Exposure Therapy Boosts CBT Impact in Prolonged Grief

Liam Davenport

October 22, 2014

Exposure therapy that involves repeatedly reliving the death of a loved one enhances the effect of cognitive-behavioral therapy (CBT) in patients with prolonged grief disorder (PGD), leading to a greater reduction both in symptoms and in the number of patients meeting PGD criteria compared with CBT alone.

"I think the take-home message for us is that you really do need to be doing this emotional engaging in treatment," lead researcher Richard A. Bryant, PhD, of the University of New South Wales, Sydney, Australia, told Medscape Medical News.

"It is difficult for patients, and they found it very difficult. But without exception, those who did it said they were glad that they did, because it apparently facilitated their capacity to re-engage with the grief process, reframe a lot of their beliefs about things, engage in new relationships, and set up new goals and activities for the future," he added.

"That then translates into the quantitative responses we have in terms of people showing better functioning."

The study was published online October 22 in JAMA Psychiatry.

For the study, 80 patients with PGD were randomly assigned to CBT/exposure therapy (n = 41) or CBT alone (n=39). Both groups completed 10 weekly 2-hour group CBT therapy sessions, alongside which they received four individual sessions of either exposure therapy or the opportunity to discuss whatever they preferred.

Measures of depression, cognitive appraisals, and functioning, in addition to the Complicated Grief Assessment interview, revealed that CBT/exposure led to greater reductions in depression, negative appraisals, and functional impairment than CBT alone at 6-month follow-up.

Furthermore, fewer patients in the CBT/exposure group met the criteria for PGD than those in the CBT-alone group, at 14.8% vs 37.9% (odds ratio, 3.51; P = .04). The number needed to treat was 4.32.

There was, however, no impact on antidepressant use with CBT/exposure therapy.

The researchers conclude: "In the most valuable lesson from this study, optimal gains with PGD patients are achieved when the emotions associated with the memories of the death and the sequelae of the loss are fully accessed."

Innovative, Helpful

Commenting on the findings for Medscape Medical News, 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, said that the research was "innovative and helpful."

"The two things I think that are particularly useful about it was that the treatment was delivered in groups, [and] often a question that people ask is whether the treatment can be delivered in a group setting," Dr Shear said. "I think that's a real positive."

"The other thing, of course, is the randomization...I think those two things were quite innovative."

The research complements a study conducted by Dr Shear and colleagues and reported by Medscape Medical News. This showed that 151 older adults with complicated grief who received 16 sessions of complicated grief treatment had more than twice the response rate 5 months later than those who received 16 sessions of interpersonal psychotherapy.

Dr Shear noted that the CBT-based approach utilized by Dr Bryant and colleagues lacks some of the more grief-specific approaches in her study, such as aspirational goals and situational revisiting.

Separate From Depression

Nevertheless, both studies underline the fact that PGD is an entity in its own right, separate from depression.

"There's been an enormous amount of work done over the last decade or so demonstrating that probably 7% to 10% of bereaved have what we call prolonged grief, which is really characterized by long-term yearning, missing the person, and all the emotional sequelae that go with that," said Dr Bryant.

"Why it matters is because it is associated with a lot of mental, physical, and social problems, including suicidality, poor health behaviors, comorbidity, and cardiovascular and immunological disease."

Dr Bryant emphasized that the previously available treatment options for PGD have been inadequate: "Grief counseling has been around for decades, and essentially what a lot of the evidence shows now is that it is largely ineffective in limiting these persistent grief reactions."

"We really need to start coming up with treatments that are targeted towards prolonged grief, because, as it stands,...many of them are probably being inaccurately treated with antidepressants, as they are seen as depressed."

The supposed lack of effectiveness of antidepressants in PGD is indeed used to define the disorder.

Not Included in DSM-5

However, Dr Shear disagrees with this assumption, and is taking part in a large, four-site study in the United States to examine the effects of antidepressants in PGD patients.

"We are guessing that the antidepressants will be somewhat helpful ― helpful enough to be a significant difference," Dr Shear said, adding: "The reason we got that study funded is because there is unclarity in the existing data about the question of whether antidepressant medication works."

"You know, antidepressant medication is called that because it just happens to have been used first for depression, but it really helps lots of things," she said.

However, the greatest task facing researchers and clinicians tackling PGD is simply to get it recognized. "I was on the committee for DSM-5, where I was trying to get prolonged grief introduced as a new diagnosis there," said Dr Bryant.

"It got rejected, which I found somewhat disturbing, given the weight of evidence that it has behind it relative to the weight that other new diagnoses had that were accepted."

This is part of a wider lack of acceptance of grief as a psychiatric condition. Dr Bryant emphasized: "If you look in the community, in psychiatry and in medicine generally, there is a very strong emotive argument made by many, many people that we should not be medicalizing or pathologizing grief."

"Essentially, the argument is that, of course, it is a ubiquitous condition that nearly everybody will experience at some point in their lives, [and] obviously there are cultural and religious morals that people follow, and this is another example of psychiatry or medicine overstepping its mark."

He continued: "My counterargument to that is that we know that a small minority of people are going to be having marked physical, psychological, and social problems as a result of this, and it's basically unethical to be ignoring that, given the weight of evidence that we have across many studies across many cultures, and across the lifespan of people having this same constellation of symptoms."

The study was supported by a grant from the National Health and Medical Research Council Program and a grant from the National Health and Medical Research Council Project. Dr Bryant reports no relevant financial relationships. Dr. Shear reports receiving a contract to write a book on grief.

JAMA Psychiatry. Published online October 22, 2014. Abstract

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