Complicated Grief Complicated to Treat

New therapy that combines depression and PTSD techniques works, study finds

By Serena Gordon
HealthDay Reporter

TUESDAY, May 31 (HealthDay News) -- Sadness and feelings of loss are normal parts of the grieving process, but for some people the death of a loved one triggers a phenomenon dubbed complicated grief, which resembles both major depression and post-traumatic stress disorder (PTSD).

Because existing treatments haven't worked for people with complicated grief, University of Pittsburgh School of Medicine researchers have developed a promising technique that combines interpersonal depression treatment with PTSD treatment.

The good news: The combination therapy had a 51 percent response rate compared with 28 percent for standard depression treatment.

"Complicated grief is a very underrecognized problem. It's not in the literature, and there's a lot of confusion in identifying complicated grief. We're trying to tease apart normal bereavement and the bereaved people who need help, and figure out how to provide appropriate treatment," said study author Dr. Katherine Shear, a professor of psychiatry.

"When we took a close look at grief symptoms, we saw some components that are like PTSD, so we integrated some PTSD treatment with interpersonal depression treatment," she said. "It was more effective in treating complicated grief symptoms than interpersonal depression treatment."

Results of the study appear in the June 1 issue of the Journal of the American Medical Association.

As many as 10 percent to 20 percent of all bereaved people suffer complicated grief, the study stated. Each year, about 2.5 million people die in the United States, leaving behind an average of five bereaved people each. That means that as many as 1 million Americans a year experience complicated grief.

Complicated grief isn't diagnosed unless symptoms have continued for at least six months after the death. Some of the symptoms of complicated grief are sadness, preoccupation with thoughts of the deceased, feelings of guilt due to past interactions with the deceased, intrusive images of the person dying, and a yearning or longing for the deceased, according to the study.

"Most people with complicated grief report that their family and friends are telling them to move on," said Shear. "But they still feel stuck and preoccupied with the death. They have difficulty accepting the death, almost to the point of disbelief."

Her study included 83 women and 12 men between the ages of 18 and 85 who were diagnosed with complicated grief.

The average time since their loved one had died was slightly more than two years. For about one-third of the group, the death of their loved ones had been violent.

The study volunteers were randomly assigned into two groups. The first group, which included 46 people, received standard interpersonal depression therapy. The second group -- 49 people -- received complicated grief treatment. Both groups had 16 sessions of therapy.

Some of the exercises in complicated grief therapy included telling and retelling the story of the death, having an imaginary conversation with the deceased, being asked to think about what their life would be like if their grief wasn't so intense, and setting goals and coming up with ways to meet those goals.

Both treatments were successful for some of the study participants, but complicated grief treatment was nearly twice as effective. Just over half of those in the complicated grief treatment group responded to treatment, while only 28 percent in the standard depression treatment group did.

However, the treatment isn't for everyone. Twelve percent in the complicated grief treatment dropped out, saying it was too difficult for them or they didn't believe that telling the painful story of their loved ones' death would help.

"Our treatment findings suggest that complicated grief is a specific condition in need of a specific treatment," wrote the researchers.

"Normal grief is very painful, but it's not a disorder. It's a normal part of the human condition that can be helped by support from friends and family and culturally sanctioned rituals and procedures," said Dr. Richard Glass, who wrote an accompanying editorial in the same issue of the journal. Glass is the deputy editor at JAMA and a clinical professor of psychiatry at the Pritzker School of Medicine at the University of Chicago.

"That's different from what appears to be a disorder: complicated grief. It's grief that doesn't go away and persists. Many people, if they think about friends and relatives, may know a person affected by this, but right now we don't have a solid sense of how many people this affects," Glass said.

What is known, however, is that "standard treatment for depression doesn't really work for complicated grief. This new treatment worked better than standard treatment," Glass added.

Because the technique is new, Shear said that if you seek treatment for complicated grief, it's reasonable to ask your therapist if he or she is familiar with complicated grief treatment.

More information

The American Cancer Society offers information about coping with grief.

SOURCES: Katherine Shear, M.D., professor, psychiatry, University of Pittsburgh School of Medicine; Richard Glass, M.D., deputy editor, Journal of the American Medical Association, and clinical professor, psychiatry, Pritzker School of Medicine, University of Chicago; Journal of the American Medical Association, June 1, 2005

Newly developed treatment for severe grief more effective than standard therapy

May 31, 2005

CHICAGO—A recently developed method for treating complicated grief, which includes discussing certain aspects of the death of a loved one, was found more effective than a standard therapy for depression, according to a study in the June 1 issue of JAMA.

Many physicians are uncertain about how to identify bereaved individuals who need treatment, and what treatments work for bereavement-related mental health problems, according to background information in the article. Bereavement-related major depressive disorder (MDD) is a well-recognized consequence of loss. Complicated grief also occurs in the aftermath of loss but is different from depression. Key features of complicated grief, persisting more than 6 months after the death of a loved one, include (1) a sense of disbelief regarding the death; (2) anger and bitterness over the death; (3) recurrent pangs of painful emotions, with intense yearning and longing for the deceased; and (4) preoccupation with thoughts of the loved one, often including distressing intrusive thoughts related to the death.

Complicated grief is a source of significant distress and impairment and is associated with a range of negative health consequences, but the results of existing treatments for it have been disappointing. Prevalence rates are estimated at approximately 10 percent to 20 percent of bereaved persons. Approximately 2.5 million people die yearly in the United States. Estimates suggest each death leaves an average of 5 people bereaved, suggesting that more than 1 million people per year are expected to develop complicated grief in the United States.

Given observations regarding the specificity and clinical significance of complicated grief symptoms, including the lack of response to standard treatments for depression, the researchers developed a targeted complicated grief treatment (CGT). They modified standard interpersonal psychotherapy (IPT) for grief-related depression to include cognitive-behavioral therapy-based techniques for addressing trauma and working with loss-specific distress.

Katherine Shear, M.D., of the University of Pittsburgh School of Medicine, Pittsburgh and colleagues examined whether CGT would be superior to IPT with respect to overall response rates and time to response and if CGT would produce greater resolution of complicated grief symptoms than IPT. The study included 83 women and 12 men aged 18 to 85 years recruited through professional referral, self-referral, and media announcements who met criteria for complicated grief. The study was conducted at a university-based psychiatric research clinic as well as a satellite clinic in a low-income African American community between April 2001 and April 2004. Participants were randomly assigned to receive interpersonal psychotherapy (n = 46) or complicated grief treatment (n = 49); both were administered in 16 sessions during an average interval of 19 weeks per participant.

IPT included identifying and reviewing symptoms, focusing on grief. The IPT therapist helped patients arrive at a more realistic assessment of the relationship with the deceased, addressing both its positive and negative aspects, and encouraged the pursuit of satisfying relationships and activities. Treatment gains were reviewed, plans were made for the future, and feelings about ending treatment were discussed.

CGT included a discussion of grief and loss and personal life goals, entailing both restoration of a satisfying life and adjustment to the loss. Similar to IPT, the last phase focused on review of progress, plans for the future, and feelings about ending treatment. In contrast to IPT, however, traumalike symptoms were addressed using procedures for retelling the story of the death and exercises entailing confrontation with avoided situations. The therapist tape-recorded the story and the patient was given the tape to listen to at home. Distress related to the loss (e.g., yearning and longing, reveries, fears of losing the deceased forever) was targeted using techniques to promote a sense of connection to the deceased. These included an imagined conversation with the deceased and completion of a set of memories questionnaires, primarily focused on positive memories, though also inviting reminiscence that was negative. The patient was asked to imagine that he/she could speak to the person who died and that the person could hear and respond. The patient was invited to talk with the loved one in an imagined conversation and then to take the role of the deceased and answer.

The researchers found that both treatments produced improvement in complicated grief symptoms. The response rate was greater for complicated grief treatment (51 percent) than for interpersonal psychotherapy (28 percent) and time to response was faster for complicated grief treatment.

"In summary, we conducted the first randomized controlled trial of therapy targeting symptoms of complicated grief. We found better response to CGT compared with IPT, which is a proven efficacious psychotherapy for depression. Similarity of Inventory of Complicated Grief scores across age, cultural, and death-related variables supports the diagnostic validity of the syndrome. Our treatment findings suggest that complicated grief is a specific condition in need of a specific treatment. More research is needed to confirm our findings, to test potential moderators of treatment response, and to improve treatment acceptance," the authors write.
JAMA. 2005;293:2601-2608.

Editor's Note: This work was supported by grants from the National Institute of Mental Health (NIMH). Dr. Shear has received financial support from Pfizer and Forest Pharmaceuticals. Co-author Ellen Frank, Ph.D., has received financial support from Pfizer, Pfizer Italia, Eli Lilly, Forest Research Institute, and the Pittsburgh Foundation.

EDITORIAL: IS GRIEF A DISEASE? SOMETIMES.

In an accompanying editorial, Richard M. Glass, M.D., Deputy Editor, JAMA, Chicago, comments on the findings by Shear et al.

"The results of the Shear et al study, while interesting and provocative, obviously leave a number of unanswered questions about complicated grief and its treatment. Although CGT was shown to be superior to IPT, a finding of particular relevance to the distinction of complicated grief from depressive disorder in view of IPT's demonstrated efficacy for MDD, the 51 percent response rate could be viewed as disappointing. Does that indicate a need for improvements in the treatment procedures or perhaps a need for longer duration of treatment? Do the psychological demands that the CGT exposure techniques place on patients mean that its acceptability and effectiveness will be limited in nonresearch clinical practice?" "The question of whether this condition should be an officially recognized mental disorder separate from MDD and posttraumatic stress disorder (PTSD) is an important issue for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, currently planned for publication by the American Psychiatric Association in 2012. It is clear that awareness about depression is important for all physicians. Is that also true about complicated grief, since patients and families almost certainly consult primary care physicians about the persisting symptoms and dysfunction associated with it?

"A concern that some might raise is that the concept of complicated grief as a disorder warranting treatment is yet another example of the medicalization of various aspects of the human condition. The available evidence that distinguishes complicated grief from normal grief and also from MDD and PTSD appears to provide a compelling response to that concern. Thus, the answer to the question 'Is grief a disease?' is 'sometimes.' The painful process of normal grief following bereavement certainly warrants sympathy and concern, along with the support of family and friends. Complicated grief warrants more research about effective ways to prevent and treat it," Dr. Glass concludes.
JAMA. 2005;293:2658-2660.

For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations@jama-archives.org .

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