The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief
Complicated grief (CG), variously called pathological or traumatic grief, is a debilitating syndrome that is not currently included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) nomenclature. One issue that remains under debate is whether this condition can be clearly distinguished from other psychiatric disorders, such as major depression and posttraumatic stress disorder, with which CG frequently coexists. Using a structured clinical interview for CG and the Structured Clinical Interview for DSM-IV, trained experienced raters conducted careful diagnostic assessments of individuals seeking treatment of bereavement-related distress. All study participants met criteria for a current CG syndrome. Liberal criteria were used to diagnose DSM-IV disorders, making no attempt to decide if symptoms could be explained by grief. Of 206 who met the criteria for CG, 25% had no evidence of a current DSM-IV Axis I disorder. When present, psychiatric comorbidity was associated with significantly greater severity of grief; however, even after adjustment for the presence of comorbidity, severity of CG symptoms was associated with greater work and social impairment. It is likely that our study underestimated the rate of CG without comorbidity because fewer DSM diagnoses would have been made if a judgment about grief had been taken into consideration. Our data provide further support for the need to identify CG as a psychiatric disorder.
The prevalence and correlates of psychiatric comorbidity in individuals
with complicated grief
Naomi M. Simon
, Katherine M. Shear
, Elizabeth H. Thompson
, Alyson K. Zalta
, Charles F. Reynolds
, Ellen Frank
, Nadine M. Melhem
, Russell Silowash
Massachusetts General Hospital and Harvard Medical School
Columbia University School of Social Work
University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic
Background: Complicated grief (CG), variously called pathological or traumatic grief, is a debilitating syndrome that is not currently
included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) nomenclature. One issue that remains
under debate is whether this condition can be clearly distinguished from other psychiatric disorders, such as major depression and
posttraumatic stress disorder, with which CG frequently coexists.
Methods: Using a structured clinical interview for CG and the Structured Clinical Interview for DSM-IV, trained experienced raters
conducted careful diagnostic assessments of individuals seeking treatment of bereavement-related distress. All study participants met criteria
for a current CG syndrome. Liberal criteria were used to diagnose DSM-IV disorders, making no attempt to decide if symptoms could be
explained by grief.
Results: Of 206 who met the criteria for CG, 25% had no evidence of a current DSM-IV Axis I disorder. When present, psychiatric
comorbidity was associated with significantly greater severity of grief; however, even after adjustment for the presence of comorbidity,
severity of CG symptoms was associated with greater work and social impairment.
Limitations: It is likely that our study underestimated the rate of CG without comorbidity because fewer DSM diagnoses would have been
made if a judgment about grief had been taken into consideration.
Conclusions: Our data provide further support for the need to identify CG as a psychiatric disorder.
© 2007 Elsevier Inc. All rights reserved.
The syndrome of complicated grief (CG), variously called
pathological or traumatic grief, is chronic and debilitating,
results in substantial distress and impairment [1-3], worsens
quality of life , and has been linked to excess medical
morbidity [5,6] and suicidality [5,7-9]. As currently defined,
CG consists of symptoms at least 6 months after the loss of a
loved one that include a sense of disbelief regarding the
death; persistent intense longing, yearning, and preoccupa-
tion with the deceased; recurrent intrusive images of the
dying person; and avoidance of painful reminders of the
death [10-14]. Individuals with the syndrome of CG often
report anger and bitterness related to the death, feel estranged
from other close friends and relatives, and cannot find
satisfaction in ongoing life [1,15,16]. Complicated grief has
been distinguished from other co-occurring psychiatric
Comprehensive Psychiatry 48 (2007) 395 – 399
Naomi Simon is a consultant for Paramount Biosciences and is on the
Speaker's Bureau for Continuing Medical Education and other presentations
for Forest Laboratories, Janssen, Lilly, Pfizer, Sepracor and UCB Pharma.
Dr Simon has participated in clinical trials sponsored by Cephalon, Janssen,
UCB Pharma, and Sepracor. Dr Simon has received investigator-initiated
grants from AstraZeneca, Cephalon, Forest Laboratories, GlaxoSmithKline,
Pfizer, Lilly, the National Institute of Mental Health, and the National
Alliance for Research of Schizophrenia and Depression. Katherine Shear is a
consultant for Pfizer and receives research grant funding from Forest
Laboratories. Charles Reynolds III receives research support in the form of
pharmaceutical supplies for National Institutes of Health–sponsored work
from GlaxoSmithKline, Forest, Pfizer, Lilly, and Bristol-Myers Squibb.
Ellen Frank is a consultant for Pfizer, Eli Lilly, and Novartis. Dr Frank
receives grant support from the National Institute of Mental Health and the
Forest Research Institute and serves on the advisory board for Pfizer, Eli
Lilly, and Servier. Nadine Melhem has received a travel award from the
American Foundation for Suicide Prevention. All other authors declare that
they have no conflicts of interest.
Corresponding author. Tel.: +1 617 726 7913; fax: +1 617 643 3080.
E-mail address: email@example.com (N.M. Simon).
0010-440X/$ – see front matter © 2007 Elsevier Inc. All rights reserved.
disorders such as major depressive disorder (MDD) and
posttraumatic stress disorder (PTSD) [2,17-20]. For exam-
ple, CG symptoms have been shown to contribute to
impairment beyond that associated with PTSD and major
Nonetheless, there is still c ontroversy regarding the
distinctiveness of the syndrome . There are limited
data available examining the co-occurrence of CG disorder
and other Diagnost ic and Statistical Manual of Mental
Disorders, Fourth Edition, (DSM-IV) conditions in clinical
populations with CG. In addition, little has been done to
evaluate the impact of psychiatric comorbidity on the course
or severity of CG. In our pilot study of psychotherapy for 23
individuals with CG , current MDD was present in 52%,
PTSD in 30%, panic disorder in 26%; 48% had more than
one comorbid psychiatric disorder. Coexisting psychiatric
disorders were associated with greater grief severity .
The current article reports secondary analyses conducted
to examine both the question of coexisting psychiatric
disorders and CG symptoms together with the impact of
current psychiatric comorbidity in 206 individuals recruited
for participation in a randomized controlled treatment study
. We hypothesized that (1) a substantial subgroup of
individuals with CG would have no DSM-IV comorbidity,
(2) grief severity would be linked to greater work and social
impairment after controlling for the presence of psychiatric
comorbidity, (3) individuals with psychiatric comorbidity
would have more severe CG symptoms, and (4) comorbid
disorders would commonly be preexisting, supporting the
possibility that mood and anxiety disorders may elevate risk
Data reported here were from participants in a rando-
mized controlled treatment trial comparing traumatic grief
thera py and interp erson al psychotherapy . Br iefly,
bereaved individuals recruited through profes sional referral,
self-referral, and media announcements were assessed with
the Inventory of Complicated Grief (ICG) . Complicated
grief was diagnosed for participants with a score ≥30 on the
ICG at least 6 months after the death of a loved one and with
endorsement of grief as their primary problem. The ICG
score is the sum of ratings for 19 questions that assess the
frequency (from 0 = “never” to 4 = “always”; total scale
range 0-76) of a range of symptoms that may be categorized
as separation distress (eg, recurrent painful emotions about
the loss, yearning and longing for the deceased, preoccupa-
tion with thoughts of the loved one) and traumatic distress
(eg, sense of disbelief regarding the death; anger and
bitterness; distressing, intrusive thoughts related to the death;
and pronounced avoidance of reminders of the painful loss)
[1,14]. The DSM-IV Axis I diagnoses were determined using
the Structured Clinical Interview for DSM-IV (SCID IV)
 administered by master's- or doctoral-level trained and
certified experienced clinical rater s. To fully characterize
current symptoms and disorders without risking errors of
omission due to opinions about causality, raters followed the
convention of assigning symptoms to DSM-IV categories,
even if it seemed that they could be explained by grief. When
comorbidity was present, the patient, clinical evaluators, and
treating thera pists agreed in all cases that CG symptoms were
the primary clinical problem; if another condition was
primary, the patient was not included in the study. All
participants gave informed consent, and the Institutional
Review Boa rd at the University of Pittsburgh Medical Center
approved the study.
For the present report, we examined all patients meeting
the study criteria for CG who completed baseline assess-
ments. Assessments included diagnostic evaluation with the
SCID-IV, ICG, 25-item Hamilton Rating Scale for Depres-
sion , Hamilton Rating Scale for Anxiety , Impact of
Events Sc ale , Pittsburgh Sleep Quality Index , and
Work and Social Adjustment Scale (WSAS) . Age of
onset for DSM-IV disorders was determined from SCID
modules and compared with the self-reported time of the
CG-related death to determine order of onset of the earliest
comorbid Axis I disorder and the loss.
2.1. Statistical methods
Binary proportions were tested with the Fisher exact test; t
tests were used for continuous data. Linear regression was
used to examine the association of CG severity (ICG score)
with work and social impairment (WSAS score) beyond the
contribution of psychiatric comorbidity. We used a P value
.05 for statistical significance.
3.1. Characteristics of participants
Of 417 patients who received an initial brief prescreening
assessment, 217 patients were evaluated; 206 met the study
criteria for CG and were included in analyses. The mean
(SD) age of the sample was 46.5 (12.4) years, and 81.6% (n =
168) were women. They were 70.1% white, 27% African
American, and 2.9% other races (n = 2 missing). The mean
ICG score (n = 206) was 47.1 (±9.6), and the mean time since
the CG-related death (n = 205) was 5.0 ± 7.5 years (range
0.42-51.7 years, median 2.4 years; 1 patient was included
with a duration of only 5 months).
3.2. Presence of psychiatric comorbidity
After assigning symptoms to DSM-IV categories with no
attempt to decide if these symptoms were better explained
by grief, we observed that 51 participants (25%) had no
current DSM-IV Axis I disorder and 16% had no lifetime
disorder (Table 1). With respect to specific comorbid
disorders, 45% (of the entire sample) did not meet the
criteria for current MDD and 28% were free of lifetime
396 N.M. Simon et al. / Comprehensive Psychiatry 48 (2007) 395–399
MDD. Similarly, 51% failed to meet the criteria for current
PTSD and 47% for lifetime PTSD (Fig. 1). Both conditions
share symptoms with CG. Other conditions that were
diagnosed in our grief sample include generalized anxiety
disorder (GAD) and panic with or without agoraphobia
(Table 1). Although analyses were limited by the high
proportion of women and white participants, there were no
sex or race differences in comorbidity rates. Patients with at
least one current comorbid disorder were younger (45.1
[11.5] years) compared with those without comorbidity
(50.6 [14.1] years: t(df) = 2.8(204), P b .01). In addition,
those with psychiatric comorbidity tended to present for
treatment sooner after the loss at the level of a statistical
trend (mean 4.4 [6.2] years vs 6.6 [10.3] years: t(df) = 1.89
(203), P = .06).
Complicated grief patients with psychiatric comorbidity
were more severely ill and more impaired than those
without comorbidity (Table 2). This was also the case for
those with at least one anxiety disorder compared with those
with no anxiety disorder (Table 2). To examine whether the
severity of CG contributes to work and social impairment
above and beyond the presence of current comorbid anxiety
disorders and/or MDD, we examined the prediction of
WSAS score by ICG score in a linear regression including
covariates for MDD and anxiety disorders. The ICG scores
remained significantly associated with greater work and
social impairment (B = 0.43, t = 5.57, P b .001) after
adjustment for current depression and anxiety comorbidity
and also after adjustment for lifetime comorbidity (B = 0.52,
t = 6.74, P b .001).
Most individuals with lifetime psychiatric comorbidity
(75%, 128 of 175) reported an age of onset for at least one
psychiatric disorder before the reported CG-associated loss,
with the earliest disorder onset at a mean of 16.7 ± 14.3
(range 0.2-65.6, 95% confidence interval 14.2-19.2) years
before the loss. Of note, more than 80% of those with MDD
(87%, 127 of 146) and PTSD (82.2%, 88 of 107) reported
onset of the DSM disorder before bereavement.
We found that one fourth of help-seeking CG patients had
no current DSM-IV Axis I comorbidity, despite diagnosing
DSM conditions without judging if they were better
explained by grief. High rates of psychiatric comorbidity
are common in treatment-seeking populations, and our
comorbidity rates are similar to those for mood and anxiety
disorders in the recent replication of the National Comor-
bidity Study [29,30]. Thus, the 25% of our CG sample
without such comorbidity represents psychopathology dis-
tinct from other mood and anxiety disorders.
As predicted, study participants with a comorbid mood or
anxiety disord er were more severely ill ; with g reater
functional impairment, sleep disturbance, depression,
trauma, and general anxiety symptom s; and with higher
levels of grief. Nonetheless, CG severity in and of itself was
linearly associated with greater work and social impairment
after controlling for the presence of psychiatric comorbidity,
thus pr oviding add itional support for its indepe ndent
contribution to impairment. Also of interest, age of onset
of psychiatric comorbidity occurred before bereavement in
most of the patients, suggesting that preexisting psychiatric
illness may be a risk factor for CG . This finding is
similar to data suggesting that individuals with a history of
mood or anxiet y disorders are at increased risk for the
development of PTSD after a traumatic event  and is
consistent with the notion of CG as a stress response disorder
Psychiatric comorbidity in treatment-seeking individuals with CG (n = 206)
Current % (n) Lifetime % (n)
MDD 55.34 (114) 71.84 (148)
PTSD 48.54 (100) 52.91 (109)
Panic disorder 13.59 (28) 21.84 (45)
Agoraphobia without panic 0.97 (2) 0.97 (2)
GAD 18.45 (38) N/A
Social anxiety disorder 7.77 (16) 13.11 (27)
Obsessive-compulsive disorder 6.31 (13) 6.80 (14)
Any anxiety disorder
62.62 (129) 69.42 (143)
Any comorbid disorder 75.24 (155) 84.47 (174)
1 comorbid disorder 24.76 (51) 21.36 (44)
2 comorbid disorders 30.58 (63) 33.01 (68)
3 comorbid disorders 13.59 (28) 18.45 (38)
≥ 4 comorbid disorders 6.31 (13) 11.65 (24)
No comorbid disorder 24.76 (51) 15.53 (32)
Bipolar disorder was an exclusion criterion for randomization in the
treatment study, but was diagnosed in 10 individuals at screening assessment
(6 bipolar I, 4 bipolar II).
The presence of any anxiety disorder was defined as at least one DSM-
IV diagnosis of panic disorder with or without agoraphobia, agoraphobia
without panic, obsessive-compulsive disorder, GAD, PTSD, or social
Fig. 1. Current PTSD a nd MDD comorbidity in treatment-seeking
individuals with CG disorder (n = 206).
397N.M. Simon et al. / Comprehensive Psychiatry 48 (2007) 395–399
[10,16]. Of note, we have also reported high rates of CG
comorbidity in individuals with bipolar disorder: 24% of a
group of patients with bipolar disorder with a lifetime loss
had CG; and its presence was associated with additional
psychiatric comorbidity, greater bipolar disorder severity and
functional imp airment, and lifetime suicide attempts . It
should be noted that another possible explan ation for our
findings is that CG shares underlying risk factors wi th mood
and anxiety disorders; our current data, however, do not
allow examination of this hypothesis.
Among the limitations of our study is that data are derived
from treatment-seeking people who probably have greater
severity and higher rates of comorbidity than a community-
based sample. Furthermore, our cross-sectional data do not
allow determination of causality. In addition, we did not
assess Axis II disorders and thus cannot comment on the
presence or absence of personality disorders in CG. Finally,
it is possible that individuals with substance use disorders
and CG may differ: because current substance use disorders
were exclusionary in the parent study, we could not examine
this question. Despite these limitations, our data demonstrate
that CG occurs without Axis I psychiatric comorbidity in
approximately one fourth of treatment-seeking persons and
that CG contributes to impairment even after controlling for
the effects of coexisting psychiatric disorders. Targeted
treatment of CG symptoms has been asso ciated with
reduction in depression and anxiety , although prior
work has shown that the reverse is not the case [22,32].
Nevertheless, comorbidity is common, frequently begins
before the loss, and is associated with greater severity of
grief intensity. Our results provide support for the distinc-
tiveness and associated impairment of CG. Our findings also
suggest that comorbid disorders may comprise a risk factor
for CG symptoms.
This work was supported by a National Institute of
Mental Health grant to Dr Shear: MH60783. Supported in
part by P30 MH71944 (CFR) and MH30915 (EF), and a
Massachusetts Gene ral Hospital Claflin Distinguished
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Impact of current psychiatric comorbidity on current symptom severity in CG
Current comorbidity ICG (n = 206) HAM-D 25 (n = 187) IES (n = 170) HAM-A (n = 182) PSQI (n = 165) WSAS (n = 164)
MDD (n = 114) 49.5 ± 9.6 (114)*** 30.8 ± 8.4 (106)*** 44.3 ± 14.9 (98)*** 24.3 ± 7.1 (104)*** 10.7 ± 4.2 (94)*** 26.7 ± 9.3 (95)***
Any anxiety disorder
(n = 129)
48.5 ± 9.7 (129)** 27.6 ± 9.9 (122)** 42.4 ± 15.0 (111) 22.6 ± 7.9 (119)*** 10.2 ± 4.2 (107) 24.2 ± 10.2 (106) **
Any comorbid disorder
(n = 155)
48.1 ± 9.6 (155)** 27.8 ± 9.6 (145)*** 42.7 ± 14.9 (131)** 22.5 ± 7.6 (142)*** 10.2 ± 4.1 (127)** 24.7 ± 10.0 (126) ***
No comorbid disorder
(n = 51)
44.1 ± 8.8 (51) 19.7 ± 8.3 (42) 34.7 ± 14.1 (39) 16.0 ± 7.8 (40) 8.2 ± 3.3 (38) 15.9 ± 9.6 (38)
P values are for t tests comparing the particular disorder group to absence of that disorder classification (ie, MDD vs no MDD, at least one anxiety disorder vs no
anxiety disorder, at least one comorbid disorder vs no comorbid disorder). Mean values for the absence of any comorbid psychiatric disorder are also included for
reference. Sample size given for each measure to account for missing data (full sample n = 206).
ICG indicates Inventory of Complicated Grief; HAM-D 25, 25-item Hamilton Depression Scale; IES, Impact of Events Scale; HAM-A, Hamilton Rating Scale
for Anxiety; PSQI, Pittsburgh Sleep Quality Index.
*P b .05, **P b .01, ***Pb .001.
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