists in the social networks literature.[71,72]The
finding that social support predicts increased risk of
CG, but only when the CG is related to bereavement,
might indicate that social support is a marker of the
magnitude of loss rather than a true vulnerability
654Shear et al.
Depression and Anxiety
factor. Studies of social support in older bereaved
samples indicate an association between greater emo-
tional loneliness and instrumental social support.[73,74]
However, it is unclear how this relates to CG. We are
unaware of previous studies that examined effects of
social competence on CG. Our finding that social
competence does not protect against CG due to
nonbereavement loss raises the possibility that protec-
tive effects of social competence might be specific to
interpersonal losses. All these specifications need to be
replicated in other datasets, though, before they are
A number of study limitations are important to note.
First, the CAG excluded people who we could not trace
as well as those not reachable by telephone, which
likely resulted in the underrepresentation of individuals
with the greatest exposure to hurricane-related stressors
and, potentially, the highest rates of CG. Second, CG
was assessed using a brief symptom scale that included
only a subset of the symptoms now recommended for
assessment of CG. In addition, symptoms were
assessed 5–19 months after the hurricane even though
the DSM-V workgroup suggested a minimum duration
of at least 12 months for a diagnosis of bereavement-
related adjustment disorder.Prevalence estimates of
CG and results regarding associations should be
considered only provisional. It is noteworthy, though,
that results regarding correlates of CG did not vary
significantly as a function of time between the
hurricane and the survey, which means that the patterns
reported here are broadly consistent whether CG is
defined with durations as short as 4–5 months (i.e.,
symptoms in the past month among respondents
interviewed 5–6 months after the hurricane, 6–11 months,
or 121 months). Third, although the screening scales
of co-occurring mental disorders used here have been
validated,[54,56]screening scales are inherently less
precise than comprehensive diagnostic interviews,
which undoubtedly led to at least some misclassifica-
tion of respondents. Fourth, it would have been
valuable if the survey had included a comprehensive
assessment of other disorders that might be comorbid
with CG, allowing us to investigate whether or not
unique associations could be found with CG after
controlling those other disorders. Fifth, it is difficult to
interpret results for the 8.1% of respondents who said
that they had a most significant hurricane-related loss
that was intangible (e.g., quality of life, sense of well-
being, control, security, way of life), as the kinds of
experiences included in the description of intangible
losses overlap considerably with the symptoms of CG.
It is noteworthy, though, that prevalence of clinically
significant CG was quite low in this subsample (1.3%),
minimizing the impact of this problem. These limita-
tions need to be corrected in future studies.
Despite these limitations, the results reported here
suggest that CG is associated with losses other than
death, that nondeath grief might make up a large
proportion of CG after a natural disaster and that the
predictors of CG might differ depending on type of
loss, although replication of these results in a study that
assesses a wide range of other DSM disorders is needed
to determine the extent to which these patterns hold up
after controlling for all other relevant disorders. A
practical implication of the results for disaster response
involves the fact that postdisaster interventions for grief
have been developed, although not systematically
tested,and could be applied if clinicians increased
their recognition of potentially problematic postdisa-
ster grief reactions. Previous studies indicate that grief-
focused therapies out-perform more conventional
therapies in ameliorating CG symptoms,[28–30]but this
work has not targeted disaster-bereaved individuals and
has not included losses other than death. Data reported
here suggest that the magnitude and heterogeneity of
the problem of postdisaster CG are large enough to
warrant systematic investigation of these possibilities.
Dr. Kessler had full access to all of the data in the study
and takes responsibility for the integrity of the data and
the accuracy of the data analysis.
Funding/Support: This study is supported by NIH
MH081832 from the US Department of Health and
Human Services, National Institutes of Health (NIH),
the Office of the Assistant Secretary of Planning and
Evaluation, the Federal Emergency Management Agency,
and the Administration for Children and Families,
and by NIH Research Grants R01MH070741 and
R01MH06078 from the National Institute of Mental
Role of the Sponsor: The funding agencies had no
role in the design and conduct of the study; in the
collection, analysis, and interpretation of the data; or in
the preparation, review, or approval of the manuscript.
Data access and responsibility:
1. Chou FH, Wu HC, Chou P, et al. Epidemiologic psychiatric
studies on post-disaster impact among Chi-Chi earthquake
survivors in Yu-Chi, Taiwan. Psychiatry Clin Neurosci 2007;61:
2. DiGrande L, Neria Y, Brackbill RM, et al. Long-term posttrau-
matic stress symptoms among 3,271 civilian survivors of the
September 11, 2001, terrorist attacks on the World Trade Center.
Am J Epidemiol 2011;173:271–281.
3. Freedy JR, Saladin ME, Kilpatrick DG, et al. Understanding
acute psychological distress following natural disaster. J Trauma
4. Hobfoll SE, Tracy M, Galea S. The impact of resource loss and
traumatic growth on probable PTSD and depression following
terrorist attacks. J Trauma Stress 2006;19:867–878.
5. Ironson G, Wynings C, Schneiderman N, et al. Posttraumatic
stress symptoms, intrusive thoughts, loss, and immune function
after Hurricane Andrew. Psychosom Med 1997;59:128–141.
6. Johannesson KB, Lundin T, Frojd T, et al. Tsunami-exposed
tourist survivors: signs of recovery in a 3-year perspective. J Nerv
Ment Dis 2011;199:162–169.
655 Research Article: Complicated Grief and Hurricane Katrina
Depression and Anxiety
7. Kun P, Chen X, Han S, et al. Prevalence of post-traumatic stress
disorder in Sichuan Province, China after the 2008 Wenchuan
earthquake. Public Health 2009;123:703–707.
8. Kun P, Han S, Chen X, et al. Prevalence and risk factors for
posttraumatic stress disorder: a cross-sectional study among
survivors of the Wenchuan 2008 earthquake in China. Depress
9. Kuo CJ, Tang HS, Tsay CJ, et al. Prevalence of psychiatric
disorders among bereaved survivors of a disastrous earthquake in
Taiwan. Psychiatr Serv 2003;54:249–251.
10. Norris FH, Friedman MJ, Watson PJ. 60,000 disaster victims
speak. Part II: summary and implications of the disaster mental
health research. Psychiatry 2002;65:240–260.
11. Norris FH, Friedman MJ, Watson PJ, et al. 60,000 disaster
victims speak. Part I: an empirical review of the empirical
literature 1981–2001. Psychiatry 2002;65:207–239.
12. Raphael B, Ma H. Mass catastrophe and disaster psychiatry. Mol
13. Smith BW, Freedy JR. Psychosocial resource loss as a mediator
of the effects of flood exposure on psychological distress and
physical symptoms. J Trauma Stress 2000;13:349–357.
14. Su CY, Tsai KY, Chou FH, et al. A three-year follow-up study of
the psychosocial predictors of delayed and unresolved post-
traumatic stress disorder in Taiwan Chi-Chi earthquake survi-
vors. Psychiatry Clin Neurosci 2010;64:239–248.
15. Tang CS. Positive and negative postdisaster psychological
adjustment among adult survivors of the Southeast Asian
earthquake-tsunami. J Psychosom Res 2006;61:699–705.
16. Wahlstrom L, Michelsen H, Schulman A, et al. Different types of
exposure to the 2004 tsunami are associated with different levels
of psychological distress and posttraumatic stress. J Trauma
17. Shear MK, Simon N, Wall M, et al. Complicated grief and
related bereavement issues for DSM-5. Depress Anxiety 2011;28:
18. Ghaffari-Nejad A, Ahmadi-Mousavi M, Gandomkar M, et al.
The prevalence of complicated grief among Bam earthquake
survivors in Iran. Arch Iran Med 2007;10:525–528.
19. Johannesson KB, Lundin T, Hultman CM, et al. The effect of
traumatic bereavement on tsunami-exposed survivors. J Trauma
20. Kristensen P, Weisaeth L, Heir T. Predictors of complicated grief
after a natural disaster: a population study two years after the
2004 South-East Asian Tsunami. Death Stud 2010;34:137–150.
21. Bryant RA, Friedman MJ, Spiegel D, et al. A review of acute
stress disorder in DSM-5. Depress Anxiety 2010 (e-publication
ahead of print).
22. Shear K, Shair H. Attachment, loss, and complicated grief. Dev
23. Prigerson HG, Bierhals AJ, Kasl SV, et al. Complicated grief as a
disorder distinct from bereavement-related depression and anxiety:
a replication study. Am J Psychiatry 1996;153:1484–1486.
24. Prigerson HG, Frank E, Kasl SV, et al. Complicated grief and
bereavement-related depression as distinct disorders: preliminary
empirical validation in elderly bereaved spouses. Am J Psychiatry
25. Shear KM, Jackson CT, Essock SM, et al. Screening for complicated
grief among Project Liberty service recipients 18 months after
September 11, 2001. Psychiatr Serv 2006;57:1291–1297.
26. Horowitz MJ, Siegel B, Holen A, et al. Diagnostic criteria for
complicated grief disorder. Am J Psychiatry 1997;154:904–910.
27. Simon NM, Shear KM, Thompson EH, et al. The prevalence
and correlates of psychiatric comorbidity in individuals with
complicated grief. Compr Psychiatry 2007;48:395–399.
28. Shear K, Frank E, Houck PR, et al. Treatment of complicated
grief: a randomized controlled trial. JAMA 2005;293:2601–2608.
29. Shear MK, Frank E, Foa E, et al. Traumatic grief treatment: a
pilot study. Am J Psychiatry 2001;158:1506–1508.
30. Boelen PA, de Keijser J, van den Hout MA, et al. Treatment of
complicated grief: a comparison between cognitive-behavioral
therapy and supportive counseling. J Consult Clin Psychol 2007;
31. American Psychiatric Association. DSM-5 development: adjust-
ment disorders. 2011 [cited January 27, 2011]; Available from:
32. Archer J, Rhodes V. The grief process and job loss: a cross-
sectional study. Br J Psychol 1993;84:395–410.
33. Archer J, Hawes J. Grief and rehousing. Br J Med Psychol 1988;
34. Persinger MA. Personality changes following brain injury as a
grief response to the loss of sense of self: phenomenological
themes as indices of local lability and neurocognitive structuring
as psychotherapy. Psychol Rep 1993;72:1059–1068.
35. Zinner ES, Ball JD, Stutts ML, et al. Modification and factor-
analysis of the Grief Experience Inventory in non-death loss
bereavement situations. OMEGA-J Death Dying 1991;23:
36. Fulton G, Madden C, Minichiello V. The social construction of
anticipatory grief. Soc Sci Med 1996;43:1349–1358.
37. Harvey B. Complications of complicated grief in renal failure.
EDTNA ERCA J 2000;26:36–37.
38. Herman D, Felton C, Susser E. Mental health needs in
New York state following the September 11th attacks. J Urban
39. Loos C, Bowd A. Caregivers of persons with Alzheimer’s disease:
some neglected implications of the experience of personal loss
and grief. Death Stud 1997;21:501–514.
40. Sanders S, Ott CH, Kelber ST, et al. The experience of high
levels of grief in caregivers of persons with Alzheimer’s disease
and related dementia. Death Stud 2008;32:495–523.
41. Galea S, Brewin CR, Gruber M, et al. Exposure to hurricane-
related stressors and mental illness after Hurricane Katrina. Arch
Gen Psychiatry 2007;64:1427–1434.
42. Kessler RC, Galea S, Gruber MJ, et al. Trends in mental illness
and suicidality after Hurricane Katrina. Mol Psychiatry 2008;13:
43. Kessler RC, Galea S, Jones RT, et al. Mental illness and
suicidality after Hurricane Katrina. Bull World Health Organ
44. McLaughlin KA, Berglund P, Gruber MJ, et al. Recovery from
PTSD following Hurricane Katrina. Depress Anxiety 2011;6:
45. Rosenbaum S. US health policy in the aftermath of Hurricane
Katrina. JAMA 2006;295:437–440.
46. Abramson D, Garfield R. On the Edge: Children and Families
Displaced by Hurricanes Katrina and Rita Face a Looming
Medical and Mental Health Crisis. New York, NY: Columbia
University Mailman School of Public Health; 2008.
47. Prigerson HG, Maciejewski PK, Reynolds 3rd CF, et al.
Inventory of complicated grief: a scale to measure maladaptive
symptoms of loss. Psychiatry Res 1995;59:65–79.
48. Simon NM, Wall MM, Keshaviah A, et al. Informing the
symptom profile of complicated grief. Depress Anxiety 2011;28:
49. Prigerson HG, Bierhals AJ, Kasl SV, et al. Traumatic grief as a
risk factor for mental and physical morbidity. Am J Psychiatry
656 Shear et al.
Depression and Anxiety
50. Prigerson HG, Horowitz MJ, Jacobs SC, et al. Prolonged grief Download full-text
disorder: psychometric validation of criteria proposed for DSM 5
and ICD-11. PLoS Med 2009;6:e1000121.
51. Endicott J, Andreasen N, Spitzer R. Family History Research
Diagnostic Criteria. New York, NY: Biometrics Research, NY
State Psychiatric Institute; 1978.
52. Kendler KS, Silberg JL, Neale MC, et al. The family history
method: whose psychiatric history is measured? Am J Psychiatry
53. Nock MK, Holmberg EB, Photos VI, et al. Self-injurious
thoughts and behaviors interview: development, reliability, and
validity in an adolescent sample. Psychol Assess 2007;19:309–317.
54. Kessler RC, Barker PR, Colpe LJ, et al. Screening for serious
mental illness in the general population. Arch Gen Psychiatry
55. Furukawa T, Kessler R, Slade T, et al. The performance of the
K6 and K10 screening scales for psychological distress in the
Australian National Survey of Mental Health and Well-Being.
Psychol Med 2002;33:357–362.
56. Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to
monitor population prevalences and trends in non-specific
psychological distress. Psychol Med 2002;32:959–976.
57. First M, Spitzer R, Gibbon M, et al. Structured Clinical
Interview for DSM-IV Axis I Disorders, Research Version,
Non-patient Edition (SCID-I/NP). New York, NY: Biometrics
Research, New York State Psychiatric Institute; 2002.
58. Cohen S, Wills TA. Stress, social support, and the buffering
hypothesis. Psychol Bull 1985;98:310–357.
59. Kessler RC, Avenevoli S, Costello EJ, et al. National comorbidity
survey replication adolescent supplement (NCS-A). II: overview
and design. J Am Acad Child Adolesc Psychiatry 2009;48:
60. Kessler R, Aguilar-Gaxiola S, Alonso J, et al. Lifetime prevalence
and age of onset distributions of mental disorders in the World
Mental Health Survey initiative. In: Kessler RC, U¨stu ¨n TB,
editors. The WHO World Mental Health Surveys: Global
Perspectives on the Epidemiology of Mental Disorders. New
York, NY: Cambridge University Press; 2008:511–521.
61. Kessler R, Aguilar-Gaxiola S, Alonso J, et al. Prevalence and
severity of mental disorders in the WMH Surveys. In: Kessler RC,
U¨stu ¨n TB, editors. The WHO World Mental Health Surveys:
Global Perspectives on the Epidemiology of Mental Disorders.
New York, NY: Cambridge University Press; 2008:534–540.
62. Kohn R, Levav I, Donaire I, et al. Psychological and
psychopathological reactions in Honduras following Hurricane
Mitch: implications for service planning. Rev Panam Salud
63. Middleton W, Burnett P, Raphael B, et al. The bereavement
response: a cluster analysis. Br J Psychiatry 1996;169:167–171.
64. Neria Y, Gross R, Litz B, et al. Prevalence and psychological
correlates of complicated grief among bereaved adults 2.5–3.5
years after September 11th attacks. J Trauma Stress 2007;20:
65. Silverman GK, Jacobs SC, Kasl SV, et al. Quality of life
impairments associated with diagnostic criteria for traumatic
grief. Psychol Med 2000;30:857–862.
66. Latham AE, Prigerson HG. Suicidality and bereavement:
complicated grief as psychiatric disorder presenting greatest risk
for suicidality. Suicide Life Threat Behav 2004;34:350–362.
67. Simon NM, Pollack MH, Fischmann D, et al. Complicated grief
and its correlates in patients with bipolar disorder. J Clin
68. Szanto K, Prigerson H, Houck P, et al. Suicidal ideation in
elderly bereaved: the role of complicated grief. Suicide Life
Threat Behav 1997;27:194–207.
69. Szanto K, Shear MK, Houck PR, et al. Indirect self-destructive
behavior and overt suicidality in patients with complicated grief.
J Clin Psychiatry 2006;67:233–239.
70. Melhem NM, Rosales C, Karageorge J, et al. Comorbidity of axis
I disorders in patients with traumatic grief. J Clin Psychiatry
71. Turner RJ, Noh S. Class and psychological vulnerability among
women: the significance of social support and personal control.
J Health Soc Behav 1983;24:2–15.
72. Whyte W. Street Corner Society: The Social Structure of an
Italian Slum. Chicago, IL: University of Chicago Press; 1981.
73. Bisconti TL, Bergeman CS, Boker SM. Social support as a
predictor of variability: an examination of the adjustment
trajectories of recent widows. Psychol Aging 2006;21:590–599.
74. van Baarsen B. Theories on coping with loss: the impact of social
support and self-esteem on adjustment to emotional and social
loneliness following a partner’s death in later life. J Gerontol B
Psychol Sci Soc Sci 2002;57:S33–S42.
75. Walsh F. Traumatic loss and major disasters: strengthening
657 Research Article: Complicated Grief and Hurricane Katrina
Depression and Anxiety