Disturbed Sleeps Derails Therapy for Complicated Grief

Nancy A. Melville

April 09, 2019

CHICAGO — The benefits of cognitive grief treatment (CGT), the gold standard treatment for complicated grief, significantly exceed those of antidepressant monotherapy, but sleep disturbances can derail CGT's effects, new research shows.

Results from two analyses of nearly 400 adult patients with complicated grief, defined as the persistent preoccupation with a deceased loved one and intense emotional pain that impairs functioning for at least 6 months post loss, were presented here at the Anxiety and Depression Association of America (ADAA) 2019.

In the first analysis, researchers sought to determine whether CGT improves maladaptive beliefs that underlie persistent grief.

Results at 20 weeks showed that those who received CGT demonstrated greater changes on the Typical Beliefs Questionnaire (TBQ) compared to patients who received placebo alone or who received the antidepressant citalopram (multiple brands) in combination with CGT. In addition, citalopram alone was no better than placebo.

"These results show that maladaptive beliefs decrease significantly with complicated grief treatment but not medication," lead author Natalia A. Skritskaya, PhD, Columbia University, New York City, said during her presentation. These beliefs "are important to pay attention to in treatment," she added.

In the second analysis, sleep disturbances during mid-treatment predicted treatment response, grief symptom severity, and quality-of-life scores, even after adjusting for factors such as posttraumatic stress disorder (PTSD).

The research "adds further evidence to indicate that impaired sleep quality is associated with greater complicated grief severity, above and beyond the effects of PTSD or depression," said presenter Kristin Szuhany, PhD, postdoctoral fellow with the Anxiety and Complicated Grief Program at NYU Langone Health, New York City.

Managing Painful Emotions

Both analyses evaluated data on 395 bereaved adult patients who were part of a National Institute of Mental Health–sponsored, multisite trial conducted at Massachusetts General Hospital, Columbia University, the University of California, San Diego, and the University of Pittsburgh Medical Center.

For the participants (78% women; 82% white; mean age, 53 years), the mean time since loss was 5 years. In addition, 36% had lost a spouse, 29% a parent, and 20% a child.

CGT helps patients adapt to the loss of a loved one through strategies to facilitate the acceptance of grief, manage painful emotions, and tolerate the emotional pain associated with memories of the loved one. It also aims to help patients move on by encouraging them to focus on the future.

In the first analysis, each patient was assigned to one of four treatment groups: citalopram only (n = 101), citalopram plus CGT (n = 99), CGT plus placebo (n = 96), or placebo only (n = 99).

The CGT groups received 16 sessions of treatment over 20 weeks. The citalopram-only and placebo-only groups received 12 sessions of enhanced medication management

After 20 weeks of treatment, citalopram was no better than placebo with respect to total TBQ scores. There was no significant change in either group from baseline.

The two CGT groups showed significant improvement after 20 weeks, compared to the two groups who did not receive CGT.

Sleep Disturbance Common

In a second presentation, Szuhany reported findings from an analysis of the same clinical trial on the effect of sleep disturbances.

Subjective sleep disturbances were assessed by a single, grief-anchored item of the Pittsburgh Sleep Quality Index (PSQI-1) and by the first four sleep-related items on the Quick Inventory of Depressive Symptomatology–Self Report (QIDS-4). Results showed that sleep disturbances were very common — 91% of patients (n = 355) reported experiencing disturbed sleep with respect to at least one area of the QIDS-4.

About half (46%) reported having trouble sleeping for three or more nights because of grief, as assessed by the PSQI-1.

The severity of baseline complicated grief was a significant predictor of sleep disturbance (QIDS-4, P = .02; PSQI-1, P = .001), even after adjusting for the covariates of depression and PTSD.

Although sleep disturbances at baseline did not predict treatment response, the disturbances during mid-treatment, assessed on the QIDS-4, did significantly predict treatment response (P = .01), as well as the severity of grief symptoms endpoint, as assessed with the Inventory of Complicated Grief (P = .001), and quality of life (P < .001).

"This research overall provides more evidence for the clinical importance of sleep quality, particularly at midpoint stage of treatment," Szuhany said.

"However we might see that this is all intertwined. As grief gets better, sleep also gets better, and some of the other outcomes get better. So future analyses may look at which comes first," she added.

In addition, the combination of a complicated grief–targeted psychological intervention with a pharmacologic treatment "appears to improve sleep quality more than antidepressants alone," Szuhany noted.

"This might mean that both biological and psychological processes may be important in the pathophysiology and treatment of sleep disturbance in complicated grief," she said.

Implications for Future Interventions

Commenting on the findings for Medscape Medical News, Sarah T. Stahl, PhD, assistant professor of psychiatry and clinical and translational science, Department of Psychiatry, University of Pittsburgh, Pennsylvania, said her own research also has shown that CGT yields the strongest treatment benefits of the therapies tested in this research.

Although not involved with the current study, Stahl has reported phase 1 findings on a complicated grief intervention.

"Complicated grief treatment seems to be the gold standard for treating patients with complicated grief," she said.

Previous analyses of the multicenter complicated grief trial have shown that antidepressants are benefical with respect to measures of depression, which is common in complicated grief. Although antidepressants were not included in Stahl's study of a complicated grief intervention, she confirmed that sleep disturbances were common.

"We do measure sleep, and almost all of our participants say they would like to improve their sleep," she said.

"We look at changes in circadian-influenced behaviors (sleep, meals, and physical activity) to see if changes in these behaviors place bereaved individuals at risk for mood disorders like depression," she added.

Stahl said she agreed with the investigators' findings that objective sleep and circadian rhythm assessments are "imperative in understanding how sleep disturbance and changes to day- and nighttime rhythms are unique in these patients.

"These objective assessments may help tailor future behavioral interventions," she said.

The study authors and Stahl have reported no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) 2019: Abstract 1315. Presented March 30, 2019.

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