So-called ‘complicated’ grief following the death of a loved one and lasting 6 months or longer, can be relieved more effectively with interpersonal therapy combined with a focus on treating the loss than with interpersonal psychotherapy alone, according to a new study reported in this week’s Journal of the American Medical Association.

Symptoms of complicated grief are not the same as those of major depression or posttraumatic stress disorder (PTSD), Dr. Katherine Shear told.

“Complicated grief has specific symptoms,” she noted, which include “a sense of disbelief, anger and bitterness about the death, episodic pangs of painful emotion and very prominent longing for the person that died, with recurrent images of the death itself and avoidance behavior.”

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Posttraumatic stress disorder Definition
Post-traumatic stress disorder (PTSD) is a type of anxiety problem. It can develop after your life is threatened, or after you experience or see a traumatic event. Usually, the event makes you feel very afraid or helpless. Some examples of traumatic events are a natural disaster, rape or a severe car crash.

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Symptoms can persist for years, she added. The predominant emotion is sadness, rather than the fear and anxiety that usually accompany PTSD.

Shear and her colleagues at the University of Pittsburgh School of Medicine in Pennsylvania devised a novel approach for treating complicated grief that combines aspects of interpersonal psychotherapy and cognitive-behavioral therapy techniques.

Patients are encouraged to retell the story of the death using a procedure called “revisiting.” They are also instructed to carry on an “imaginal conversation” with the deceased. During the treatment sessions the patient is also helped to identify personal life goals and to develop plans to meet those goals.

For their study, Shear’s group randomly assigned 49 subjects to complicated grief treatment and 46 others to interpersonal psychotherapy for an average of 16 sessions.

Among the 35 subjects assigned to complicated grief treatment and 34 assigned to interpersonal therapy who completed treatment, rates of improvement were 66 percent and 32 percent, respectively, the team reports. Those in the complicated grief treatment group also responded sooner.

According to Shear, “People with more intense grief reactions during the first 2 months are more vulnerable to developing complicated grief.”

She proposes several modifications that could improve the success rate of complicated grief treatment.

“About half of both groups were using Antidepressant medication, and they tended to do better, so we think adding an antidepressant to the treatment protocol is one strategy,” she said.

Those who dropped out of treatment often did so because they found process was “too hard to do,” Shear added. “We want to work with negative emotions before we do the actual revisiting, (including) strategies for dealing with negative emotion, self-soothing and other cognitive techniques.”

In a related editorial, Dr. Richard M. Glass, deputy editor of JAMA from the University of Chicago, notes the concern 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.”

He adds, “Evidence that distinguishes complicated grief from normal grief and also from major depressive disorder and PTSD appears to provide a compelling response to that concern.”

SOURCE: Journal of the American Medical Association, June 1, 2005.