Complicated grief (CG) due to suicide is better treated with grief-oriented therapy than with medication, new research shows.
Investigators compared treatment with antidepressants alone to complicated grief therapy (CGT) in individuals bereaved by suicide (SB), accident/homicide (A/H), or natural causes (NC).
There was a higher dropout rate among those who received medication alone than among those who received CGT. All participants in the CGT group experienced improvement in the number and severity of grief symptoms, suicidal ideation, grief-related impairment, avoidance, and maladaptive beliefs.
Although the response rates to CGT were lower in participants with SB (n = 58) than in those who experienced A/H (n = 74) and NC (n = 263), they were still “substantial.”
“We were surprised to discover — although in retrospect we really shouldn’t have been so surprised — that we did not uncover more of a role for medications in complicated grief, since we had all seen patients in clinical practice who seemed to get better with antidepressants,” first author Sidney Zisook, MD, distinguished professor of psychiatry, University of California, San Diego, told Medscape Medical News.
“Therapy had a very robust effect, and we were a little surprised at how many dropouts there were in people given medication without therapy, especially in the suicide bereaved group, which was the group that most required therapy as the core of their treatment,” he said.
The study was published online March 13 in the Journal of Clinical Psychiatry.
Suicide Bereavement More Traumatic
CG is a “painful and debilitating condition” characterized by “prolonged acute grief and complicating psychological features,” the authors write.
A previous trial, Healing Emotions After Loss (HEAL), evaluated the effectiveness of citalopram (multiple brands) with and without CGT for CG and found that CGT was more effective and acceptable than medication therapy alone.
The current study was a secondary analysis of the parent study’s outcomes. It compared the two treatments in an analysis with respect to cause of death: SB, A/H, and NC.
“In this study, we looked at whether therapy works for people who were suicide bereaved, with the idea that losing a loved one to suicide is more traumatic than losing a loved one to natural causes or even accidents and homicides because of the shame, guilt, and stigma that often accompanies this type of loss,” said Zisook.
Study participants were bereaved individuals (n = 395); they ranged in age from 18 to 95 years.
Participants were required to have scored ≥30 on the Inventory of Complicated Grief and to not be currently involved in substance use. In addition, participants were required to be free of psychosis and bipolar I disorder and to have no active suicidal plans necessitating hospitalization.
Also excluded were individuals of low cognition, those with pending lawsuits or disability claims related to the death, and those who were receiving concurrent psychotherapy or treatment with an antidepressant.
Participants completed an array of measurement tools to assess complicated grief, suicidality, work and social adjustment, grief-related avoidance, and maladaptive beliefs.
Pharmacotherapy consisted of citalopram. Medication visits were scheduled at baseline and at weeks 2, 4, 8, 12, 20, and 1 to 2 weeks after any change in dose.
Pharmacotherapists were restricted from providing exposure instructions, emotional regulation strategies, or cognitive reframing. They were allowed to provide empathic support and general encouragement for behavioral activation, including confronting avoided situations.
Participants in the CGT group received treatment with a manualized approach “aimed at resolving grief complications and facilitating adaptation to loss.”
The 16-session protocol, delivered over a 20-week period, included self-regulation techniques, aspirational goals, connection rebuilding, revisiting the story of the death, revisiting the world, and memories/continuing bonds.
Participants were randomly assigned to receive citalopram (n = 101), placebo (n = 99), citalopram + CGT (n = 99), or placebo + CGT (n = 96).
The permuted-block randomization used to divide participants into groups did not stratify participants by mode of death; treatment arms were “relatively balanced” in the groups.
Becoming Unstuck
For participants who received medication alone, medication completion rates for SB participants (36%) were lower than for A/H participants (54%) and NC participants (68%) (χ2 = 11.76; P < .01).
On further evaluation, the researchers found that 19% of the SB participants dropped out of the medication-only arms within the first week of the trial, compared to only 9% of the AH participants and 6% of the NC participants.
Medication completion rates did not differ across bereavement categories for participants receiving CGT alone.
Completion rates for the full 16-session intervention were comparable for participants across all bereavement categories.
Given the high dropout rate for those assigned to medication alone, the researchers evaluated outcomes only for participants who received CGT.
The CGT + citalopram and the CGT + placebo groups “reported virtually identical outcomes.” To have a sufficiently large sample for each bereavement category, the researchers therefore combined those two arms for outcome analysis.
After adjusting for missing response data at week 20, the researchers found that although there were “substantial response rates” among SB participants to CGT, the rates were nevertheless lower than for those of the other groups (SD = 63% vs A/H = 94% and NC = 86%; χ2 = 6.12; P < .05).
Despite the presence of active suicidal ideation in more than 40% of SB participants prior to treatment, there was no reported active suicidal ideation post treatment in this group. Among the other participants, posttreatment rates were very low as well.
“We confirmed that complicated grief therapy, with or without medication, was effective for all, whether it occurred in the context of suicide, accident, homicide, or natural causes,” Zisook commented.
He noted that CGT is “very specifically designed for dealing with the death of a loved one.” Exposure sessions are the “cornerstone, though not the only component, of treatment” with CGT.
Exposure includes both an in-session imaginal component and a situational component.
“People are encouraged to bring in pictures, videos, and reminders of the person who died,” which enables them to “face what they are avoiding,” he explained.
“To get to the normal grieving response, people must break through avoidance, because it is the avoidance that gets them stuck, and the idea is to unstick them, because grief can be very adaptive,” he said.
No Pill for Grief
Commenting on the study for Medscape Medical News, Edward Rynearson, MD, medical director, National Homicide Support Project, Separation and Loss Services, Virginia Mason Center, Seattle, Washington, who was not involved in the study, called it “exceptionally well-designed and completed.
“Dr Zisook and his coauthors are to be congratulated on this well-controlled study that makes a crucially important clinical observation in this era of overemphasis of medication,” he said.
Rynearson added, “Unfortunately, there is no pill for grief, and clinicians should be discouraged from starting medications without clear indications, which Dr Zisook references.”
Zisook encouraged clinicians to “ask people who have lost loved ones how they are doing with their grief, if they are stuck in it, and if they are healing.” He noted that “complicated grief usually does not get better on its own.”
He recommended contacting the Center for Complicated Grief at Columbia School of Social Work for additional resources and information about effective interventions for CG.
The research was supported by the National Institute for Mental Health and the American Foundation for Suicide Prevention. Dr Zisook and Dr Rynearson have disclosed no relevant financial relationships. A listing of other authors’ relevant financial relationships is included in the original article.
J Clin Psychiatry. Published online March 13, 2018. Abstract
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