Treating prolonged grief disorder with prolonged grief-specific cognitive behavioral therapy: study protocol for a randomized controlled trial

Symptoms and levels of ICD-11 Prolonged Grief Disorder in a representative community sample of UK adults

BACKGROUND

Prolonged Grief Disorder (PGD) is a new disorder included in ICD-11 (WHO, 2018). There is a growing body of literature surrounding the prevalence and correlates of ICD-11 PGD symptoms as assessed using various measures. This study was the first to assess levels of ICD-11 PGD symptoms as measured by the International Prolonged Grief Disorder Scale (IPGDS), a self-report scale directly aligned with the ICD-11 definition of PGD, among the United Kingdom adult general population, and identify correlates.

METHOD

Participants included 2025 adults who participated in Wave 5 of the COVID-19 Psychological Research Consortium Study (C19PRC-UK). Prevalence rates of PGD were estimated based on two commonly used algorithms defined as 'strict' and 'moderate'. Sociodemographic, loss-related, and mental health correlates (i.e., anxiety, depression, mental health treatment seeking, loneliness) of strict and moderate PGD were then examined using multinomial logistic regressions.

RESULTS

It was found that 2.4% (n = 43) of participants met probable caseness for PGD using the strict criteria while 7.9% (n = 140) met probable caseness for PGD using the moderate criteria. Multinomial logistic regression analysis results showed, as predicted, that income, time since bereavement, death of a child, religiosity, and depression were associated with both moderate and strict PGD. Correlates of moderate PGD included country of residence, urbanicity, younger age of bereaved, and loneliness.

CONCLUSIONS

This study highlights that some symptoms of PGD are commonly reported in the general population, although relatively few meet the criteria for clinical significance. The routine assessment for PGD following a bereavement is discussed and the development of appropriate interventions are recommended.

Prolonged Grief in Times of Lockdown During the COVID-19 Pandemic

This study aimed to estimate the prevalence of prolonged grief (PG) during the COVID-19 pandemic and to analyze associated variables. 142 family members of patients who died during the lockdown at a hospital were surveyed 6 months after the death. Prolonged grief, depression and anxiety, grief rumination, and loss-related variables were captured. Logistic regression analyses were conducted to detect the associated variables of PG symptoms. Prolonged grief was present in 44.4% of the bereaved. 76.2% of the relatives reported feeling distressed due to visitor restrictions, and the majority of them were unable to bid farewell to their family member at the time of death. Pastoral or psychological care was also lacking. Low education (p < 0.001), emotional closeness (p = 0.007), loss of a spouse (p < 0.001), inability to bid farewell after death (p = 0.024), feeling of threat due to the pandemic (p < 0.001), depression (p = 0.014), and anxiety (p = 0.028) were significantly associated with prolonged grief.

Interpersonal problems and cooperative behavior in patients suffering from prolonged grief disorder as compared to bereaved healthy controls

OBJECTIVES

Interpersonal factors, such as impairments in social interaction or lack of social support, have an important share when it comes to the development, maintenance, and progression of various mental disorders.

METHODS

Individuals suffering from prolonged grief disorder (PGD) and matched bereaved healthy controls (n = 54) underwent a thorough diagnostic procedure, further completed the Inventory of Interpersonal Problems (IIP-D-32), and participated in a finitely iterated prisoner's dilemma (FIPD).

RESULTS

Individuals suffering from PGD reported significantly more interpersonal problems. Both groups behaved differently in the FIPD with healthy controls being more carefully, adapting their behavior more flexible, whereas PGD patients displayed a lower responsiveness, which may indicate an inability to adapt to changes in relationships.

CONCLUSION

We conclude that interpersonal problems appear to be a relevant feature of PGD. Future studies need to clarify the causal relation behind this link, and should also include measures of attachment, social support, and disconnectedness.

[Before the diagnosis was established … A retrospective analysis of bereavement care in Germany]

INTRODUCTION

In Germany, many health care providers work in bereavement care. An epidemiological study of this field of work has not yet been conducted.

METHODS

In the initial survey of this three-phase trend study the situation of grief-specific health care in Germany in 2009/2010 is examined, i. e., at the time before the introduction of the new ICD-11 diagnosis of Prolonged Grief Disorder. For this purpose, bereavement care providers at different organizational levels participated in an online survey.

RESULTS

410 questionnaires were included in the study. Data analysis was descriptive. The most frequent reason for using grief-specific support services was the loss of a partner. In more than half of all cases of bereavement, people experienced a loss that was preceded by an illness and suffering. More than half of those providing bereavement care do not follow a concept of intervention.

DISCUSSION

There is considerable need for further development in German bereavement care, in particular with regard to qualification and the degree of professionalization, designation of the respective interventions, diagnostics, and intervention.

CONCLUSION

This three-phase trend study enables health care providers to derive bereavement care service standards that aim to treat people according to their needs. Whether the diagnosis of Prolonged Grief Disorder has led to changes in bereavement care is currently analyzed in the second survey phase of the study.

Predictors of Prolonged Grief Disorder in a German Representative Population Sample: Unexpectedness of Bereavement Contributes to Grief Severity and Prolonged Grief Disorder

Most people adapt to bereavement over time. For a minority, the grief persists and may lead to a prolonged grief disorder (PGD). Identifying grievers at risk of PGD may enable specific prevention measures. The present study examined the extent to which the subjective unexpectedness of the death predicted grief outcomes above and beyond known sociodemographic and objective loss-related variables in a sample drawn from a population-representative investigation. In our sample (n = 2,531), 811 participants (M _age 55.1 ± 17.8 years, 59.2% women) had experienced the loss of a significant person six or more months ago. Participants provided demographic and loss-related information, perceptions of the unexpectedness of the death and completed the Prolonged Grief Disorder-13 + 9 (PG-13 + 9). The PG-13 + 9 was used to determine PGD caseness. A binary logistic regression investigated predictors of PGD caseness, and a linear regression predictors of grief severity. ANCOVAs compared PGD symptoms between the groups who had experienced an "expected" vs. "unexpected" loss, while controlling for the relationship to the deceased and time since loss. The loss of a child (OR = 23.66; 95%CI, 6.03-68.28), or a partner (OR = 5.32; 95%CI, 1.79-15.83), the time since loss (OR = 0.99; 95%CI, 0.99-1.00) and the unexpectedness of the death (OR = 3.58; 95%CI, 1.70-7.69) were significant predictors of PGD caseness (Nagelkerke's R² = 0.25) and grief severity. Participants who had experienced the loss as unexpected (vs. expected) reported higher scores on all PGD symptoms. Unexpectedness of the death emerged as significant risk factor for PGD, even after controlling for demographic and other loss-related variables. While our findings replicate previous research on the importance of the relationship to the deceased as a risk factor for PGD, they also highlight the importance of assessing the subjective unexpectedness of a death and may help to identify risk groups who can profit from preventive interventions.

Introduction and evaluation of a therapeutic adherence and competence scale for grief-focused cognitive behavioural therapy

BACKGROUND

There is no therapeutic competence and adherence scale for grief-focused cognitive behavioural therapy (grief-focused CBT). However, given the growing body of evidence for the efficacy of grief-focused CBT, such a scale is needed both to ensure the internal validity of clinical trials and to facilitate psychotherapy process research.

OBJECTIVE

To develop and undertake a psychometric evaluation of a therapeutic adherence and competence scale for grief-focused CBT.

METHOD

The scale was developed in two steps. (I) Five experts on the treatment of prolonged grief disorder provided feedback on the relevance and appropriateness of the items. The scale was revised to reflect their feedback. The final therapeutic adherence and competence scale for grief (TACs-G) consisted of 15 adherence and 16 competence items. (II) Psychometric evaluation of the TACs-G was based on the rating of 48 randomly selected PG-CBT sessions by two independent raters. The videos were recorded in the context of a randomized controlled trial (RCT; DRKS00012317.) ICC was used to calculate inter-rater reliability and TACs-G stability over time (re-evaluation of 10 sessions after 12 months).

RESULTS

The five experts confirmed the relevance and appropriateness of the items. Interrater reliability was found to be high for the total adherence and competence scores (ICC = 0.889 and 0.782, respectively) and moderate to excellent for individual items (ICC = 0.509-1.00). The TACs-G stability over time was found to be strong for both adherence (ICC = 0.970) and competence total scores (ICC = 0.965).

CONCLUSIONS

The TACs-G for CBT is a reliable instrument that can be used not only to ensure internal validity but is also suited for psychotherapy process studies. Additionally, it provides a valuable database for targeted feedback in training settings.

HIGHLIGHTS

This is the first study to report on the development and psychometrical evaluation of a grief-focused adherence and competence scale.Although an increasing number of clinical trials do report the efficacy of grief-focused cognitive-behavioural therapy, none of these studies used a standardized adherence and competence scale to control internal validity.In the present study, we introduced a therapeutic adherence and competence scale for grief (TACs-G) that can be applied efficiently across different research settings (e.g. manipulation check, dissemination), and report results of good to excellent psychometric properties.The scale itself could prove useful beyond the research setting as it could possibly serve as a basis for feedback in training settings.

Mental Imagery in Patients with Prolonged Grief Disorder: a Comparison with Matched Bereaved Healthy Controls

Mental imagery is a transdiagnostic feature that has been increasingly researched in mental disorders in the past years. This study is the first to investigate mental imagery in individuals suffering from Prolonged Grief Disorder (PGD), a new disorder which will be included into the new edition of the International Classification of Diseases and Related Health Problems (ICD-11).Our objective was to find out to what extent patients suffering from PGD differ from healthy, but equally bereaved, controls in terms of mental imagery, and how mental imagery is related to psychopathology. Patients with PGD and matched bereaved healthy controls (n = 54) completed a mental imagery questionnaire specifically designed for the study, and other established measures of psychopathology. Patients suffering from PGD reported mental images more frequently, had less control over them, and described negative images as more vivid than did healthy controls. Also, in reaction to mental images, patients less frequently experienced joy, but more often grief, anger and guilt. Besides these group differences, significant correlations between mental imagery other psychopathological measures could be found. Mental imagery is clearly related to PGD. The underlying mechanisms on whether it is a developing or maintaining factor need to be addressed in future studies. Future research should also investigate in what way mental imagery might be used in therapeutic approaches.

Inclusion of the other in the self as a potential risk factor for prolonged grief disorder: A comparison of patients with matched bereaved healthy controls

Pathological grief has received increasing attention in recent years, as about 10% of the bereaved suffer from one kind of it. Pathological grief in the form of prolonged grief disorder (PGD) is a relatively new diagnostic category which will be included into the upcoming ICD-11. To date, various risk and protective factors, as well as treatment options for pathological grief, have been proposed. Nevertheless, empirical evidence in that area is still scarce. Our aim was to identify the association of interpersonal closeness with the deceased and bereavement outcome. Interpersonal closeness with the deceased in 54 participants (27 patients suffering from PGD and 27 bereaved healthy controls) was assessed as the overlap of pictured identities via the inclusion of the other in the self scale (IOS scale). In addition to that, data on PGD symptomatology, general mental distress and depression were collected. Patients suffering from PGD reported higher inclusion of the deceased in the self. By contrast, they reported feeling less close towards another living close person. Results of the IOS scale were associated with PGD severity, general mental distress and depression. Inclusion of the deceased in the self is a significant statistical predictor for PGD caseness.

Review of Grief Therapies for Older Adults

Purpose of Review

The objective of this review is to provide background on common theories of grief, describe the impact of grief on older adults and to introduce various modalities that are currently used and/or being researched for treatment. The objective is also to condense information and identify what has been found beneficial versus what has been found lacking. A brief examination of overlap of other disorders is done. It also will suggest what further research is necessary on this subject, and highlight what research is being done during the COVID-19 Pandemic.

Findings

The latest research of grief primarily involves refining the definitions of grief. More concrete definitions of grief will help for better screening tools, and thus target interventions more appropriately. There is considerable need for applying it to the unique and real-world COVID-19 pandemic.

Summary

Grief disorders are relatively common and the symptoms overlap other disorders. Since the treatments differ, identifying grief disorders is important, especially in the elderly who are more susceptible to grief disorders. Therapy improves grief better than medications, but medications will help with any co-occurring disorders. No clear superior therapy has been identified but research continues. The pandemic has highlighted the need to refine the definitions of grief disorders and to treat them effectively.

From virtual to real healing: a critical overview of the therapeutic use of virtual reality to cope with mourning

In recent years, virtual reality (VR) has been effectively employed in several settings, ranging from health care needs to leisure and gaming activities. A new application of virtual stimuli appeared in social media: in the documentary ‘I met you’ from the South-Korean Munhwa Broadcasting, a mother made the experience of interacting with the avatar of the seven-year-old daughter, who died four years before. We think that this new application of virtual stimuli should open a debate on its possible implications: it represents contents related to grief, a dramatic and yet natural experience, that can have deep psychological impacts on fragile subjects put in virtual environments. In the present work, possible side-effects, as well as hypothetical therapeutical application of VR for the treatment of mourning, are discussed.

How are women supported in making decisions regarding fertility preservation after a breast cancer diagnosis?

Although there has been an increase in fertility preservation treatment options in recent years, existing evidence would suggest that many young women who have breast cancer do not feel well supported in making decisions in this area. A breast cancer diagnosis and the possibility of becoming infertile are known to cause psychological issues for young women and many find it difficult to make decisions at this time, causing them a great deal of stress and anxiety. Given the need for patient-centred care, this literature review looked at the decision-making support given to women with a diagnosis of breast cancer as part of fertility preservation treatment. The review found that women lacked support and struggled to make decisions at this critical point in their lives. The findings of the review suggest that women would benefit from a wide range of decision support interventions prior to and following diagnosis.

Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment

Losing a loved one is one of life's greatest stressors. Although most bereaved individuals navigate through a period of intense acute grief that lessens with time, approximately 10% will develop a prolonged grief condition. This review provides an overview of the course of grief and describes risk factors for developing prolonged grief disorder. The evolution of the prolonged grief disorder diagnosis, including the latest criteria sets for ICD-11 and DSM-5, as well as common comorbid conditions and differential diagnosis are discussed. Clinically useful self-report and clinician-rated measures for assessing symptom constructs and overall prolonged grief disorder severity, evidence-based psychotherapies (such as complicated grief treatment), as well as evidence about pharmacologic approaches are presented. Finally, the authors discuss important future directions, including a potential increase in prolonged grief disorder cases due to the COVID-19 pandemic.

Prevalence of prolonged grief disorder

BACKGROUND

Prolonged grief is a disorder (PGD) characterized by severe and disabling grief reactions for an extended period of time after the loss of a significant person. ICD-11 and DSM-5-TR differ substantially in individual criteria.

OBJECTIVE

Estimation of the respective prevalence of PGD_ICD-11 and PGD_DSM-5-TR and the frequency with which single symptoms of prolonged grief occur in the general population.

METHODS

Out of a representative sample of the German general population (N=2498), n = 914 reported a significant loss and prolonged grief symptoms based on the extended version of the self-reported Prolonged Grief Disorder-13+9 (PG13+9). Sociodemographic and loss-related characteristics were collected.

RESULTS

The probable prevalence of PGD_ICD-11 was 1.5% and that of PGD_DSM-5-TR was 1.2% in the general sample. Among bereaved persons (n=914), the prevalence of developing PGD_ICD-11 was 4.2% and that of PGD_DSM-5-TR was 3.3%. Diagnostic agreement between the two criteria-sets was very high and did not increase after heightening the accessory symptom threshold for PGD_ICD-11. Difficulties accepting the loss was the most frequent single symptom (14-25%) and grief-related impairment was common (10-16%). Over 60% of participants with a probable PGD diagnosis utilized health care services.

LIMITATIONS

Results are based on self-reported data. The PG13+9 was not designed to assess grief symptoms according to ICD-11 and DSM-5-TR diagnostic criteria.

CONCLUSIONS

Prolonged grief according to ICD-11 and DSM-5-TR is a notable disorder in the general population. Among bereaved persons, single symptoms of prolonged grief are relatively frequent and cause substantial degrees of impairment.

Narrative reconstruction therapy for prolonged grief disorder - a pilot study

Background: Prolonged grief disorder (PGD) is a chronic and disabling condition that affects approximately 10% of non-traumatically bereaved people. Narrative reconstruction (NR), originally designed for the treatment of posttraumatic stress disorder (PTSD), is a time-limited integrative therapy consisting of exposure to the loss memory, detailed written reconstruction of the loss memory narrative, and an elaboration of the personal significance of that memory for the bereaved. Objective: This pilot study examined the efficacy of NR therapy in reducing symptoms in bereaved people diagnosed with PGD. Method: Ten PGD patients participated in the study and were treated with 16 weekly sessions of NR. PGD, PTSD, and depression symptoms, as well as levels of loss integration, were assessed at pre-treatment, post-treatment, and at a 3-month follow-up. Results: Following NR, participants showed significant reductions in PGD, depression, and PTSD symptoms, and elevated levels of trauma integration. Symptoms showed further improvement at the three-month follow-up. Conclusions: These findings provide preliminary evidence for the feasibility and efficacy of NR in treating PGD. Narrative reconstruction therapy requires further evaluation in randomized controlled trials.

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.

Prevalence and associated factors of prolonged grief disorder in Chinese parents bereaved by losing their only child

In China, parents who have lost their only child and remained childless are labelled Shidu () parents. Previous research suggests high levels of psychological distress in this population, yet little is known regarding the prevalence of prolonged grief disorder (PGD) based on the new ICD-11 formulation. The present study examined prevalence rates and associated factors of prolonged grief disorder in this population. 1030 Chinese Shidu parents (381 male, 643 female) who were recruited through convenient sampling completed questionnaires assessing grief severity. Multiple linear regression models were used to examine socio-demographic, loss-related and self-reported number of chronic physical conditions associated with PGD symptoms. Results showed prevalence rate was 35.5% based on the ICD-11 PGD criteria, which was almost twice as that of Prigerson et al. (2009) criteria. Younger age of parents, being a mother, living in a rural place, lower monthly income per capital, shorter time since loss and more comorbid chronic physical conditions were related to severer PGD symptoms. The present findings revealed high rates of PGD experienced by Chinese Shidu parents and identified key risk factors which can be used for future prevention or intervention designs in this population.

Commentary on evidence in support of a grief-related condition as a DSM diagnosis

The death of a loved one is one of life's greatest stressors. Most bereaved individuals experience a period of acute grief that diminishes in intensity as they adapt to the changes brought about by their loss. Over the past four decades, a growing body of research has focused on a form of prolonged grief that is painful and impairing. There is a substantial and growing evidence base that supports the validity and significance of a grief-related disorder, including the clinical value of being able to diagnose it and provide effective targeted treatment. ICD-11 will include a new diagnosis of prolonged grief disorder (PGD). DSM-5 called this condition persistent complex bereavement disorder (PCBD) and included it in Section III, signaling agreement that a diagnosis is warranted while further research is needed to determine the optimal criteria. Given the remaining uncertainties, reading this literature can be confusing. There is inconsistency in naming the condition (including complicated grief as well as PGD and PCBD) and lack of uniformity in identifying it, with respect to the optimal threshold and timeframe for distinguishing it from normal grief. As an introductory commentary for this Depression and Anxiety special edition on this form of grief, the authors discuss the history, commonalities, and key areas of variability in identifying this condition. We review the state of diagnostic criteria for DSM-5 and the current ICD-11 diagnostic guideline, highlighting the clinical relevance of making this diagnosis.

When does grief become pathological? Evaluation of the ICD-11 diagnostic proposal for prolonged grief in a treatment-seeking sample

Background: Prolonged grief disorder (PGD) will be newly included in the ICD-11, while a clinically similar diagnosis, persistent complex bereavement disorder (PCBD), has already been added to the DSM-5. Only few studies have evaluated these criteria-sets for prolonged grief. Objective: The aim of this study was to evaluate the ICD-11 accessory symptom threshold and compare the diagnostic performance of the two criteria-sets in treatment-seeking bereaved persons. Method: 113 grief treatment-seeking bereaved persons completed the Interview for Prolonged Grief-13. We used receiver operator characteristic analysis to determine an optimum ICD-11 accessory symptom threshold. We calculated diagnostic rates for PGD and PCBD and examined associations of PGD and PCBD caseness with concurrently assessed psychopathology and prolonged grief symptoms assessed one month later. Results: An ICD-11 threshold of six accessory symptoms distinguished optimally between interview-diagnosed participants with and without prolonged grief. The prevalence of PGD (69%) was significantly higher than that of PCBD (48%) and of PGD with a 6-symptom threshold (47%). PGD caseness was associated with the relation to the deceased, 6-symptom threshold PGD and PCBD caseness with the time since loss. All criteria-sets were linked to concurrent prolonged grief, depression, and general mental distress. PCBD and 6-symptom threshold PGD but not PGD were associated with prolonged grief severity one month later. Conclusions: The results support the validity of PGD and PCBD but, at the same time, they provide further support for differing prevalence rates. Using an empirically determined ICD-11 accessory symptom threshold could prevent the pathologisation of grief reactions.

Present-centered therapy (PCT) for post-traumatic stress disorder (PTSD) in adults

BACKGROUND

Present-centered therapy (PCT) is a non-trauma, manualized psychotherapy for adults with post-traumatic stress disorder (PTSD). PCT was originally designed as a treatment comparator in trials evaluating the effectiveness of trauma-focused cognitive-behavioral therapy (TF-CBT). Recent trials have indicated that PCT may be an effective treatment option for PTSD and that patients may drop out of PCT at lower rates relative to TF-CBT.

OBJECTIVES

To assess the effects of PCT for adults with PTSD. Specifically, we sought to determine whether (1) PCT is more effective in alleviating symptoms relative to control conditions, (2) PCT results in similar alleviation of symptoms compared to TF-CBT, based on an a priori minimally important differences on a semi-structured interview of PTSD symptoms, and (3) PCT is associated with lower treatment dropout as compared to TF-CBT.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register, the Cochrane Library, Ovid MEDLINE, Embase, PsycINFO, PubMed, and PTSDpubs (previously called the Published International Literature on Traumatic Stress (PILOTS) database) (all years to 15 February 2019 search). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing trials. Reference lists of included studies and relevant systematic reviews were checked. Grey literature searches were also conducted to identify dissertations and theses, clinical guidelines, and regulatory agency reports.

SELECTION CRITERIA

We selected all randomized clinical trials (RCTs) that recruited adults diagnosed with PTSD to evaluate PCT compared to TF-CBT or a control condition. Both individual and group PCT modalities were included. The primary outcomes of interest included reduced PTSD severity as determined by a clinician-administered measure and treatment dropout rates.

DATA COLLECTION AND ANALYSIS

We complied with the Cochrane recommended standards for data screening and collection. Two review authors independently screened articles for inclusion and extracted relevant data from eligible studies, including the assessment of trial quality. Random-effects meta-analyses, subgroup analyses, and sensitivity analyses were conducted using mean differences (MD) and standardized mean differences (SMD) for continuous data or risk ratios (RR) and risk differences (RD) for dichotomous data. To conclude that PCT resulted in similar reductions in PTSD symptoms relative to TF-CBT, we required a MD of less than 10 points (to include the 95% confidence interval) on the Clinician-Administered PTSD Scale (CAPS). Five members of the review team convened to rate the quality of evidence across the primary outcomes. Any disagreements were resolved through discussion. Review authors who were investigators on any of the included trials were not involved in the qualitative or quantitative syntheses.

MAIN RESULTS

We included 12 studies (n = 1837), of which, three compared PCT to a wait-list/minimal attention (WL/MA) group and 11 compared PCT to TF-CBT. PCT was more effective than WL/MA in reducing PTSD symptom severity (SMD -0.84, 95% CI -1.10 to -0.59; participants = 290; studies = 3; I² = 0%). We assessed the quality of this evidence as moderate. The results of the non-inferiority analysis comparing PCT to TF-CBT did not support PCT non-inferiority, with the 95% confidence interval surpassing the clinically meaningful cut-off (MD 6.83, 95% CI 1.90 to 11.76; 6 studies, n = 607; I² = 42%). We assessed this quality of evidence as low. CAPS differences between PCT and TF-CBT attenuated at 6-month (MD 1.59, 95% CI -0.46 to 3.63; participants = 906; studies = 6; I² = 0%) and 12-month (MD 1.22, 95% CI -2.17 to 4.61; participants = 485; studies = 3; I² = 0%) follow-up periods. To confirm the direction of the treatment effect using all eligible trials, we also evaluated PTSD SMD differences. These results were consistent with the primary MD outcomes, with meaningful effect size differences between PCT and TF-CBT at post-treatment (SMD 0.32, 95% CI 0.08 to 0.56; participants = 1129; studies = 9), but smaller effect size differences at six months (SMD 0.17, 95% CI 0.05 to 0.29; participants = 1339; studies = 9) and 12 months (SMD 0.17, 95% CI 0.03 to 0.31; participants = 728; studies = 5). PCT had approximately 14% lower treatment dropout rates compared to TF-CBT (RD -0.14, 95% CI -0.18 to -0.10; participants = 1542; studies = 10). We assessed the quality of this evidence as moderate. There was no evidence of meaningful differences on self-reported PTSD (MD 4.50, 95% CI 3.09 to 5.90; participants = 983; studies = 7) or depression symptoms (MD 1.78, 95% CI -0.23 to 3.78; participants = 705; studies = 5) post-treatment.

AUTHORS' CONCLUSIONS

Moderate-quality evidence indicates that PCT is more effective in reducing PTSD severity compared to control conditions. Low quality of evidence did not support PCT as a non-inferior treatment compared to TF-CBT on clinician-rated post-treatment PTSD severity. The treatment effect differences between PCT and TF-CBT may attenuate over time. PCT participants drop out of treatment at lower rates relative to TF-CBT participants. Of note, all of the included studies were primarily designed to test the effectiveness of TF-CBT which may bias results away from PCT non-inferiority.The current systematic review provides the most rigorous evaluation to date to determine whether PCT is comparably as effective as TF-CBT. Findings are generally consistent with current clinical practice guidelines that suggest that PCT may be offered as a treatment for PTSD when TF-CBT is not available.

Psychosocial Issues and Bereavement

Patients with serious illness and their family caregivers face numerous ongoing psychological and social concerns and stressors throughout the disease trajectory. Common challenges relate to the need to manage the disease by making complex and often difficult medical decisions. In addition, the presence of psychological and psychiatric distress, including depression and anxiety, may significantly add to the overall symptom burden for the patient and family caregivers. These challenges negatively impact mood, cognitive function, interpersonal relationships, and medical decision making. If not recognized and adequately addressed, they can seriously undermine coping and resilience, eroding psychological well-being and quality of life.