Impact of concurrent naturalistic pharmacotherapy on psychotherapy of complicated grief

Simon, Naomi M.; Shear, M. Katherine; Fagiolini, Andrea; Frank, Ellen; Zalta, Alyson K.; Thompson, Elizabeth H.; Reynolds, Charles F.; Silowash, Russell

doi:10.1016/j.psychres.2007.05.011

Cited by 48 publications

(23 citation statements)

References 11 publications

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“…Inverse probability weighting, a standard strategy to account for missing assessment data, 21–24 provided weights in the model (eAppendix 1 in Supplement 2). Our enrollment target of 440 participants lost 10% to follow-up and had a power of 76% to 83% to detect predicted between-group difference in response based on data from our 2005 study 5,11 (CGT with PLA, 40%; CGT with CIT, 60%; CIT, 40%; and PLA, 20%). All P values were 2-tailed, and statistical significance was defined as P < .05.…”

Section: Methodsmentioning

confidence: 99%

Optimizing Treatment of Complicated Grief

et al. 2016

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IMPORTANCE To our knowledge, this is the first placebo-controlled randomized clinical trial to evaluate the efficacy of antidepressant pharmacotherapy, with and without complicated grief psychotherapy, in the treatment of complicated grief. OBJECTIVE To confirm the efficacy of a targeted complicated grief treatment (CGT), determine whether citalopram (CIT) enhances CGT outcome, and examine CIT efficacy without CGT. DESIGN, SETTING, AND PARTICIPANTS Included in the study were 395 bereaved adults who met criteria for CG recruited from March 2010 to September 2014 from academic medical centers in Boston, Massachusetts; New York, New York; Pittsburgh, Pennsylvania; and San Diego, California. Co-occurring substance abuse, psychosis, mania, and cognitive impairment were exclusionary. Study participants were randomized using site-specific permuted blocks stratified by major depression into groups prescribed CIT (n = 101), placebo (PLA; n = 99), CGT with CIT (n = 99), and CGT with PLA (n = 96). Independent evaluators conducted monthly assessments for 20 weeks. Response rates were compared under the intention-to-treat principle, including all randomized participants in a logistic regression with inverse probability weighting. INTERVENTIONS All participants received protocolized pharmacotherapy optimized by flexible dosing, psychoeducation, grief monitoring, and encouragement to engage in activities. Half were also randomized to receive manualized CGT in 16 concurrent weekly sessions. MAIN OUTCOMES AND MEASURES Complicated grief–anchored Clinical Global Impression scale measurments every 4 weeks. Response was measured as a rating of “much improved” or “very much improved.” RESULTS Of the 395 study participants, 308 (78.0%) were female and 325 (82.3%) were white. Participants’ response to CGT with PLA vs PLA (82.5% vs 54.8%; relative risk [RR], 1.51; 95% CI, 1.16–1.95; P = .002; number needed to treat [NNT], 3.6) suggested the efficacy of CGT, and the addition of CIT did not significantly improve CGT outcome (CGT with CIT vs CGT with PLA: 83.7% vs 82.5%; RR, 1.01; 95% CI, 0.88–1.17; P = .84; NNT, 84). However, depressive symptoms decreased significantly more when CIT was added to treatment (CGT with CIT vs CGT with PLA: model-based adjusted mean [standard error] difference, −2.06 [1.00]; 95% CI, −4.02 to −0.11; P = .04). By contrast, adding CGT improved CIT outcome (CIT vs CGT with CIT: 69.3% vs 83.7%; RR, 1.21; 95% CI, 1.00–1.46; P = .05; NNT, 6.9). Last, participant response to CIT was not significantly different from PLA at week 12 (45.9% vs 37.9%; RR, 1.21; 95% CI, 0.82–1.81; P = .35; NNT, 12.4) or at week 20 (69.3% vs 54.8%; RR, 1.26; 95% CI, 0.95–1.68; P = .11; NNT, 6.9). Rates of suicidal ideation diminished to a substantially greater extent among participants receiving CGT than among those who did not. CONCLUSIONS AND RELEVANCE Complicated grief treatment is the treatment of choice for CG, and the addition of CIT optimizes the treatment of co-occurring depressive symptoms. TRIAL REGISTRATION clinical...

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Section: Methodsmentioning

confidence: 99%

Optimizing Treatment of Complicated Grief

et al. 2016

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“…Antidepressants have also been shown to improve adherence and augment response to complicated grief therapy, although benzodiazepines did not improve outcomes, findings similar to the ineffectiveness of benzodiazepines in PTSD. 65 Viewing complicated grief as astress-response condition with symptom overlap with PTSD and depression suggests that antidepressants, but not benzodiazepines, are likely to be beneficial in treating complicated grief. Benzodiazepine treatment can result in psychological and physical dependence and may interfere with learning and memory, important for psychological adaptation to a loss.…”

Section: Clinical Management Of Complicated Grief: Treatment Approachesmentioning

confidence: 99%

Treating Complicated Grief

Simon

2013

JAMA

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148

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IMPORTANCE The death of a loved one is one of life’s greatest, universal stressors to which most bereaved individuals successfully adapt without clinical intervention. For a minority of bereaved individuals, grief is complicated by superimposed problems and healing does not occur. The resulting syndrome of complicated grief causes substantial distress and functional impairment even years after a loss, yet knowing when and how to intervene can be a challenge. OBJECTIVE To discuss the differential diagnosis, risk factors for and management of complicated grief based on available evidence and clinical observations. EVIDENCE REVIEW MEDLINE was searched from January 1990 to October 2012. Additional citations were procured from references of select research and review articles. Available treatment studies targeting complicated grief were included. RESULTS A strong research literature led to inclusion of complicated grief in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (termed persistent complex bereavement disorder as a subtype of other specified trauma and stressor-related disorders), although it is a condition for which more research is formally recommended, and there is still ongoing discussion about the optimal name and diagnostic criteria for the disorder. Reliable screening instruments are available, and the estimated prevalence rate is 7% of bereaved people. Randomized controlled data support the efficacy of a targeted psychotherapy including elements that foster resolution of complicating problems and facilitate the natural healing process. Preliminary studies suggest antidepressant medications may be helpful. CONCLUSION AND RELEVANCE Individuals with complicated grief have greater risk of adverse health outcomes, should be diagnosed and assessed for suicide risk and comorbid conditions such as depression and posttraumatic stress disorder, and should be considered for treatment.

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“…13, 15, 16 There is evidence that Complicated Grief responds very differently from depression to interpersonal psychotherapy and that it can be effectively treated using strategies and techniques that specifically target the syndrome of Complicated Grief. 15 Complicated Grief Therapy utilizes a dual focus on coming to terms with the loss and restoring the capacity for pleasure and satisfaction in on-going life and contains elements of interpersonal therapy, cognitive behavioral therapy, and motivational interviewing.…”

Section: Complicated Griefmentioning

confidence: 99%

“…15 Complicated Grief Therapy utilizes a dual focus on coming to terms with the loss and restoring the capacity for pleasure and satisfaction in on-going life and contains elements of interpersonal therapy, cognitive behavioral therapy, and motivational interviewing. The role of medications is not clear, but there is preliminary evidence that serotonin active antidepressant medications may provide some relief 15–18 , and may augment Complicated Grief Therapy 16 .…”

Section: Complicated Griefmentioning

confidence: 99%