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.

Psychotherapies for prolonged grief disorder in adults: A systematic review and network meta-analysis

BACKGROUND

Prolonged grief disorder (PGD), a condition characterized by severe, persistent, and disabling grief, is newly included in ICD-11 and DSM-5-TR. Psychotherapies are among the most recommended treatments for PGD, but which should be considered as first-line treatment needs to be clarified. The purpose of this systematic review and network meta-analysis was to synthesize the available evidence to compare five outcomes of different psychotherapies on PGD in adults and identify the optimal psychotherapy modality to inform clinical decision-making for the treatment of PGD.

METHOD

A comprehensive search was conducted in 7 databases from inception until March 20th, 2023. In the frequentist framework, pairwise and network meta-analyses using random-effects models were performed for outcomes with 95 % confidence interval (CI).

RESULTS

There were 2962 records found and 55 studies (1,0330 participants) assessing 11 different psychological interventions were included. Compared with the waiting list, behavioral therapy (SMD=-1.05; 95 %CI=-1.71, -0.38), third-wave cognitive behavior therapy (SMD=-1.00; 95 %CI =-1.41, -0.58), family therapy (SMD=-0.87; 95 %CI=-1.59, -0.16), psychodynamic therapy (SMD=-0.88; 95 %CI=-1.67, -0.10) and cognitive therapy (SMD=-0.84; 95 %CI=-1.57, -0.12) were statistically effective in reducing grief symptom. Only cognitive behavior therapy (OR =0.48; 95 %CI = 0.27, 0.85) was more acceptable than waiting list. In terms of secondary outcome, third-wave CBT can statistically significantly reduce depression (SMD= -0.60; 95 %CI =- 0.84, -0.36), PTSD (SMD=-0.99; 95 %CI =- 1.62, -0.36) and anxiety (SMD= -1.44; 95 %CI =-2.63, -0.25) respectively.

CONCLUSIONS

Most psychological interventions are effective, but only cognitive behavior therapy has the highest acceptability. Third-wave CBT with higher efficacy rates may be more beneficial for reducing secondary outcomes. To provide more robust evidence, high-quality trials should be conducted in the future.

Individual behavioral activation in the treatment of depression: A meta analysis

OBJECTIVE

Behavioral activation (BA) is an extensively examined treatment for depression which is relatively simple to apply in comparison to other psychotherapies. BA aims to increase positive interactions between a person and the environment. All previous meta-analyses focused on BA in groups and guided self-help, but none focused on BA in individual psychotherapy. The goal of the current meta-analysis is to examine the pooled effects of trials comparing individual BA to control conditions.

METHODS

We conducted systematic searches and conducted random effects meta-analyses to examine the effects of BA.

RESULTS

We included 22 randomized controlled trials (with 819 patients) comparing individual behavioral activation with waitlist, usual care, or other control conditions on distal treatment outcomes. Nine studies were rated as low risk of bias. We found a large effect (Hedges' g = 0.85; 95% CI: 0.57; 1.1) with high heterogeneity (75%; 95% CI: 62; 83). When only studies with low risk of bias were considered, the effect size was still significant (g = 0.56; 95% CI: 0.09; 1.03), with high heterogeneity (I² = 80%; 95% CI: 66; 89; prediction interval: -0.85; 1.98).

CONCLUSION

BA is an effective, relatively simple type of therapy that can be applied broadly in differing populations/.

The role of experiential avoidance in the relationship between traumatic distress and yearning in sudden and unexpected bereavement

BACKGROUND

Distressing preoccupation with the circumstances of the death, experiential avoidance, and yearning often manifest in pathological forms of grief following the sudden or unexpected death of a loved one. Traumatic distress-the emotional distress linked to circumstances or reminders of a death-often leads to avoidance behaviors, whereas yearning has been conceptualized as an emotional state which leads to proximity-seeking behaviors following bereavement. A gap exists in the literature explaining how these variables may interact and perpetuate one another.

AIMS

The present study aims to examine the role of experiential avoidance in the relationship between traumatic distress and yearning in a sample of suddenly and unexpectedly bereaved young adults. Results suggest that the association between traumatic distress and yearning may be partially mediated by experiential avoidance. Implications of these findings for theoretical models of grief and yearning are discussed.

MATERIALS & METHODS

Data include a sample of 606 bereaved young adults (Mage = 21.25; 77.4% female) who participated in a larger, online survey study conducted at two universities in the United States exploring the prevalence of trauma exposure in college students.

RESULTS

Mediation analysis demonstrated experiential avoidance as partially mediating the relationship between traumatic distress and yearning (ab = .21, SE = .10, 95% CI [.02, .40]) when controlling for presence at the scene of death or injury. This indirect effect accounted for 11.67% of the total effect. An additional moderated mediation analysis indicated this indirect effect was present across all levels of prolonged grief disorder (PGD) symptom severity.

DISCUSSION

Results indicate that the association between traumatic distress and yearning may be partially mediated by experiential avoidance across all levels of PGD symptom severity.

CONCLUSION

Findings suggest that bereaved individuals experiencing recurrent, death-related intrusive thoughts, imagery, and/or other memories related to the circumstances of the death may be more likely to experience intense yearning for the deceased in part due to attempts to avoid painful internal experiences associated with such cues.