Treatment of Complicated Grief in Survivors of Suicide Loss: A HEAL Report
Abstract
OBJECTIVE: Suffering associated with complicated grief (CG) is profound. Because suicide loss survivors are susceptible to developing CG, identifying effective treatments for suicide loss survivors with CG is a high priority. This report provides data on the acceptability and effectiveness of antidepressant medication and complicated grief therapy (CGT), a CG-targeted psychotherapy, for suicide loss survivors with CG identified by an Inventory of Complicated Grief score ≥ 30. METHODS: This is a secondary analysis of data collected from March 2010 to September 2014 for a 4-site, double-blind, placebo-controlled randomized trial comparing the effectiveness of antidepressant medication alone or in combination with CGT for participants with CG (score ≥ 30 on the Inventory of Complicated Grief) who were bereaved by suicide (SB; n = 58), accident/homicide (A/H; n = 74), or natural causes (NC; n = 263). Using mode of death as a grouping factor, we evaluated acceptability of treatments by comparing 12-week medication and 16-session CGT completion; we evaluated effectiveness by comparing response at week 20, defined by a score of 1 or 2 on the Complicated Grief Clinical Global Impressions-Improvement scale (CG-CGI-I), and additional secondary response measures. RESULTS: Among participants receiving medication alone, SB medication completion rates (36%) were lower than rates for A/H (54%) and NC (68%; χ² = 11.76, P < .01). SB medication completion rates were much higher for SB individuals receiving CGT (82%; χ² = 12.45, P < .001) than for SB individuals receiving medication alone. CGT completion rates were similar in the 3 groups (SB = 74%, A/H = 64%, NC = 77%; χ² = 2.48, P = .29). For SB participants receiving CGT, CG-CGI-I response rates were substantial (64%), but lower compared to the other groups (A/H = 93%, NC = 84%; χ² = 8.00, P < .05). However, on all other outcomes, changes from baseline for SB participants were comparable to those for A/H and NC participants, including number and severity of grief symptoms, suicidal ideation, and grief-related impairment, avoidance, and maladaptive beliefs. CONCLUSIONS: These results raise concern about the acceptability of medication alone as a treatment for complicated grief in treatment-seeking suicide-bereaved adults. In contrast, CGT is an acceptable and promising treatment for suicide-bereaved individuals with complicated grief. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01179568.
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A community-based crisis intervention program and an intensive grief therapy program reported decreases in suicidality.
“A community-based crisis intervention program and an intensive grief therapy program reported decreases in suicidality (Visser et al., 2014; Zisook et al., 2018).”
From Suicide Postvention Service Models and Guidelines 2014–2019: A Systematic Review (2019) · cites this paper as Zisook et al., 2018
Supiano et al. (2017) and Zisook et al. (2018) offered manualized intensive grief therapy to individuals with high levels of grief symptoms.
“Supiano et al. (2017) and Zisook et al. (2018) offered manualized intensive grief therapy to individuals with high levels of grief symptoms.”
From Suicide Postvention Service Models and Guidelines 2014–2019: A Systematic Review (2019) · cites this paper as Zisook et al., 2018
Those highly distressed and/or at-risk of disordered grief or ill mental health might benefit from specialized psychotherapy.
“while those highly distressed and/or at-risk of disordered grief or ill mental health might benefit from specialized psychotherapy (Supiano et al., 2017; Zisook et al., 2018).”
From Suicide Postvention Service Models and Guidelines 2014–2019: A Systematic Review (2019) · cites this paper as Zisook et al., 2018
Eight of the 11 studies were conducted in the USA.
“Eight studies were conducted in the USA [33–40].”
No study specifically involved interventions targeting older adults.
“A few studies included participants aged 65+ (e.g., Zisook et al. [40]), but no study specifically involved interventions targeting older adults.”
Several studies involved manualised interventions.
“Several studies involved manualised interventions [37, 38, 40–42].”
The duration of the intervention varied from one session in one study to a series of 16 therapeutic sessions delivered over 20 weeks in another.
“The duration of the intervention varied from one session in one study [43] to a series of 16 therapeutic sessions delivered over 20 weeks in another [40].”
Zisook et al. found that complicated grief therapy resulted in similar reduction of complicated grief symptoms in the three bereaved samples, though the sample sizes may have been too small for detecting statistically significant differences.
“Complicated grief therapy resulted in similar reduction of complicated grief symptoms in the three bereaved samples, though the sample sizes may have been too small for detecting statistically significant differences [40].”
Zisook et al. found that complicated grief therapy resulted in a significant reduction in suicidal ideation in participants bereaved through suicide.
“However, Zisook et al. [40] found that complicated grief therapy resulted in a significant reduction in suicidal ideation in participants bereaved through suicide.”
Results were mixed, as only Zisook et al. reported a significant reduction in suicidal ideation in both the suicide bereaved and the non-suicide bereaved groups.
“Again, results were mixed, as only Zisook et al. [40] reported a significant reduction in suicidal ideation in both the suicide bereaved and the non-suicide bereaved groups.”
Two studies that tested CBT-based interventions targeting complicated grief yielded some positive short-term results.
“Two studies that tested CBT-based interventions targeting complicated grief, such as an intervention with psycho-education [44] and targeted complicated grief therapy [40], yielded some positive short-term results.”
These three studies were relatively recent RCTs and evaluated effectiveness of a CBT-based psychotherapy intervention.
“Of interest, these three studies were relatively recent RCTs and evaluated effectiveness of a CBT-based psychotherapy intervention [40, 41, 44].”
Other RCTs also failed to find positive effects on complicated grief outcomes.
“Other RCTs [40, 41] also failed to find positive effects on complicated grief outcomes.”
The use of manuals or guidelines may help guiding the intervention.
“The use of manuals or guidelines may help guiding the intervention [37, 38, 40–42].”
It remains unclear which intervention modalities delivered in particular settings, such as schools, participants' own homes or clinical settings, are most helpful for suicide survivors across a range of age, gender and/or national/cultural groups.
“It also remains unclear which intervention modalities delivered in particular settings, such as schools [43], participants’ own homes [41, 44] or clinical settings [40], are most helpful for suicide survivors across a range of age, gender and/or national/cultural groups.”
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- Authors
- Zisook, S., Shear, M. K., Reynolds, C. F., Simon, N. M., Mauro, C., Skritskaya, N. A., Lebowitz, B., Wang, Y., Tal, I., Glorioso, D., Wetherell, J. L., Iglewicz, A., Robinaugh, D., & Qiu, X.
- Affiliations
- University of California San Diego (US)
- Columbia University (US)
- University of Pittsburgh (US)
- Harvard University (US)
- VA San Diego Healthcare System (US)
- Massachusetts General Hospital (US)
- ORCID
- Venue
- The Journal of Clinical Psychiatry
- Publisher
- Physicians Postgraduate Press, Inc
- Published
- 2018-04-25
- Volume
- 79
- Issue
- 2
- Pages
- 17m11592
- ISSN
- 0160-6689 (ISSN-L)
- OpenAlex
- W2792473669
- Cited by
- 41
- References
- 0
- Citations by year
- 2026: 3 · 2025: 9 · 2024: 6 · 2023: 6 · 2022: 2 · 2021: 6 · 2020: 6 · 2019: 3
- FWCI
- 4.40
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute of Mental Health (R01MH085297, P30MH090333, R01MH085308, R01MH060783, R01MH085288)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Social Sciences › Anthropology › Death, Funerary Practices, and Mourning
- Keywords
- complicated grief, suicide loss survivors, antidepressants, treatment acceptability, bereavement, Inventory of Complicated Grief, suicidal ideation, grief symptoms, mode of death, maladaptive beliefs
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, Antidepressive Agents, Combined Modality Therapy, Double-Blind Method, Grief, Humans, Middle Aged, Patient Acceptance of Health Care, Psychotherapy, Suicide, Outcome Assessment, Health Care, Survivors, Young Adult
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