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. Available pre-embargo to the media at www.jamamedia.org)
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. Available pre-embargo to the media at www.jamamedia.org)
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