The American Psychiatric Association recently announced the inclusion in the DSM-5-TR of a new category for prolonged grief disorder (PGD)^{1, 2}, following introduction of this category in the ICD-11. Our group previously demonstrated the efficacy of a targeted treatment (complicated grief therapy, CGT) for complicated grief, a condition corresponding in many respects to PGD. We examined now the performance of that treatment among people who met the DSM-5-TR criteria for PGD.

CGT is a manualized 16-session intervention developed when we observed that treatments for depression did not appear to be effective for complicated grief³. We considered loss of a loved one to be a major life stressor⁴ and understood grief from an attachment theory perspective⁵. We conceptualized grief after attachment loss as typically emerging in an acute form and becoming integrated over time as the reality of the loss is accepted and the capacity for well-being is restored. We understood complicated grief as a condition in which the initial intense form of grief persisted and interfered with functioning. A body of research informed our understanding of impediments to adapting to the loss. We developed a treatment that focused on facilitating adaptation to loss and addressing impediments, drawing upon strategies and techniques from prolonged exposure, motivational interviewing, positive psychology, interpersonal psychotherapy, and psychodynamic psychotherapy.

CGT was tested in three randomized controlled trials funded by the US National Institute of Mental Health^6-8. For the present report, we analyzed data from one of these trials⁶, in which participants (N=395) were people with a score of 30 or higher on the Inventory of Complicated Grief (ICG) who underwent a clinical interview confirming that grief was the primary problem. People with current substance use disorder, or a lifetime history of psychotic disorder, bipolar I disorder, active suicidal plans requiring hospitalization, or a Montreal Cognitive Assessment score less than 21 were excluded.

These patients were evaluated through the Structured Clinical Interview for Complicated Grief (SCI-CG), an instrument that can be used to identify DSM-5-TR criteria for PGD⁹. The evaluation was available for 307 study participants, 77 (25.1%) of whom were bereaved between 6 and 12 months and therefore did not meet the DSM-5-TR criteria solely due to time considerations. Of the remaining 230, 194 (84.3%) met DSM-5-TR criteria for PGD and 36 (15.7%) did not. All patients recruited for the parent study were randomized either to citalopram or to placebo, with or without CGT⁶.

Among patients meeting criteria for PGD (N=194), we compared study outcomes at endpoint (week 20) for those who received CGT (N=96) versus those who did not receive it (N=98). The main outcome was treatment response measured as a rating of “much improved” or “very much improved” on the Clinical Global Impression (CGI) Improvement. We further used several grief symptom measures: the ICG, the Grief-Related Avoidance Questionnaire (GRAQ), the Typical Beliefs Questionnaire (TBQ), and the Grief-Related Work and Social Adjustment Scale (WSAS). Chi-squared tests were used for binary outcomes and two sample t-tests for continuous outcomes. All hypothesis tests were two-sided with a 5% level of significance. All analyses were performed in R (v1.4.1717). The parent study had been approved by the relevant institutional review board⁶. Written informed consent had been obtained from all participants before baseline assessment.

The sample of patients with PGD was not significantly different with respect to demographic and clinical variables from the parent study sample. Most patients were female (79.9%), white (80.9%), completed at least partial college (90.2%), and were bereaved of a parent or spouse (68.6%) by illness (65.5%) for 4-5 years on average. The sample had an average age of 52.7±14.2 years. Patients had high rates of current depression (69.6%), current post-traumatic stress disorder (46.4%), and suicidal ideation since the loss (61.9%) (see also supplementary information).

Treatment response for the sample with PGD closely reflected that of the parent study. Specifically, response rates for those randomized to CGT vs. no CGT were 88.2% vs. 60.9% (p<0.001) for the DSM-5-TR PGD group compared to 82.9% vs. 63.4% for all participants in the parent study. Also comparable to the parent study, average post-treatment scores on grief-related symptoms and impairment were significantly lower for those who received CGT vs. no CGT (ICG: 17.7 vs. 25.4, p<0.001; WSAS: 7.9 vs. 13.4, p=0.001; GRAQ: 9.4 vs. 14.6, p=0.01; TBQ: 3.9 vs. 7.1, p<0.001) (see also supplementary information).

Our results indicate that study participants who met DSM-5-TR criteria for PGD showed no significant demographic or clinical differences from the full parent study sample. Those diagnosed with PGD showed significantly greater response rates to CGT vs. no CGT, with results nearly identical to the parent study.

These findings are limited by the need to apply retrospectively the DSM-5-TR criteria for PGD, and diagnosis may have been less accurate than if made using a validated instrument¹. Additionally, those diagnosed with PGD for these analyses represented only half of the originally randomized sample. However, almost half (43.8%) of the omitted participants simply did not receive the assessment needed to diagnose PGD, and another 38% were excluded because it was too soon (six months to one year since the loss) to receive a PGD diagnosis. Further, those assessed showed no differences in demographic or clinical characteristics from participants in the parent study.

We endorse continued study of effective treatments for PGD. In the meantime, we believe that clinicians will benefit from knowing that CGT, a strongly validated intervention^6-8, can be appropriately re-labeled as prolonged grief disorder therapy (PGDT).

美国精神病学协会最近宣布在ICD-11 中引入这一类别后，在 DSM-5-TR 中加入了一个新的长期悲伤障碍 (PGD) 类别^{1, 2 。}我们小组之前证明了针对复杂悲伤的靶向治疗（复杂悲伤疗法，CGT）的功效，复杂悲伤在许多方面都对应于 PGD。我们现在检查了满足 PGD 的 DSM-5-TR 标准的人中该治疗的表现。

当我们观察到抑郁症的治疗似乎对复杂的悲伤³无效时，CGT 是一种手动的 16 次干预措施。我们认为失去亲人是主要的生活压力源⁴并从依恋理论的角度理解悲伤⁵. 我们将失去依恋后的悲伤概念化为通常以急性形式出现并随着时间的推移随着失去的现实被接受并恢复幸福的能力而变得整合。我们将复杂的悲伤理解为最初强烈的悲伤形式持续存在并干扰功能的情况。大量研究让我们了解了适应损失的障碍。我们开发了一种治疗方法，专注于促进适应损失和解决障碍，利用长期暴露、动机性访谈、积极心理学、人际关系心理治疗和心理动力学心理治疗的策略和技术。

CGT 在美国国家心理健康研究所资助的三项随机对照试验中进行了测试^6-8。在本报告中，我们分析了其中一项试验⁶的数据，其中参与者 (N=395) 是复杂性悲伤清单 (ICG) 得分为 30 或更高的人，他们接受了临床访谈，确认悲伤是首要问题。目前有物质使用障碍，或终生有精神病史、双相 I 型障碍、需要住院的主动自杀计划或蒙特利尔认知评估评分低于 21 分的人被排除在外。

这些患者通过复杂悲伤的结构化临床访谈 (SCI-CG) 进行了评估，该工具可用于识别 PGD ⁹的 DSM-5-TR 标准。该评估适用于 307 名研究参与者，其中 77 名（25.1%）在 6 至 12 个月之间失去亲人，因此仅出于时间考虑不符合 DSM-5-TR 标准。在剩余的 230 人中，194 人（84.3%）符合 DSM-5-TR 的 PGD 标准，36 人（15.7%）不符合。为父研究招募的所有患者被随机分配到西酞普兰或安慰剂组，有或没有 CGT ⁶。

在符合 PGD 标准的患者 (N=194) 中，我们比较了接受 CGT (N=96) 与未接受 CGT (N=98) 的患者在终点（第 20 周）的研究结果。主要结果是治疗反应，测量为临床总体印象（CGI）改善的“大大改善”或“非常改善”的评级。我们进一步使用了几种悲伤症状测量方法：ICG、悲伤相关回避问卷 (GRAQ)、典型信念问卷 (TBQ) 和悲伤相关工作和社会适应量表 (WSAS)。卡方检验用于二元结果，两个样本 t 检验用于连续结果。所有假设检验都是双向的，显着性水平为 5%。所有分析均在 R (v1.4.1717) 中进行。父母研究已获得相关机构审查委员会的批准⁶. 在基线评估之前已从所有参与者获得书面知情同意书。

PGD​​ 患者样本在人口统计学和临床​​变量方面与父研究样本没有显着差异。大多数患者是女性（79.9%），白人（80.9%），至少完成了部分大学教育（90.2%），平均因病失去父母或配偶（68.6%）（65.5%）4-5年. 样本的平均年龄为 52.7±14.2 岁。患者目前的抑郁症（69.6%）、目前的创伤后应激障碍（46.4%）和自杀念头的发生率很高（61.9%）（另见补充信息）。

PGD​​ 样本的治疗反应密切反映了父研究的治疗反应。具体而言，DSM-5-TR PGD 组随机分配至 CGT 与无 CGT 的反应率为 88.2% 与 60.9%（p<0.001），而母研究中所有参与者的反应率为 82.9% 与 63.4%。与父母研究相比，接受 CGT 与未接受 CGT 的患者治疗后悲伤相关症状和损伤的平均得分显着降低（ICG：17.7 与 25.4，p<0.001；WSAS：7.9 与 13.4， p=0.001；GRAQ：9.4 对 14.6，p=0.01；TBQ：3.9 对 7.1，p<0.001）（另见补充信息）。

我们的结果表明，符合 PGD 的 DSM-5-TR 标准的研究参与者与完整的父母研究样本没有显着的人口统计学或临床差异。与无 CGT 相比，诊断为 PGD 的患者对 CGT 的反应率显着提高，结果与父研究几乎相同。

这些发现受限于回顾性应用 DSM-5-TR 标准进行 PGD 的需要，并且诊断可能不如使用经过验证的仪器¹准确。此外，在这些分析中被诊断为 PGD 的人仅代表最初随机样本的一半。然而，几乎一半 (43.8%) 被遗漏的参与者根本没有接受诊断 PGD 所需的评估，另外 38% 被排除在外，因为接受 PGD 诊断为时过早（自丢失后 6 个月到 1 年）。此外，被评估的人与父母研究的参与者在人口统计学或临床特征上没有差异。

我们支持继续研究 PGD 的有效治疗方法。与此同时，我们相信临床医生会受益于知道 CGT 是一种经过严格验证的干预^6-8，可以适当地重新标记为延长悲伤障碍治疗 (PGDT)。