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Posttraumatic Symptoms and Change of Complicated J Korean Med Sci. 2019 Jul 22;34(28):e194 https://doi.org/10.3346/jkms.2019.34.e194 eISSN 1598-6357·pISSN 1011-8934 Original Article Posttraumatic Symptoms and Change Psychiatry & Psychology of Complicated Grief among Bereaved Families of the Sewol Ferry Disaster: One Year Follow-up Study Hyesung Han ,1,2* Ji-Ae Yun ,3* Hyu Jung Huh ,1 Seung Huh ,1 Jihyun Hwang ,1 Ji-Young Joo ,1 Young-Ae Yoon ,1 Eun-Gyeong Shin ,1 Won Joon Choi ,1 Sangmin Lee ,1 and Jeong-Ho Chae 1 1Department of Psychiatry, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea 2Good Image Clinic, Seoul, Korea 3Department of Neuropsychiatry, Eulji University Hospital, Daejeon, Korea Received: Mar 29, 2019 ABSTRACT Accepted: Jul 5, 2019 Address for Correspondence: Background: The objective of this study was to determine whether severity and severity Jeong-Ho Chae, MD change of coexisting psychiatric symptoms might affect change of complicated grief (CG) Department of Psychiatry, Seoul St. Mary's regarding the Sewol ferry disaster. Hospital, College of Medicine, The Catholic Methods: Data from a cross-sectional survey were obtained 18 months (Time 1) and 30 months University of Korea, 222 Banpo-daero, Seocho- gu, Seoul 06591, Korea. (Time 2) after the disaster. We ascertained sociodemographic variables and variables obtained E-mail: [email protected] from self-reporting questionnaires (i.e., CG, depression, anxiety, post-traumatic stress disorder [PTSD], insomnia, embitterment, and suicidal risk) among 56 bereaved family members. *Hyesung Han and Ji-Ae Yun contributed Results: Severity of other psychiatric symptoms at Time 1 had no effect on change of CG at equally to this work. Time 2. However, changes in severity of PTSD over a year affected change of CG. © 2019 The Korean Academy of Medical Conclusion: It is important to evaluate changes in severity of PTSD and its treatment during Sciences. management of CG, especially when it involves bereaved families experiencing a traumatic This is an Open Access article distributed accident. under the terms of the Creative Commons Attribution Non-Commercial License (https:// Keywords: Grief; Bereavement; Disasters; Traumatic Loss creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly INTRODUCTION cited. ORCID iDs Studies have suggested that most people can adapt to traumatic loss with a reduction in Hyesung Han grief intensity in about 6 months.1 However, people afflicted with complicated grief (CG) https://orcid.org/0000-0002-2994-0421 are essentially frozen or stuck in a state of chronic mourning for 6–12 months or longer after Ji-Ae Yun the loss.2 The prevalence of CG varies depending on studies. According to a previous study, https://orcid.org/0000-0002-6682-3275 CG occurs in about 10% of individuals who have experienced bereavement.3 Individuals Hyu Jung Huh https://orcid.org/0000-0001-8050-9189 with CG also suffer from intense longing or yearning for the dead person. CG is known to Seung Huh cause significant distress and functional impairment clinically.4 Therefore, it is clinically https://orcid.org/0000-0001-8378-0177 meaningful to conduct a study defining the diagnostic criteria for CG and identify factors Jihyun Hwang affecting its onset, course, and treatment. https://orcid.org/0000-0003-1553-3857 https://jkms.org 1/13 Effects of PTSD on Complicated Grief Ji-Young Joo CG is closely related to other psychiatric symptoms. The prevalence of CG is high among https://orcid.org/0000-0002-8753-2768 individuals with a history of psychiatric disorder.3 Grief is known to affect the onset and Young-Ae Yoon course of other psychiatric symptoms.3 Grief often serves as a stress factor that increases https://orcid.org/0000-0003-1789-7582 the risk of depression and anxiety disorders, panic disorder, post-traumatic stress disorder Eun-Gyeong Shin https://orcid.org/0000-0001-8426-7826 (PTSD), insomnia, suicidal thoughts and attempts, and challenges associated with alcohol Won Joon Choi abuse.5-7 Particularly, when normal grief is followed by CG, he or she is more likely to manifest https://orcid.org/0000-0002-6729-9233 comorbid mental disorders. A study has found that 75.2% of individuals diagnosed with CG Sangmin Lee manifest other psychiatric symptoms of axis I in Diagnostic and Statistical Manual of Mental https://orcid.org/0000-0001-5954-9442 Disorders, Fifth Edition (DSM-5).7,8 Due to correlation between CG and other psychiatric Jeong-Ho Chae https://orcid.org/0000-0002-6070-9324 symptoms, previous studies have attempted to elucidate CG as a symptom associated with depressive disorder, PTSD, or adjustment disorder rather than as an independent diagnosis.2,9 Funding However, several studies have suggested that CG is an independent disorder that can be This research was supported by a grant of the distinguished from other psychiatric disorders.1,10 In recent years, persistent complex Korea Health Technology R&D Project through bereavement disorder has been included in the criteria for ‘conditions for further study’ in the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of DSM-5. Further studies are required to determine the correlation between other psychiatric Health & Welfare, Republic of Korea (grant No. symptoms and CG for independent diagnosis of CG under diagnostic criteria of DSM officially. HM15C1054). Previous studies on the relationship between CG and other psychiatric symptoms have Disclosure The authors have no potential conflicts of mainly investigated how clinically different symptoms of CG and other psychiatric symptoms interest to disclose. are distinguished and what symptoms are mainly coexisted with CG.5,11-13 Few studies have explored the severity of other coexisting psychiatric symptoms or longitudinal effects Author Contributions of change of coexisting psychiatric symptoms.14,15 Accurate diagnosis of CG for prompt Conceptualization: Han H. Data curation: Han H, Huh S, Hwang J, Joo JY, Yoon YA, intervention requires insight into the effect of other coexisting psychiatric symptoms on Shin EG, Choi WJ, Lee S. Formal analysis: Han change of CG. In particular, a few studies have reported high prevalence of CG and high H, Huh HJ, Hwang J. Investigation: Han H. probability of other psychiatric symptoms in those suffering from traumatic loss.16,17 Methodology: Han H, Huh HJ, Huh S, Hwang However, studies analyzing the impact of other psychiatric symptoms on change of CG in J, Joo JY. Software: Han H. Validation: Han H. those afflicted with traumatic loss are limited. Therefore, we conducted a longitudinal study Writing - original draft: Han H. Writing - review of change in CG involving bereaved families following traumatic loss in the Sewol ferry & editing: Han H, Yun JA. disaster. We assessed the severity of CG and severity of other psychiatric symptoms including depression and anxiety disorders, PTSD, post-traumatic embitterment disorder (PTED), insomnia, and suicidal risk at 18 months (Time 1) and 30 months (Time 2) after the loss. The objective of this study was to investigate the effect of severity of other psychiatric symptoms at Time 1 and the change of coexisting psychiatric symptoms at Time 2 on change of CG. METHODS Participants We contacted representatives of families who lost their family member in the Sewol ferry disaster at Ansan, Korea, to explain the purpose of this study. Study goals conveyed included identification of the risk and prognostic factors affecting mental health of individuals who had experienced death of a family member. After obtaining agreement from representatives, 93 bereaved family members were surveyed for Time 1 after obtaining informed consent from all participants. Psychiatrists specializing in the field of disaster mental health interviewed participants. Sociodemographic data and psychiatric scales were retrieved from self- reporting questionnaires. One of them died of lung cancer within a year. Thirty subjects refused to participate in the longitudinal study. Six were excluded because of missing data of psychiatric scales. Finally, 56 (60.2%) of 93 subjects were included in the analysis. A flow diagram of the participants in this longitudinal study is presented in Fig. 1. https://jkms.org https://doi.org/10.3346/jkms.2019.34.e194 2/13 Effects of PTSD on Complicated Grief months postdisaster bereaved families Time Self-report questionnaires Sociodemographic variables, complicated grief (ICG), Excluded: depression (PHQ-), · psychometric measure missing anxiety (GAD-), PTSD (PCL-), · death insomnia (ISI), · drop-out embitterment (PTED), suicidal risk (P) months postdisaster Time used in analysis Fig. 1. Flow diagram of participants in the study of bereaved family members of the Sewol ferry disaster. ICG = inventory of complicated grief, PHQ-9 = patient health questionnaire-9, GAD-7 = generalized anxiety disorder 7-item questionnaire, PCL-5 = PTSD checklist-5, ISI = insomnia severity index, PTED = post-traumatic embitterment disorder. Those lost to attritions (n = 37, 39.8%) did not differ from study participants in terms of sociodemographic factors (age: t = 1.506, P = 0.136; gender: χ2 = 0.797, P = 0.399; marital status: χ2 = 3.074, P = 0.233; religion: χ2 = 7.493, P = 0.130; and education: χ2 = 3.491, P = 0.206) or psychiatric symptoms (depression: t = 0.673, P = 0.503; anxiety: t = 0.616, P = 0.540; PTSD: t = 0.891, P = 0.375; CG: t = 1.159, P = 0.250; and embitterment, t = 0.559, P = 0.578) at Time 1. Measures Sociodemographic variables included age, gender, relationship with a victim, educational level, marital status, religion, total monthly income of the household, experience of visiting a mental hospital or undergoing counseling for psychological therapy before the accident, and birth order of victim. We used self-reported questionnaires to investigate CG and other psychiatric symptoms. Inventory complicated grief (ICG) ICG is a self-rated inventory developed to evaluate the symptom of grief in order to predict functional mental disorders.18 The instrument consists of 19 items related to subjects' immediate bereavement-related thoughts and behaviors.
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