[Show abstract][Hide abstract] ABSTRACT: Complicated grief (CG) is increasingly recognized as a debilitating outcome of bereavement. Given the intensity of the stressor, its chronicity, and its association with depression, it is important to know the impact CG may have on cognitive functioning. This exploratory and descriptive study examined global and domain-specific cognitive functioning in a help-seeking sample of individuals with CG (n=335) compared to a separately ascertained control sample (n=250). Cognitive functioning was assessed using the Montreal Cognitive Assessment (MoCA). Controlling for age, sex and education effects, CG participants had lower total MoCA, visuospatial and attention scores relative to control participants. The two groups did not differ significantly in the domains of executive function, language, memory or orientation. Age, sex, and education accounted for much of the variance in MoCA scores, while CG severity and chronicity accounted for a very small percentage of MoCA score variance. Major depression was not a significant predictor of MoCA scores. This study is consistent with previous work demonstrating lower attention and global cognitive performance in individuals with CG compared to control participants. This study newly identifies the visuospatial domain as a target for future studies investigating cognitive functioning in CG.
Journal of Psychiatric Research 11/2014; 58. DOI:10.1016/j.jpsychires.2014.07.002 · 3.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper discusses each of several potential consequences of bereavement. First, we describe ordinary grief, followed by a discussion of grief gone awry, or complicated grief (CG). Then, we cover other potential adverse outcomes of bereavement, each of which may contribute to, but are not identical with, CG: general medical comorbidity, mood disorders, post-traumatic stress disorder, anxiety, and substance use.
Current Psychiatry Reports 10/2014; 16(10):482. DOI:10.1007/s11920-014-0482-8 · 3.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background Although Complicated Grief (CG) has been associated with comorbid Panic Disorder (PD), little is known about panic attacks in CG, and whether panic symptoms may be grief-related. The present study examines the presence and impact of grief-related panic symptoms in CG. Methods Individuals with CG (n=146, 78% women, mean (SD) age=52.4(15.0)) were assessed for CG, DSM-IV diagnoses, work and social impairment, and with the Panic Disorder Severity Scale modified to assess symptoms "related to or triggered by reminders of your loss" and anticipatory worry. Results Overall, 39.7% reported at least one full or limited-symptom grief-related panic attack over the past week, and 32.2% reported some level of anticipatory worry about grief-related panic. Of interest, 17% met DSM criteria for PD. Among those without PD, 34.7% reported at least one full or limited-symptom grief-related panic attack over the past week, and this was associated with higher CG symptom severity (t=-2.23, p<0.05), and functional impairment (t=-3.31, p<0.01). Among the full sample, controlling for CG symptom severity and current PD, the presence of at least one full or limited-symptom grief-related panic attack was independently associated with increased functional impairment (B(SE)=4.86(1.7), p<0.01). Limitations Limitations include a lack of assessment of non-grief-related panic symptoms and examination of a sample of individuals seeking treatment for CG. Conclusions Grief-related panic symptoms may be prevalent among individuals with CG and independently contribute to distress and functional impairment.
[Show abstract][Hide abstract] ABSTRACT: Background:
It is unclear whether bereaved parents with Complicated Grief (CG) struggle with their grief differently than others with CG. This study addressed this question by comparing CG severity, CG-related symptoms, thoughts and behaviors, and comorbid psychiatric diagnoses of bereaved parents with CG to the diagnoses and symptoms of others with CG.
Baseline data from 345 participants enrolled in the Healing Emotions After Loss (HEAL) study, a multi-site CG treatment study, were used to compare parents with CG (n=75) to others with CG (n=275). Data from the parent group was then used to compare parents with CG who had lost a younger child (n=24) to parents with CG who had lost an older child (n=34). Demographic and loss-related data were also gathered and used to control for confounders between groups.
Parents with CG demonstrated slightly higher levels of CG (p=0.025), caregiver self-blame (p=0.007), and suicidality (p=0.025) than non-parents with CG. Parents who had lost younger children were more likely to have had a wish to be dead since the loss than parents who had lost older children (p=0.041).
All data were gathered from a treatment research study, limiting the generalizability of these results. No corrections were made for multiple comparisons. The comparison of parents who lost younger children to parents who lost older children was limited by a small sample size.
Even in the context of CG, the relationship to the deceased may have a bearing on the degree and severity of grief symptoms and associated features. Bereaved parents with CG reported more intense CG, self-blame, and suicidality than other bereaved groups with CG, though this finding requires confirmation. The heightened levels of suicidal ideation experienced by parents with CG, especially after losing a younger child, suggest the value of routinely screening for suicidal thoughts and behaviors in this group.
[Show abstract][Hide abstract] ABSTRACT: Background: Patients with serious mental illness can be at higher risk for suicide. Most research has focused on determining the risk factors for suicide-related events using quantitative methodologies and psychological autopsies. However, fewer studies have examined patients' perspectives regarding the experience of suicidal events. Aims: To better understand suicide experiences from the perspective of patients diagnosed with serious mental illness. Method: This study purposively sampled and qualitatively interviewed 23 patients within the Veterans Affairs Hospital who were diagnosed with serious mental illness and who had attempted suicide. Using a phenomenological design, hermeneutic interviews included questions about the precursors, characteristics, and treatment of the suicide events, as well as patients' recommendations for care. Results: Loneliness, isolation, depression, and hopelessness were commonly described as emotional precursors to the suicide events for all patients, while command hallucinations were reported among patients with schizophrenia-spectrum disorders. When evaluating whether treatments were effective, patients focused primarily on the level of empathy and compassion shown by their providers. Conclusion: The most common recommendation for the improvement of care was to increase clinicians' empathy, compassion, and listening skills. Additionally, efforts to bolster social supports were highlighted as a means to diminish suicide events.
Crisis The Journal of Crisis Intervention and Suicide Prevention 04/2014; 35(3):1-7. DOI:10.1027/0227-5910/a000247 · 1.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Every clinical specialty has its own high risk patient challenges that threaten to undermine their trainees' professional identity, evolving sense of competence. In psychiatric training, it is patient suicide, an all-too frequently encountered consequence of severe mental illness that may leave the treating resident perplexed, guilt-ridden, and uncertain of their suitability for the profession. This study evaluates a patient suicide training program aimed at educating residents about patient suicide, common reactions, and steps to attenuate emotional distress while facilitating learning.
The intervention was selected aspects of a patient suicide educational program, "Collateral Damages,"-video vignettes, focused discussions, and a patient-based learning exercise. Pre- and post-survey results were compared to assess both knowledge and attitudes resulting from this educational program. Eight psychiatry residency training programs participated in the study, and 167 of a possible 240 trainees (response rate = 69.58 %) completed pre- and post-surveys.
Knowledge of issues related to patient suicide increased after the program. Participants reported increased awareness of the common feelings physicians and trainees often experience after a patient suicide, of recommended "next" steps, available support systems, required documentation, and the role played by risk management.
This patient suicide educational program increased awareness of issues related to patient suicide and shows promise as a useful and long overdue educational program in residency training. It will be useful to learn whether this program enhances patient care or coping with actual patient suicide. Similar programs might be useful for other specialties.
[Show abstract][Hide abstract] ABSTRACT: Background:
Non-adherence to antidepressant treatment is not routinely measured in practical clinical trials. It has not been related to outcomes in a large sample of adults with chronic and/or recurrent major depressive disorder (MDD) or any sample treated with antidepressant combinations.
Adult outpatients with chronic and/or recurrent MDD were randomized to 12 weeks of treatment with bupropion-SR plus escitalopram, venlafaxine-XR plus mirtazapine, or escitalopram plus placebo. We compared non-adherence (the frequency with which daily medications were not taken) and specifically the frequency of temporarily stopping and/or skipping medication, or reducing or increasing the dose across treatments in 567 participants using a self-report questionnaire collected at each visit. We tested the association between non-adherence, and both treatment type and outcomes.
A non-adherence rate under 10% was reported by 77.9%, 70.9%, and 71.6% of participants during weeks 1-4, 5-12, and 1-12, respectively. Antidepressant combinations were associated with a higher non-adherence rate than monotherapy during weeks 1-4 and 1-12. During weeks 1-4, 24.1% stopped/skipped doses and 6.1% reduced the dose. During weeks 5-12, 34.7% stopped/skipped doses and 9.4% reduced the dose. Across 12 weeks, 43.2% stopped/skipped doses, and 12.9% reduced the dose. Stopping/skipping doses during all time frames and dose decreases during weeks 1-12 occurred most frequently with combination treatments. Non-adherence was unrelated to symptom remission, response, or symptom change.
With closely monitored treatment, non-adherence is low and unrelated to depressive symptom outcome. Nonadherence is highest with antidepressant combinations. Specific non-adherent events are most often sporadic.
[Show abstract][Hide abstract] ABSTRACT: The relationship between homelessness among veterans and mental illness and suicidality has not been clearly defined. To further examine this relationship, we compared rates of mental illness and suicidality among homeless and domiciled veterans seeking urgent psychiatric care at a US Department of Veterans Affairs (VA) facility.
Information was collected by survey from 482 consecutive veterans seeking care at the Psychiatric Emergency Clinic (PEC) at the VA San Diego Healthcare System. A total of 73 homeless veterans were designated the homeless group and 73 domiciled veterans were randomly selected as the domiciled group. Suicidality and mental illnesses were assessed by self-assessment questionnaires and chart review of diagnoses.
The homeless group had significantly higher rates of past suicide attempts (47% vs 27%) and recent reckless or self-harming behavior (33% vs 18%) compared with the domiciled group but significantly lower rates of depressive disorder (25% vs 44%), as diagnosed by a PEC physician. There were no differences between groups on the questionnaires for posttraumatic stress disorder (PTSD), depression, or alcohol abuse. Nor were there differences in diagnoses of bipolar disorder, PTSD, anxiety disorder, schizophrenia/schizoaffective disorder, or alcohol abuse.
Veterans seeking help from a VA-based urgent psychiatric care clinic often are burdened by substantial depression, alcohol use disorders, PTSD, and both past and present suicide risk.
Annals of Clinical Psychiatry 11/2013; 25(4):275-82. · 2.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Since 1980, the DSM-III and its various iterations through the DSM-IV-TR have systematically excluded individuals from the diagnosis of major depressive disorder if symptoms began within months after the death of a loved one (2 months in DSM-IV), unless the depressive syndrome was 'severely' impairing and/or accompanied by specific features. This criterion became known as the 'bereavement exclusion'. No other adverse life events were noted to negate the diagnosis of major depressive disorder if all other symptomatic, duration, severity and distress/impairment criteria were met. However, studies since the inception of the bereavement exclusion have shown that depressive syndromes occurring after bereavement share many of the same features as other, non-bereavement related depressions, tend to be chronic and/or recurrent if left untreated, interfere with the resolution of grief, and respond to treatment. Furthermore, the bereavement exclusion has had the unintended consequence of suggesting that grief should end in only 2 months, or that grief and major depressive disorder cannot co-occur. To prevent the denial of diagnosis and the consideration of sometimes much needed care, even after bereavement or other significant losses, the DSM-5 no longer contains the bereavement exclusion. Instead, the DSM-5 now permits the diagnosis of major depressive disorder after and during bereavement and includes a note and a comprehensive footnote in the major depressive episode criteria set to guide clinicians in making the diagnosis in this context. The decision to make this change was widely and publically debated and remains controversial. This article reports on the rationale for this decision and the way the DSM-5 now addresses the challenges of diagnosing major depressive disorder in the context of someone grieving the loss of a loved one.
Current Psychiatry Reports 11/2013; 15(11):413. DOI:10.1007/s11920-013-0413-0 · 3.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Based on a review of the best available evidence and the importance of providing clinicians an opportunity to ensure that patients and their families receive the appropriate diagnosis and the correct intervention without necessarily being constrained by a somewhat arbitrary 2-month period of time, the DSM-5 Task Force recommended eliminating the "bereavement exclusion" (BE) from the diagnosis of major depressive disorder. This article reviews the initial rationale for creating a BE in DSM-III, reasons for not carrying the BE into DSM-5, and sources of continued controversy. The authors argue that removing the BE does not "medicalize" or "pathologize" grief, "stigmatize" bereaved persons, imply that grief morphs into depression after 2 weeks, place any time limit on grieving, or imply that antidepressant medications should be prescribed. Rather, eliminating the BE opens the door to the same careful attention that any person suffering from major depressive disorder deserves and allows the clinician to provide appropriate education, support, hope, care, and treatment. (Journal of Psychiatric Practice 2013;19:386-396).
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE Generalized anxiety disorder is common among older adults and leads to diminished health and cognitive functioning. Although antidepressant medications are efficacious, many elderly individuals require augmentation treatment. Furthermore, little is known about maintenance strategies for older people. The authors examined whether sequenced treatment combining pharmacotherapy and cognitive-behavioral therapy (CBT) boosts response and prevents relapse in older adults with generalized anxiety disorder. METHOD Participants were individuals at least 60 years of age with generalized anxiety disorder (N=73) who were recruited from outpatient clinics at three sites. Participants received 12 weeks of open-label escitalopram and were then randomly assigned to one of four conditions: 16 weeks of escitalopram (10-20 mg/day) plus modular CBT, followed by 28 weeks of maintenance escitalopram; escitalopram alone, followed by maintenance escitalopram; escitalopram plus CBT, followed by pill placebo; and escitalopram alone, followed by placebo. RESULTS Escitalopram augmented with CBT increased response rates on the Penn State Worry Questionnaire but not on the Hamilton Anxiety Rating Scale compared with escitalopram alone. Both escitalopram and CBT prevented relapse compared with placebo. CONCLUSIONS This study demonstrates effective strategies for treatment of generalized anxiety disorder in older adults. The sequence of antidepressant medication augmented with CBT leads to worry reduction in the short-term. Continued medication prevents relapse, but for many individuals, CBT would allow sustained remission without requiring long-term pharmacotherapy.
American Journal of Psychiatry 05/2013; 170(7). DOI:10.1176/appi.ajp.2013.12081104 · 12.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: It remains unclear how augmenting anti-psychotic medications with anti-depressants impacts primary positive and negative symptoms of schizophrenia. In this study, we used data collected from a randomized trial comparing citalopram to placebo for management of subsyndromal depression (SSD) in schizophrenia and schizoaffective disorder, to assess the effects of antidepressant augmentation on positive and negative symptoms.
Participants in this study conducted at the University of California, San Diego and the University of Cincinnati, were persons with schizophrenia or schizoaffective disorder aged 40 or older and who met study criteria for SSD. Patients were randomly assigned to flexible-dose treatment with citalopram or placebo augmentation of their current anti-psychotic medication. Analysis of covariance was used to compare changes in positive and negative syndrome scale (PANSS) scores between treatment groups. We also assessed mediating effects of improvement in depression and moderating effects of multiple factors on positive and negative symptoms.
There was significant improvement in PANSS negative symptoms scores in the citalopram group, which was partially mediated by improvement in depressive symptoms. There was no effect on PANSS positive scores.
In patients with schizophrenia/schizoaffective disorder, treating depressive symptoms with citalopram appears to carry the added benefit of improving negative symptoms.
Indian Journal of Psychiatry 04/2013; 55(2):144-8. DOI:10.4103/0019-5545.111452