Internet-based cognitive-behavioral therapy for complicated grief: a randomized controlled trial

A machine learning personalized treatment rule to optimize assignment to psychotherapies for grief among veterans

BACKGROUND

Complex grief patterns are associated with significant suffering, functional impairments, health and mental health problems, and increased healthcare use. This burden may be even more pronounced among veterans. Behavioral Activation and Therapeutic Exposure (BATE-G) and Cognitive Therapy for Grief (CT-G) are two evidence-based interventions for grief. The goal of this study was to use a precision medicine approach to develop a personalized treatment rule to optimize assignment among these psychotherapies.

METHODS

We analyzed data (N = 155) from a randomized clinical trial comparing BATE-G and CT-G. Outcome weighted learning was used to estimate an optimal personalized treatment rule. Baseline characteristics including demographics, social support, variables related to the death, and psychopathology dimensions were used as prescriptive factors of treatment assignment.

RESULTS

The estimated rule assigned 72 veterans to CT-G and 56 to BATE-G. Assigning participants according to this rule was estimated to lead to markedly lower mean grief level following 6 months from treatment compared to assigning everyone to either BATE-G (Vdopt - VBATE-G = -18.57 [95 % CI: -29.41, -7.72]) or CT-G (Vdopt - VBATE-G = -20.89 [95 % CI: -30.7, -11.07]) regardless of their characteristics.

LIMITATIONS

Participants were primarily male veterans, and identified with Black or White race. The estimated rule was not externally validated.

CONCLUSION

The estimated rule used relatively simple, easily accessible, client characteristics to personalize assignment to treatment using a precision medicine approach based on machine learning and causal inference. Upon further validation, such a rule can be easily implemented in clinical practice to prescriptively maximize treatment benefits.

The meaning in loss protocol: A clinical trial of online grief therapy

For a minority of the bereaved, the loss of a significant other can trigger an overwhelming emotional reaction and impaired functioning across life domains, known as prolonged grief disorder (PGD). Hence, ongoing efforts have been made to refine existing treatments to increase their efficacy and to accommodate the idiosyncrasies of grief reactions. This study presents the results of an open clinical trial of the feasibility and effectiveness of the Meaning in Loss (MIL) protocol in an online format. The brief intervention of 12 to 16 sessions combines constructivist and narrative strategies to explore and work through impediments to meaning reconstruction in loss. The sample included 25 participants diagnosed with PGD who were treated by six therapists. Baseline and post-therapy comparisons showed a significant improvement in all clinical measures (grief symptomatology, depression and general distress) and an increase of meaning making regarding the loss. Meaning making was found to be a prospective mediator of symptomatic improvement in grief across the course of therapy. These findings suggest the effectiveness of the MIL protocol in decreasing grief specific and associated symptomatology and argue for the relevance of further controlled evaluations of its efficacy. Moreover, results confirm previous findings that meaning making is a relevant factor in the evolution of grief reactions, including in the context of psychotherapy.

Understanding the complexity of suicide loss: PTSD, complex PTSD and prolonged grief disorder following suicide bereavement

Suicide-bereaved individuals are often confronted with profound grief reactions and have an increased risk for mental health disorders. Little is known about the development of complex post-traumatic stress disorder (CPTSD) following a loss by suicide. This paper aims to assess the prevalence of CPTSD, PTSD, prolonged grief disorder (PGD), and depression as well as to identify sociodemographic and loss-related factors regarding their development. A total of 161 suicide loss survivors (91.3% female) completed a questionnaire, which collected symptoms of grief (TGI-SR+), PTSD, CPTSD (ITQ), and depression (PHQ-D). In total, 12.4% met the diagnosis for CPTSD, 5.0% for PTSD. A total of 22.0% fulfilled the diagnosis for PGD. 41.6% showed at least moderate symptoms of depression. Pearson's correlation showed that time since loss was negatively associated with PG and PTSD symptoms, kinship to the deceased was associated with PG severity. The sample scored high on all disturbances in self-organization (DSO) symptom clusters typical for CPTSD. A focus on symptoms of CPTSD may be a necessary component in the care of survivors of suicide loss.

Deathbed experiences and meaning-making: Perspectives of family caregivers of patients who received cancer palliative care

OBJECTIVES

The deathbed symbolizes a time when the patient is dangerously ill and where death is imminent. The memories of family caregivers during this time can potentially shape their meaning-making of the patient's death and bereavement adjustment. We aimed to understand the experiences of family caregivers at the deathbed of patients receiving palliative care. We also examined caregiver's meaning-making that occurred after the patient's death.

METHODS

In this retrospective qualitative study, family caregivers of cancer patients who received palliative care in Singapore were recruited through purposive sampling. In-person, semi-structured interviews were individually conducted with study participants to understand their experiences from a caregiver's perspective before and after the death of the patient. Thematic content analysis method was conducted.

RESULTS

A total of 25 bereaved family caregivers were interviewed, with spouses, adult children, and others comprising one-third each of the sample. Six themes emerged from caregivers' recollected experiences around the patient deathbed: Lasting image of the patient, A time of intense emotions, Healthcare providers prepare caregivers, A time for saying goodbye, Rituals provide comfort, and Impact on family ties. Four themes emerged surrounding post-loss meaning-making: An end to the pain and suffering, "Have I done enough?," Significance in the timing of events, and Gaining strength and personal growth.

SIGNIFICANCE OF RESULTS

The deathbed is a salient time for family caregivers as they prepare for patient's death. There are opportunities to provide support to the family based on the study findings.

The change of working alliance and the association to treatment outcome in an internet-based therapy after pregnancy loss

BACKGROUND

Working alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss.

METHODS

228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10).

RESULTS

Data for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms.

CONCLUSION

The results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions.

TRIAL REGISTRATION

Not applicable.

Letter Writing as a Clinical Tool in Grief Psychotherapy

The benefits of expressive writing have been explored since at least the 1980s. The effect of expressive bereavement-related writing has been studied primarily in college students, yielding inconclusive results. Nonetheless, recent effective, integrated psychotherapy protocols, targeting complicated and prolonged grief, include writing assignments, typically in the form of letters. The present paper explores how and why letter writing might be effective and meaningful as a therapeutic tool in the context of grief psychotherapy. It describes how working with letters, addressed to the deceased, might help facilitate self-disclosure, promote exposure to what is avoided, confront unfinished business, encourage continuing bonds, and help achieve a coherent narrative around experiences with the loss. As a therapeutic tool, letter writing has the potential to be helpful to many bereaved people, as it is a simple, effective, and meaningful way to access and work with relevant clinical material in the context of psychotherapy.

Positive psychotherapy and cognitive behavioral therapy in anxiety patients - A study protocol for a randomized control trial in an online group setting

BACKGROUND

Anxiety disorders are common and debilitating which is why treatment is so important. According to the guidelines, Cognitive Behavioral Therapy (CBT) has the highest level of effectiveness among psychotherapeutic treatments and is the recommended procedure. However, not everyone responds well or at all to CBT which makes a wider range of therapy options valuable. Positive Psychotherapy (PPT) comes to mind as an alternative with its strength-based approach focusing on enhancing well-being and life satisfaction. Additionally, it has not yet been extensively studied how the processes that occur during treatment sessions and between treatment sessions effect treatment outcome. Thus, to lessen the lack of evidence regarding the efficacy of PPT as an anxiety treatment the planned study examines and compares the effectiveness of CBT and PPT as well as the effect of intrasession and intersession processes of the two therapy approaches.

METHOD

The study is in the planning stage and consists of an efficacy and a process study. The efficacy study is a randomized controlled comparative study of patients with anxiety disorders (generalized anxiety disorder and/or panic disorder with or without agoraphobia) with two active treatment conditions (PPT and CBT) and a control group (CG; positive psychotherapy with minimal therapeutic supervision) in an online group setting. There are three measurement time points: before treatment begins (T0), at the end of the ten-week treatment (T1), and a follow-up after three months (T2). The aim of the study is to evaluate the efficacy of PPT and CBT in the treatment of anxiety disorders, and to compare the efficacy of online-based PPT with minimal therapeutic supervision and online-based PPT with intensive therapeutic supervision in the treatment of anxiety disorders. The process study will be used to evaluate both the intrasession processes and the intersession processes of the therapy in the two intervention groups. In addition, the process variables that predict the success of the therapy and the extent to which PPT and CBT differ in the therapy processes will be tested. The study is registered at the German Clinical Trial Register (№ DRKS00027521).

DISCUSSION

To our knowledge, this is the first randomized controlled comparative study to examine the effectiveness of CBT and PPT for anxiety disorders in an online group setting.

Healing grief - an online self-help intervention programme for bereaved Chinese with prolonged grief: study protocol for a randomised controlled trial

Background: In China, mental health services do not currently meet the needs of bereaved people with symptoms of prolonged grief disorder (PGD). Internet-based grief interventions may help fill this gap, but such programmes have not yet been developed or evaluated in China. The proposed study aims to investigate the effectiveness, acceptability, and feasibility of an online self-help intervention programme named Healing Grief for bereaved Chinese with prolonged grief, and to explore the psychological mechanisms of potential improvements.Methods: We designed a two-arm randomised controlled trial. At least 128 participants will be randomly assigned to either an Internet-based intervention group or a waitlist-control group. The Internet-based intervention will be developed based on the dual process model, integrating techniques of psychoeducation, behavioural activation, cognitive reappraisal, and meaning reconstruction, and will be delivered via expressive writing. The intervention comprises six modules, with two sessions in each module, and requires participants to complete two sessions per week and complete the intervention in 6 weeks. The primary outcomes include effectiveness, acceptability, and feasibility. The effectiveness will be assessed by measures of prolonged grief, posttraumatic stress, anxiety, and depressive symptoms. Acceptability and feasibility will be evaluated using survey and interview on user experience characteristics. Secondary outcomes include moderators and mediators, such as dual process coping, grief rumination, mindfulness, and continuing bond, to explore the psychological mechanisms of potential improvement. Assessments will take place at pre-intervention, post-intervention, and 3-month follow-up.Conclusion: The proposed study will determine the effectiveness, acceptability, and feasibility of the newly developed online self-help intervention for bereaved Chinese with prolonged grief and clarify how the intervention helps with symptom improvements. Such an intervention may play an important role in easing the imbalance between the delivery and receipt of bereavement psychological services in China.

Grieving the Loss of a Child and the Use of Online Social Support: An Exploratory Survey Study

PURPOSE

To describe social media online grief supports, accessing behaviors, psychosocial variables, and feelings of support among individuals grieving the loss of a child aged <18 years.

METHOD

This online survey study recruited 26 adults grieving the loss of a child using social media. Dependent variables included feelings of support and frequency of access. Independent variables included sleep disturbance, cognitive function, depression, anxiety, and self-efficacy to manage emotions (SEMA). Data were collected from May to September 2018.

RESULTS

Participants' T scores were higher in level of sleep disturbance (mean = 59.4, SD = 6.1), depression (mean = 62.1, SD = 6.1), and anxiety (mean = 62.8, SD = 7.9), and lower in cognitive function (mean = 37.4, SD = 7.3) and SEMA (mean = 39.3, SD = 5.7). SEMA showed a positive correlation with feeling emotionally supported (p = 0.034). Participants who were accessing online grief supports more frequently reported higher levels of emotional support (F = 9.31, p = 0.006).

CONCLUSION

Current findings will help guide the design of online grief support interventions for individuals grieving the loss of a child. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Using an Electronic Mindfulness-based Intervention (eMBI) to improve maternal mental health during pregnancy: Results from a randomized controlled trial

Prevalence rates of peripartum depression and anxiety are high and correlate with adverse maternal and neonatal outcomes. Mindfulness-based interventions (MBI) have been shown to reduce mental distress during pregnancy. A multicenter, randomized controlled study was conducted after screening for depressive symptoms. The intervention group (IG) was given access to an 8-week supervised eMBI between weeks 29 and 36 of pregnancy and followed up to 5 months postpartum. Psychometric data were collected using the Edinburgh Postnatal Depression Scale (EPDS), the State-Trait Anxiety Inventory (STAI), the Pregnancy-Related Anxiety Questionnaire (PRAQ-R), the Freiburg Mindfulness Inventory (FMI-14) as well as the Patient Health Questionnaire (PHQ). Out of 5299 pregnant women, 1153 scored >9 on the EPDS and N = 460 were included in the RCT. No significant interaction effects for depressive symptoms and anxiety were found. Pregnancy- and birth-related anxiety decreased significantly in the IG and 6 weeks after birth, the rate of women at risk for adverse mental outcome was significantly lower compared to the CG. Mindfulness scores improved significantly in the IG. The eMBI program did not show effective regarding general depressive or anxiety symptoms, however, positive results were demonstrated regarding pregnancy and birth-related anxiety and the prevention of postpartum depression.

Online cognitive behavioral therapy for prolonged grief after traumatic loss: a randomized waitlist-controlled trial

Prolonged grief disorder, a condition characterized by severe, persistent, and disabling grief, is newly included in ICD-11 and DSM-5-TR. Prolonged grief symptoms can be effectively treated with face-to-face or internet-delivered cognitive behavioral therapy. Traumatic losses may elicit higher prevalence of severe grief reactions. While face-to-face cognitive behavioral therapy appears efficacious in treating prolonged grief symptoms in traumatically bereaved individuals, it is not yet clear if internet-based cognitive behavioral therapy is efficacious for this population. Therefore, we investigated the efficacy of a 12-week internet-delivered cognitive behavioral therapy for people bereaved through traffic accidents in a randomized waitlist-controlled trial (registration number: NL7497, Dutch Trial Register). Forty adults bereaved though a traffic accident were randomized to internet-based cognitive behavioral therapy (n = 19) or a waitlist control condition (n = 21). Prolonged grief, post-traumatic stress, and depression symptoms were assessed at baseline, post-treatment, and 8-week follow-up. Dropout in the treatment condition was relatively high (42%) compared to the control condition (19%). Nevertheless, multilevel analyses showed that internet-based cognitive behavioral therapy strongly reduced prolonged grief, post-traumatic stress, and depression symptoms relative to the control condition at post-treatment and follow-up. We conclude that internet-based cognitive behavioral therapy appears a promising treatment for traumatically bereaved adults.

Complicated grief knowledge and practice: a qualitative study of general practitioners in Ireland

OBJECTIVE

Complicated grief is a debilitating condition that individuals may experience after losing a loved one. General practitioners (GPs) are well positioned to provide patients with support for grief-related issues. Traditionally, Irish GPs play an important role in providing patients with emotional support regarding bereavement. However, GPs have commonly reported not being aptly trained to respond to bereavement-related issues. This study explores GPs' current knowledge of and practice regarding complicated grief.

METHODS

A qualitative study adopting a phenomenological approach to explore the experiences of GPs on this issue. Semi-structured interviews were carried out with a purposive sample of nine GPs (five men and four women) in Ireland. Potential participants were contacted via email and phone. Interviews were audio-recorded, transcribed and analysed using Braun & Clarke's () model of thematic analysis.

RESULTS

GPs had limited awareness of the concept of complicated grief and were unfamiliar with relevant research. They also reported that their training was either non-existent or outdated. GPs formed their own knowledge of grief-related issues based on their intuition and experiences. For these reasons, there was not one agreed method of how to respond to grief-related issues reported by patients, though participants recognised the need for intervention, onward referral and review.

CONCLUSIONS

The research highlighted that GPs felt they required training in complicated grief so that they would be better able to identify and respond to complicated grief.

Self-guided online treatment of disturbed grief, posttraumatic stress, and depression in adults bereaved during the COVID-19 pandemic: A randomized controlled trial

OBJECTIVE

This randomized-waitlist controlled trial is the first study examining short-term effects of a self-guided online grief-specific cognitive behavioral therapy (CBT) in reducing early persistent complex bereavement disorder (PCBD), posttraumatic stress disorder (PTSD), and depression symptoms in adults bereaved during the COVID-19 pandemic.

METHOD

Sixty-five Dutch adults, bereaved at least three months earlier during the pandemic, with clinically-relevant PCBD, PTSD, and/or depression symptoms, were allocated to a treatment (n = 32) or waitlist condition (n = 33). Telephone interviews were conducted to assess PCBD, PTSD, and depression symptoms (using validated instruments) at baseline, post-treatment, and post-waiting period. Participants received an eight-week self-guided online grief-specific CBT including exposure, cognitive restructuring, and behavioral activation assignments. Analyses of covariance were performed.

RESULTS

Intention-to-treat analyses indicated that people in the intervention condition showed significantly lower PCBD (d = 0.90), PTSD (d = 0.71), and depression (d = 0.57) symptom-levels post-treatment relative to waitlist controls post-waiting, while taking baseline symptom-levels and use of professional psychological co-intervention into account.

CONCLUSIONS

The online CBT proved to be an effective intervention, reducing PCBD, PTSD, and depression symptoms. Pending replication of these findings, early online interventions may be widely implemented in practice to improve treatments for distressed bereaved people.

The relationship between suicide bereavement and suicide ideation: Analysis of the mediating effect of complicated grief

People who have experienced suicide bereavement within social relationships are known to have high risk for suicide, which means that their suicide ideation is high. However, little is known about how suicide bereavement leads to suicide ideation. Therefore, this study aims to understand the pathway of suicide bereavement on suicide ideation by analyzing the mediating effect of complicated grief, which does not abate over time and is known to be highly related to suicide ideation. Data of 1224 people aged 19 or older with bereavement (636 bereaved by suicide and 585 by other causes) were obtained from the Longitudinal study on Suicide Survivors' Mental Health (LoSS) WAVE I [2015-2018], the first nationally-representative longitudinal study in South Korea. Suicide ideation, the dependent variable, was measured by the Scale for Suicide Ideation (SSI), and complicated grief, severe grief that does not abate over time, was measured by the Korean version of the Inventory of Complicated Grief (K-ICG). The results show that suicide bereavement was found to have a significant effect on suicide ideation, and that complicated grief plays a mediating role in the path of suicide bereavement to suicide ideation (Effect = 0.667, [0.387, 0.981]). Based on these findings, clinical and policy suggestions were discussed to understand and prevent suicide ideation of people with suicide bereavement.

Developing an eMental health monitoring module for older mourners using fuzzy cognitive maps

Objective

Effective internet interventions often combine online self-help with regular professional guidance. In the absence of regularly scheduled contact with a professional, the internet intervention should refer users to professional human care if their condition deteriorates. The current article presents a monitoring module to recommend proactively seeking offline support in an eMental health service to aid older mourners.

Method

The module consists of two components: a user profile that collects relevant information about the user from the application, enabling the second component, a fuzzy cognitive map (FCM) decision-making algorithm that detects risk situations and to recommend the user to seek offline support, whenever advisable. In this article, we show how we configured the FCM with the help of eight clinical psychologists and we investigate the utility of the resulting decision tool using four fictitious scenarios.

Results

The current FCM algorithm succeeds in detecting unambiguous risk situations, as well as unambiguously safe situations, but it has more difficulty classifying borderline cases correctly. Based on recommendations from the participants and an analysis of the algorithm's erroneous classifications, we propose how the current FCM algorithm can be further improved.

Conclusion

The configuration of FCMs does not necessarily demand large amounts of privacy-sensitive data and their decisions are scrutable. Thus, they hold great potential for automatic decision-making algorithms in mental eHealth. Nevertheless, we conclude that there is a need for clear guidelines and best practices for developing FCMs, specifically for eMental health.

A therapist-supported internet-based intervention for bereaved siblings: A randomized controlled trial

BACKGROUND

The loss of a sibling can have a long-term impact on the mental and physical health of the surviving sibling throughout adolescence and later adulthood. Even though bereaved siblings can be identified as a high-risk group, evidence-based interventions for this bereavement group are still missing.

AIM

To evaluate the treatment effects of an internet-based writing intervention for bereaved siblings aged 16-65 years.

DESIGN

A two-armed randomized controlled trial (DRKS00011514) compared the intervention to a waiting list control group. The 6-week intervention consisted of six structured writing assignments that were based on cognitive behavioral therapy, focusing on the specific situation of bereaved siblings.

SETTING/PARTICIPANTS

Eighty-six bereaved siblings (loss >1 month ago, no severe psychiatric symptoms) were randomly allocated to the intervention group (n = 47) or the waiting list control group (n = 39). Primary outcomes were symptoms of prolonged grief disorder and depression; secondary outcomes were posttraumatic stress symptoms and survivor guilt.

RESULTS

Symptoms of depression and prolonged grief disorder improved significantly in the intention-to-treat analyses from pre-to post-measurement compared with the control group (gDepression = -0.62, gGrief = 0.33). In the intervention group, all primary and secondary outcomes decreased significantly from baseline to 12-month follow-up (gs = -0.38 to -1.04). A significant clinical change could be found for depression (34%) compared to the waitlist control group (10%).

CONCLUSIONS

Bereaved siblings profited from this brief internet-based writing intervention in the short- and long-term. However, future research, such as dismantling studies, may help to further optimize the benefits of an intervention aimed at bereaved siblings.

Coping Styles Utilized during Suicide and Sudden Death Bereavement in the First Six Months

Individuals bereaved by suicide experience substantial emotional distress and are at risk for poorer mental health, substance use concerns, and suicidal behaviors. This study aimed to explore whether those bereaved by suicide reported different coping styles compared to those bereaved by sudden death in the first six months. It also aimed to determine whether a previous mental health diagnosis (PMHD) and experiencing stigma and/or shame impacted the utilization of adaptive and maladaptive coping. The sample was constituted by individuals bereaved by suicide (n = 142) compared to those bereaved by sudden death (n = 63), six months after loss. The study included immediate family members who were 18 years or older and understood the English language. After controlling for demographics there were no significant differences in coping styles between bereavement types. Regardless of bereavement type, having a PMHD was associated with increased avoidant and problem-focused coping, and stigma and shame were each associated with increased avoidant coping. Women were also more likely to report using adaptive coping. Findings demonstrate no difference by bereavement type and have implications for the tailoring of grief/postvention supports that are sensitive to perceived stigma/shame to better facilitate utilization of adaptive emotion-focused coping, particularly for men and those with pre-existing mental health problems.

Effects of a compassion-based program on the grief experienced by caregivers of people suffering from dementia: a randomized controlled clinical trial

BACKGROUND

Dementia is a syndrome that reduces the cognitive and functional abilities of the brain increasing the need for care. The caregivers of these patients are mostly their family members. The great care burden causes devastating effects on the health of family caregivers and the grief experienced by these family caregivers is considerable. This study was conducted to investigate the effects of a compassion-based program on the grief experienced by caregivers of people suffering from dementia.

METHOD

The present study was a randomized controlled clinical trial in which 70 family caregivers of people suffering from dementia were sampled through the block method and they were divided into experimental and control groups. The data collection tools included demographic information questionnaire and grief inventory that was completed before, a week and a month after the implementation of the compassion-based program in five sessions virtually by sending offline content to the experimental group. The obtained data were analyzed by SPSS 22 software using the repeated measures analysis of variance.

RESULTS

The mean comparison of scores of the grief experienced in the experimental group between pretest and posttest and follow-up, unlike the control group, showed a significant difference (p < 0.001). The mean scores of the experimental and the control groups were significantly different in terms of experiencing mourning and all of its fields (p < 0.001). The mean comparison of post-test and follow-up showed that the effect of a compassion-based program at the follow-up stage has been mitigated.

CONCLUSIONS

According to the study results, the compassion-based program reduced the grief experienced by the family caregivers of people suffering from dementia. Nevertheless, the effect of a compassion-based program has been reduced over time. This program can be a good guide for providing society-oriented services to the health team.

TRIAL REGISTRATION

This study is registered by Iranian Registry of Clinical Trials with decree code: IRCT20190712044181N4  on 02/06/2020.

An Internet-delivered Cognitive-Behavioral Therapy (iCBT) for Prolonged Grief Disorder (PGD) in adults: A multiple-baseline single-case experimental design study

The death of a loved one has physical, psychological, and social consequences. Between 9.8 and 21.5 % of people who lose a loved one develop Prolonged Grief Disorder (PGD). Internet- and computer-based interventions (i.e., Internet-delivered Cognitive-Behavioral Therapy, iCBT) are cost-effective and scalable alternatives that make it possible to reach more people with PGD. The main goal of the present investigation was to examine the effect and feasibility (usability and satisfaction) of an iCBT (GROw program) for adults with PGD. A secondary objective was to detect adherence to the app (Emotional Monitor) used to measure daily grief symptoms. The study had a single-case multiple-baseline AB design with six participants. The GROw program is organized sequentially in eight modules, and it is based on the dual-process model of coping with bereavement. Evaluations included a pre-to-post treatment assessment of depression, grief symptoms, and typical grief beliefs, along with daily measures of symptom frequency and intensity on the Emotional Monitor App. Treatment opinions and adherence to the App were also collected. Efficacy data were calculated using a Nonoverlap of All Pairs (NAP) analysis and Reliable Change Index (RCI). The mean age of the sample was 29.5 years (SD = 8.19). Two participants dropped out of the study. Adherence to the App varied across patients (4.8 % -77.8 %). Most participants (75 %) showed a clinically significant change (recovered) in depression, and 50 % obtained a clinically significant improvement (recovered) in symptoms of loss and typical beliefs in complicated grief. The participants reported high usability and satisfaction with the treatment content and format. In sum, the GROw program was very well accepted and generally feasible, and it has strong potential for treating PGD. The results support scaling up the treatment by using more complex designs with larger samples (i.e., randomized controlled trials comparing GROw with active conditions).

Childhood maltreatment, emotion regulation strategies and depressive symptoms during spousal bereavement

BACKGROUND

Childhood maltreatment increases the risk of depression, especially after experiencing a stressful life event, such as bereavement. Employing emotion regulation strategies can mitigate the impact childhood maltreatment has on depression later in life following the loss of a spouse.

OBJECTIVE

We evaluated how cognitive reappraisal and expressive suppression moderated the impact of childhood maltreatment and depressive symptoms following spousal bereavement.

PARTICIPANTS AND SETTING

We examined 130 bereaved individuals 3 months after the death of a spouse, 4 months after the death of a spouse, and 6 months after the death of a spouse.

METHODS

We utilized a mixed model approach to test the interaction between childhood maltreatment and cognitive reappraisal and between childhood maltreatment and expressive suppression to predict depressive symptoms across 3 time points.

RESULTS

Cognitive reappraisal moderated the relationship between childhood maltreatment and depressive symptoms (b = - 0.17,p = .003); expressive suppression did not (b = 0.06,p = .452). Participants who used less cognitive reappraisal had a positive relationship between childhood maltreatment and depressive symptoms (b = 3.27,p < .001);participants who used more cognitive reappraisal did not (b = 1.09,p = .065).

CONCLUSIONS

Childhood maltreatment interacted with cognitive reappraisal, but not expressive suppression, to predict depressive symptoms following spousal bereavement. This study reveals how emotion regulation strategies can be utilized as a tool to buffer the impact of childhood maltreatment on mental health following a stressor later in life, which can serve as a target for future interventions for individuals experiencing a stressful life event.

The Role of Emotion Regulation and Loss-Related Coping Self-efficacy in an Internet Intervention for Grief: Mediation Analysis

BACKGROUND

Internet interventions for mental disorders and psychological problems such as prolonged grief have established their efficacy. However, little is known about how internet interventions work and the mechanisms through which they are linked to the outcomes.

OBJECTIVE

As a first step in identifying mechanisms of change, this study aimed to examine emotion regulation and loss-related coping self-efficacy as putative mediators in a randomized controlled trial of a guided internet intervention for prolonged grief symptoms after spousal bereavement or separation or divorce.

METHODS

The sample comprised older adults who reported prolonged grief or adaptation problems after bereavement, separation, or divorce and sought help from a guided internet intervention. They were recruited mainly via newspaper articles. The outcome variables were grief symptoms assessed using the Texas Revised Inventory of Grief and psychopathology symptoms assessed using the Brief Symptom Inventory. A total of 6 module-related items assessed loss-focused emotion regulation and loss-related coping self-efficacy. In the first step, path models were used to examine emotion regulation and loss-related coping self-efficacy as single mediators for improvements in grief and psychopathology symptoms. Subsequently, exploratory path models with the simultaneous inclusion of emotion regulation and self-efficacy were used to investigate the specificity and relative strength of these variables as parallel mediators.

RESULTS

A total of 100 participants took part in the guided internet intervention. The average age was 51.11 (SD 13.60) years; 80% (80/100) were separated or divorced, 69% (69/100) were female, and 76% (76/100) were of Swiss origin. The internet intervention increased emotion regulation skills (β=.33; P=.001) and loss-related coping self-efficacy (β=.30; P=.002), both of which correlated with improvements in grief and psychopathology symptoms. Path models suggested that emotion regulation and loss-related coping self-efficacy were mediators for improvement in grief. Emotion regulation showed a significant indirect effect (β=.13; P=.009), whereas coping self-efficacy showed a trend (β=.07; P=.06). Both were confirmed as mediators for psychopathology (β=.12, P=.02; β=.10; P=.02, respectively). The path from the intervention to the improvement in grief remained significant when including the mediators (β=.26, P=.004; β=.32, P≤.001, respectively) in contrast to the path from the intervention to improvements in psychopathology (β=.15, P=.13; β=.16, P=.10, respectively).

CONCLUSIONS

Emotion regulation and loss-related coping self-efficacy are promising therapeutic targets for optimizing internet interventions for grief. Both should be further examined as transdiagnostic or disorder-specific putative mediators in internet interventions for other disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02900534; https://clinicaltrials.gov/ct2/show/NCT02900534.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-016-1759-5.

How can we know what we don't know? An exploration of professionals' engagement with complicated grief

OBJECTIVE

Research has shown that complicated grief has the potential to adversely affect bereaved individuals, and in this context, understanding how mental health professionals engage with it in practice is of relevance. Gaining an understanding of professionals' knowledge, attitudes, skills and training in relation to complicated grief could provide insights that will inform their training and professional development. The aim of this study was to consider professionals' engagement with complicated grief, as represented by self-reported knowledge, attitudes, skills and training.

METHODS

The study used a three-phase mixed methods design (systematic review, qualitative interviews, and a quantitative survey) with empirical data being collected from psychologists, psychiatrists and counselor/psychotherapists.

RESULTS

Analysis yielded 15 integrated findings across the three phases, which were grouped into two clusters: the first highlighted tension between professionals' reported confidence and competence and the second explored the parameters and contribution of research and training in this area.

CONCLUSION

Professionals' perception of their competence to work with complicated grief seems overstated and research and professional practice are not aligned.

PRACTICE IMPLICATIONS

These findings are positioned to inform empirically supported training that addresses identified deficits in professionals' knowledge, attitudes and skills. It is important therefore that training is reflective of the needs of different professional groups.

Consulting the Oracle: A Delphi study for determining parameters for a mental health user profile and personalization strategy for an online service to aid grieving older adults

While much effort has been devoted to the development of mental e-health interventions, the tailoring of these applications to user characteristics and needs is a comparatively novel field of research. The premise of personalizing mental e-health interventions is that personalization increases user motivation and (thereby) mitigates intervention dropout and enhances clinical effectiveness. In this study, we selected user profile parameters for personalizing a mental e-health intervention for older adults who lost their spouse. We conducted a three-round Delphi study involving an international and interdisciplinary expert panel (N = 16) with two objectives. The first aim was to elicit adaptation strategies that can be used to dynamically readjust the intervention to the user's needs. The second aim was to identify a set of meaningful indicators for monitoring the user from within the grief intervention to escalate from self-help to blended care, whenever advisable. This Delphi study used as starting point an evaluated, text-based grief intervention composed of ten modules, including psychoeducation about grief and cognitive-behavioral exercises to support the user in adjusting their lives after bereavement. Every user follows this grief intervention in a linear fashion from beginning to end. The resulting conceptual adaptation model encompasses dynamic adjustments, as well as one-time adjustments performed at the initialization of the service. On the level of the application structure, the adaptations affect when which topic module is presented to the user. The adaptations further provide strategies for adjusting the text-based content of individual intervention modules dependent on user characteristics and for selecting appropriate reactions to user input. Eighteen monitoring parameters were elicited and grouped into four categories: clinical, behavioral/emotional, interactive, and external. Parameters that were perceived as most urgent to attend to for escalation were Suicidality, Self-destructive behavior, Client-initiated escalation, Unresponsiveness and (Complicated) Grief symptoms.

Effects of internet-based cognitive behavioral therapy on postpartum depression: A protocol for systematic review and meta-analysis

BACKGROUND

Postpartum depression is one of the most common complications during the postpartum period. In recent years, internet-based psychological interventions have made significant progress and provided a new psychotherapy model. Internet-based cognitive behavioral therapy (ICBT) for postpartum depression has achieved good results. However, the effectiveness of ICBT for postpartum depression reported by different studies still remains inconsistent. Therefore, a meta-analysis was used to further evaluate the efficacy of ICBT for postpartum depression, aiming to provide evidence to support nonpharmacological intervention strategies in the clinic.

METHODS

The databases of PubMed, Web of Science, Scopus, Cochrane Library, Embase, China Scientific Journal Database, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang Data will be searched. The randomized controlled trials of ICBT will be included for postpartum depression published before February 2022. Two independent researchers will independently complete literature selection, risk of bias assessment and data extraction. The disagreements will be discussed with a third party for the final decision. Cochrane Risk of Bias Assessment Tool will be used for literature quality assessment. Data processing will be conducted by RevMan 5.4 software.

RESULTS

The results of this meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSIONS

For the question whether ICBT for postpartum depression is efficacy, this study can provide more comprehensive and strong evidence.

ETHICS AND DISSEMINATION

The ethical approval was not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and shared on social media platforms.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/EQJDH.

Therapist-Assisted Web-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement: Randomized Controlled Trial

BACKGROUND

Bereavement due to cancer increases the risk of prolonged grief disorder. However, specialized treatment options for prolonged grief after a loss due to illness are still scarce.

OBJECTIVE

The aim of this study is to extend previous findings by evaluating a web-based cognitive behavioral intervention with asynchronous therapist support, consisting of structured writing tasks adapted specifically for prolonged grief after cancer bereavement.

METHODS

The intervention was evaluated in a purely web-based randomized waitlist-controlled trial. Open-access recruitment of participants was conducted on the web. Prolonged grief (Inventory of Complicated Grief), depression, anxiety, posttraumatic stress, posttraumatic growth, somatization, sleep quality, and mental and physical health were assessed on the web via validated self-report measures.

RESULTS

A total of 87 participants were randomized into the intervention group (IG; 44/87, 51%) or the waitlist control group (43/87, 49%). Of the participants, 7% (6/87) dropped out of the study (5/44, 11%, in the IG). Of the 39 completers in the IG, 37 (95%) completed all intervention tasks. The intervention reduced symptoms of prolonged grief (intention-to-treat: P<.001; η²=0.34; Cohen d=0.80) to a clinically significant extent. It had favorable effects on depression, anxiety, posttraumatic stress, posttraumatic growth, and overall mental health but not on somatization, sleep quality, or physical health.

CONCLUSIONS

The web-based intervention for prolonged grief after cancer bereavement is effective in reducing symptoms of prolonged grief disorder and accompanying syndromes in a timely, easily realizable manner and addresses specific challenges of bereavement to illness. Considering web-based approaches in future mental health care policy and practice can reduce health care gaps for those who are bereaved to cancer.

TRIAL REGISTRATION

German Clinical Trial Register U1111-1186-6255; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011001.

Interdisciplinary, internet-based trans health care (i²TransHealth): study protocol for a randomised controlled trial

INTRODUCTION

Living in an area with no or deficient structures for trans health care is disadvantageous for trans people. By providing an internet-based health care programme, i²TransHealth aims at reducing structural disadvantages for trans people living in areas lacking specialised care. The e-health intervention consists of video consultations and a 1:1 chat with a study therapist. Additionally, the i²TransHealth network cooperates with physicians, who especially offer crisis intervention close to the participants' place of residence. The aim of this study is to evaluate the (cost-)effectiveness of the internet-based health care programme for trans people compared with a control (waiting) group. The following research questions will be examined with a sample of 163 trans people: Does a 4-month treatment with the i²TransHealth internet-based health care programme improve patient-reported health-outcomes? Is i²TransHealth cost-effective compared with standard care from a societal or health care payers' perspective? Does the participation in and support by i²TransHealth lead to an increase of trans-related expertise in the physician network?

METHODS AND ANALYSIS

In a randomised controlled trial, the outcomes of an internet-based health care programme for trans people will be investigated. In the intervention group, participants are invited to use i²TransHealth for 4 months. Participants allocated to the control group will be able to start with their transition-related care after 4 months of study participation. The primary outcome measure is defined as the reduction of psychosomatic symptoms, as assessed by the Brief Symptom Inventory-18, 4 months after using the i²TransHealth programme. Participants in both groups will undergo an assessment at baseline and 4 months after using i²TransHealth.

ETHICS AND DISSEMINATION

Positive ethical approval was obtained from the Hamburg Medical Association (PV7131). The results will be disseminated to service users and their families via media, to health care professionals via professional training and meetings and to researchers via conferences and publications.

TRIAL REGISTRATION NUMBER

NCT04290286.

PROTOCOL VERSION

22 December 2021 (V.1.0).

Trauma-focused guided self-help interventions for posttraumatic stress disorder: A meta-analysis of randomized controlled trials

Trauma-focused guided self-help (TF-GSH) is an important alternative to psychological therapy delivered by a therapist. This meta-analysis evaluates the efficacy of TF-GSH in reducing posttraumatic stress disorder  (PTSD) symptoms and comorbid depressive and anxiety symptoms. A total of 17 trials were included that compared a TF-GSH intervention (N = 610) to various control comparators (N = 570). Control conditions included treatment as usual (k = 2), waiting list (k = 11), phone monitoring (k = 1), nontrauma writing (k = 1), general support (k = 1), and supportive counseling (k = 1). A moderate- to large-sized effect favouring TF-GSH was observed for PTSD (k = 17, g = -0.81, 95% confidence interval [CI]: -1.24, -0.39) and a moderate-sized effect was observed for depressive (k = 13, g = -0.73, 95% CI: -1.16, -0.31) and anxiety (k = 11, g = -0.72, 95% CI: -1.18, -0.27) symptoms, with considerable heterogeneity. Moderator analyses were all not statistically significant. Results indicate that TF-GSH is a promising treatment for PTSD and comorbid depressive and anxiety symptoms. We discuss the nature, extent, and quality of the literature to provide a point of departure for future research. TF-GSH (and unguided self-help) may not be appropriate for certain individuals at certain times. Exploring a broad range of treatment delivery modalities will move the field closer towards a model of evidence-based care in which the likely appropriate dose and type of intervention can be matched to individuals based on presenting problems and other variables.

Change in avoidance and negative grief-related cognitions mediates treatment outcome in older adults with prolonged grief disorder

Objective: The present study investigated the role of the two theoretically derived mediators in the treatment of Prolonged Grief Disorder (PGD). Mediators were changes in avoidance and maladaptive cognitions. An additional hypothesis tested whether these candidate mediators are specific to CBT-based Complicated Grief Treatment (CGT) compared to Interpersonal Therapy (IPT). Method: We performed secondary analyses with assessment completers (n = 131) from a randomized-controlled trial with older adults with PGD. Patients received 16 sessions of CGT or IPT. Outcomes were treatment response and reductions in grief symptoms and grief-related related impairment. Results: Reductions in avoidance between baseline and week 16 mediated reductions in grief symptoms and grief-related impairment. Reductions in maladaptive grief-related cognitions over the same period mediated treatment response, reductions in grief symptoms and grief-related impairment. There were no significant treatment-mediator interactions. We could not establish that mediators changed before the outcomes. Conclusion: Results are consistent with theoretical models of PGD, including the CGT treatment model. Despite different therapeutic procedures, we found no significant interaction effect, but CGT produced larger effects. Future research needs to establish a timeline of change through the use of multiple measurements of mediators and outcomes.Trial registration: ClinicalTrials.gov identifier: NCT01244295.

Effectiveness and Feasibility of Internet-Based Interventions for Grief After Bereavement: Systematic Review and Meta-analysis

BACKGROUND

Although grief and its symptoms constitute a normal reaction to experiences of loss, some of those affected still report elevated levels of distress after an extended period, often termed complicated grief. Beneficial treatment effects of face-to-face therapies, for example, grief counseling or cognitive behavioral therapy against complicated grief, have been reported. Evaluations of internet- and mobile-based interventions targeting symptoms of grief in bereaved individuals with regard to objective quality criteria are currently lacking.

OBJECTIVE

We aim to conduct a systematic review and meta-analysis on the effectiveness and feasibility of internet- and mobile-based interventions against symptoms of grief after bereavement.

METHODS

We conducted systematic literature searches of randomized controlled trials or feasibility studies published before January 9, 2020, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, in PubMed, PsycINFO, Web of Science Core Collection, and the Cochrane Library. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations system. We further assessed aspects of feasibility and rated quality of interventions using criteria suggested by an expert panel on mental health care (German Association for Psychiatry, Psychotherapy, and Psychosomatics). A random-effects meta-analysis was conducted to assess between-group effect sizes.

RESULTS

In total, 9 trials (N=1349) were included. Of these, 7 studies were analyzed meta-analytically. Significant effects were found for symptoms of grief (g=0.54, 95% CI 0.32-0.77), depression (g=0.44, 95% CI 0.20-0.68), and posttraumatic stress (g=0.82, 95% CI 0.63-1.01). Heterogeneity was moderate for grief and depression (I2=48.75% and 55.19%, respectively) and low for posttraumatic stress symptoms (I2=0%). The overall quality of evidence was graded low (grief and depression) to moderate (posttraumatic stress). User satisfaction with the interventions was high, as was the quality of the interventions assessed using objective quality criteria.

CONCLUSIONS

Internet- or mobile-based interventions might constitute an effective treatment approach against symptoms of grief in bereaved adults. However, the small sample sizes and limited number of studies included in the review warrant further investigation.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42012002100; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131428.

Mourning During Corona: A Phenomenological Study of Grief Experience Among Close Relatives During COVID-19 Pandemics

Considering the need for observing health protocols, the experience of the loss and the grieving process has changed in nature during this disease. Therefore, this study aims to gain a deep understanding of the experience of mourning during COVID-19 pandemic by exploring the experiences of survivors of the death of their loved. During COVID-19 pandemic, the inability to hold the usual ceremonies for mourning and receive the social support needed in this period, the relatives of the deceased encounter various conditions that disrupt the grieving process and may lead to the spread of unresolved grief in future.

Internet-delivered Cognitive-Behavioral Therapy (iCBT) for Adults with Prolonged Grief Disorder (PGD): A Study Protocol for a Randomized Feasibility Trial

INTRODUCTION

Grief is an emotional reaction to the loss of a loved one with a natural recovery. Approximately 10% of people who lose a loved one develop prolonged grief disorder (PGD). Internet-based and computer-based interventions (ie, internet-delivered cognitive-behavioural therapy, iCBT) are a cost-effective alternative that makes it possible to reach more people with PGD. The main aim of this study is to assess the feasibility of a new iCBT-called GROw-for PGD. As a secondary objective, the potential effectiveness of GROw will be explored.

METHODS AND ANALYSIS

This study is a two-arm feasibility randomised trial. A total of 48 adults with PGD who meet the eligibility criteria will be randomised to the experimental group (iCBT: GROw) or the active control group (face-to-face CBT treatment). The treatment is organised sequentially in eight modules in the iCBT format and 8-10 sessions in the face-to-face format, and both formats have the same therapeutic components. There will be five assessment points with qualitative and quantitative evaluations: screening, baseline, after the intervention, 3-month follow-up and 12-month follow-up. Consistent with the objectives, the measures are related to the feasibility outcomes for the main aim of the study (participant adherence, expectations and satisfaction with the treatment, preferences, alliance and utility) and psychological and mental health outcomes for secondary analyses (symptoms of grief, symptoms of depression, symptoms of anxiety, affectivity, quality of life, work and social adaptation, post-traumatic growth, purpose in life, mindfulness and compassion).

ETHICS AND DISSEMINATION

The Ethics Committee of the Universitat Jaume I (Castellón, Spain) granted approval for the study (CD/002/2019). Dissemination will include publications and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04462146.

Initial outcomes of couple HOPES: A guided online couple intervention for PTSD and relationship enhancement

Couple HOPES (Helping Overcome PTSD and Enhance Satisfaction) is a guided, online couple intervention adapted from Cognitive-Behavioral Conjoint Therapy for posttraumatic stress disorder (PTSD). It was created to overcome a range of barriers to accessing evidence-based treatments for PTSD and the intimate relationship problems associated with it. This manuscript describes initial outcomes of the intervention in a series of 10 couples. Participants were military, veteran and first responders with probable PTSD and their intimate partners. Couples completed the program and measurements of PTSD, relationship satisfaction, and secondary outcomes at pre-, mid-, and post-intervention. Mean satisfaction for the program was high and it was completed by seven of ten couples. Participants with PTSD evidenced significant and large pre- to post-intervention effect size improvements in PTSD symptoms (g = 0.80) and perceived health (g = 1.13). They also exhibited non-significant but medium effect size pre- to post-intervention improvements in quality of life (g = 0.62), and depression (g = 0.53), and small effect size pre- to post-intervention improvements in argumentativeness (g = 0.43), anger (g = 0.31), and anxiety (g = 0.31). Partners reported significant and moderate pre- to post-intervention effect size improvements in relationship satisfaction (g = 0.68), and medium but not significant effect size improvements in accommodation of PTSD (g = 0.56). Results provide initial support for the feasibility, acceptability, and efficacy of Couple HOPES for improving PTSD and relationship satisfaction. However, more testing in larger samples, including with randomized controlled designs, is needed.

Developing a theoretically grounded, digital, ecological momentary intervention for parental bereavement care using the ORBIT model-Phase 1

Current models of bereavement care do not address all of bereaved parents' unique needs. Diverse challenges limit parents' ability to access certain bereavement services. A web-based intervention prototype for bereaved parents was developed. Using convenience and snowball techniques, 14 participants (pediatric providers, software developers, and bereaved parents) were enrolled in a descriptive, cross-sectional feasibility and usability study. While the intervention was generally considered acceptable, three themes were identified to enhance its usability and acceptability: timing; delivery; and revisions. Further intervention development is needed to improve both short- and long-term physical and psychological outcomes for bereaved parents.

Internet-delivered exposure therapy versus internet-delivered cognitive behavioral therapy for panic disorder: A pilot randomized controlled trial

AIM

To compare the efficacy and acceptability of internet-delivered exposure therapy for panic disorder, to multi-component internet-delivered cognitive behavioral therapy (iCBT) that included controlled breathing, cognitive restructuring and exposure.

METHODS

Participants with panic disorder, with or without agoraphobia, were randomized to internet-delivered exposure therapy (n = 35) or iCBT (n = 34). Both programs were clinician guided, with six lessons delivered over eight weeks. Outcomes included panic disorder and agoraphobia symptom severity, as well as depression symptom severity, functional impairment and days out of role.

RESULTS

Participants in both conditions displayed a large reduction in panic disorder symptom severity (ds >1.30) from pre- to post-treatment. Participants in both conditions displayed medium to large reduction in agoraphobia and depression symptom severity, functional impairment and days out of role. Effects were maintained at three- and six-month follow-up. There was no significant difference between the interventions in clinical outcomes, adherence or treatment satisfaction.

CONCLUSIONS

Internet-delivered exposure therapy appeared to be as acceptable and efficacious as more established iCBT, despite including less strategies. However, a fully powered replication is now needed to compare the two approaches.

Comparative efficacy and acceptability of expressive writing treatments compared with psychotherapy, other writing treatments, and waiting list control for adult trauma survivors: a systematic review and network meta-analysis

BACKGROUND

Expressive writing about a traumatic event is promising in treating posttraumatic stress disorder (PTSD) symptoms in adult trauma survivors. To date, the comparative efficacy and acceptability of this approach is uncertain. Therefore, we aimed to examine the comparative efficacy and acceptability of expressive writing treatments.

METHODS

We included 44 RCTs with 7724 participants contributing 54 direct comparisons between expressive writing (EW), enhanced writing (i.e. including additional therapist contact or individualized writing assignments; EW+), PTSD psychotherapies (PT), neutral writing (NW), and waiting-list control (WL).

RESULTS

EW, EW+, PT, and NW were statistically significantly more efficacious than WL at the longest available follow-up, with SMDs (95% CI) of -0.78 (-1.10 to -0.46) for PT, -0.81 (-1.02 to -0.61) for EW+ , -0.43 (-0.65 to -0.21) for EW, and -0.37 (-0.61 to -0.14) for NW. We found small to moderate differences between the active treatments. At baseline mean PTSD severity was significantly lower in EW+ compared with WL. We found considerable heterogeneity and inconsistency and we found elevated risk of bias in at least one of the bias dimensions in all studies. When EW+-WL comparisons were excluded from the analyses EW+ was no longer superior compared with EW.

CONCLUSIONS

The summarized evidence confirms that writing treatments may contribute to improving PTSD symptoms in medium to long-term. Methodological issues in the available evidence hamper definite conclusions regarding the comparative efficacy and acceptability of writing treatments. Adequately sized comparative randomized controlled trials preferably including all four active treatment approaches, reporting long-term data, and including researchers with balanced preferences are needed.

Exposure-Based Writing Therapies for Subthreshold and Clinical Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis

We undertook a systematic review to assess the efficacy of exposure-based writing therapies (WTs) for trauma-exposed adults with subthreshold or clinical levels of posttraumatic stress disorder. Four databases (PsycINFO, Medline, Wiley Online, PILOTS) were searched for randomized controlled trials (RCTs) of exposure-based WTs. A total of 13 RCTs that reported on results from 17 WT versus control comparisons were included. The primary outcomes were posttraumatic stress symptom severity at posttreatment and/or clinical response. An overall unclear or high risk of bias was identified in 84.6% of studies. In comparison to both waitlist k = 3, Hedges' g = -0.97, 95% CI [-1.20, -0.73], and placebo writing conditions, k = 9, Hedges' g = -0.48, 95% CI [-0.87, -0.08], WTs were more beneficial to participants. There was no evidence of a difference between WTs that were longer in duration compared to other psychotherapy, k = 2; pooled OR = 1.42; 95% CI [0.83, 2.43]. These findings indicate that exposure-based WTs are effective when compared to waitlist and placebo writing control conditions. The evidence needs to be considered in the context of the modest number of studies conducted to date, the high methodological heterogeneity between the studies, and the high or unclear risk of bias across many studies. Further research is needed to increase the evidence base regarding the efficacy of WTs for posttraumatic stress. Future research should also measure the mediators and predictors of outcomes to further develop protocols and understand which variants of WTs work for different populations or individuals.

Seeking to Understand the Conditions Under Which Exposure-Based Writing Therapy for Posttraumatic Stress Disorder is an Effective Approach: A Commentary on Dawson et al. (2020)

Exposure-based writing interventions for posttraumatic stress disorder (PTSD) have shown promise when compared with waitlist conditions, placebo writing control conditions, and evidence-based, trauma-focused treatments. Recently, Dawson et al. (2020) conducted a systematic review and meta-analysis to examine existing published randomized controlled trials investigating exposure-based writing interventions. The findings were encouraging; however, the studies included in the meta-analysis had a high degree of methodological heterogeneity. Our own work examining exposure-based writing as an intervention for PTSD has demonstrated that methodological differences in the structure of exposure-based writing can have a meaningful impact on treatment outcome. Accordingly, we urge caution in interpreting the meta-analysis findings reported by Dawson and colleagues and encourage investigation into better understanding the mechanisms underlying exposure-based writing interventions to further propel this important area of work.

Behavioral Activation and Therapeutic Exposure vs. Cognitive Therapy for Grief Among Combat Veterans: A Randomized Clinical Trial of Bereavement Interventions

Approximately two-thirds of Operations Enduring Freedom, Iraqi Freedom, and New Veterans reported knowing someone who was killed or seriously injured, lost someone in their immediate unit, or personally saw dead or seriously injured Americans (Hoge et al., 2004; Thomas et al., 2010; Toblin et al., 2012). Thus, it is not surprising that prevalence of Persistent Complex Bereavement Disorder (PCBD) is high in these groups. Importantly, PCBD impact appears to be independent of both Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (Bonnano, 2007), 2 disorders that are also highly prevalent in these groups, thus tailored treatments for grief are indicated. The Department of Veterans Affairs suggests Cognitive Therapy for Grief as a first line psychotherapy, however treatments relatively more focused on behavior change and exposure to grief cues also may be useful for this population. To address this question, the present study used a randomized controlled trial to compare a 7-session program of Behavioral Activation and Therapeutic Exposure for Grief vs. Cognitive Therapy for Grief among 155 OIF/OEF/OND veterans. Both treatments produced significant treatment gains over baseline, and these improvements were maintained over 6-month followup; however no differences were observed between groups. Given equal efficacy, implications for matching treatment to patient characteristics are discussed.

Feasibility of Present-Centered Therapy for Prolonged Grief Disorder: Results of a Pilot Study

Present-centered therapy (PCT) was originally developed as a strong comparator for the non-specific effects of psychotherapy in the treatment of posttraumatic stress disorder. PCT qualifies as a not strictly supportive treatment as it is structured and homework is assigned between sessions. It does not focus on cognitive restructuring or exposure. A growing body of literature supports its beneficial effects. For example, it demonstrated only slightly inferior effect sizes and lower dropout rates compared to that of trauma-focused cognitive behavioral therapy in several trials with patients suffering from posttraumatic stress disorder. The current study is the first to evaluate the feasibility and the treatment effects of PCT in adults with prolonged grief disorder (PGD). Meta-analyses on psychotherapy for PGD have yielded moderate effect sizes. N = 20 individuals suffering from PGD were treated with PCT by novice therapists as part of a preparation phase for an upcoming RCT in an outpatient setting. Treatment consisted of 20-24 sessions á 50 min. All outcomes were assessed before treatment, at post-treatment, and at the 3-month follow-up. The primary outcome, PGD symptom severity, was assessed using the Interview for Prolonged Grief-13. Secondary outcomes were self-reported PGD severity, depression, general psychological distress, and somatic symptom severity. Furthermore, therapists evaluated their experiences with their first PCT patient and the treatment manual. In intent-to-treat analyses of all patients we found a significant decrease in interview-based PGD symptom severity at post-treatment (d = 1.26). Decreases were maintained up to the 3-month follow-up assessment (d = 1.25). There were also significant decreases in self-reported PGD symptoms, depression, and general psychological distress. No changes were observed for somatic symptoms. The completion rate was 85%. Therapists deemed PCT to be a learnable treatment program that can be adapted to the patient's individual needs. The preliminary results of PCT as a treatment for PGD demonstrate large effects and indicate good feasibility in outpatient settings. The treatment effects were larger than those reported in meta-analyses. Thus, PCT is a promising treatment for PGD. Possible future research directions are discussed.

Traumatic grief research and care in the aftermath of the COVID-19 pandemic

BACKGROUND

A significant increase in the number of individuals suffering from prolonged grief disorder is expected in the aftermath of the COVID-19 pandemic for two main reasons. First, the number of excess deaths has contributed to an immense number of bereaved individuals. Second, recent literature has shown that circumstances associated with COVID-19 deaths may be contributing to increased risk for the development of prolonged grief disorder.

OBJECTIVE

To best support those affected by loss during the COVID-19 pandemic, it is important to inform clinicians and researchers about the development, the nature and the treatment of prolonged grief disorder and employ sound research.

METHOD

In this editorial, we discuss important themes regarding prolonged grief disorder in the aftermath of the COVID-19 pandemic, to gather and present useful information for clinicians and researchers.

RESULTS

The following themes were addressed: 1. Harmonization in the diagnosis of prolonged grief disorder. 2. Screening tools and interventions. 3. Pharmacotherapy. 4. Special attention for the elderly. 5. Special attention for children and adolescents. 6. A causal system perspective for understanding grief and prolonged grief disorder.

CONCLUSIONS

If those involved in bereavement research and care manage to collaborate, the tragic consequences of COVID-19 might catalyse improvement of care for those most impaired following the loss of a loved one.

Online treatment of persistent complex bereavement disorder, posttraumatic stress disorder, and depression symptoms in people who lost loved ones during the COVID-19 pandemic: study protocol for a randomized controlled trial and a controlled trial

BACKGROUND

Losing a loved one during the COVID-19 pandemic is a potentially traumatic loss that may result in symptoms of persistent complex bereavement disorder (PCBD), posttraumatic stress disorder (PTSD), and depression. To date, grief-specific cognitive-behavioural therapy (CBT) has mostly been delivered through individual face-to-face formats, while studies have shown that online treatment also yields promising results. Offering treatment online is now more than ever relevant during the pan demic and may offer important benefits compared with face-to-face CBT, such as lower costs and higher accessibility. Our expectation is that grief-specific online CBT is effective in reducing PCBD, PTSD, and depression symptoms.

OBJECTIVE

Our aim is to evaluate the short-term and long-term effectiveness of grief-specific online CBT in reducing PCBD, PTSD, and depression symptom-levels for adults who lost a loved one during the COVID-19 pandemic.

METHOD

This study consists of two parts. In part 1, a two-armed (unguided online CBT versus waitlist controls) randomized controlled trial will be conducted. In part 2, a two-armed (guided online CBT versus unguided online CBT) controlled trial will be conducted. Symptoms of PCBD, PTSD, and depression will be assessed via telephone interviews at pre-treatment/pre-waiting period, post-treatment/post-waiting period, and six months post-treatment. Potential participants are people who lost a loved one at least three months earlier during the COVID-19 pandemic with clinically relevant levels of PCBD, PTSD, and/or depression. Analysis of covariance and multilevel modelling will be performed.

DISCUSSION

This is one of the first studies examining the effectiveness of online grief-specific CBT. More research is needed before implementing online grief-specific CBT into clinical practice.

Brief Eclectic Psychotherapy for Moral Trauma (BEP-MT): treatment protocol description and a case study

Background: Traumatic events can be related to severe transgressions or violations of moral boundaries. Moral injury (MI) has been described as 'the lasting psychological, biological, spiritual, behavioral and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.' These events can provoke emotions such as remorse, guilt and shame, and affects someone's self-image and identity. Objective: The aim of the study is to evaluate a treatment protocol that addresses the specific characteristics of moral trauma in treatment of PTSD, next to anxiety. Method: Brief Eclectic Psychotherapy for Moral Trauma (BEP-MT) is an adaptation of the evidence-based Brief Eclectic Psychotherapy for PTSD (BEPP). BEP-MT integrates components of cognitive-behavioural, psychodynamic, constructivist, and systemic psychotherapy. In the current study treatment progress of a refugee Dusan was monitored. Prior to and after treatment the Clinical-Administered PTSD Scale for DSM-5, the PTSD Checklist (PCL-5), the Brief Symptom Inventory (BSI) and the Moral Injury Appraisal Scale (MIAS) were administered. Every session moral emotions were assessed on a Likert scale. Results: Whereas PTSD complaints and strong feelings of guilt and shame were manifest prior to treatment, during BEP MT a gradual decline in the intensity of the moral emotions was found. After BEP-MT Dusan no longer met criteria for PTSD and his psychological complaints diminished. Conclusion: The case of Dusan has shown it is worthwhile to address moral trauma and BEP- MT is a promising treatment protocol for patients suffering from PTSD after moral trauma. Further research is needed to examine the effectiveness of BEP-MT.

Efficacy of an Internet-based cognitive-behavioural grief therapy for people bereaved by suicide: a randomized controlled trial

Background: The loss of a loved one due to suicide can be a traumatic event associated with prolonged grief and psychological distress. Objective: This study examined the efficacy of an Internet-based cognitive-behavioural grief therapy (ICBGT) specifically for people bereaved by suicide. Methods: In a randomized controlled trial, 58 participants with prolonged grief disorder (PGD) symptoms who had lost a close person to suicide were randomly allocated either to the intervention group (IG) or waitlist-control group (WCG). The 5-week intervention comprised ten writing assignments in three phases: self-confrontation, cognitive restructuring, and social sharing. Symptoms of PGD, common grief reactions after suicide, depression, and general psychopathology were assessed at pre-, post-test and follow-up. Results: Between-group effect sizes were large for the improvement of PGD symptoms in treatment completers (d_ppc2 = 1.03) and the intent-to-treat analysis (d_ppc2 = 0.97). Common grief reactions after suicide and depressive symptoms also decreased in the IG compared to the WCG (moderate to large effects). The results are stable over time. Only for general psychopathology, there was no significant time by group interaction effect found. Conclusions: The ICBGT represents an effective treatment approach for people suffering from PGD symptoms after bereavement by suicide. Considering the effect sizes, the small treatment dose, duration, and the stability of the results, the ICBGT constitutes an appropriate alternative to face-to-face grief interventions.

Treatment gap in bereavement care: (Online) bereavement support needs and use after traumatic loss

People bereaved through road traffic accidents (RTAs) are at risk for severe and disabling grief (i.e., pathological grief). Knowledge about needs and use of bereavement care, including psychotherapy, pharmacotherapy, and support groups, is limited. This study charted (correlates of) the needs and use of bereavement care in RTA bereaved people. Furthermore, although online grief treatment seems effective, it is unknown whether it is perceived as acceptable. Accordingly, we examined the acceptability of online treatment. Dutch RTA bereaved adults (N = 273) completed self‐report measures about needs and use of bereavement care, acceptability of online grief treatment, and pathological grief. Regression analyses were used to identify correlates of care needs and use and acceptability of online treatment. The majority (63%) had received help from psychotherapy, pharmacotherapy, and/or support groups. One in five participants had not used bereavement care services, despite reporting elevated pathological grief levels and/or expressing a need for care, pointing to a treatment gap. Use of psychological support before the loss was the strongest predictor of bereavement care needs and use following the loss. A minority (35%) reported being inclined to use online grief treatment if in need of support. More openness towards online services was related to greater acceptability of online treatment. In conclusion, 20% of RTA bereaved people with pathological grief or care needs had not received care. This treatment gap may be reduced by improving accessibility of online treatments. However, as only 35% was open to using online treatments, increasing the acceptability of (online) treatments appears important.

Digital Interventions for PTSD Symptoms in the General Population: a Review

There has been a significant development of digital interventions for the treatment of Post-Traumatic Symptom Disorder (PTSD) over the past two decades. However, the majority of research has examined their clinical efficacy for military service members and veteran populations whereas community-based trauma survivors have received significantly less attention. Their effectiveness for this population, therefore, remains unclear. The aim of this review was to evaluate the effectiveness of digitally delivered psychological therapies to alleviate PTSD symptomatology in the general population. Findings showed that digitally delivered Cognitive Behavioural Therapy (iCBT) produced more consistently significant improvements in PTSD symptoms, compared to interapy, expressive writing, psychoeducation, mindfulness, cognitive tasks and psychosocial interventions. iCBT - associated improvements were also independent of the focus (i.e. trauma vs. non-trauma) of the intervention, the provision of therapeutic support (e.g. guided vs. unguided), type of feedback (e.g. automated vs. individualised) or the number of sessions provided. Nevertheless, the number of included studies for subgroup analyses was relatively low. Digital interventions have an enormous potential to improve accessibility, efficiency, clinical effectiveness and personalisation of mental health interventions. Future research is needed to investigate further the use of a wider range of therapeutic approaches across different clinical and subclinical groups and settings and test the impact of these interventions (or components) against a wider range of comparison conditions (e.g. face to face CBT) with optimal power.

LEAVES (optimizing the mentaL health and resiliencE of older Adults that haVe lost thEir spouSe via blended, online therapy): Proposal for an Online Service Development and Evaluation

Background

Loss of a spouse is a frequent occurrence in later life. While most older adults successfully process this loss and will return to a normal life, about 10% of the individuals are unable to cope, and progress to prolonged grief (PG). PG, in turn, can result in mental and physical problems including poor sleep, cardiovascular problems, depression, and suicidal tendencies.

Objective

LEAVES (optimizing the mentaL health and resiliencE of older Adults that haVe lost thEir spouSe via blended, online therapy) is an online bereavement program that will support the prevention and treatment of PG, so that elderly mourners can continue to lead an active, meaningful, and dignified life. LEAVES will cater to secondary end users (eg, family, informal caregivers) by reducing stress.

Methods

LEAVES will help older adults to process the loss of a spouse in an online environment, which consists of (1) an existing online grief self-help program LIVIA, (2) the Before You Leave program that allows for storing personal memories, (3) a virtual agent platform, and (4) an accessible front-end design. LEAVES can detect persons at risk for complications, reveal negative trends in their emotional life, and act to counter such trends. The service relies on online support whenever possible but is blended with telephone or face-to-face counseling when necessary.

Results

The project will take place between February 2020 and January 2023 and includes a real-life evaluation in which 315 end users will use the service across 3 countries (the Netherlands, Portugal, and Switzerland). The evaluation of LEAVES will focus on clinical effect, its business case, and technology acceptance. The results will pave the way for smooth integration into existing care paths and reimbursement schemes.

Conclusions

The LEAVES service aims to soften the mourning process, prevents depression or social isolation, strengthens widow(er)s resilience and well-being, and quickens one’s return to societal participation.

International Registered Report Identifier (IRRID)

DERR1-10.2196/19344

Online cognitive-behavioural therapy for traumatically bereaved people: study protocol for a randomised waitlist-controlled trial

INTRODUCTION

The traumatic death of a loved one, such as death due to a traffic accident, can precipitate persistent complex bereavement disorder (PCBD) and comorbid post-traumatic stress disorder (PTSD) and depression. Waitlist-controlled trials have shown that grief-specific cognitive-behavioural therapy (CBT) is an effective treatment for such mental health problems. This is the first study that will examine the effectiveness of online CBT (vs waitlist controls) in a sample exclusively comprised of people bereaved by a traumatic death. Our primary hypothesis is that people allocated to the online CBT condition will show larger reductions in PCBD, PTSD and depression symptom levels at post-treatment than people allocated to a waitlist. We further expect that reductions in symptom levels during treatment are associated with reductions of negative cognitions and avoidance behaviours and the experience of fewer accident-related stressors. Moreover, the effect of the quality of the therapeutic alliance on treatment effects and drop-out rates will be explored.

METHODS AND ANALYSIS

A two-arm (online CBT vs waiting list) open-label parallel randomised controlled trial will be conducted. Participants will complete questionnaires at pretreatment and 12 and 20 weeks after study enrolment. Eligible for participation are Dutch adults who lost a loved one at least 1 year earlier due to a traffic accident and report clinically relevant levels of PCBD, PTSD and/or depression. Multilevel modelling will be used.

ETHICS AND DISSEMINATION

Ethics approval has been received by the Medical Ethics Review Board of the University Medical Center Groningen (METc UMCG: M20.252121). This study will provide new insights in the effectiveness of online CBT for traumatically bereaved people. If the treatment is demonstrated to be effective, it will be made publicly accessible. Findings will be disseminated among lay people (eg, through newsletters and media performances), our collaborators (eg, through presentations at support organisations), and clinicians and researchers (eg, through conference presentations and scientific journal articles).

TRIAL REGISTRATION NUMBER

NL7497.

Integration of palliative care into COVID-19 pandemic planning

The COVID-19 pandemic is expected to surpass the healthcare system’s capacity to provide intensive care to all patients who deteriorate as a result of the disease. This poses a unique challenge to healthcare teams of rationing care during pandemic when resources are scarce. Healthcare providers will need to acquire new skills in care decision making and effective symptom control for patients who do not receive life-saving measures. In this review, we describe some of the important palliative care considerations that need to be incorporated into COVID-19 pandemic planning. The main aspects to be considered include decision algorithms for rationing care, training on effective symptoms management, alternative delivery methods of palliative care services such as telemedicine and finally death and bereavement support for surviving family members who are likely to be isolated from their loved one at the moment of death.

Evaluation of an internet-based intervention for service members of the German armed forces with deployment-related posttraumatic stress symptoms

BACKGROUND

The present study was designed to evaluate the efficacy of a therapist-guided internet-based cognitive-behavioral therapy (iCBT) intervention for service members of the German Armed Forces with posttraumatic stress disorder (PTSD). The iCBT was adapted from Interapy, a trauma-focused evidence-based treatment based on prolonged exposure and cognitive restructuring. It lasted for 5 weeks and included 10 writing assignments (twice a week). The program included a reminder function if assignments were overdue, but no multimedia elements. Therapeutic written feedback was provided asynchronously within one working day.

METHODS

Male active and former military service members were recruited from the German Armed Forces. Diagnoses were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Mini-International Neuropsychiatric Interview. Psychopathology was assessed at pre-treatment, post-treatment, and 3-month follow-up. Severity of PTSD was the primary outcome and anxiety was the secondary outcome. Participants were randomly allocated to a treatment group that received iCBT immediately or to a waitlist group that received iCBT after 6 weeks. Due to the overall small sample size (n = 37), the two groups were collapsed for the statistical analyses. Change during the intervention period was investigated using latent-change score models.

RESULTS

Improvements in the CAPS-5 were small and not statistically significant. For anxiety, small significant improvements were observed from pre- to follow-up assessment. The dropout rate was 32.3%.

CONCLUSIONS

The low treatment utilization and the high dropout rate are in line with previous findings on treatment of service members. The interpretation of the current null results for the efficacy of iCBT is limited due to the small sample size, however for military samples effect estimates were also smaller in other recent studies. Our results demonstrate the need to identify factors influencing treatment engagement and efficacy in veterans.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN12616000956404.