Cognitive behavioral therapy shows promise for prolonged grief disorder

A clinical trial finds that integrative cognitive behavioral therapy (PG-CBT) is more effective than present-centered therapy (PCT) in reducing grief severity and comorbid symptoms after treatment, providing hope for individuals with prolonged grief disorder.

Study: Grief-Specific Cognitive Behavioral Therapy vs Present-Centered Therapy. Image Credit: Microgen/Shutterstock.com

In a recent study published in the JAMA Psychiatry, a group of researchers evaluated whether integrative cognitive behavioral therapy for prolonged grief (PG-CBT) is more effective than present-centered therapy (PCT) in reducing prolonged grief disorder (PGD) symptoms.

Background

PGD is now recognized as a distinct diagnosis in both International Classification of

Diseases, 11th Revision (ICD-11) and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), marked by intense, persistent yearning and preoccupation with the deceased, often leading to identity disruption and loss of meaning.

PGD prevalence is around 5%, with higher rates among older adults and those who experience violent or unnatural losses. PGD is associated with increased risks of suicidality, physical health issues, and co-occurring mental health disorders, particularly depression.

While grief-focused CBT shows promise in reducing PGD symptoms, research comparing it to active treatments remains scarce, necessitating the need for further study.

About the study

The present trial was conducted across four university outpatient clinics in Germany. Ethical approval was obtained from each center’s review board, and participants provided written informed consent before randomization.

Participants were aged 18 to 75, had primary PGD based on the Prolonged Grief Disorder 13 (PG-13) interview, demonstrated sufficient cognitive ability, and could read and answer questions in German. Exclusion criteria included severe mental health disorders, concurrent therapy, acute suicidality, or recent changes in psychotropic medication. 

The trial aimed to assess the efficacy of integrative PG-CBT compared to PCT by analyzing changes in PGD severity scores after 12 months. PG-CBT, combining exposure, psychoeducation, and cognitive restructuring, was compared to PCT, which provided support for daily stressors without core cognitive restructuring.

Randomization was managed by an independent center using block randomization. Treatment included 20 weekly sessions with up to 4 optional sessions, conducted face-to-face or via video during the coronavirus disease 2019 (COVID-19) pandemic.

Blinded raters conducted assessments at multiple points, and statistical analyses used a linear mixed-effects model for continuous outcomes. This study followed Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines and was registered with the German Clinical Trials Register.

Study results

Between April 2017 and May 2022, 544 individuals were screened for eligibility, with 213 enrolled and randomly assigned to PCT or PG-CBT. After one participant withdrew consent, 212 participants (mean age 51.8, ranging from 19 to 75 years; 82% female) remained.

Baseline characteristics were balanced between the groups, including the time since loss, which averaged 26.5 months. Among participants, 47% had at least one comorbid mental disorder, with depressive disorder being the most common (57%).

In the intention-to-treat (ITT) analysis, both therapies led to substantial reductions in PGD severity at follow-up. PG-CBT was initially more effective than PCT on the PG-13 severity score after treatment, with a mean change difference of -3.15 (Cohen’s d = 0.31), though this advantage diminished by the 12-month follow-up, showing only a trend-level difference (Cohen’s d = 0.28).

Secondary outcomes revealed PG-CBT’s significant superiority over PCT in reducing overall psychopathology at six and twelve months and depressive symptoms at twelve months. Both therapies were comparable in improving somatic symptoms.

Within each group, improvements from baseline to follow-up in PGD severity were significant and large (PG-CBT: Cohen’s d = 1.64; PCT: Cohen’s d = 1.38). Suicide risk reductions, measured by the Columbia-Suicide Severity Rating Scale (C-SSRS) severity score, were significant post-treatment for both therapies, though only PG-CBT maintained significance through follow-up.

Diagnostic assessments indicated no significant difference in PGD remission rates between the groups, with PGD persisting post-treatment for 10 in PG-CBT and 17 in PCT and at follow-up for 8 in PG-CBT and 15 in PCT.

The study had a lower-than-expected dropout rate, with 18% of participants discontinuing treatment. The main reasons for dropout were external stressors and lack of motivation.

Treatment adherence and safety were high across both groups, with no serious treatment-related adverse events. Sensitivity analyses confirmed the treatment responses, showing consistency across various methods.

The study also evaluated the potential impact of the COVID-19 pandemic, categorizing participants based on their participation timing relative to the pandemic. There was no differential treatment response among these groups, with effect sizes suggesting stability across pre-, during, and post-pandemic periods.

Conclusions

To summarize, PG-CBT showed superior short-term effects on PGD symptoms, but this advantage lessened at follow-up. Both therapies effectively reduced PGD and comorbid depressive symptoms, with similar remission and dropout rates to other trials.

Unlike previous studies using non-specific controls, PCT focused on addressing daily grief-related stressors, potentially enhancing its effectiveness.