A Study of Medication With or Without Psychotherapy for Complicated Grief (HEAL)

• Change from baseline in Inventory of Complicated Grief (ICG) [ Time Frame: Week 40 ] [ Designated as safety issue: No ]
  The 19-item self-report instrument that assesses symptoms of CG. This scale has been utilized previously in treatment studies of CG. Additional times points will include weeks 4, 8, 12, 16, and 20.
• Change from baseline in Work and Social Adjustment Scale (WSAS) [ Time Frame: Week 40 ] [ Designated as safety issue: No ]
  The WSAS is a modification of a scale introduced by Hafner and Marks (1976), consisting of 0-8 point ratings of the extent to which symptoms interfere with five areas of daily functioning: work, home management, private leisure, social leisure, and family relationships. It is a well-validated, widely used self-report measure. Additional times points will include weeks 4, 8, 12, 16, and 20.
• Change from baseline in Complicated Grief Clinical Global Impression-Improvement (CGI-I) Scale [ Time Frame: Weeks 4, 8, 12, 16, and 20. ] [ Designated as safety issue: No ]
  Brief rating scale frequently used in clinical trials. For this study, version modified for complicated grief will be used. The rating will be done by Independent Evaluator.

• Inventory of Complicated Grief (ICG) [ Time Frame: Weeks 4, 8, 12, 16, 20 and 40 ] [ Designated as safety issue: No ]
  The 19-item self-report instrument that assesses symptoms of CG. This scale has been utilized previously in treatment studies of CG.
• Work and Social Adjustment Scale (WSAS) [ Time Frame: Weeks 4, 8, 12, 16, 20 and 40 ] [ Designated as safety issue: No ]
  The WSAS is a modification of a scale introduced by Hafner and Marks (1976), consisting of 0-8 point ratings of the extent to which symptoms interfere with five areas of daily functioning: work, home management, private leisure, social leisure, and family relationships. It is a well-validated, widely used self-report measure.
• Complicated Grief Clinical Global Impression-Improvement (CGI-I) Scale [ Time Frame: Weeks 4, 8, 12, 16, 20 and 40 ] [ Designated as safety issue: No ]
  Brief rating scale frequently used in clinical trials. For this study, version modified for complicated grief will be used. The rating will be done by Independent Evaluator.

The major goal of this 4-site, double blind, placebo-controlled intervention trial is to assess the efficacy of medication (Citalopram) alone or with psychotherapy (Complicated Grief Therapy) to treat the symptoms of complicated grief.

Complicated grief (CG) is a debilitating condition that is estimated to affect millions of people in the United States alone. We conducted the first RCT to address this condition (MH60783) and confirmed efficacy of a targeted psychotherapy, complicated grief treatment (CGT). Participants in our prior study continued stable antidepressant medication while receiving CGT or Interpersonal Psychotherapy (IPT). Individuals taking antidepressants had better outcome in both treatments, though CGT was superior to IPT when administered with (60% responders v. 40%) or without (42% v.19%) antidepressants. Studies of antidepressant medication alone have shown mixed results with SSRIs appearing to be promising. However, there has been no randomized controlled study of SSRIs for CG. Determining the efficacy of SSRI treatment for CG, when administered with and without CGT, is of great public health importance.

We assembled 4 groups of investigators with strong track records in bereavement research and extensive experience with intervention studies and multicenter projects, to conduct a study of citalopram (CIT) efficacy. We plan to enroll participants with a primary diagnosis of Complicated Grief and randomly assign them (n=480; 50 at Columbia) to receive treatment with CIT, Placebo (PBO), CIT + CGT or PBO + CGT over a period of approximately 16 weeks. We want to determine whether citalopram shows a better response than placebo, when administered either with or without CGT. We will also address the question of whether CIT performs as well when administered alone as it does when administered with CGT.

• Complicated Grief
• Bereavement

• Drug: Citalopram
  16 weeks of medication provided flexibly up to 60 mg/day Medication will be administered in a double-blind fashion.
  Other Name: Celexa
• Behavioral: Complicated Grief Treatment
  Complicated Grief Treatment (CGT) is a targeted psychotherapy for complicated grief. The treatment integrates principles, strategies and techniques from interpersonal psychotherapy, trauma-focused cognitive behavioral treatment and motivational interviewing. Treatment includes 16 sessions provided within 20 weeks.
  Other Name: Celexa or Sugar pill
• Other: Placebo
  16 weeks of daily inactive medication. It will be administered in a double-blind fashion.
  Other Name: Sugar pill

• Active Comparator: CGT with Citalopram
  Targeted psychotherapy for complicated grief will be combined with SSRI medication.
  Interventions:

  • Drug: Citalopram
  • Behavioral: Complicated Grief Treatment
• Active Comparator: Citalopram
  Citalopram is an Selective Serotonin Reuptake Inhibitor (SSRI) medication. It will be combined with grief-focused clinical management.
  Intervention: Drug: Citalopram
• Placebo Comparator: Placebo (Sugar pill)
  Inactive medication. It will be combined with grief-focused clinical management.
  Intervention: Other: Placebo
• Active Comparator: CGT with Placebo
  The targeted psychotherapy for complicated grief will be combined with inactive medication.
  Interventions:

  • Behavioral: Complicated Grief Treatment
  • Other: Placebo

• Simon NM, Thompson EH, Pollack MH, Shear MK. Complicated grief: a case series using escitalopram. Am J Psychiatry. 2007 Nov;164(11):1760-1. No abstract available.
• Shear K, Frank E, Houck PR, Reynolds CF 3rd. Treatment of complicated grief: a randomized controlled trial. JAMA. 2005 Jun 1;293(21):2601-8.
• Schwartz D, Lellouch J. Explanatory and pragmatic attitudes in therapeutical trials. J Chronic Dis. 1967 Aug;20(8):637-48. No abstract available.
• Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA. 2003 Sep 24;290(12):1624-32.
• Jacobs SC, Nelson JC, Zisook S. Treating depressions of bereavement with antidepressants. A pilot study. Psychiatr Clin North Am. 1987 Sep;10(3):501-10.

Inclusion Criteria:

• Diagnosed with Complicated Grief and this is the patient's most important (primary) problem
• Ability to give informed consent
• Fluent in English
• Willingness to have sessions audiotaped
• Willingness to undergo random assignment

Exclusion Criteria:

• Diagnosis of one or more of the following disorders: Schizophrenia or other psychotic disorder, current (past 6 months) substance abuse, Bipolar Disorder, current manic episode, Dementia
• Pregnant or lactating women and women of childbearing potential not using medically accepted forms of contraception
• Acute, unstable or severe medical illness such as (but not limited to) stroke, epilepsy, or other neurodegenerative disorders, metastatic or active cancer, hepatic disease, or primary renal disease requiring dialysis
• Prior intolerance of citalopram
• Pending or active disability claim or lawsuit related to the death

• National Institute of Mental Health (NIMH)
• American Foundation for Suicide Prevention