The CAG is one of the largest disaster-related surveys that screened for CG and the first to investigate CG associated with non-bereavement 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-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-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 post-disaster 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 non-bereavement loss. Interestingly, because of the comparatively low prevalence 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 mood-anxiety disorders[27,64,65]
and suicidal ideation[66–69]
is consistent with previous research, and was particularly common (over 80%) among 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 non-bereavement 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 disadvantage.[18,25,64]
This failure to find strong socio-demographic correlates of CG is part of a larger pattern in the CAG for socio-demographics 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 socio-demographic advantage, leading to a wider distribution of psychopathological reactions than in more typical natural disasters.
Another CAG finding consistent with previous research is that pre-hurricane history of psychopathology strongly predicted clinically significant 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 predicted bereavement-related CG but not other CG, while pre-hurricane history of psychopathology and social competence predicted only non-bereavement-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 non-bereavement 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 education) 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 factor. Studies of social support in older bereaved samples indicate an association between greater emotional 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 non-bereavement loss raises the possibility that protective effects of social competence might be specific to interpersonal losses. All these specifications need to be replicated in other datasets, though, before they are considered reliable.
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 under-representation 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 5 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 12+ 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 misclassification 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 g for 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 sub-sample (1.3%), minimizing the impact of this problem. These limitations 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 non-death 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 post-disaster interventions for grief have been developed, although not systematically tested,
and could be applied if clinicians increased their recognition of potentially problematic post-disaster 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 post-disaster CG are large enough to warrant systematic investigation of these possibilities.