Treatment of complicated grief in elderly persons: a randomized clinical trial

Abstract

Importance: Complicated grief (CG) is a debilitating condition, most prevalent in elderly persons. However, to our knowledge, no full-scale randomized clinical trial has studied CG in this population.

Objective: To determine whether complicated grief treatment (CGT) produces greater improvement in CG and depressive symptoms than grief-focused interpersonal psychotherapy (IPT).

Design, setting, and participants: Randomized clinical trial enrolling 151 individuals 50 years or older (mean [SD] age, 66.1 [8.9] years) scoring at least 30 on the Inventory of Complicated Grief (ICG). Participants were recruited from the New York metropolitan area from August 20, 2008, through January 7, 2013, and randomized to receive CGT or IPT. The main outcome was assessed at 20 weeks after baseline, with interim measures collected at 8, 12, and 16 weeks after baseline.

Interventions: Sixteen sessions of CGT (n = 74) or IPT (n = 77) delivered approximately weekly.

Main outcomes and measures: Rate of treatment response, defined as a rating from an independent evaluator of much or very much improved on the Improvement subscale of the Clinical Global Impression Scale.

Results: Both treatments produced improvement in CG symptoms. Response rate for CGT (52 individuals [70.5%]) was more than twice that for IPT (24 [32.0%]) (relative risk, 2.20 [95% CI, 1.51-3.22]; P < .001), with the number needed to treat at 2.56. Secondary analyses of CG severity and CG symptom and impairment questionnaire measures confirmed that CGT conferred a significantly greater change in illness severity (22 individuals [35.2%] in the CGT group vs 41 [64.1%] in the IPT group were still at least moderately ill [P = .001]), rate of CG symptom reduction (1.05 ICG points per week for CGT vs 0.75 points per week for IPT [t633 = 3.85; P < .001]), and the rate of improvement in CG impairment (0.63 work and Social Adjustment Scale points per week with CGT and 0.39 points per week with IPT [t503 = 2.87; P = .004]). Results were not moderated by participant age.

Conclusions and relevance: Complicated grief treatment produced clinically and statistically significantly greater response rates for CG symptoms than a proven efficacious treatment for depression (IPT). Results strongly support the need for physicians and other health care providers to distinguish CG from depression. Given the growing elderly population, the high prevalence of bereavement in aging individuals, and the marked physical and psychological impact of CG, clinicians need to know how to treat CG in older adults.

Trial registration: clinicaltrials.gov Identifier: NCT01244295.

Figure 1. Study Flowchart

CGT indicates complicated grief treatment; IPT, interpersonal psychotherapy.

Figure 2. Response Rates at Week 20 Adjusted for Missing Data by Inverse Probability Weighting

Among those receiving complicated grief treatment (CGT), 52 individuals (70.5%; 95% CI, 60.3%–82.6%) responded compared with 24 (32.0%; 95% CI, 22.7%–45.2%) among those receiving interpersonal psychotherapy (IPT). Whiskers indicate 95% confidence intervals.

Figure 3. Estimated Linear Trends for Symptom and Functioning Measures Based on the Mixed-Effects Model

A, Estimated linear trends for mean total scores on the Inventory of Complicated Grief (ICG) (total range, 0–76). B, Estimated linear trends for mean total scores on the Work and Social Adjustment Scale (WSAS) (total range, 0–40). C, Estimated linear trends for mean total scores on the Grief-Related Avoidance Questionnaire (GRAQ) (total range, 0–60). D, Estimated linear trends for mean total scores on the Beck Depression Inventory (BDI) (total range, 0–63). Scores are totaled by study week for complicated grief treatment (CGT) and interpersonal psychotherapy (IPT) groups in the intention-to-treat sample estimated from a linear mixed-effects model with random intercepts and random slopes.