Reading of the Week: CBT vs Mindfulness for Prolonged Grief Disorder – the New JAMA Psych Study; Also, Wildman on Her Grief, and Clozapine & MedEd

From the Editor

She still wears black. She mourns her partner’s death every day. Despite the passing years, she can’t seem to move forward. DSM-5-TR includes prolonged grief disorder, which has sparked controversy, but it explains well my patient’s complicated bereavement.

What’s evidenced for treatment? Is CBT superior to mindfulness? Richard A. Bryant (of the University of New South Wales) and his co-authors try to address these questions in a new JAMA Psychiatry paper. They describe a randomized clinical trial involving 100 adults offered CBT or mindfulness-based cognitive therapy. “In this study, grief-focused cognitive behavior therapy conferred more benefit for core prolonged grief disorder symptoms and associated problems 6 months after treatment than mindfulness-based cognitive therapy.” We consider the paper and its implications.

In the second selection, Sarah Wildman, a writer and editor, discusses her daughter’s death in an essay for The New York Times. She is candid about her grief. She talks about the passage of time, small things like calendars, and, yes, signs – her daughter promised that if she sees a red fox, it will be her. “I wonder if I should keep every item of clothing I can picture Orli in, I wonder what she would say about each movie I see, each book I read.”

In the third selection, Dr. Theodore R. Zarzar (of the University of North Carolina) emphasizes the importance of clozapine in the treatment of patients with schizophrenia. In his JAMA Psychiatry Viewpoint, he argues for incorporating clozapine proficiency into medical education. “Clozapine initiation can be conceptualized as the community psychiatric equivalent of a procedural skill and deserves the mentorship, knowledge acquisition, and practice that learning a procedure entails.”

DG

Selection 1: “Cognitive Behavior Therapy vs Mindfulness in Treatment of Prolonged Grief Disorder: A Randomized Clinical Trial”

Richard A. Bryant, Suzanna Azevedo, Srishti Yadav, et al.

JAMA Psychiatry, July 2024

Prolonged grief disorder has recently been recognized by the International Classification of Diseases, 11th Revision (ICD-11) and the DSM-5-TR as a psychiatric disorder. Characterized by persistent yearning for the deceased, along with associated emotional pain and impairment, it affects between 4% and 10% of bereaved people… Over the past 20 years, a number of grief-focused cognitive behavior therapies have been shown to reduce prolonged grief disorder severity and outperform antidepressant medication and interpersonal psychotherapy. However, between 15% and 25% of patients with prolonged grief disorder offered grief-focused cognitive behavior therapy decline to participate in treatment, and between 17% and 50% may not respond to treatment. Although evidence suggests that a pivotal component of this treatment is actively engaging with memories of the death and associated emotions, up to 22% of patients report that this is excessively difficult…

A viable means to advance treatment of prolonged grief disorder is to evaluate therapeutic options that do not explicitly evoke distress through loss-focused strategies. Mindfulness-based cognitive therapy has emerged as an efficacious treatment strategy to treat depression. This treatment involves learning strategies that promote awareness of emotions and sensory states in a nonjudgmental manner in order to manage thoughts and emotions that contribute to the psychological disorder…

So begins Bryant et al.

Here’s what they did:

• They conducted a single-blind, parallel, randomized clinical trial for adults aged 18 to 70 years with prolonged grief disorder.
• Patients were assessed by clinical interview using the Prolonged Grief−13 (PG-13) scale.
• “Both groups received once-weekly 90-minute individual sessions for 11 weeks. Grief-focused cognitive behavior therapy comprised 5 sessions of recalling memories of the deceased, plus cognitive restructuring and planning future social and positive activities. Mindfulness-based cognitive therapy comprised mindfulness exercises adapted to tolerate grief-related distress.”
• Primary outcome: “change in prolonged grief disorder severity measured by the PG-13 scale assessed at baseline, 1 week posttreatment, and 6 months after treatment (primary outcome time point)…”

Here’s what they found:

• 164 people were screened. The trial included 100 participants: 50 in the grief-focused cognitive behavior therapy group and 50 in the mindfulness-based cognitive therapy group.
• Demographics. The mean age was 47.3 years. Most were White (71.0%) and female (87%).
• Primary outcome. “Participants in the grief-focused cognitive behavior therapy group showed greater reduction in PG-13 scale score relative to those in the mindfulness-based cognitive therapy group (mean difference, 7.1…), with a large between-group effect size (0.8…).” 
• Second outcomes. “Participants in the grief-focused cognitive behavior therapy group also demonstrated greater reductions in depression as measured on the Beck Depression Inventory than those in the mindfulness-based cognitive therapy group (mean difference, 6.6…) and grief-related cognition (mean difference, 14.4…).”
• Adverse events. None reported.

A few thoughts:

1. This is an interesting study, with a nice dataset of a “new” disorder, addressing a practical issue, and published in a major journal.

2. The main finding in a sentence: CBT showed a greater reduction in the PG-13 than mindfulness-based cognitive therapy – though superiority was only seen at the six-month mark.

3. For those struggling with a complicated bereavement (meeting criteria for a prolonged grief disorder), there are clinical implications.

4. Like all studies, there are limitations. The authors note several, including the gender bias in the sample. 

5. Additionally, there were significant recruitment problems stretching over a decade. (!!) “The study occurred over 10 years because of delays during the COVID-19 pandemic, slowed recruitment, and staff turnover necessitating the training of therapists to the point of competency in each treatment modality.”

6. Of course, there remains a bigger debate about the inclusion of prolonged grief disorder in the DSM. Is this an overdue recognition of a problem? Has psychiatry now pushed into the realm of normalcy?

7. Past Readings have focused on prolonged grief disorder. In one, we reviewed the Prigerson et al. paper advocating its inclusion into the DSM. 

https://davidgratzer.com/reading-of-the-week/reading-of-the-week-cannabis-also-prolonged-grief-disorder-jama-psych-and-the-life-and-legacy-of-alan-a-stone-nyt/

And we also discussed a New York Times article describing the debate.

https://davidgratzer.com/reading-of-the-week/reading-of-the-week-way-up-alcohol-related-deaths-during-the-pandemic-jama-also-addressing-the-opioid-crisis-cjp-and-the-nyt-on-grief/

The full JAMA Psych Viewpoint can be found here:

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2818040

Selection 2: “If You See a Fox and I’ve Died, It Will Be Me”

Sarah Wildman  

The New York Times, 14 March 2024 

A block from my house at the edge of Washington, there is a winding park with a road running through it. One Sunday recently, walking my regular loop along the trail, I heard leaves rustling on the wooded hill above me. I often see deer here; this time it was a bright young fox. 

She paused. We stood there for a moment, she and I, aware. I wanted desperately for her to come closer, to stay in her orbit a moment longer. I lingered long after she left. 

Sometime in my daughter Orli’s last months of life, she told me, lightly, ‘If you see a fox and I’ve died, it will be me.’ I had never seen a fox in my neighborhood. Over the past several months, I have seen maybe a half dozen, here and elsewhere. Each time, I try to quell my desire to shout out, to ask the animal to stay, to call it by her name. It feels crazy; it feels sane.

So begins an essay by Wildman.

She describes her interest in signs. “Now I notice when an interview runs exactly 1 hour and 13 minutes or when the hour is exactly 1:13. Orli was born on Jan. 13. It means nothing; it means something. A double rainbow stretched over a farm in Maine represents more than beauty.”

She also notes the weight of time. “A year is a strange and terrible marker of time, simultaneously endless and instant. A year of loss is a new form of permanence: This is the life we lead. It will not change. A year furthers us on the long march toward our altered future. In the life of a child, a year is transformative. Her peers have molted in the year from 14 to 15. They no longer attend the same school; they have begun new sports, met new friends, moved forward, moved on.”

Not surprisingly, coping is challenging. “Each of us in our rump family has felt an almost visceral physicality of these past few weeks – the slide from her birthday toward this anniversary, the terrible knowledge that we each hold of the last moments of her life, the good minutes we had, the harder hours, the terror of those final days.” And her grief manifests in small ways, including with a simple calendar. “When 2023 turned to 2024, I thought: It is a terrible thing to buy a calendar for a year Orli will not see. Still, I put up a calendar in her old room, the same feminist calendar she chose each year. As February turned to March, I found the page hard to flip over. Until this point, I have been able to look at the photos in my phone and say: This time last year, we were at this concert, we were at this movie, we had this meal. Now those memories slide farther back.”

A few thoughts:

1. This essay is a beautiful and moving. 

2. My summary doesn’t quite capture the subtlety and nuance of her writing.

3. I’ve never met Wildman and make no attempt at understanding her clinically. I selected this essay because it illustrates well the experience of bereavement for some.

The full NYT essay can be found here:

https://www.nytimes.com/2024/03/14/opinion/child-loss-grief-anniversary.html

Selection 3: “Clozapine Proficiency as a Milestone in Psychiatric Training”

Theodore R. Zarzar

JAMA Psychiatry, 1 May 2024

Medical education is shifting from a structure- and process-based focus to one that emphasizes core competencies and outcomes. The former relies on exposure to various content areas for specified periods, while competencies tailor the curriculum to the desired outcome… The Accreditation Council for Graduate Medical Education (ACGME) lists 6 competencies that apply across specialties: (1) patient care, (2) medical knowledge, (3) practice-based learning and improvement, (4) professionalism, (5) interpersonal and communication skills, and (6) systems-based practice. In psychiatry, competencies are divided into 21 subcompetencies into which over 200 milestones are sorted…

The subcompetency somatic therapies includes psychopharmacology and neurostimulation but does not endorse specific treatments, giving training programs the freedom to tailor… A consequence of this approach, however, is that therapies with even the highest degree of evidence may not be emphasized universally.

So begins a Viewpoint by Dr. Zarzar.

He argues that more must be done to promote the use of clozapine. “Clozapine’s benefits have been extolled for more than 3 decades, yet its use remains quite limited.” He makes the (familiar) case for clozapine, noting that “clozapine is the only approved medication for treatment-resistant schizophrenia (TRS), yet it is more common for individuals with TRS to receive 2 or more nonclozapine antipsychotics, a practice with less supporting evidence.” He adds that clozapine “reduces suicide risk in people with schizophrenia or schizoaffective disorder,” which is important since “five percent of people with schizophrenia die by suicide…” And there is compelling evidence supports “clozapine as the standard treatment for patients with psychosis with persistent aggression.”

He acknowledges that clozapine is a difficult drug to work and notes “prescribers’ hesitancy.” He responds by quoting Dr. Joseph P. McEvoy (of Georgia Regents University): “we would be horrified if oncologists avoided using chemotherapy because the agents had life-threatening side effects and because knowledge and skill are necessary to prescribe them appropriately.”

He feels that part of this rests with residency training and the lack of focus on clozapine. “If not exposed to clozapine in training, many psychiatrists will not reach for it at all, perhaps for the remainder of their careers.” He reviews the literature:

• “Psychiatrists without training in clozapine tend to overestimate challenges associated with its use. Surveys of prescribers and patients also show that clinicians are likely to overestimate patients’ concerns about blood monitoring and sedation.”
• “A recent survey of psychiatric residents found that two-thirds did not have a clozapine clinic in their program while 41% did not feel comfortable initiating clozapine for patients who met criteria.”
• In contrast, in those training programs that offer specialized clozapine experiences, there is “a higher degree of comfort with clozapine use.” For example, “a survey of residents at one program found that all had received exposure to clozapine during training while over 90% reported feeling comfortable with clozapine initiation.”

He thus advocates “clozapine proficiency merits status as a milestone in psychiatric residency education.” 

He recognizes that smaller programs may worry about implementation. “If psychiatric residencies lack faculty with sufficient clozapine experience, they may partner with institutions that do have available faculty. For example, a smaller program may partner with a large, academic medical center or state hospital for case consultation and review.”

He argues for training that goes beyond exposure. He also notes the importance of recognizing “racial and ethnic disparities in clozapine use and the treatment of patients with benign ethnic neutropenia.” Thus, “[a] milestone in clozapine proficiency could promote more equitable prescribing, particularly in carceral settings, where racial and ethnic minority populations and people with severe mental illness are overrepresented.”

Dr. Zarzar closes with a call to action. “Until a paradigm shift occurs in psychiatric residency training, clozapine use will remain restricted.”

A few thoughts:

1. This is a well-written commentary.

2. Dr. Zarzar raises good points about clozapine. 

3. The author is an American writing about US training. Given the limited clozapine prescribing internationally, his comments about training would be relevant elsewhere. In Canada, clozapine proficiency is not directly required for training. Though, of course, individual programs may do more; at the University of Toronto, where I’m affiliated, core teaching includes clozapine, and a new online course is being rolled out soon. 

4. Of course, increasing clozapine use isn’t just about education. A Psychiatric Services paper looked at several approaches with a focus on New York state. You can find that paper here:

https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201500493

The full JAMA Psych Viewpoint can be found here:

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2818045

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.