Research Highlights
Trial tests therapies for chronic, disabling grief
August 30, 2010
Grief is part of life. Losing a loved one—whether a spouse, combat buddy, or any close friend or relative—naturally entails weeks or months of shock, sorrow, anguish and a range of other wrenching emotions.
Most people gradually recover and move on. For some, though, grief lingers and intensifies, even over several years. It gets in the way of normal life. Clinicians call this 'complicated grief." The disorder affects about one in ten people after bereavement. It's not yet a formally recognized condition in its own right—it shares symptoms of depression, anxiety and PTSD—but some experts, like Sidney Zisook, MD, a psychiatrist with VA and the University of California, San Diego,say it should be. Zisook and colleagues published an article in last month's Journal of Clinical Psychiatry recommending that complicated grief be included in the next edition of the DSM, the official diagnostic guide for mental health professionals. What's more, they are now conducting a four-site clinical trial to determine the best way to treat the condition.
'It's becoming an increasingly welldefined disorder," says Zisook. 'But it is vastly under-recognized, and, we think, un- or under-treated."
That's dangerous, says the psychiatrist. He says the condition brings people's lives to a standstill and robs them of a sense of purpose. Some seek to deal with the ongoing intense grief by taking on unhealthy behaviors such as smoking and overeating. They may become at higher risk for high blood pressure and heart disease, as well as complicating psychiatric conditions like major depression or panic disorder. They are also at risk for suicidal thinking and behavior. Zisook and colleagues write, 'Suicidal urges are usually related to hopes of finding or joining the deceased loved one or feeling that life without the deceased person is unbearable."
'It's very clear," says Zisook. 'Complicated grief must be taken seriously and treated appropriately."
The new trial will include 440 adults, including Veterans and others between 18 and 85. Two therapies will be put to the test, alone and in combination: an antidepressant, and a form of psychotherapy designed especially to treat complicated grief.
'We're testing the effectiveness of antidepressant medications for complicated grief, both when used alone and also when administered with complicated grief therapy, as well as the effectiveness of complicated grief therapy with and without medications," explains Zisook. 'We feel these goals are very important and that our results will shape the treatment of this condition for years to come."
Complicated grief therapy was developed by Zisook's collaborator Katherine Shear, MD, now with Columbia University and formerly with the University of Pittsburgh. One component involves the patient revisiting the story of the death and reflecting on it. Proponents of the therapy say it helps quench the raw, burning emotion that persists in those with complicated grief and helps them come to terms with the finality and consequences of the death. The therapy usually entails weekly sessions over four months. Zisook has great faith in the therapy, although he points out that the revisiting exercises can be difficult for patients.
'The treatment asks people to confront painful emotions, but it's administered in a respectful, collaborative manner to ensure a sense of support and companionship in the pain," Zisook says. He adds that part of each session is aimed at helping the person focus on pleasurable activities and work toward meaningful life goals. 'No treatment works for everyone," he says, 'but this appears to be the most effective way to help people with complicated grief so far. Existing data indicate that gains are maintained long-term."
The study will take about five years. Besides San Diego, patients will be enrolled at Columbia University in New York; the University of Pittsburgh; and Massachusetts General Hospital. The effort is funded by the National Institute of Mental Health and the American Foundation for Suicide Prevention.
This article originally appeared in the September 2010 issue of VA Research Currents.