New Criteria Can Help Clinicians Diagnose, Treat Prolonged Grief Disorder

The addition of the diagnostic category prolonged grief disorder to DSM-5-TR is timely and important given the COVID-19 pandemic’s enormous death toll, wrote Holly Prigerson, Ph.D., of Weill Cornell Medicine and colleagues in a Viewpoint article published yesterday in JAMA Psychiatry. It is vital clinicians know how to identify pathological manifestations of grief and connect patients with proven treatments, notes Prigerson and her co-authors, psychiatrists Katherine Shear, M.D., of Columbia University and Charles F. Reynolds III, M.D., of the University of Pittsburgh Medical Center.

“[Prolonged grief disorder] is a serious mental disorder that puts the patient at risk for intense distress, poor physical health, shortened life expectancy, and suicide,” the authors wrote.

“The DSM-5-TR criteria for [prolonged grief disorder] require that distressing symptoms of grief continue for at least 12 months following the loss of a close attachment and that the grief response is characterized by intense longing/yearning for the deceased person and/or preoccupation with thoughts and memories of the lost person to a clinically significant (i.e., impairing) degree, nearly every day for at least the past month,” the authors continued. Patients must also experience symptoms such as feeling as though a part of oneself has died, intense emotional pain, emotional numbness, or feeling that life is meaningless because of the death.

The PG-13 Revised scale—a 13-item questionnaire that asks patients about the length of time since their loved one’s death and their symptoms of grief—can help to determine the severity of grief. A score of 30 or higher on the PG-13 Revised scale is consistent with a prolonged grief disorder diagnosis and may indicate treatment is needed.

Several studies suggest that patients with prolonged grief disorder may respond better to targeted therapy than to other therapies used to treat major depression (including citalopram and interpersonal therapy). Among 641 participants experiencing complicated grief, 71% of those treated with prolonged grief disorder therapy reported improvement on the Clinical Global Impression Scale compared with 44% of those who received either interpersonal psychotherapy or citalopram, the authors wrote.

Prolonged grief disorder therapy works under the central premise that, for patients with prolonged grief disorder, the coping responses typical of early grief—such as self-blame, avoidance, and anger—derail the naturally adaptive process of transforming and integrating grief, according to the authors. Prolonged grief disorder therapy helps the patient learn to accept his or her new reality and restore a sense of autonomy and competence. It includes seven themes, “or healing milestones,” the authors wrote, that are introduced sequentially:

1. Understanding and accepting grief
2. Managing grief emotions
3. Seeing a promising future
4. Strengthening relationships
5. Narrating the story of death
6. Living with reminders
7. Connecting with memories

“Because of the pandemic, the absolute number of [prolonged grief disorder] cases is likely to increase and the 7% to 10% prevalence rate among … bereaved people may rise,” they wrote. “[C]linicians should learn how to accurately assess, to accurately and differentially diagnose, and to offer or refer patients for treatment.”

For related information, see the Psychiatric News article “Pandemic Takes Toll on Those Who Grieve.”

(Image: iStock/sorrapong)

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Test May Offer Clues About Elderly Patients Likely to Benefit From Aripiprazole

Elderly patients with major depressive disorder (MDD) who score well on a test that measures the ability to shift attention between tasks may be more likely to respond to augmentation with aripiprazole after failing to respond to first-line therapy with venlafaxine, according to a study published yesterday in JAMA Psychiatry. The findings suggest standardized neuropsychological tests of this cognitive process could one day help to guide therapeutic decisions.

Over half of older adults with MDD do not adequately respond to first-line pharmacotherapy with selective serotonin reuptake inhibitors or selective serotonin-norepinephrine reuptake inhibitors. In September 2015, Charles Reynolds III, M.D., a professor of geriatric psychiatry at the University of Pittsburgh, and colleagues published findings that showed that adding aripiprazole to the treatment regimen of patients aged 60 and older whose major depression had failed to remit after 12 weeks of venlafaxine monotherapy helped more patients achieve remission than those who did not take the combination of medications.

As a follow-up to this trial, the researchers examined the potential moderating effects of executive dysfunction, comorbid anxiety, and medical burden in remission of treatment-resistant late-life depression after 12 weeks of aripiprazole augmentation. (All of these factors have been implicated in contributing to poor antidepressant responses in late-life depression, but they have not previously been examined in second-line therapies.)

Prior to starting the 12 weeks of venlafaxine extended-release treatment, study participants were given a series of neuropsychological tests, including the Color-Word Interference task, which measures response inhibition, and the Trail Making Test tasks, which measures set-shifting (the ability to shift attention from one task to another). Researchers also used the Brief Symptom Inventory and Cumulative Illness Rating Scale for Geriatrics to assess comorbid anxiety and medical burden, respectively.

Of the 181 trial participants whose major depression had failed to remit with venlafaxine hydrochloride monotherapy (150 mg/day to 300 mg/day for 12 weeks), 91 received aripiprazole (target dose 10 mg/day), and 90 received placebo. Remission occurred in 40 (43%) who received aripiprazole and 26 (29%) who received placebo. Set-shifting performance was found to moderate the effectiveness of aripiprazole augmentation; among participants with a Trail Making Test scaled score of 7 or higher, the odds of remission were significantly higher with aripiprazole than with placebo (53% vs 28%). Among participants with a Trail Making Test scaled score of less than 7, aripiprazole and placebo were equally efficacious. Greater severity of anxiety at baseline predicted a lower remission rate but did not moderate aripiprazole efficacy; each standard deviation greater anxiety severity was associated with 50% reduced odds of remission in both aripiprazole and placebo arms. Neither medical morbidity nor response inhibition was related to remission.

“Our findings support set-shifting performance as a moderator of short-term remission (i.e., influencing the efficacy of aripiprazole) and distinguish anxiety as a general short-term prognostic variable (predictor),” the authors wrote. “Further examining a wider range of pretreatment factors, including other aspects of cognition, as well as the neurobiological basis of these observed effects, will continue to improve our understanding of how treatments work and for whom they do or do not work.”

In a related editorial, Warren Taylor, M.D., an associate professor of psychiatry at Vanderbilt University Medical Center, offered several reflections on the implications of the findings for clinical treatment and clinical trial methodology.

“Although this study’s findings require replication, the potential for using a common, easy-to-administer neuropsychological test to personalize antidepressant treatment decisions for older adults is appealing. However, even with this approach, remission rates continue to be lower than we would like,” Taylor wrote. “This study’s findings are thus a step forward, but it also highlights the need for more effective interventions, particularly for individuals with executive dysfunction or substantial comorbid anxiety.”

For related information, see the Psychiatric News article “Combining Aripiprazole, Venlafaxine Reduces Depressive Symptoms in Older Adults.”

(Image: Alexander Raths/Shutterstock)