Complicated Grief Treatment

This dissertation is an exploration of the putative mediators of complicated grief treatment (CGT) in an effort to gain a better understanding of the mechanisms by which the treatment exerts its effects. This three-paper dissertation utilizes data from an NIMH-funded randomized controlled trial of CGT (Shear et al., 2005), which showed that CGT is more effective than Interpersonal Psychotherapy (IPT) in reducing symptoms of complicated grief (CG). The first paper examines a broad range of ancillary outcomes including symptoms of anxiety, depression, complicated grief and sleep disturbance due to bad dreams. Antidepressant use is examined as a possible moderator since half the sample was taking antidepressants and those taking antidepressants had a marginally better response rate in CGT than those not taking them (59% vs. 42% in CGT and 40% vs. 19% in IPT). CGT was more effective than IPT in reducing cognitive symptoms of anxiety, depression as measured by the Hamilton Rating Scale for Depression (HRSD), somatic symptoms of depression, guilt/self-blame, negative thoughts about the future, avoidance and poor sleep due to bad dreams. The difference in treatment effect on the HRSD for CGT over IPT was more pronounced for participants not taking antidepressants where CGT reduced depression but IPT did not. Paper two examines possible mediators specific to the model of CGT including: guilt/self-blame specific to the death or deceased; negative thoughts about the future; avoidance of reminders of the loss; anxiety and depression (intense negative emotions). Antidepressants are also examined as a potential moderator to explore whether their use affects the mediating role of the identified variables. All of these variables emerged as either full or partial mediators of CGT. Antidepressant use had no effect on the mediating role of these variables. Paper three examines whether alliance (measured at week 4) predicts subsequent change in grief symptoms (controlling for early symptom change) and if so, whether it accounts for the difference in treatment effect between CGT and IPT (mediation). Working alliance emerged as a mediator of CGT, accounting for 28% of the treatment effect found between CGT/IPT and grief symptoms. Discussion sections for each paper summarize study findings, limitations and implications for future research.