CBT Beats Mindfulness for Prolonged Grief Disorder

Cognitive behavior therapy (CBT) bested mindfulness therapy for patients with prolonged grief disorder, a randomized clinical trial showed.

In Australian study of 100 patients, grief-focused CBT led to greater reductions in scores on the Prolonged Grief-13 (PG-13) scale at 6 months compared with mindfulness-based cognitive therapy (mean difference 7.1 points, 95% CI 1.6-12.5, P=0.01) with a large between-group effect size (0.8, 95% CI 0.2-1.3), according to Richard Bryant, PhD, of the University of New South Wales in Sydney, Australia, and colleagues. PG-13 scores range from 11-55, with higher scores indicating greater prolonged grief disorder severity.

However, there were no significant differences in PG-13 scores immediately after treatment, and both groups had a reduction in symptoms at both time points, they reported in JAMA Psychiatry.

For instance, PG-13 scores fell from 43.6 points at baseline to 31.2 after treatment and 28.7 at 6 months for those who had CBT, and they fell from 40.6 points at baseline to 29.5 after treatment and 32.8 at 6 months for those who had mindfulness therapy.

"All trials to date have highlighted that grief-focused psychotherapy is the treatment of choice. However, this does show that symptom relief can also be achieved by alternate approach such as mindfulness," Bryant told MedPage Today in an email.

Melanie Lean, PsychD, of Stanford University in California, told MedPage Today that this trial provides a "thorough and rigorous" comparison between two evidence-based treatments, but grief-focused CBT appeared to be more effective with "quite a large effect size."

"These results are an important contribution to the evidence base needed to guide clinicians working with people who have become stuck in their grief," Lean told MedPage Today in an email. "Asking people to participate in a therapy that makes them confront difficult memories and emotions is challenging. It's good to know that the evidence supports this hard task that we ask of our patients."

Prolonged grief disorder is a relatively new condition that was recently recognized by the DSM-5-TR, which was released in March 2022, and by the International Classification of Diseases, 11th Revision (ICD-11). It is characterized by emotional pain and impairment brought on by persistent yearning for an individual who died, and affects between 4% and 10% of bereaved people, the researchers wrote. Patients can also experience increased risk of suicide, functional impairment, and other severe comorbidities.

For their study, the researchers recruited 100 adults, mean age 47.3 years, 87% female, from November 2012 to November 2022, randomizing 50 to the CBT group and 50 to the mindfulness therapy group. Patients were excluded if they had severe suicide risk, presence of psychosis, or substance dependence.

Treatment involved 11 weeks of once-weekly 90-minute sessions at a traumatic stress clinic in Sydney. Grief-focused CBT involved recalling memories of the deceased, cognitive restructuring, and planning future social activities, while mindfulness therapy focused on exercises adapted to tolerate grief-related distress. Patients were followed through 6 months.

In addition to the primary outcome of effects on PG-13 scores, those in the CBT group also had greater reductions in depression at 6 months as measured on the Beck Depression Inventory than those in the mindfulness group (mean difference 6.6 points, 95% CI 0.5-12.8, P=0.04; scores range from 0-63 with higher scores indicating more severe depression).

The CBT group also had greater reductions in grief-related cognition at 6 months as measured by the Grief Cognition Scale (mean difference 14.4 points, 95% CI 2.8-25.9, P=0.02; scores range from 0-190 with higher scores indicating more severe grief cognition).

There were no significant differences in terms of anxiety or quality of life, and no reported adverse events.

The study was limited by several factors including its single-blinded nature, wherein therapists were not blinded to the treatment condition. The trial was also conducted in a largely white population in a high-income country, so results might not be generalizable to low- and middle-income countries. The authors also noted that they did not include a no-treatment group.

Nonetheless, Bryant said the diagnosis of prolonged grief disorder will likely become more common, and experts will need guidance for delivering treatment.

"Bottom line is that recommended treatment for prolonged grief is grief-focused psychotherapy, but if clinicians or patients are reluctant to engage in this, one can use mindfulness," he said.

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