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RESEARCH: Marieke de Groot, Jos de Keijser, Jan Neeleman, Ad Kerkhof, Willem Nolen, and Huibert Burger Cognitive behaviour therapy to prevent complicated grief among relatives and spouses bereaved by suicide: cluster randomised controlled trial BMJ 2007; 0: bmj.39161.457431.55v1 [Abstract]

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Cognitive behaviour therapy (CBT) and Comlicated grief

Imran Mushtaq, Northampton   (12 May 2007)

CBT to prevent complicated grief - methodological issues

Caroline S Flood   (1 June 2007)

Cognitive behaviour therapy (CBT) and Comlicated grief 12 May 2007
Imran Mushtaq, Psychiatrist Princess Marina Hospital, Northampton Send response to journal: Re: Cognitive behaviour therapy (CBT) and Comlicated grief	Are there any effective interventions for complicated grief? De Groot et al, (1) randomised control trail tries to answer thIS important question.CBT is a wonderful psychological intervention, which works for various conditions like depression and other anxiety disorders, OCD etc. but not for complicated grief reaction, which is highlighted by the study. Participants of the study, allocated to CBT arm were counselled between 3- 6 months after the death (suicide) of their relative. Although I acknowledge the authors noble intentions to intervene before negative beliefs becoming fixed, but here a fundamental question arises. Have they defined their question appropriately? My understanding is that we call a grief reaction, abnormal or complicated only, when symptoms are present for atleast six months. A recently proposed evidence based guidelines for the diagnosis and treatment of complicated grief (2) confirms it. References: 1.de Groot M, de Keijser J, Neeleman J, Kerkhof A, Nolen W, Burger H. Cognitive behaviour therapy to prevent complicated grief among relatives and spouses bereaved by suicide: cluster randomised controlled trial. BMJ 2007 doi: 10.1136/bmj.39161.457431.55 2.Zhang B, El-Jawahri A, Prigerson HG. Update on bereavement research: evidence-based guidelines for the diagnosis and treatment of complicated bereavement. J Palliat Med 2006;9:1188-203 Competing interests: None declared
CBT to prevent complicated grief - methodological issues 1 June 2007
Caroline S Flood, Specialist Registrar in Psychiatry Millbrook Unit, Kingsmill Hospital, Mansfield, NG17 4JT Send response to journal: Re: CBT to prevent complicated grief - methodological issues	The article by de Groot et al (1) highlights the emotional and cognitive responses to bereavement, especially suicides, which may be reduced through a counselling-based intervention. However, before such findings can be usefully generalised to clinical practice, there are two important methodological flaws in their research. Firstly, there are the diagnostic issues raised by Dr Mushtaq(2). Can an abnormal grief reaction be so classified if it is being diagnosed within 6 months of bereavement? Evidence for the traditionally taught stage theory of grief suggests that “Given that the negative grief indicators all peak within 6 months, those individuals who experience any of the indicators beyond 6 months postloss would appear to deviate from the normal response to loss … [supporting] the duration criterion of 6 months postloss for diagnosing complicated grief disorder”(3). A further American study suggested the “normal” period for experiencing distressing yearnings and other features of grief as being a year after a loss(4). Secondly, the assertion in the results that “Counselling had no effect on complicated grief” but that “Maladaptive grief reactions, however, were substantially less common in the intervention group” seems contradictory as the assessment tool used for interviewing participants at follow up was “a semi-structured clinical interview… based on the consensus criteria for complicated grief”(1). How can the outcome measures find both no effect and a substantial difference for the same clinical criteria? Despite these flaws, as the study rightly concludes, a CBT-based intervention may help to reduce the level of grief following suicide to one similar to that of naturally bereaved people, which can only benefit those who have lost a loved one in this way. 1 de Groot M, de Keijser J, Neeleman J, Kerkhof A, Nolen W, Burger H. Cognitive behaviour therapy to prevent complicated grief among relatives and spouses bereaved by suicide: cluster randomised controlled trial. BMJ 2007; 334: 994-6. 2 Mushtaq I. Cognitive behaviour therapy (CBT) and Complicated grief. BMJ 2007 eletters/334/7601/994 3 Maciejewski PK, Zhang B, Block SD, Prigerson HG. An empirical examination of the stage theory of grief. JAMA. 2007 Feb 21;297(7):716-23. 4 Horowitz MJ, Siegel B, Holen A, Bonanno GA, Milbrath C, Stinson CH. Diagnostic criteria for complicated grief disorder. Am J Psychiatry. 1997 Jul;154(7):904-10. Competing interests: None declared