Cognitive Behavioural Therapy for Complicated Grief Reactions in Old Age
- Conditions
- DepressionAnxietyProlonged Grief DisorderPosttraumatic Stress DisorderBereavement
- Interventions
- Behavioral: Group-based Cognitive Behavioural Therapy for Complicated Grief ReactionsBehavioral: Individually delivered Cognitive Behavioural Therapy for Complicated Grief Reactions
- Registration Number
- NCT04694807
- Lead Sponsor
- University of Aarhus
- Brief Summary
While most bereaved individuals cope adaptively with the loss of a loved one, a significant minority experiences more severe and complicated grief reactions. Complicated grief reactions is an umbrella term for different types of post-loss complications, including symptoms of Prolonged Grief Disorder (PGD), depression, anxiety, and posttraumatic stress. These post-loss complications may all cause persistent suffering and functional impairment, thus pointing to a need for efficacious treatment.
While Cognitive Behavioural Therapy (CBT) is a relatively well-documented efficacious treatment for symptoms of PGD, depression, anxiety, and posttraumatic stress in the period after a loss, the relative efficacy of a transdiagnostic individually delivered versus group-based CBT for these types of complicated grief reactions (CBTgrief) remain unknown. Furthermore, little evidence exists about the relative cost-effectiveness of individually delivered versus group-based CBTgrief and why and how it works. The theory of CBTgrief proposes that it works by targeting three maintaining mechanisms in PGD: 1) Insufficient integration of the loss, 2) negative loss-related cognitions, and 3) depressive and anxious avoidance. These maintaining mechanisms have also shown to be statistically associated with depression, anxiety, and posttraumatic stress in the period after a loss, suggesting that different types of complicated grief reactions might share some of the same maintaining mechanisms. However, this proposed theory of change has yet to be empirically tested as a whole.
These knowledge gaps are crucial for the understanding of efficacious and cost-effective treatment formats as well as central treatment mechanisms in the psychological treatment of complicated grief reactions. The present study thus aims to examine the relative efficacy of an individually delivered versus group-based CBTgrief by means of a randomized non-inferiority trial. Secondary aims include an investigation of the relative cost-effectiveness of individually delivered versus group-based CBTgrief as well as treatment mediators. Finally, explorative analyses of potential moderators of intervention effects of CBTgrief will be conducted.
- Detailed Description
Aims of the study:
1. Evaluate the relative efficacy of an individually delivered versus group-based CBTgrief.
2. Evaluate the relative cost-effectiveness of an individually delivered versus group-based CBTgrief.
3. Examine the theoretically proposed treatment mediators of CBTgrief.
4. Explore loss-related and sociodemographic characteristics as possible moderators of intervention effects.
Primary hypothesis:
Group-based CBTgrief will show non-inferiority (i.e., equal efficacy) in reducing symptoms of PGD compared to individually delivered CBTgrief at six months follow-up.
Secondary hypotheses:
1. Group-based CBTgrief will show non-inferiority (i.e., equal efficacy) in reducing symptoms of posttraumatic stress, depression, and anxiety compared to individually delivered CBTgrief at six months follow-up.
2. Group-based CBTgrief will be more cost-effective than individually delivered CBTgrief.
3. The observed effect of CBTgrief is mediated by changes in theoretically proposed maintaining mechanisms of complicated grief reactions (i.e. insufficient integration of the loss; negative loss-related cognitions; depressive and anxious avoidance).
4. Gender, level of education, age, baseline grief symptom level, type of loss, circumstances of the loss, time since loss, and number of additional losses will moderate the observed effects of CBTgrief.
5. Additional exploratory analyses include an additional matched comparison group, who have not received treatment in order to compare the effect of individual and group-based CBTgrief to a non-treatment group. This group will be extracted from a large-scale survey study: The Aarhus Bereavement Study (NCT03049007). Here, it is hypothesized that CBTgrief will have a statistically significant medium size effect on symptoms of PGD at six months follow-up compared to a matched comparison group, who did not receive treatment.
Design: The present study is conducted as a randomized non-inferiority trial of individually delivered versus group-based CBTgrief using block randomization.
Participants: Participants are recruited from the Danish National Center for Grief (DNCG), which is a Danish national organization that provide specialized psychological therapy to bereaved individuals who have lost a loved one. The therapists at the DNCG will screen and treat bereaved elderly people for complicated grief reactions with CBTgrief at their clinics in Odense and Copenhagen, Denmark. DNCG identifies participants through consultants, local practitioners, self-referral, and the DNCG grief support line.
Assessment points: Participants will be assessed at pre-, mid-, and post-intervention as well as at three and six months follow-up (T1-T5). Additionally, data on healthcare utilization will be retrieved from the Danish national registers concerning use of health care services such as visits to general practitioners, psychologists etc.
Sample size: A group sample size of 2x64 will enable us to detect non-inferiority between individually delivered and group-based CBTgrief with a non-inferiority of -0.5 SD on the primary outcome, i.e. symptoms of PGD, and a statistical power of 0.80. The true difference is assumed to be 0.0 and the one-sided significance level (alpha) of the test is 0.025. Based on an estimated dropout rate of 20% the total number of participants needed to recruit is N=160 participants.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 160
- Age ≥ 65 years (older adult).
- Lost a loved one (e.g., spouse, partner) ≥ 6 months ago.
- Clinically relevant symptoms of one or more types of complicated grief reactions (i.e. symptoms of prolonged grief (PG-13 ≥ 29), depression (CESD-10 ≥ 10), anxiety (GAD-7 ≥ 10), and/or posttraumatic stress (PCL ≥ 31)).
- No clinically relevant symptoms of one or more types of complicated grief reactions (i.e. symptoms of prolonged grief, depression, anxiety and/or posttraumatic stress).
- No informed consent given.
- Insufficient Danish proficiency.
- Inability to transport oneself to the clinic.
- Severe psychopathology (e.g., schizophrenia).
- Severe cognitive impairment (e.g., Alzheimer's disease).
- Substance abuse.
- Acute suicidal ideation.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Group-based Cognitive Behavioural Therapy Group-based Cognitive Behavioural Therapy for Complicated Grief Reactions A group delivered treatment format of CBTgrief (12 sessions). Individually delivered Cognitive Behavioural Therapy Individually delivered Cognitive Behavioural Therapy for Complicated Grief Reactions An individual delivered treatment format of CBTgrief (12 sessions).
- Primary Outcome Measures
Name Time Method Symptoms of prolonged grief disorder From baseline (T1) to post-intervention (T3; up to one week after the 12th session) and to six months follow-up (T5). Changes in symptoms of prolonged grief disorder will be measured with Prolonged Grief Disorder-13 (PG-13; Prigerson et al., 2009). Higher total scores indicate higher symptom level (minimum value: 11; maximum value: 57).
- Secondary Outcome Measures
Name Time Method Anxiety symptoms From baseline (T1) to post-intervention (T3; up to one week after the 12th session), three months follow-up (T4), and six months follow-up (T5). Changes in anxiety symptoms will be measured with Generalized Anxiety Disorder-7 (GAD-7; Spitzer, Kroenke, Williams, \& Löwe, 2006). Higher total scores indicate higher symptom level (minimum value: 0; maximum value: 21).
Posttraumatic stress symptoms From baseline (T1) to post-intervention (T3; up to one week after the 12th session), three months follow-up (T4), and six months follow-up (T5). Changes in posttraumatic stress symptoms will be measured with Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) (PCL; Ashbaugh, Houle-Johnson, Herbert, El-Hage, \& Brunet, 2016; Weathers et al., 2013). Higher total scores indicate higher symptom level (minimum value: 0; maximum value: 80).
Symptoms of ICD-11 prolonged grief disorder From baseline (T1) to post-intervention (T3; up to one week after the 12th session), three months follow-up (T4), and six months follow-up (T5). Changes in symptoms of ICD-11 prolonged grief disorder (i.e. the 11th revision of the International Classification of Diseases definition) will be measured by mapping questionnaire items from Prolonged Grief Disorder-13 (PG-13; Prigerson et al., 2009); Inventory of Complicated Grief Revised (ICG-r; Prigerson \& Jacobs, 2001); Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5; Ashbaugh et al., 2016; Weathers et al., 2013).
Depressive symptoms From baseline (T1) to post-intervention (T3; up to one week after the 12th session), three months follow-up (T4), and six months follow-up (T5). Changes in depressive symptoms will be measured with Center for Epidemiologic Studies Short Depression Scale (CESD-10; Andresen, Malmgren, Carter, \& Patrick, 1994). Higher total scores indicate higher symptom level (minimum value: 0; maximum value: 30).
Functional impairment From baseline (T1) to post-intervention (T3; up to one week after the 12th session), three months follow-up (T4), and six months follow-up (T5). Changes in functional impairment will be measured with Sheehan Disability Scale (SDS; Leon, Olfson, Portera, Farber, \& Sheehan, 1997). Higher total scores indicate greater functional impairment (minimum value: 0; maximum value: 30).
Symptoms of prolonged grief disorder (at three months follow-up) From baseline (T1) to three months follow-up (T3). Changes in symptoms of prolonged grief disorder will be measured with Prolonged Grief Disorder-13 (PG-13; Prigerson et al., 2009). Higher total scores indicate higher symptom level (minimum value: 11; maximum value: 57).
Quality adjusted life years From baseline (T1) to post-intervention (T3; up to one week after the 12th session), three months follow-up (T4), and six months follow-up (T5). Changes in quality adjusted life years will be assessed with 5Q-5D-5L (EuroQol Research Foundation, 2019) and used in order to evaluate cost-effectiveness.
Social support From baseline (T1) to post-intervention (T3; up to one week after the 12th session), three months follow-up (T4), and six months follow-up (T5). Changes in social support will be measured with Crisis Social Support scale (CSS; Joseph, Andrews, Williams, \& Yule, 1992). Higher total scores indicate higher level of support (minimum value: 7; maximum value: 49).
Well-being From baseline (T1) to post-intervention (T3; up to one week after the 12th session), three months follow-up (T4), and six months follow-up (T5). Changes in well-being will be measured with the five-item WHO Well-Being Index (WHO-5; Heun, Bonsignore, Barkow, \& Jessen, 2001). Higher total scores indicate higher well-being (minimum value: 0; maximum value: 100).
Loneliness From baseline (T1) to post-intervention (T3; up to one week after the 12th session), three months follow-up (T4), and six months follow-up (T5). Changes in loneliness will be measured with Three-Item Loneliness Scale (TILS; Hughes, Waite, Hawkley, \& Cacioppo, 2004). Higher total scores indicate greater loneliness (minimum value: 3; maximum value: 9).
Mental and physical function From baseline (T1) to post-intervention (T3; up to one week after the 12th session), three months follow-up (T4), and six months follow-up (T5). Changes in mental and physical function will be measured with 12-Item Short Form Health Survey (SF-12; Ware, Kosinski, \& Keller, 1996).
Trial Locations
- Locations (1)
Unit for Bereavement Research, Dept. of Psychology, Aarhus University
🇩🇰Aarhus C, Denmark