Prevalence, comorbidities, and factors associated with prolonged grief disorder, posttraumatic stress disorder and complex posttraumatic stress disorder in refugees: a systematic review.

BACKGROUND: The number of refugees worldwide is at an all-time high with many being exposed to potentially traumatic events and the loss of loved ones. The 11th revision of the International Statistical Classification of Diseases and Related Health Problems now includes prolonged grief disorder and complex posttraumatic stress disorder and revised criteria for posttraumatic stress disorder. An overview of these stress-related disorders among people who have become refugees is therefore needed. Consequently, we conducted a systematic review to determine prevalence rates, comorbidities, and associated factors for each of the disorders. METHOD: We systematically searched PubMed, Web of Science, and PsycArticles to identify studies that reported prevalence rates, predictors or associated factors, and/or comorbid mental disorders for either (1) prolonged grief disorder, (2) posttraumatic stress disorder, or (3) complex posttraumatic stress disorder among refugees. The selection process followed the PRISMA guidelines. RESULTS: A total of 36 studies met the inclusion criteria. Most of the studies were of high quality. There was substantial variation in prevalence rates by disorder, with prolonged grief ranging from 6 to 54%, posttraumatic stress disorder ranging from 0.4 to 80%, and complex posttraumatic stress disorder ranging from 3 to 74.6%. Pooled prevalence for posttraumatic stress disorder was estimated at 29.8% in treatment seeking samples and 9.92% in population samples. For complex posttraumatic stress disorder, it was estimated at 57.4% in treatment seeking samples and 7.8% in population samples. Posttraumatic stress disorder was among the most frequent comorbidities for prolonged grief disorder while depressive symptoms were the most frequently occurring co-morbidity across all three disorders. Sociodemographic variables, trauma exposure, and loss characteristics were associated with higher symptom severity. Postmigration living difficulties played an important role in prolonged grief and complex posttraumatic stress disorder. CONCLUSION: The review revealed substantial differences in prevalence rates between the three studied disorders but underscored a very high prevalence of ICD-11 stress-related disorders among refugees. The identified associated factors point to subgroups that may be particularly at risk and establishes a foundational basis for targeted interventions and potential policy changes. Future research should incorporate longitudinal investigations and emphasize culturally sensitive assessments.

Climate change-related concerns in psychotherapy: therapists' experiences and views on addressing this topic in therapy.

BACKGROUND: While adverse impacts of climate change on physical health are well-known, research on its effects on mental health is still scarce. Thus, it is unclear whether potential impacts have already reached treatment practice. Our study aimed to quantify psychotherapists' experiences with patients reporting climate change-related concerns and their views on dealing with this topic in psychotherapy. METHODS: In a nationwide online survey, responses were collected from 573 psychotherapists from Germany. Therapists reported on the presence of such patients, their socio-demographic characteristics, and climate change-related reactions. Psychotherapists' views on dealing with this topic in psychotherapy were also assessed. Descriptive statistics were used to analyse the responses. RESULTS: About 72% (410/573) of psychotherapists indicated having had patients expressing concerns about climate change during treatment. Out of these therapists, 41% (166/410) stated that at least one patient sought treatment deliberately because of such concerns. Patients were mainly young adults with higher education. Most frequent primary diagnoses were depression, adjustment disorder, and generalized anxiety disorder. Psychotherapists having encountered such patients differed from those without such encounters in their views on potential functional impairment and the necessity to target the concerns in treatment. Although 79% (326/415) of all respondents felt adequately prepared by their current therapeutic skills, 50% (209/414) reported a lack of information on how to deal with such concerns in therapy. CONCLUSIONS: Results indicate that psychotherapists are frequently confronted with climate change-related concerns and regard the mental health impact of climate change on their patients as meaningful to psychotherapeutic care. Regular care could be improved by a continuous refinement of the conceptualization and knowledge of the mental health influences of climate change. This would allow providing tailored methods of assessing and addressing climate change-related concerns in practice.

Cross-national analysis of the prevalence of prolonged grief disorder.

BACKGROUND: Prolonged grief disorder (PGD) is now included as a diagnosis in international classification systems. Most research on PGD is based on Western populations, but first data from non-Western countries have recently become available. Little is still known about country-related effects on PGD's prevalence. OBJECTIVE: Determining possible causes of variations in the prevalence of PGD as defined by DSM-5-TR and ICD-11 within and between countries. METHODS: We retrieved data from 24 prevalence studies, the World Bank and the 2022 World Risk Report. Negative binomial regressions were used to explore methodological, loss-related and country context characteristics as predictors of PGD. The average rate of PGD was calculated using random effects models. RESULTS: The included studies comprised 34 samples from 16 countries (20,347 participants). Non-probability sampling and older mean age of the sample as well as lower country vulnerability were associated with higher PGD rates. The average PGD prevalence was 13 % (95 % CI [11, 22]), varying from 5 % (95 % CI [3, 11]) in probability to 16 % (95 % CI [13, 25]) in non-probability samples. LIMITATIONS: Samples from Europe and North America were overrepresented. For about half of the countries, data were available from only one sample. CONCLUSIONS: While confirming the importance of studies' methodological quality, the results show that PGD is of public health relevance around the world, but especially common in less vulnerabled countries with better access to daily necessities and healthcare services, highlighting sociocultural impacts on grief processing. Further investigations of cross-national differences are needed.

A Mobile-Based Preventive Intervention for Young, Arabic-Speaking Asylum Seekers During the COVID-19 Pandemic in Germany: Design and Implementation.

BACKGROUND: Most individuals seeking asylum in Germany live in collective housing and are thus exposed to a higher risk of contagion during the COVID-19 pandemic. OBJECTIVE: In this study, we aimed to test the feasibility and efficacy of a culture-sensitive approach combining mobile app-based interventions and a face-to-face group intervention to improve knowledge about COVID-19 and promote vaccination readiness among collectively accommodated Arabic-speaking adolescents and young adults. METHODS: We developed a mobile app that consisted of short video clips to explain the biological basis of COVID-19, demonstrate behavior to prevent transmission, and combat misconceptions and myths about vaccination. The explanations were provided in a YouTube-like interview setting by a native Arabic-speaking physician. Elements of gamification (quizzes and rewards for solving the test items) were also used. Consecutive videos and quizzes were presented over an intervention period of 6 weeks, and the group intervention was scheduled as an add-on for half of the participants in week 6. The manual of the group intervention was designed to provide actual behavioral planning based on the health action process approach. Sociodemographic information, mental health status, knowledge about COVID-19, and available vaccines were assessed using questionnaire-based interviews at baseline and after 6 weeks. Interpreters assisted with the interviews in all cases. RESULTS: Enrollment in the study proved to be very challenging. In addition, owing to tightened contact restrictions, face-to-face group interventions could not be conducted as planned. A total of 88 participants from 8 collective housing institutions were included in the study. A total of 65 participants completed the full-intake interview. Most participants (50/65, 77%) had already been vaccinated at study enrollment. They also claimed to comply with preventive measures to a very high extent (eg, "always wearing masks" was indicated by 43/65, 66% of participants), but practicing behavior that was not considered as effective against COVID-19 transmission was also frequently reported as a preventive measure (eg, mouth rinsing). By contrast, factual knowledge of COVID-19 was limited. Preoccupation with the information materials presented in the app steeply declined after study enrollment (eg, 12/61, 20% of participants watched the videos scheduled for week 3). Of the 61 participants, only 18 (30%) participants could be reached for the follow-up interviews. Their COVID-19 knowledge did not increase after the intervention period (P=.56). CONCLUSIONS: The results indicated that vaccine uptake was high and seemed to depend on organizational determinants for the target group. The current mobile app-based intervention demonstrated low feasibility, which might have been related to various obstacles faced during the delivery. Therefore, in the case of future pandemics, transmission prevention in a specific target group should rely more on structural aspects rather than sophisticated psychological interventions.

The Ambiguous Loss Inventory Plus (ALI+): Introduction of a Measure of Psychological Reactions to the Disappearance of a Loved One.

BACKGROUND: The disappearance of a significant person is an ambiguous loss due to the persistent uncertainty about the whereabouts of the person. Measures specifically capturing the psychological consequences of ambiguous loss are lacking. Therefore, this study aimed to develop the Ambiguous Loss Inventory Plus (ALI+) and evaluated its suitability for use with relatives of missing persons. METHODS: ALI+ items were generated based on established measures for prolonged grief symptoms and literature on psychological responses to ambiguous loss. Eight relatives of missing persons (three refugees, five non-refugees) and seven international experts on ambiguous loss rated all items in terms of understandability and relevance on a scale from 1 (not at all) to 5 (very well). RESULTS: On average, the comprehensibility of the items was rated as high (all items ≥ 3.7). Likewise, all items were rated as relevant for the assessment of common responses to the disappearance of a loved one. Only minor changes were made to the wording of the items based on the experts' feedback. CONCLUSIONS: These descriptive results indicate that the ALI+ seems to cover the intended concept, thus showing promising face and content validity. However, further psychometric evaluations of the ALI+ are needed.

Homesickness in asylum seekers: The role of mental health and migration-related factors.

Background: While homesickness in refugees is a recurring theme in clinical practice, respective research in this population is scarce. The Utrecht Homesickness Scale (UHS) allows distinguishing between certain aspects of homesickness, namely genuine separation distress like missing family and friends or yearning for home on the one side and problems regarding adjustment to the new situation on the other; so far, the instrument was applied mainly in samples of university students, and never in refugees. Objective: We aimed to explore homesickness in a refugee population and its association with mental health symptoms and migration-related factors. In addition, we wanted to evaluate the UHS's factor structure in a sample other than students. Methods: Individuals from different countries (N = 99) seeking asylum in Germany were assessed for homesickness, migration-related variables (e.g., number of losses and stage of the asylum proceedings), and mental health symptoms (symptoms of depression, posttraumatic stress and prolonged grief). After exploratory factor analysis, standardized mean factors scores were fed into subsequent correlational and regression analyses to identify the most prominent predictors of homesickness scores. Results: The participants showed substantial levels of homesickness. We found a three-factor solution that implied distinct factors regarding (1) adjustment difficulties and loneliness, (2) ruminations about home, and (3) missing family and/or friends. The total homesickness score was associated with mental health but regression analyses with the three mean factor scores showed differential associations with mental health and migration-related variables. While adjustment difficulties and loneliness were-besides time since arrival in Germany-associated with mental health problems (depressive and posttraumatic stress symptoms), ruminating about home was predicted by migration-related variables (number of losses and asylum status). For the factor scores regarding missing family and/or friends, the regression model was not significant. Conclusion: The assessment of homesickness in refugee populations is feasible and of clinical importance, especially when distinguishing between separation distress and difficulties with adjusting to the new situation.

Introduction and evaluation of a therapeutic adherence and competence scale for grief-focused cognitive behavioural therapy.

Background: There is no therapeutic competence and adherence scale for grief-focused cognitive behavioural therapy (grief-focused CBT). However, given the growing body of evidence for the efficacy of grief-focused CBT, such a scale is needed both to ensure the internal validity of clinical trials and to facilitate psychotherapy process research. Objective: To develop and undertake a psychometric evaluation of a therapeutic adherence and competence scale for grief-focused CBT. Method: The scale was developed in two steps. (I) Five experts on the treatment of prolonged grief disorder provided feedback on the relevance and appropriateness of the items. The scale was revised to reflect their feedback. The final therapeutic adherence and competence scale for grief (TACs-G) consisted of 15 adherence and 16 competence items. (II) Psychometric evaluation of the TACs-G was based on the rating of 48 randomly selected PG-CBT sessions by two independent raters. The videos were recorded in the context of a randomized controlled trial (RCT; DRKS00012317.) ICC was used to calculate inter-rater reliability and TACs-G stability over time (re-evaluation of 10 sessions after 12 months). Results: The five experts confirmed the relevance and appropriateness of the items. Interrater reliability was found to be high for the total adherence and competence scores (ICC = 0.889 and 0.782, respectively) and moderate to excellent for individual items (ICC = 0.509-1.00). The TACs-G stability over time was found to be strong for both adherence (ICC = 0.970) and competence total scores (ICC = 0.965). Conclusions: The TACs-G for CBT is a reliable instrument that can be used not only to ensure internal validity but is also suited for psychotherapy process studies. Additionally, it provides a valuable database for targeted feedback in training settings. HIGHLIGHTS: This is the first study to report on the development and psychometrical evaluation of a grief-focused adherence and competence scale.Although an increasing number of clinical trials do report the efficacy of grief-focused cognitive-behavioural therapy, none of these studies used a standardized adherence and competence scale to control internal validity.In the present study, we introduced a therapeutic adherence and competence scale for grief (TACs-G) that can be applied efficiently across different research settings (e.g. manipulation check, dissemination), and report results of good to excellent psychometric properties.The scale itself could prove useful beyond the research setting as it could possibly serve as a basis for feedback in training settings.

Predictors of Prolonged Grief Disorder in a German Representative Population Sample: Unexpectedness of Bereavement Contributes to Grief Severity and Prolonged Grief Disorder.

Most people adapt to bereavement over time. For a minority, the grief persists and may lead to a prolonged grief disorder (PGD). Identifying grievers at risk of PGD may enable specific prevention measures. The present study examined the extent to which the subjective unexpectedness of the death predicted grief outcomes above and beyond known sociodemographic and objective loss-related variables in a sample drawn from a population-representative investigation. In our sample (n = 2,531), 811 participants (M age 55.1 ± 17.8 years, 59.2% women) had experienced the loss of a significant person six or more months ago. Participants provided demographic and loss-related information, perceptions of the unexpectedness of the death and completed the Prolonged Grief Disorder-13 + 9 (PG-13 + 9). The PG-13 + 9 was used to determine PGD caseness. A binary logistic regression investigated predictors of PGD caseness, and a linear regression predictors of grief severity. ANCOVAs compared PGD symptoms between the groups who had experienced an "expected" vs. "unexpected" loss, while controlling for the relationship to the deceased and time since loss. The loss of a child (OR = 23.66; 95%CI, 6.03-68.28), or a partner (OR = 5.32; 95%CI, 1.79-15.83), the time since loss (OR = 0.99; 95%CI, 0.99-1.00) and the unexpectedness of the death (OR = 3.58; 95%CI, 1.70-7.69) were significant predictors of PGD caseness (Nagelkerke's R2 = 0.25) and grief severity. Participants who had experienced the loss as unexpected (vs. expected) reported higher scores on all PGD symptoms. Unexpectedness of the death emerged as significant risk factor for PGD, even after controlling for demographic and other loss-related variables. While our findings replicate previous research on the importance of the relationship to the deceased as a risk factor for PGD, they also highlight the importance of assessing the subjective unexpectedness of a death and may help to identify risk groups who can profit from preventive interventions.

Beliefs About Causes and Cures of Prolonged Grief Disorder Among Arab and Sub-Saharan African Refugees.

Background: Many refugees have experienced the death of a loved one under traumatic circumstances. Accordingly, the prevalence of Prolonged Grief Disorder (PGD) among refugees is high. Culture-specific symptoms of PGD have been described previously, but beliefs about causes and cures of PGD among refugees remain unknown. We therefore aimed at identifying illness beliefs and treatment expectations regarding PGD among refugees. Method: We focused on refugees from Arab countries (n = 14) and from Sub-Sahara Africa (n = 9) and applied qualitative and quantitative methods. In a semi-structured interview, participants first answered questions about assumed causes and potential cures for prototypical PGD symptoms according to ICD-11 that were presented in a vignette as representatives of their own culture. In the quantitative part, they completed the Cause Subscale of the Illness Perception Questionnaire (IPQ-R) that included additional culture-specific items. Interviews were analyzed with Qualitative Content Analysis. Results: In both groups of refugees, PGD symptoms were predominantly attributed to a close relationship to the deceased, lack of social support, personal vulnerabilities, and circumstances of the death. Participants also named a number of flight-related causes (e.g., inability to perform or participate in rituals, feeling isolated in the host country). None of the participants attributed PGD symptoms to supernatural causes. Descriptive analyses of responses on the IPQ-R indicated that participants predominantly attributed PGD symptoms to psychological causes. Participants believed that PGD can be cured and predominantly mentioned social and religious support. Psychological help was only mentioned by a minority of participants. In both groups, participants emphasized that a therapist must be familiar with the patient's culture and rituals. Participants also mentioned stigma associated with seeking psychological help. Conclusion: Results suggest specific beliefs of refugees regarding causes and cures of PGD as well as similarities with Western conceptualizations. A culture-sensitive approach to the treatment of PGD in refugees that can include knowledge of culture-specific rituals and incorporating religious beliefs as well as decreasing stigma and increasing mental health literacy seem important. The study is limited by its focus on only two groups of refugees and its small sample size.

Same name, same content? Evaluation of DSM-5-TR and ICD-11 prolonged grief criteria.

OBJECTIVE: Investigating the concordance of prolonged grief disorder (PGD) criteria that have been recently introduced to the 5th text revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) and the International Classification of Diseases 11th Revision (ICD-11). METHOD: N = 193 treatment-seeking bereaved adults were assessed with the prolonged grief disorder 13 + 9 interview. Data were examined in terms of (a) diagnostic rates for PGDDSM-5-TR and PGDICD-11, including increases of the PGDICD-11 accessory symptom threshold (PGDICD-11-X+) and time criterion (PGDICD-11-12 months), (b) dimensionality, (c) the frequency with which single PGD symptoms occur, and (d) concurrent validity in terms of psychological symptoms and loss-related characteristics. RESULTS: The diagnostic rate of PGDDSM-5-TR (52%) was significantly lower than that of PGDICD-11 (76%) and agreement between the two criteria sets was moderate, κ = 0.51, 95% CI [0.47-0.55]. Increasing the PGDICD-11 accessory symptom threshold did not improve the diagnostic agreement. In contrast, increasing the ICD-11 time criterion led to almost perfect agreement between PGDICD-11-12 months and PGDDSM-5-TR, κ = 0.91, 95% CI [0.89-0.93]. Confirmatory factor analysis results indicated a one-factor model fit best for both PGDDSM-5-TR and PGDICD-11. Emotional pain symptoms (e.g., guilt) were predominantly reported by patients with a PGDICD-11 diagnosis, while attachment disturbance symptoms (e.g., identity disruption) were reported more often by patients with a PGDDSM-5-TR diagnosis. CONCLUSIONS: Despite methodological limitations of this study, results indicate discordance in PGDDSM-5-TR and PGDICD-11 regarding diagnostic rates and single symptom occurrence, while the factor structure is similar. Changes in the ICD-11 time criterion could reduce these differences. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Prolonged grief in refugees living in Germany confronted with ambiguous or confirmed loss.

BACKGROUND AND OBJECTIVES: People often disappear in the context of displacement or armed conflicts. Although such an ambiguous loss is accompanied by persistent uncertainty about the whereabouts, the psychological consequences are not well understood. This study investigated the effects of ambiguous compared to a confirmed loss on prolonged grief disorder (PGD) and its correlates in refugees to Germany. METHODS AND DESIGN: We investigated data on mental health outcomes of refugees from Syria, Iraq, Iran and Afghanistan who had applied for/were granted asylum in Germany. In a secondary analysis, we compared 87 refugees with disappeared (n = 33) and deceased relatives (n = 54) who had completed questionnaire-based interviews. RESULTS: Participants with ambiguous loss displayed more severe symptoms of PGD than those with confirmed loss. However, we found no group differences in terms of probable disorder rates and the number of traumatic experiences. Even after controlling for several correlates of PGD, higher PGD symptom severity was associated with ambiguous loss, more PTSD symptoms and low perceived social support. CONCLUSIONS: These results show a higher prolonged grief symptom severity after the loss of a significant other due to disappearance, indicating that this type of loss could be a specific risk factor for PGD severity.

The German Translation of the Stress and Anxiety to Viral Epidemics-9 (SAVE-9) Scale: Results from Healthcare Workers during the Second Wave of COVID-19.

Healthcare workers (HCW) are among those most directly affected by the COVID-19 pandemic. Most research with this group has used ad hoc measures, which limits comparability across samples. The Stress and Anxiety to Viral Epidemics-9 scale (SAVE-9) is a nine-item scale first developed in Korea, and has since been translated into several languages. We report on data collected from 484 German HCW between November 2020 and March 2021, during the "second wave" of coronavirus infections. We conducted item analysis, confirmatory factor analysis on the previously found factor solutions of the SAVE-9, examined correlations with established measures of depression, generalized anxiety, and insomnia, and compared scores between different groups of HCW. The psychometric properties of the German SAVE-9 were satisfactory and comparable to previous findings from Korea and Russia. Correlations with mental health measures were positive, as expected. We found some significant differences between groups of HCW on the SAVE-9 which were consistent with the literature but did not appear on the other mental health measures. This suggests that the SAVE-9 taps into specifically work-related stress, which may make it a helpful instrument in this research area.

Feasibility of Present-Centered Therapy for Prolonged Grief Disorder: Results of a Pilot Study.

Present-centered therapy (PCT) was originally developed as a strong comparator for the non-specific effects of psychotherapy in the treatment of posttraumatic stress disorder. PCT qualifies as a not strictly supportive treatment as it is structured and homework is assigned between sessions. It does not focus on cognitive restructuring or exposure. A growing body of literature supports its beneficial effects. For example, it demonstrated only slightly inferior effect sizes and lower dropout rates compared to that of trauma-focused cognitive behavioral therapy in several trials with patients suffering from posttraumatic stress disorder. The current study is the first to evaluate the feasibility and the treatment effects of PCT in adults with prolonged grief disorder (PGD). Meta-analyses on psychotherapy for PGD have yielded moderate effect sizes. N = 20 individuals suffering from PGD were treated with PCT by novice therapists as part of a preparation phase for an upcoming RCT in an outpatient setting. Treatment consisted of 20-24 sessions á 50 min. All outcomes were assessed before treatment, at post-treatment, and at the 3-month follow-up. The primary outcome, PGD symptom severity, was assessed using the Interview for Prolonged Grief-13. Secondary outcomes were self-reported PGD severity, depression, general psychological distress, and somatic symptom severity. Furthermore, therapists evaluated their experiences with their first PCT patient and the treatment manual. In intent-to-treat analyses of all patients we found a significant decrease in interview-based PGD symptom severity at post-treatment (d = 1.26). Decreases were maintained up to the 3-month follow-up assessment (d = 1.25). There were also significant decreases in self-reported PGD symptoms, depression, and general psychological distress. No changes were observed for somatic symptoms. The completion rate was 85%. Therapists deemed PCT to be a learnable treatment program that can be adapted to the patient's individual needs. The preliminary results of PCT as a treatment for PGD demonstrate large effects and indicate good feasibility in outpatient settings. The treatment effects were larger than those reported in meta-analyses. Thus, PCT is a promising treatment for PGD. Possible future research directions are discussed.

Prevalence of prolonged grief disorder.

BACKGROUND: Prolonged grief is a disorder (PGD) characterized by severe and disabling grief reactions for an extended period of time after the loss of a significant person. ICD-11 and DSM-5-TR differ substantially in individual criteria. OBJECTIVE: Estimation of the respective prevalence of PGDICD-11 and PGDDSM-5-TR and the frequency with which single symptoms of prolonged grief occur in the general population. METHODS: Out of a representative sample of the German general population (N=2498), n = 914 reported a significant loss and prolonged grief symptoms based on the extended version of the self-reported Prolonged Grief Disorder-13+9 (PG13+9). Sociodemographic and loss-related characteristics were collected. RESULTS: The probable prevalence of PGDICD-11 was 1.5% and that of PGDDSM-5-TR was 1.2% in the general sample. Among bereaved persons (n=914), the prevalence of developing PGDICD-11 was 4.2% and that of PGDDSM-5-TR was 3.3%. Diagnostic agreement between the two criteria-sets was very high and did not increase after heightening the accessory symptom threshold for PGDICD-11. Difficulties accepting the loss was the most frequent single symptom (14-25%) and grief-related impairment was common (10-16%). Over 60% of participants with a probable PGD diagnosis utilized health care services. LIMITATIONS: Results are based on self-reported data. The PG13+9 was not designed to assess grief symptoms according to ICD-11 and DSM-5-TR diagnostic criteria. CONCLUSIONS: Prolonged grief according to ICD-11 and DSM-5-TR is a notable disorder in the general population. Among bereaved persons, single symptoms of prolonged grief are relatively frequent and cause substantial degrees of impairment.

Ecological Grief as a Response to Environmental Change: A Mental Health Risk or Functional Response?

The perception of the impact of climate change on the environment is becoming a lived experience for more and more people. Several new terms for climate change-induced distress have been introduced to describe the long-term emotional consequences of anticipated or actual environmental changes, with ecological grief as a prime example. The mourning of the loss of ecosystems, landscapes, species and ways of life is likely to become a more frequent experience around the world. However, there is a lack of conceptual clarity and systematic research efforts with regard to such ecological grief. This perspective article introduces the concept of ecological grief and contextualizes it within the field of bereavement. We provide a case description of a mountaineer in Central Europe dealing with ecological grief. We introduce ways by which ecological grief may pose a mental health risk and/or motivate environmental behavior and delineate aspects by which it can be differentiated from related concepts of solastalgia and eco-anxiety. In conclusion, we offer a systematic agenda for future research that is embedded in the context of disaster mental health and bereavement research.

Challenges in recruiting and retaining adolescents with abuse-related posttraumatic stress disorder: lessons learned from a randomized controlled trial.

BACKGROUND: Research on effective recruitment and retention strategies for adolescents and young adults suffering from posttraumatic stress disorder is scarce. The aim of the current study was to provide data on recruitment sources, barriers, and facilitators for participation in a randomized controlled trial for young individuals with histories of sexual and/or physical abuse. METHODS: Study participants aged 14 to 21 were asked to complete a checklist on individual sources of recruitment, barriers, and facilitators for participation in the trial. Fifty-three out of the 80 study participants who were contacted completed the checklist (66.3%). RESULTS: Most respondents reported multiple recruitment sources, with online and media advertising search strategies indicated most frequently (45.4% of all mentions), followed by practitioner-referred sources (38.7%). Respondents' reported barriers included additional demands of the trial (60.3%), followed by distress caused by having to talk about painful topics (15.5%). The most frequently indicated facilitators were the organizational setting (55.1%) and monetary incentives (22.2%), followed by social support (12.0%) and non-monetary incentives (10.2%). No significant differences were observed between adolescent and young adult respondents with the exception that adolescents reported significantly more frequently that they had learned about the trial from their caregiver. CONCLUSIONS: Our findings permit the formulation of recommendations for planning and conducting trials with this clientele. Future research is needed on how specific barriers can be effectively overcome.

When does grief become pathological? Evaluation of the ICD-11 diagnostic proposal for prolonged grief in a treatment-seeking sample.

Background: Prolonged grief disorder (PGD) will be newly included in the ICD-11, while a clinically similar diagnosis, persistent complex bereavement disorder (PCBD), has already been added to the DSM-5. Only few studies have evaluated these criteria-sets for prolonged grief. Objective: The aim of this study was to evaluate the ICD-11 accessory symptom threshold and compare the diagnostic performance of the two criteria-sets in treatment-seeking bereaved persons. Method: 113 grief treatment-seeking bereaved persons completed the Interview for Prolonged Grief-13. We used receiver operator characteristic analysis to determine an optimum ICD-11 accessory symptom threshold. We calculated diagnostic rates for PGD and PCBD and examined associations of PGD and PCBD caseness with concurrently assessed psychopathology and prolonged grief symptoms assessed one month later. Results: An ICD-11 threshold of six accessory symptoms distinguished optimally between interview-diagnosed participants with and without prolonged grief. The prevalence of PGD (69%) was significantly higher than that of PCBD (48%) and of PGD with a 6-symptom threshold (47%). PGD caseness was associated with the relation to the deceased, 6-symptom threshold PGD and PCBD caseness with the time since loss. All criteria-sets were linked to concurrent prolonged grief, depression, and general mental distress. PCBD and 6-symptom threshold PGD but not PGD were associated with prolonged grief severity one month later. Conclusions: The results support the validity of PGD and PCBD but, at the same time, they provide further support for differing prevalence rates. Using an empirically determined ICD-11 accessory symptom threshold could prevent the pathologisation of grief reactions.

Antecedentes: El trastorno de duelo prolongado (PGD) se incluirá nuevamente en el CIE-11, mientras que un diagnóstico clínicamente similar, el trastorno de duelo complejo persistente (PCBD), ya se ha agregado al DSM-5. Solo unos pocos estudios han evaluado este conjunto de criterios para el duelo prolongado.Objetivo: El objetivo de este estudio fue evaluar el umbral de síntomas accesorios de la CIE-11 y comparar el rendimiento diagnóstico de dos conjuntos de criterios en personas en duelo que buscan tratamiento.Método: 113 personas en procesos de duelo en busca de tratamiento completaron la Entrevista para el Duelo Prolongado-13. Utilizamos el análisis característico del operador receptor para determinar un umbral óptimo de síntomas accesorios CIE-11. Calculamos las tasas de diagnóstico para PGD y PCBD y examinamos las asociaciones de ambas tasas con psicopatología evaluada de manera concurrente y síntomas de duelo prolongado evaluados un mes después.Resultados: Un umbral de CIE-11 de seis síntomas accesorios distinguió de manera óptima entre los participantes diagnosticados con y sin duelo prolongado. La prevalencia de PGD (69%) fue significativamente mayor que la del PCBD (48%) y de PGD con un umbral de 6 síntomas (47%). Los casos de PGD se asociaron con la relación de fallecidos, los 6 síntomas umbrales de PGD y casos de PCBD con el tiempo transcurrido desde la pérdida vivida. Todo el conjunto de criterios se vinculó al duelo prolongado concurrente, la depresión y la angustia mental general. El PCBD y el umbral de 6 síntomas PGD, pero no el PGD total, se asociaron con la severidad del duelo prolongado un mes después.Conclusiones: Los resultados respaldan la validez de PGD y PCBD pero, al mismo tiempo, brindan respaldo para las diferentes tasas de prevalencia encontradas. El uso de un umbral de síntomas accesorio CIE-11 determinado empíricamente podría prevenir la patologización de las reacciones de duelo.