PITTSBURGH, May 31 – Each year in the United States, approximately 2.5 million people die, each leaving behind, on average, five grieving survivors. Many of these survivors – more than a million people each year – develop a chronic, debilitating condition known as complicated grief that is more intense than normal grief, yet differs from clinical depression. Despite complicated grief being so prevalent, it has been under recognized and under treated. But according to a University of Pittsburgh study reported in this week's issue of the Journal of the American Medical Association, a new treatment approach could help millions of adults who needlessly suffer.
Complicated grief treatment (CGT), which was developed by the study authors specifically to address complicated grief symptoms, was found to be significantly more effective than a comparison psychotherapy, interpersonal psychotherapy (IPT), in the treatment of complicated grief. Over the course of the three-year study, 51 percent of participants treated with CGT significantly improved, compared with 28 percent who improved following IPT. Patients being treated with CGT also responded to the therapy significantly faster.
While IPT is a treatment that has proven to be effective for depression and can be specifically focused for bereavement-related depression in clinical practice, it appeared to be less effective in treating complicated grief. So, the authors enhanced IPT to create complicated grief treatment – unique in its two-pronged approach in which therapists simultaneously guide patients to focus both on the loss and on rebuilding their own lives.
"The bereavement process can go awry, and in 15 to 20 percent of all people who are surviving a loss, it does," said Katherine Shear, M.D., principal investigator of the study and professor of psychiatry at the University of Pittsburgh School of Medicine. "Grief is natural after the death of someone close, and over time, the yearning for the deceased and the emotional pain diminish in intensity. However, when this natural process is arrested, this may very well be complicated grief, which we now know is treatable," she said.
While complicated grief is not yet included in the American Psychiatric Association's Diagnostic and Statistical Manual due to it being a newly characterized condition, its symptoms are identifiable and most often occur following the death of one member of a very close and loving relationship.
Key features include a sense of disbelief regarding the death, anger and bitterness over the death, recurrent pangs of painful emotions with intense yearning and longing for the deceased, avoidance of situations and activities that are reminders of the painful loss, and a preoccupation with thoughts of the loved one, often including distressing, intrusive thoughts related to the death. Left untreated, complicated grief is associated with negative health outcomes, which may include clinical depression, suicidal thoughts or actions, substance abuse, cancer and cardiovascular illness.
"Although it affects millions of Americans at any given time, complicated grief is under-recognized by the medical community and physicians are often at a loss to know what is best for their patients," explained Dr. Shear.
"The medical profession has very much oriented itself toward caring and healing, yet eventually, everyone dies. We physicians have been less attentive to bereavement issues in our patients who have lost loved ones. However, we can offer help to the millions of grieving people by understanding more about the psychological response that our patients can have to a loss, by making sure that they know what to anticipate from their grief, by recognizing in our patients when their grief has developed into this more complicated form of grief, and by referring these patients for a treatment that is very likely to help," said Dr. Shear.
"Standard bereavement counseling encourages patients to move forward with their lives after they start to feel better. The treatment we developed encourages people to move forward with their lives at the same time as they are dealing with the loss. This is part of how they can feel better," she said.
The randomized, controlled trial involved 83 women and 12 men who met the diagnostic criteria for complicated grief and who had lost parents, spouses, children, other relatives or close friends through violent or natural deaths. Participants were randomly assigned to receive either IPT – which focuses on behaviors and relationships – or CGT – which focuses on the dual problem areas of distress caused by the loss and the survivor's personal goals and restoration of a satisfying life. Both treatments were conducted in 16 sessions over a 19-week period.
In CGT, therapists use the IPT structure and attention to interpersonal functioning but add techniques to guide patients as they tell the story of the death, a process called "revisiting," and produce audio recordings of the exercises that enable patients to listen to the story repeatedly and put aside the thoughts about the death, thereby lessening the effect of the pain. The patient is encouraged to makes specific plans for pleasurable activities and to begin to engage in situations that he or she avoided following the death. The therapist also guides the patient through an imagined conversation and reminiscence regarding the person whom he or she has lost, which offers the opportunity to speak openly about the intense feelings that the two shared. At the same time, patients work on re-engaging in activities and relationships that promise satisfaction and work to define and achieve personal goals. Both patients and therapists evaluate their symptoms throughout the course of the therapy.
"The key findings from this study are that response rate and time to response were significantly better for CGT than IPT. However, also of note, a higher proportion of patients who received IPT responded in this study than we had seen in previous work," said Dr. Shear. "Also, those participants who were already taking an antidepressant drug at the time of their enrollment showed twice the response rate to IPT and slightly better results with CGT than those not on medication," she added.
"Since this is the very first study comparing treatments for complicated grief, we are quite pleased with the results," Dr. Shear explained. "Nevertheless, further study will enable us to help more of those who did not respond to treatment. The information that we obtained in doing this research will help the medical and bereavement support communities in their increasing interest and sophistication on issues of death and dying, and on recognizing the distinctions between natural grief, bereavement-related depression and complicated grief," she said.
Co-authors of the study included Ellen Frank, Ph.D., Patricia Houck, MSH, and Charles F. Reynolds III, M.D., all of the University of Pittsburgh School of Medicine Department of Psychiatry. The study was supported by grants by the National Institute of Mental Health.
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