Treating Complicated Grief: Grief-Focused Psychotherapy Is More Effective Than Citalopram

September 1, 2016

Bret A. Moore, Psy.D, ABPP Board-Certified Clinical Psychologist, San Antonio, TX Dr. Moore has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Review of: Shear M et al, JAMA Psychiatry, 2016;73:685–694; Study type: Randomized placebo-controlled trial

Complicated grief (CG) is a relatively common response in those who have suffered the loss of a loved one. In DSM-5, it is listed in the section on conditions for further study, and it is called “persistent complex bereavement disorder.” To meet the diagnostic criteria, your patient must have suffered bereavement for at least 6 months, and must have had at least 3 of a list of symptoms for 1 month. While there is some overlap with major depression, CG has core symptoms of yearning and sorrow and great difficulty accepting the reality of death. It’s one of the more controversial proposed DSM disorders, with critics seeing it as medicalizing a normal human experience. Nonetheless, there has been a lot of research on how to help people with CG, and a specific psychotherapy, called complicated grief treatment (CGT), is clearly effective. But how does therapy compare with a standard antidepressant?

To answer this question, researchers recruited 395 individuals diagnosed with CG; the majority were women, the mean age was 53, and the mean number of years since the loss was 4.7. These patients were randomized to one of four groups: citalopram (n = 101), placebo (n = 99), CGT with citalopram (n = 99), and CGT with placebo (n = 96). The citalopram (CIT) was flexibly dosed with an average of 33.9 mg/day. Spanning 20 weeks, patients were assessed monthly with the Clinical Global Impression scale (CGI), which was the primary outcome measure. Secondary measures to assess depression included the self-report version of the Quick Inventory of Depressive Symptoms and a modified version of the Columbia Suicide Scale.

Results
The main outcome measure was the response rate after 20 weeks, defined as “much improved” or “very much improved” on the Clinical Global Impression scale. Patients in the CGT groups did the best, whether the therapy was combined with CIT (83.7% response rate) or with placebo (82.5%). Adding CGT to CIT was more effective than CIT alone (83.7% vs. 69.3%), and CIT alone was numerically superior to placebo, but it didn’t quite reach statistical significance (69.3% vs. 54.8%, p = 0.11). On a secondary measure of depressive symptoms, adding CIT to CGT did outperform CGT alone.

TCPR’s Take
CGT was clearly more effective for complicated grief than CIT. While CIT alone did not statistically outperform placebo, there is a factor that might have put the medication at a disadvantage. The 2011 FDA warning about high CIT doses causing EKG abnormalities was issued a year into the study, forcing researchers to decrease the maximum dose allowed from 60 mg to 40 mg. That led to a lower-than-planned CIT average dosing of 33.9 mg, which may have limited its efficacy.

Practice implications
The bottom line is that while CGT is the treatment of choice for CG, adding an SSRI to this psychotherapy might provide a small efficacy boost for depressive symptoms.

General Psychiatry