Optimizing Treatment of Complicated Grief

Abstract

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...

Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability

“…Its guidelines can be used for assessment and treatment, particularly the recommendations that the management of grief symptoms should include the discussion of culturally appropriate adjustment and mourning rituals. In addition, there have been several successful randomized controlled trials of treatments for CG (Shear, Frank, Houck, & Reynolds, 2005; Shear et al, 2016, 2014) and PGD (Bryant et al, 2014; Kersting et al, 2013; Litz et al, 2014; Rosner, Pfoh, Kotoučová, & Hagl, 2014). These treatments pull valuable techniques from PTSD interventions, narrative therapy and cognitive behavioural therapy, and could be incorporated into the WHO mhGAP guidelines (Rosner, Bartl, Pfoh, Kotoučová, & Hagl, 2015; Shear, 2015).…”

Integrative kognitive Verhaltenstherapie für die anhaltende Trauerstörung: Vorstellung eines Behandlungsmanuals

“…Insgesamt ist der Ansatz hinsichtlich seiner Wirksamkeit gut untersucht, so war er im direkten Vergleich sowohl der interpersonellen Therapie [z.B. Shear et al, 2005Shear et al, , 2014 als auch pharmakologischen Behandlungen überlegen [Shear et al, 2016]. Der Behandlungserfolg scheint vor allem durch den Abbau von verlust-und trauerbezogener Vermeidung vermittelt zu werden [Glickman et al, 2017].…”

Kognitive Verhaltenstherapie bei komplizierter Trauer

“…Diese Sorge kann die Therapiemotivation reduzieren und sollte dementsprechend durch spezifische motivationsfördernde Interventionen bearbeitet werden [Rosner et al, 2015b]. Beispielsweise kann zu Beginn der Therapie Zeit für das «Vorstellen der verstorbenen Person» eingeräumt werden [Rosner et al, 2015b] Shear et al, 2016;Shear et al, 2014]). Die Wirksamkeit metakognitiver Ansätze in der Behandlung komplizierter Trauer wird derzeit untersucht [Wenn et al, 2015].…”

“…Seit dem Erscheinen dieser Übersichts-arbeiten sind einige weitere, methodisch starke randomisiert-kontrollierte Studien publiziert worden [z.B. Bryant et al, 2014;Rosner et al, 2015a;Rosner et al, 2014;Shear et al, 2016;Shear et al, 2014]. In Intent-to-treat-und Completer-Analysen zeigten sich große Effektstärken, die ebenfalls für die Wirksamkeit der kognitiven Verhaltenstherapie bei komplizierter Trauer sprechen.…”

“…Eine alleinige Pharmakotherapie komplizierter Trauer kann dagegen nicht empfohlen werden [Bui et al, 2012;Lacasse und Cacciatore, 2014]. Eine aktuelle randomisiert-kontrollierte Studie bestätigte dies [Shear et al, 2016]. Die Studie zeigte aber, dass eine zusätzliche Gabe von Citalopram (selektiver SerotoninWiederaufnahme-Hemmer) in Kombination mit einer Psychotherapie die Behandlung durch die Besserung einer begleitenden depressiven Symptomatik optimieren kann.…”