Complicated Grief Treatment Trumps Depression Therapy

Deborah Brauser

September 25, 2014

(Updated Sept. 26, 2014) An intervention specifically targeting symptoms of complicated grief, a debilitating state of prolonged, acute grief, is superior to a treatment used for depression, a new study shows.

Dr. M. Katherine Shear

A randomized controlled trial of 151 older adults with complicated grief showed that those who received 16 sessions of complicated grief treatment (CGT) had more than twice the response rate 5 months later than those who received 16 sessions of interpersonal psychotherapy (IPT). In addition, the CGT group showed significantly greater decreases in symptoms and in illness severity and greater improvements on a scale of complicated grief impairment.

Overall, CGT presented better findings than "a proven efficacious treatment for depression," write the investigators, led by M. Katherine Shear, MD, professor of psychiatry at Columbia University in New York City and director of the Center for Complicated Grief at the Columbia University School of Social Work.

"Results strongly support the need for physicians and other health care providers to distinguish CG [complicated grief] from depression," they write.

"CG is a reaction to a specific life event; and the primary emotion is a combination of sadness and yearning, whereas for major depression, it's sadness and loss of interest," Dr. Shear told Medscape Medical News. "It's also important that clinicians realize that it is treatable in older adults the same way as in younger individuals."

The study was published online September 24 in JAMA Psychiatry.

Complicated Grief Underrecognized

"Complicated grief is an under-recognized public health problem that likely affects millions of people in the United States, many of them elderly," write the researchers.

Approximately 9% of bereaved older women experience complicated grief, characterized by a state of prolonged, acute grief and difficulty imagining a meaningful future, they noted. Although IPT is commonly used for depression, symptoms of complicated grief do not appear to respond well to this form of treatment, the authors add.

For the current study, 151 New Yorkers who were 60 years of age or older (mean age, 66.1 years; 81.5% women; 86% white, 8% Hispanic) were enrolled between August 2008 and January 2013. The median time since loss of loved one was 3.2 years. All participants scored at least 30 on the Inventory of Complicated Grief (ICG).

The participants were randomly assigned to receive 16 weekly sessions of either CGT (n = 74) or IPT (n = 77). CGT was based on an "attachment theory model," which sought to facilitate natural mourning by focusing on loss and restoration, and included techniques derived from prolonged exposure and motivational interviewing.

IPT consisted of discussions about the effect of bereavement on mood, realistic assessments of the deceased, and ways to enhance current relationships and activities.

Assessments by independent evaluators were conducted at baseline and at 8, 16, and 20 weeks after baseline, and self-report questionnaires were filled out by the participants.

The primary outcome measure was treatment response 20 weeks after baseline, which was defined as "much" or "very much" improved (a score of 1 or 2) on the Improvement subscale of the Clinical Global Impression Scale (CGI-I). Secondary measures included the CGI Severity subscale and the Inventory of Complicate Grief (ICG).

Results showed that both treatment groups had improved complicated grief symptom scores. However, treatment response was achieved by 70.5% of those receiving CGT vs 32% of those receiving IPT (cohort relative risk [RR], 2.20; P < .001). The RR was 2.08 when adjusted for comorbid posttraumatic stress disorder (P < .001).

In addition, significantly fewer members of the CGT group were still considered at least moderately ill at the week-20 follow-up, based on CGI Severity scores, compared with members of the IPT group (35.2% vs 64.1%, respectively).

Public Health Implications?

Rate of improvement, as measured by the ICG, was also significantly higher for those receiving CGT, at 1.05 points per week, vs 0.75 points per week for those receiving IPT (P < .001). The cumulative between-group difference at 20 weeks was 6.10 points.

Furthermore, the CGT group had greater rates of improvement on the Work and Social Adjustment Scale (0.63 points per week vs 0.39 points, respectively; P = .004), the Grief-Related Avoidance Questionnaire (0.56 points per week vs 0.33 points, respectively; P < .05), and the Beck Depression Inventory (0.6 points per week vs 0.41 points per week, respectively; P = .03).

There was no discontinuation due to treatment-related adverse effects, and overall drop-out rates were similar (13 of the CGT members vs 14 of the IPT members).

Additional analyses at a 6-month follow-up with 112 of the participants showed that 100% of the 38 CGT responders and 86.4% of the 22 IPT responders had maintained their response to treatment.

"Results...indicated that CGT is statistically and clinically superior to IPT in ameliorating CG symptoms and impairment and statistically superior in the rate of improvement in depression," write the investigators.

"Given a growing elderly population, increased rates of bereavement with age, and the distress and impairment associated with CG, effective treatment should have important public health benefits," they add.

When asked for comment, Annelle Primm, MD, MPH, deputy medical director for the American Psychiatric Association (APA), told Medscape Medical News that she agreed that it is important for clinicians to realize that complicated grief is different from other disorders.

Dr. Annelle Primm

"While complicated grief and depression have many symptoms in common, complicated grief is distinguished by the presence of severe grief symptoms over an extended period of time," said Dr. Primm, who was not involved with this research.

On the basis of the current study, "it appears that older adults with complicated grief may benefit from therapy specifically tailored to helping patients develop healthier responses to loss," she added.

Dr. Shear reports having received a contract to write a book on grief. The other study authors have reported no relevant financial relationships.

JAMA Psychiatry. Published online September 25, 2014. Abstract

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