Medical comorbidity in complicated grief: Results from the HEAL collaborative trial
Introduction
Complicated Grief (CG) is a chronic and debilitating condition estimated to occur in 7% of bereaved people, thus affecting tens of millions of people worldwide (Kersting et al., 2011). Studies have shown that CG can reliably be distinguished from major depression both in response to treatment and primary symptomatology (Cozza et al., 2016, Shear et al., 2016, Shear et al., 2014, Supiano and Luptak, 2014). CG symptoms include prolonged yearning, longing, sorrow, persistent thoughts of the deceased, and difficulty imagining a future with purpose and meaning, together with impairment in social and occupational function (Kersting et al., 2011).
There is a strong association between bereavement, especially CG, and negative health outcomes. CG is known to shorten life expectancy, due to death from heart disease and/or cancer (Prigerson et al., 2002). CG has also been associated with physiologic symptoms, such as shortness of breath, palpitations, digestive difficulties, loss of appetite, weight loss, poor treatment adherence, sleep issues including restlessness, insomnia, and low sleep quality, and a 10-fold greater risk for hypertension and heart disease (Lannen et al., 2008; H. G. Prigerson et al., 1995a, Prigerson et al., 1995b; Prigerson et al., 1997, Shear, 2015, Stroebe et al., 2011).
CG also frequently co-exists with major depression, which is similarly associated with shortened life expectancy across a range of medical and neurological disorders (Gallo et al., 2013). Evidence-based treatment of depression in older primary care adults leads to substantial reduction in mortality risk (24% over eight years), secondary to reductions in cancer-related deaths (Gallo et al., 2013). We do not know whether evidence-based treatment of CG to remission also leads to reductions in mortality risk. However, to test whether evidence-based treatment of CG to remission also leads to reductions in mortality risk, we must first develop an understanding of the type, extent, and severity of medical comorbidity in persons with CG, with and without depression. Thus, this study addresses the following aims:
- 1.
To describe medical comorbidity in persons with complicated grief, as compared with non-bereaved depressed subjects with current major depression and with non-bereaved, non-depressed control participants.
- 2.
To test whether medical comorbidity in complicated grief is associated with the severity and duration of CG, after adjusting for the effects of age, sex, race, and severity of depressive symptoms.
Section snippets
Design
We analyzed data from a multisite clinical trial of CG (“HEAL”: “Healing Emotions After Loss”) (Shear et al., 2016), sponsored by the National Institute of Mental Health. HEAL is a double-blind, placebo-controlled, randomized clinical trial that evaluated the efficacy of antidepressant pharmacotherapy, with and without complicated grief psychotherapy, in the treatment of CG. Participants were recruited from four communities in the United States: Boston, MA; New York, NY; Pittsburgh, PA; and San
Aim 1: Comparison of medical comorbidity in persons with complicated grief, major depression, and controls
Table 1 summarizes the comparison of those with CG (HEAL) to DEPRESSED and CONTROL subjects. The three groups had been matched for age, sex, and self-reported race/ethnicity. Cumulative medical comorbidity (total CIRS-G scores) was greater in DEPRESSED than in CG subjects, and both DEPRESSED and CG subjects had greater medical morbidity scores than CONTROLS.
Analyses by organ system using individual organ-system specific CIRS-G scores showed significant differences for CG versus CONTROLs in two
Discussion
In this exploratory study, we observed that total medical comorbidity (CIRS-G scores) was greater in DEPRESSED than in CG subjects having similar age, sex, and race/ethnicity, and that medical comorbidity in either group exceeded that seen in non-depressed, non-bereaved CONTROLS. Medical comorbidity in CG was not found to be associated with severity and duration of CG after adjusting for chronological age and severity of co-occurring depressive symptoms. Medical comorbidity in complicated grief
Sources of funding
Preparation of this manuscript was supported in part by Grants from NIH K01MH103467, R01MH60783, R01MH085297, R01MH085288, R01MH085308, and P30 MH90333 from the National Institutes of Health and by grant LSRG-S_172-12 from the American Foundation for Suicide Prevention.
Conflicts of interest
Dr. Reynolds reports being supported by the NIH (P30 MH90333), and the UPMC Endowment in Geriatric Psychiatry; having received medication supplies for investigator-initiated trials from Bristol Meyers Squibb, Forrest Labs, Lily, and Pfizer; and receives royalties for industry sponsored use of the Pittsburgh Sleep Quality Index (PSQI), to which he holds intellectual property rights. Dr. Simon reports grant funding from the NNIH, the Department of Defense, Janssen, the American Foundation for
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