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Grief, Bereavement, and Coping With Loss (PDQ®)

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Treatment

Normal or Common Grief Reactions
Psychosocial Treatment of Complicated Grief
Pharmacologic Treatment of Bereavement-related Depression

The following information concerns treatment of grief after the death of a loved one, not necessarily death as a result of cancer.

Normal or Common Grief Reactions

Some controversy continues about whether normal or common grief reactions require any intervention by medical or mental health professionals. Researchers disagree about whether credible evidence on the efficacy of grief counseling exists.[1-4] Most bereaved persons experience painful and often very distressing emotional, physical, and social reactions; however, most researchers agree that most bereaved persons adapt over time, typically within the first 6 months to 2 years. Thus, the question is whether it is wise to devote professional time to interventions for normal grief when resources are limited and the need for accountability is great.

One approach is to use a spectrum of interventions, from prevention to treatment to long-term maintenance care.[5] In this model, preventive interventions could be one of the following:

  • Universal and targeted to all persons in the population.
  • Selective and targeted to persons with known risk factors.
  • Indicated for persons experiencing significant symptom distress.

In contrast, formal treatment of bereaved persons would be reserved for those identified as experiencing complicated or pathologic grief reactions. Finally, longer-term maintenance care may be warranted for persons experiencing chronic grief reactions.

Another approach has focused on families.[6,7] This brief, time-limited approach (four to eight 90-minute sessions over 9 to 18 months) identifies families at increased risk for poor outcomes and intervenes, with emphasis on improving family cohesion, communication, and conflict resolution. Adaptive coping, with efforts to strengthen family solidarity, and frequent affirmation of family strengths are emphasized.

In a randomized controlled trial,[8][Level of evidence: I] 183 (71%) of 257 families screened were identified as at risk for poor outcomes; 81 (44%) of these at-risk families participated in the trial. Family functioning was classified into one of five groups:

  • Two functional groups:
    • Supportive families.
    • Conflict-resolving families.

  • Three potentially dysfunctional groups:
    • Sullen families.
    • Hostile families.
    • Intermediate-functioning families.

Participants classified as hostile (n = 19), sullen (n = 21), or intermediate (n = 41) were randomly assigned to either the treatment group or a no-treatment control group.[8]

Results showed modest reductions in distress at 13 months postdeath for all participants, with more significant reductions in distress and depression in family members who had initially higher baseline scores on the Brief Symptom Inventory and Beck Depression Inventory.[8] Overall, global family functioning did not change, yet participants classified as sullen or intermediate showed more improvement than those classified as hostile. Results recommend caution in dealing with hostile families to avoid increasing conflict in such families.[8]

Psychosocial Treatment of Complicated Grief

With the development of proposed diagnostic criteria for complicated grief (i.e., prolonged grief disorder), targeted interventions have been tested in two randomized controlled trials. Both studies are of interventions for bereaved persons whose loved ones died from mixed (not necessarily cancer-related) causes.

The first study [9][Level of evidence: I] compared complicated grief treatment (CGT) with interpersonal psychotherapy (IPT) in 83 women and 12 men, aged 18 to 85 years prescreened, who met the criteria for complicated grief. Both interventions consisted of 16 weekly sessions spread out over an average of 19 weeks per participant. IPT is a widely researched, empirically supported treatment intervention for depression.

IPT therapists used an intervention delivered as described in a published manual,[10] using an introductory phase, a middle phase, and a termination phase. During the introductory phase, symptoms were identified, and an inventory of interpersonal relationships was completed, with a focus on interpersonal problems. Connections between symptoms, interpersonal problems, and grief were identified and discussed.[9]

During the middle phase, these interpersonal problems and issues of grief were addressed. Patients were encouraged to develop a realistic relationship with the deceased, to recognize both positive and negative aspects of the loss, and to invest in new, positive relationships.[9]

During the termination phase, gains were identified and reviewed, future plans were made and feelings about termination were discussed.[9]

CGT was also delivered according to a manual protocol, also organized into three phases. In the introductory phase, therapists described the distinctions between normal and complicated grief. They also explained the concept of dual processing, or the notion that grief progresses best when attention alternates between (a) a focus on loss and (b) a focus on restoration and future. Thus, the introductory phase included both a discussion of the loss and an identification of future goals and aspirations.[9]

Throughout the middle phase, attention alternated between the themes of loss/grief and future/restoration. A unique characteristic of CGT was the concept of revisiting loss via retelling the story of the death. This concept was particularly important for persons inclined to avoid thinking about the trauma of the loss. Specific procedures that were modeled after the "imaginal exposure" component of interventions for post-traumatic stress disorder were utilized for retelling.[9]

The termination phase for the CGT group was similar to that for the IPT group.[9]

Both treatments showed improvements in symptoms, with the CGT group showing a larger percentage of patients responding (51%) than the IPT group (28%). The CGT group also seemed to respond quicker than the IPT group. A total of 45% of all study participants were taking antidepressants. No significant differences in outcomes were found for those on antidepressant medications.[9]

The second study of complicated grief [11][Level of evidence: II] compared cognitive-behavioral therapy (CBT), offered in two different sequences, with supportive counseling for 54 bereaved persons, all prescreened and found to be experiencing complicated grief.

With researchers hypothesizing that maladaptive thoughts and behaviors are an important component of complicated grief, the CBT interventions consisted of two components (exposure therapy and cognitive restructuring) designed to directly impact grief-related thoughts and behaviors.[11] Participants were randomly assigned to receive one of three treatments:

  • Exposure therapy followed by cognitive restructuring.
  • Cognitive restructuring followed by exposure therapy.
  • Supportive counseling.

Results showed that both CBT groups experienced more improvement in symptoms of complicated grief and general psychopathology than did the supportive counseling group. In component analyses, the exposure therapy component was more effective than the cognitive restructuring component; the sequence of exposure therapy first, followed by cognitive restructuring, produced the best results.[11]

Pharmacologic Treatment of Bereavement-related Depression

The clinical decision on whether to provide pharmacologic treatment for depressive symptoms in the context of bereavement is controversial and not very extensively studied. Some health care professionals argue that distinguishing the sadness and distress of normal grief from the sadness and distress of depression is difficult, and pharmacologic treatment of a normal emotional process is not warranted. However, three open-label trials and one randomized controlled trial of treatment of bereavement-related depression with antidepressants have been reported (see Table 1).

The open-label trials evaluated desipramine,[12] nortriptyline,[13] and bupropion sustained release.[14][Level of evidence: II] The studies included patients experiencing depressive symptoms after the deaths of their loved ones. The depressive symptoms were evaluated using the Hamilton Depression Rating Scale (HDRS). All studies evaluated intensity of grief using select grief assessment questionnaires.

Data from these studies suggest that antidepressants are well tolerated and improve symptoms of depression. Data also suggest that the intensity of grief improved but that the improvement was consistently less in comparison with the symptoms of depression. Limitations of these studies include open-label treatment and small sample sizes.

The only randomized controlled study conducted to date [15][Level of evidence: I] compared nortriptyline with placebo for the treatment of bereavement-related major depressive episodes. Nortriptyline was also compared with two other treatments, one combining nortriptyline with IPT and the other combining placebo with IPT. Eighty subjects, aged 50 years or older, were randomly assigned to one of the four treatment groups: nortriptyline (n = 25), placebo (n = 22), nortriptyline plus IPT (n = 16), and placebo plus IPT (n = 17).

The 17-item HDRS was used to assess depressive symptoms. Remission was defined as a score of 7 or lower for 3 consecutive weeks. The remission rates for the four groups were as follows: nortriptyline alone, 56%; placebo alone, 45%; nortriptyline plus IPT, 69%; placebo plus IPT, 29%. Nortriptyline was superior to placebo in achieving remission (P < .03).[15]

The combination of nortriptyline with IPT was associated with the highest remission rate and highest rate of treatment completion. The study did not show a difference between IPT and placebo, possibly owing to specific aspects of the study design, including short duration of IPT (mean no. of days, 49.5) and small sample size.[15] The high remission rate with placebo was another important limitation of the study. Consistent with previous open-label studies and for all four groups, improvement in grief intensity was less than improvement in depressive symptoms.

In summary, all of the antidepressant studies conducted to date suggest that the magnitude of reduction and rate of improvement in grief symptoms are slower than the decrease in magnitude and rate of improvement in depressive symptoms. One group of researchers [15] provides possible explanations for this phenomenon, arguing that depressive symptoms may be more responsive to pharmacological intervention because they are directly related to biological dysregulation and neurochemical changes. The other possibility is that the persistence of grief without depressive symptoms is not pathological—it might be a normal and necessary consequence of the bereavement process.

Table 1. Pharmacological Intervention Studies of Bereavement-related Depression
Reference Citation Study Type Subjects Age (y) Treatment Results 
[12]Open label8 women, 2 menMean not reported; range, 26–65Desipramine7 subjects much improveda; 2 subjects minimally improved; 1 dropout
[13]Open label8 women, 5 menMean, 71.1; range, 61–78NortriptylineMean HDRS scores decreased 67.9%; no dropouts
[14]Open label17 women, 5 menMean, 63.5; range, 45–83Bupropion SRMean HDRS scores decreased 54%; 8 dropouts
[15]bRandomized controlled58 women, 22 menMean range for 4 groups, 63.2–69.5Nortriptyline vs. placebo vs. NTP+IPT or PLA+IPTNTP statistically significant compared to PLA; NTP+IPT group had lowest attrition rate

HDRS = Hamilton Depression Rating Scale; IPT = interpersonal psychotherapy; NTP = nortriptyline; PLA = placebo; SR = sustained release.
aImprovement based on the Clinical Global Impression (CGI) rating after review of the decline in HDRS score.
bSee text for details.

References
  1. Larson DG, Hoyt WT: What has become of grief counseling? An evaluation of the empirical foundations of the new pessimism. Prof Psychol Res Pr 38 (4): 347-55, 2007. 

  2. Bonanno GA, Lilienfeld SO: Let's be realistic: when grief counseling is effective and when it's not. Prof Psychol Res Pr 39 (3): 377-8, 2008. 

  3. Hoyt WT, Larson DG: A realistic approach to drawing conclusions from the scientific literature: response to Bonanno and Lilienfeld. Prof Psychol Res Pr 39 (3): 378-9, 2008. 

  4. Jordan JR, Neimeyer RA: Does grief counseling work? Death Stud 27 (9): 765-86, 2003.  [PUBMED Abstract]

  5. Mrazek PJ, Haggerty RJ, eds.: Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: National Academy Press, 1994. 

  6. Kissane DW, Lichtenthal WG: Family focused grief therapy: from palliative care into bereavement. In: Stroebe MS, Hansson RO, Schut H, et al., eds.: Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, DC: American Psychological Association, 2008, pp 485-510. 

  7. Kissane DW, Bloch S: Family Focused Grief Therapy: A Model of Family-Centered Care During Palliative Care and Bereavement. Buckingham, United Kingdom: Open University Press, 2002. 

  8. Kissane DW, McKenzie M, Bloch S, et al.: Family focused grief therapy: a randomized, controlled trial in palliative care and bereavement. Am J Psychiatry 163 (7): 1208-18, 2006.  [PUBMED Abstract]

  9. Shear K, Frank E, Houck PR, et al.: Treatment of complicated grief: a randomized controlled trial. JAMA 293 (21): 2601-8, 2005.  [PUBMED Abstract]

  10. Weissman MM, Markowitz JC, Klerman GL: Comprehensive Guide to Interpersonal Psychotherapy. New York, NY: Basic Books, 2000. 

  11. Boelen PA, de Keijser J, van den Hout MA, et al.: Treatment of complicated grief: a comparison between cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol 75 (2): 277-84, 2007.  [PUBMED Abstract]

  12. Jacobs SC, Nelson JC, Zisook S: Treating depressions of bereavement with antidepressants. A pilot study. Psychiatr Clin North Am 10 (3): 501-10, 1987.  [PUBMED Abstract]

  13. Pasternak RE, Reynolds CF 3rd, Schlernitzauer M, et al.: Acute open-trial nortriptyline therapy of bereavement-related depression in late life. J Clin Psychiatry 52 (7): 307-10, 1991.  [PUBMED Abstract]

  14. Zisook S, Shuchter SR, Pedrelli P, et al.: Bupropion sustained release for bereavement: results of an open trial. J Clin Psychiatry 62 (4): 227-30, 2001.  [PUBMED Abstract]

  15. Reynolds CF 3rd, Miller MD, Pasternak RE, et al.: Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. Am J Psychiatry 156 (2): 202-8, 1999.  [PUBMED Abstract]