Elsevier

Journal of Psychiatric Research

Volume 96, January 2018, Pages 94-99
Journal of Psychiatric Research

Medical comorbidity in complicated grief: Results from the HEAL collaborative trial

https://doi.org/10.1016/j.jpsychires.2017.09.017Get rights and content

Abstract

Objective

To describe medical comorbidity in persons with Complicated Grief (CG) and to test whether medical comorbidity in individuals with CG is associated with the severity and duration of CG, after adjusting for age, sex, race, and current depressive symptoms.

Methods

In exploratory analyses, we compared data from participants in an NIMH-sponsored multisite clinical trial of CG (“HEAL”: “Healing Emotions After Loss”) to archival data from participants matched on age, gender, and race/ethnicity, stratified by the presence or absence of current major depression. We used the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) as a measure of medical polymorbidity. We investigated the association between CG and medical comorbidity via multiple linear regression, adjusting for sociodemographic and clinical variables, including severity of depressive symptoms.

Results

Chronological age and severity of co-occurring symptoms of major depression correlated with cumulative medical polymorbidity in persons with Complicated Grief. The severity of CG and the time since loss did not correlate with global medical polymorbidity (CIRS-G score). Nor was there an interaction between severity of depressive symptoms and severity of CG symptoms in predicting global CIRS-G score. Cumulative medical comorbidity, as measured by CIRS-G scores, was greater in subjects with current major depression (“DEPRESSED”) than in CG subjects, and both DEPRESSED and CG subjects had greater medical morbidity than CONTROLS.

Conclusion

Medical comorbidity is prevalent in Complicated Grief, associated with increasing age and co-occurring depressive symptoms but apparently not with chronicity and severity of Complicated Grief per se. This observation suggests that treating depression in the context of CG may be important to managing medical conditions in individuals with Complicated Grief to attenuate or prevent the long-term medical sequelae of CG.

Introduction

Complicated Grief (CG) is a chronic and debilitating condition estimated to occur in 7% of bereaved people, thus affecting tens of millions of people worldwide (Kersting et al., 2011). Studies have shown that CG can reliably be distinguished from major depression both in response to treatment and primary symptomatology (Cozza et al., 2016, Shear et al., 2016, Shear et al., 2014, Supiano and Luptak, 2014). CG symptoms include prolonged yearning, longing, sorrow, persistent thoughts of the deceased, and difficulty imagining a future with purpose and meaning, together with impairment in social and occupational function (Kersting et al., 2011).

There is a strong association between bereavement, especially CG, and negative health outcomes. CG is known to shorten life expectancy, due to death from heart disease and/or cancer (Prigerson et al., 2002). CG has also been associated with physiologic symptoms, such as shortness of breath, palpitations, digestive difficulties, loss of appetite, weight loss, poor treatment adherence, sleep issues including restlessness, insomnia, and low sleep quality, and a 10-fold greater risk for hypertension and heart disease (Lannen et al., 2008; H. G. Prigerson et al., 1995a, Prigerson et al., 1995b; Prigerson et al., 1997, Shear, 2015, Stroebe et al., 2011).

CG also frequently co-exists with major depression, which is similarly associated with shortened life expectancy across a range of medical and neurological disorders (Gallo et al., 2013). Evidence-based treatment of depression in older primary care adults leads to substantial reduction in mortality risk (24% over eight years), secondary to reductions in cancer-related deaths (Gallo et al., 2013). We do not know whether evidence-based treatment of CG to remission also leads to reductions in mortality risk. However, to test whether evidence-based treatment of CG to remission also leads to reductions in mortality risk, we must first develop an understanding of the type, extent, and severity of medical comorbidity in persons with CG, with and without depression. Thus, this study addresses the following aims:

  • 1.

    To describe medical comorbidity in persons with complicated grief, as compared with non-bereaved depressed subjects with current major depression and with non-bereaved, non-depressed control participants.

  • 2.

    To test whether medical comorbidity in complicated grief is associated with the severity and duration of CG, after adjusting for the effects of age, sex, race, and severity of depressive symptoms.

Section snippets

Design

We analyzed data from a multisite clinical trial of CG (“HEAL”: “Healing Emotions After Loss”) (Shear et al., 2016), sponsored by the National Institute of Mental Health. HEAL is a double-blind, placebo-controlled, randomized clinical trial that evaluated the efficacy of antidepressant pharmacotherapy, with and without complicated grief psychotherapy, in the treatment of CG. Participants were recruited from four communities in the United States: Boston, MA; New York, NY; Pittsburgh, PA; and San

Aim 1: Comparison of medical comorbidity in persons with complicated grief, major depression, and controls

Table 1 summarizes the comparison of those with CG (HEAL) to DEPRESSED and CONTROL subjects. The three groups had been matched for age, sex, and self-reported race/ethnicity. Cumulative medical comorbidity (total CIRS-G scores) was greater in DEPRESSED than in CG subjects, and both DEPRESSED and CG subjects had greater medical morbidity scores than CONTROLS.

Analyses by organ system using individual organ-system specific CIRS-G scores showed significant differences for CG versus CONTROLs in two

Discussion

In this exploratory study, we observed that total medical comorbidity (CIRS-G scores) was greater in DEPRESSED than in CG subjects having similar age, sex, and race/ethnicity, and that medical comorbidity in either group exceeded that seen in non-depressed, non-bereaved CONTROLS. Medical comorbidity in CG was not found to be associated with severity and duration of CG after adjusting for chronological age and severity of co-occurring depressive symptoms. Medical comorbidity in complicated grief

Sources of funding

Preparation of this manuscript was supported in part by Grants from NIH K01MH103467, R01MH60783, R01MH085297, R01MH085288, R01MH085308, and P30 MH90333 from the National Institutes of Health and by grant LSRG-S_172-12 from the American Foundation for Suicide Prevention.

Conflicts of interest

Dr. Reynolds reports being supported by the NIH (P30 MH90333), and the UPMC Endowment in Geriatric Psychiatry; having received medication supplies for investigator-initiated trials from Bristol Meyers Squibb, Forrest Labs, Lily, and Pfizer; and receives royalties for industry sponsored use of the Pittsburgh Sleep Quality Index (PSQI), to which he holds intellectual property rights. Dr. Simon reports grant funding from the NNIH, the Department of Defense, Janssen, the American Foundation for

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