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Complicated grief treatment may beat psychotherapy.


SAN FRANCISCO -- The effectiveness of complicated grief treatment rests, to a significant extent, on its capacity to reduce the grieving patient's level of avoidance of reminders of the loss, Kim Glickman, PhD, said at the annual conference of the Anxiety and Depression Association of America.

Her psychotherapeutic mechanism-of-action study identified two other mediators of improvement in response to complicated grief treatment (CGT): guilt related to the death and negative thoughts about the future. Patients who had significant reductions in levels of those variables during CGT were much more likely to ultimately be treatment responders.

The clinical implication of these findings is that psychotherapists should focus on reducing grief complications, such as avoidance behaviors and maladaptive thoughts, including blaming oneself or others for how the person died and seeing a hopeless future, according to Dr. Glickman of the City University of New York.

Complicated grief affects about 7% of bereaved individuals. It is characterized by prolonged emotional pain, intense sorrow, preoccupation with thoughts of the loved one, and persistent yearning. It is typically resistant to antidepressant therapy. In the DSM-5, it is called "persistent complex bereavement disorder" and is described in a chapter on provisional conditions for further study. Since it doesn't have the status of a formal diagnostic entity, insurers typically will not pay for the treatment of complicated grief reactions.

CGT has been shown to be effective in three randomized clinical trials. It is a manualized 16-session therapy that can be considered a form of cognitive-behavioral therapy with added elements of interpersonal psychotherapy and motivational interviewing. The focus is on encouraging adaptation to the loss by keeping grief center stage, honoring the person who died, and envisioning a future with possibilities for happiness, Dr. Glickman explained.

The mechanisms of action of CGT haven't been well characterized. This was the impetus for Dr. Glickman's study, in which she analyzed data from the first randomized trial to demonstrate CGT's effectiveness more than a decade ago (JAMA. 2005 Jun 1;293[21]:2601-8).

Among the 69 patients with complicated grief who completed 16 sessions of psychotherapy, the clinical response rate was 51% in the CGT group, compared with 28% in patients randomized to interpersonal psychotherapy. The number needed to treat with CGT was 4.3 in order to achieve a clinical response, defined as either a Clinical Global Impression-Improvement score of 1 or 2 or at least a 20-point improvement before to after treatment on the self-rated Inventory of Complicated Grief.

Dr. Glickman said her future research plans include looking at additional possible mediators of CGT's efficacy. Complicated grief therapy was pioneered by therapists at Columbia University in New York. Dr. Glickman noted that more information about complicated grief and training in CGT is available at www. complicatedgrief. Columbia, edu.

The randomized trial on which her analysis was based was funded by the National Institute of Mental Health. Dr. Glickman reported having no financial conflicts regarding her study.


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Author:Jancin, Bruce
Publication:Clinical Psychiatry News
Date:Jul 1, 2017
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