The History of Our Research
1995 - 1999
Dr. Shear began prolonged grief research collaborating with Drs. Ellen Frank and Charles Reynolds and their postdoctoral fellow, Holly Prigerson. These colleagues had found that grief symptoms experienced by bereaved individuals seeking treatment were not responding to antidepressant medication nor to Interpersonal Psychotherapy. Our objective was to develop evidence-based ways to understand, identify and treat prolonged grief in community settings.
We used the Inventory of Complicated Grief as a reliable way to identify people experiencing prolonged grief. Based upon Mardi Horowitz’s work, we considered this a stress response syndrome with similarities to PTSD and devised a roadmap for assessment and treatment, based upon Edna Foa’s Prolonged Exposure treatment for PTSD. Additional sources of information about loss and grief contributed to an initial treatment roadmap. These included published literature about grief and psychological mechanisms involved in loss of a close relationship, our own lived experience of loss and that of people seeking our help, and the perspectives of hospice grief counselors and members of a church bereavement ministry in the community.
We began with clinical supervision of therapists targeting grief and then undertook a pilot study. We treated 21 individuals with prolonged grief in an open pilot with funding from Dr. Shear’s NIMH infrastructure grant (R24MH53817.) This study, published in 2001 resulted in a reduction in grief symptoms that was clearly greater than Drs. Frank and Reynolds had previously found with IPT. These findings led to a successful application for a full scale randomized controlled trial comparing this treatment (called Traumatic Grief Treatment at that time) to IPT. Drs. Edna Foa and Camille Wortman served as consultants to this project.
Additionally, during the late 1990’s we studied grief symptoms reported by bereaved participants in Reynolds’ depression research studies and found them to cluster together and to differ from symptom clusters of anxiety and depression. Furthermore the grief symptoms were associated with impaired functioning and increased rates of suicidal thinking. Horowitz had already proposed inclusion of a grief-related condition in the American Psychiatric Association Diagnostic and Statistical Manual (DSM 4.) This seemed warranted, and we began a long term project to work towards supporting a DSM-5 diagnosis. In 1998 we held a Consensus development conference organized by Prigerson, and co-funded by NIMH funded infrastructure grants to Drs. Shear and Reynolds’. The purpose of the conference was to discuss criteria for a possible disorder of Traumatic Grief Treatment.
2000 - 2004
We completed an NIMH-funded treatment study (R01MH60783) comparing prolonged grief therapy (at that time called complicated grief therapy, CGT) to interpersonal psychotherapy (IPT) for depression. Results showed that PGT (CGT) was nearly twice as effective as IPT, an excellent, well-validated treatment for depression that has a grief focus. This study was the first controlled clinical trial targeting prolonged grief.
We published these findings in the Journal of the American Medical Association, accompanied by an editorial by Richard Glass titled “Is Grief A Disease?” and a patient-focused version of our study report. There was considerable public interest in this paper.
We began to work on assessment development for this under-studied condition as a component of our treatment study. We modified a measure of functional impairment to assess grief-related interference in work and social functioning. We began the development of a Structured Clinical Interview for prolonged grief. We developed an initial measure of grief-related avoidance and of grief-related maladaptive thoughts.
We obtained NIDA funding for an administrative supplement to our treatment study. This supplemental study, led by Dr. Alan Zuckoff , targeted Treatment Development for Prolonged (called Traumatic at that time) Grief Treatment for Substance Users. Zuckoff conducted a small open pilot study of a modified version of prolonged grief treatment in bereaved people actively using substances. Results showed promise for this approach.
Two additional open pilot studies focused on testing the use of antidepressant medication. One targeted prolonged grief and the other focused on early bereavement-related depression. Both were funded by Forest Pharmaceuticals. Interestingly, results were quite different in the two studies. In a small (n=12) study of individuals with early bereavement related depression defined as meeting criteria or Major Depression 3-6 months after a loved one died, we found both depression and grief symptoms showed a robust response to antidepressant medication. 75% of participants completed the 12 week trial of escitalopram.
Our study of bereaved individuals with prolonged grief (n=16) resulted in less improvement for both grief and depression. Additionally, only 43% completed the 16 week study. This pilot work contributed to the background for our subsequent 4-site collaborative study of antidepressant medication in prolonged grief funded by NIMH in 2008 (see below).
Another line of our work in the early 2000’s focused on grief following the 9-11 terrorist attacks. Colleagues in New York reached out to our group after the attack on the world trade center. We completed several projects in collaboration with our NYC colleagues. One entailed work with Dr. Susan Essock at NY State Office of Mental Health to develop and implement a brief grief assessment as part of a survey used as a screener for prolonged grief among to 9-11 survivors.
Additionally, with funding from the NY state Research Foundation for Mental Hygiene we developed and implemented a training program for clinicians working with Project Liberty – the 9-11 mental health response. This included a prolonged grief treatment workshop training series as well as a training video to help clinicians recognize prolonged grief and a 10-session treatment manual modified from our successful prolonged grief treatment.
Dr. Shear led a partnership with ministerial staff led by Rev. Sharon Dennard at Mt. Ararat Church, a Black Baptist church in Pittsburgh. Funded by a grant from the Staunton Farm Foundation, they developed an Inventory of Complicated Spiritual Grief and a 2-session pastoral intervention for bereaved parishioners.
Through this time, we continued work to understand prolonged grief in ways that could be clinically useful. In 2005 we published a paper outlining an attachment theory conceptualization of grief and prolonged grief. This was published in an academic journal, Developmental Psychobiology, as part of a Festschrift for Myron Hofer, whose work documenting hidden regulators in attachment relationships was ground-breaking. This paper became one of the most frequently downloaded articles ever published in that journal.
We also continued assessment studies to understand associated features of prolonged grief, and worked with colleague Dr. Anne Germain to complete analyses of sleep disturbance, Dr. Timothy Monk to study disruption of daily life activities and Dr. Kati Szantos to examine suicidal thinking in study participants with prolonged grief.
2007 - 2009
Dr. Shear moved to the Columbia School of Social Work in 2006. In 2007 she received a second NIMH grant for a study comparing PGT (CGT) to IPT in older adults with prolonged grief. Results of this study were very similar to the first study. This work took place in a different setting with different therapists for both IPT and PGT and we again found that PGT was twice as effective (70%) as response to IPT (31%).
We collaborated with Dr. Naomi Simon on a secondary analysis of medication use in our first study comparing prolonged grief treatment to IPT. Because prolonged grief was a newly recognized syndrome that often co-occurred with other mental health issues, the grant funder as well as our institutional review board required us to continue participants on any medications they were currently taking. The analysis led by Dr. Simon was an important one. It showed that study participants taking antidepressants had a better response to both PGT and IPT than those who were not.
Dr. Simon also treated a small case series of individuals with prolonged grief treated with escitalopram and her results differed from our pilot study.
In 2008 we received NIMH funding for a third study. This was a 4-site collaborative study led by Dr. Shear and senior biostatistician Dr. Naihua Duan with principle investigators at 3 other sites: Drs. Charles Reynolds in Pittsburgh, Dr. Naomi Simon in Boston and Dr. Sidney Zisook in San Diego. This study was designed to test the efficacy of antidepressant medication when administer by a grief-informed pharmacotherapist either with or without additional prolonged grief therapy. Results again showed a high rate of response to PGT (CGT) while we did not find a difference between antidepressant and placebo medication when administered either with or without prolonged grief therapy. However, when antidepressant was administered with PGT, it had a significantly greater effect on symptoms of depression than when PGT was administered with a placebo.
Our assessment studies during the period from 2007-2009 continued to focus on secondary analyses of data from our completed treatment study, focusing on co-occurring disorders, grief-related avoidance and social support, and clinical presentation and treatment outcomes in African American study participants.
We also collaborated with colleagues on studies of prolonged grief in children and adolescents, prolonged grief and sleep in bipolar disorder and sleep and circadian rhythms in older adults.
2010 – 2014
In 2011, Naomi Simon and senior biostatistician Melanie Wall analyzed a large clinical database in order to inform the development of diagnostic criteria. Prigerson had done an initial helpful study work to inform the development of criteria for DSM-5. This was a survey study conducted in a community-based sample that included only a small number of people judged to have prolonged grief and they were all widows. Additionally, there was no independent well-validated “gold standard” needed to develop criteria for a new diagnosis. Our group of clinical researchers were among small group of clinical experts that have traditionally been used as an approximation of a gold standard in diagnostic criteria work in psychiatry. For all of these reasons, we believed it was important to consider both clinical and community samples in devising criteria. We collaborated with a large group of prolonged grief researchers and clinicians to explain this point of view in a publication discussing a rationale and suggested criteria for inclusion of complicated grief in DSM 5.
We further collaborated with national and international colleagues on projects characterizing prolonged grief in different settings, including parents who experienced a child’s death in a pediatric ICU, parents bereaved by offspring suicide, prolonged grief in outpatients with mood or anxiety disorders, individuals experiencing death-related and non-death related grief after hurricane Katrina, adults who experienced coronary artery bypass surgery. We worked on a secondary analysis of an epidemiologic data set to identify psychiatric outcomes of sudden unexpected death. We conducted research related to anxiety and depression in prolonged grief.
We continued to analyze data from our completed treatment studies including cognitive functioning, predictors of treatment outcome and associated treatment outcomes
2015 – 2019
We received funding with the Uniformed Services University from the Department of Defense for a two-site study of Grief-Focused Online Intervention for Bereaved Military Families. This study used some of the components of PGT in a self-guided grief-focused app compared to a self-guided wellness app. Interest in using the app was high with a high rate of recruitment and opening of the app but a small proportion spent more than 30 minutes on either app. Given that, there was a hint of superiority of the grief-focused app.
Additionally, we received funding from the New York Life Foundation to develop an app to promote resilience in bereaved families called GriefCare for Families.
Dr. Shear initiated a collaboration with Dr. Ken Kobak the head of a small business, the Center for Telepsychology, to develop a self-guided Online Training program in Prolonged Grief Therapy. They received funding from NIMH for this project (R41MH118126). The completed training is now available and a pilot study examining its effectiveness showed high interest and clear evidence of learning.
This was an active period of investigation of diagnostic criteria for PGD. We conducted a series of studies examining different proposals. Christine Mauro, our biostatistical colleague, completed an award-winning doctoral dissertation on a possible process for integrating domain rules for disease classification. Additionally, she used our study data to evaluate the clinical utility of ICD-11 diagnostic guidelines for prolonged grief disorder.
Steven Cozza, the Initiating Principle Investigator of our military family bereavement intervention study, previously completed the first military family bereavement survey. We worked with him to analyze the performance of DSM-5 Persistent Complex Bereavement Disorder criteria in this sample and found they failed to identify a large number of people who reported clinically significant distress and impairment from prolonged grief symptoms.
In February of 2019 we submitted a proposal for inclusion of PGD in DSM-5 although many efforts to discuss this proposal with a wide range of colleagues over many years were not successful. The result was a decision on the part of the Dr. Paul Appelbaum and the American Psychiatric Association to convene a workshop which included Drs. Reynolds and Shear, Drs. Pynoos and Lane and Drs. Prigerson and Macejewski as well as a panel led by Dr. David Brent to discuss and establish a preliminary criteria set. This was then successfully field tested by the PGD researchers.
We contributed papers to the literature describing our clinical perspective on diagnostic criteria along with ways to understand grief and it’s treatment.
We continued to conduct secondary analyses of data from our three completed treatment studies. One group of studies examined anxiety sensitivity and panic symptoms as well as medical comorbidity in prolonged grief study participants.
Another study explored the relationship between depression and prolonged grief.
We studied the impact of treatment alliance and expectancy on pharmacotherapy outcome.
We compared the clinical presentation of participants who lost a child to other losses and compares those who lost a loved one to suicide to other losses.
Eric Bui took the lead in analyzing the psychometric properties of our structured clinical interview for complicated grief
We also analyzed our grief-related cognitions questionnaire, called the Typical Beliefs Questionnaire, and found it to be a robust predictor of prolonged grief and treatment response
We analyzed interpersonal support in our study of older adults with prolonged grief and found levels of support were shockingly low. Helping people with prolonged grief gain adequate social support is clearly a priority.
Zisook took the lead on a subanalysis of treatment outcome in those bereaved by suicide.
We completed a sub-analyis of treatment effects on subjective sleep quality.
Kim Glickman completed a doctoral thesis by doing a series of secondary analyses of data from our first clinical trial that contributed important preliminary data related to effects of PGT on depression and anxiety, the role of the treatment alliance and mediators of treatment outcome.
We continued to collaborate with colleagues doing their own bereavement studies, including Annette Erlanger’s registry-based study of spousal suicide bereavement, Joscelyn Fisher’s confirmation of performance of the Inventory of Complicated Grief in a community bereaved military family sample that was similar to the way it performs in other samples. We worked with Dr. Desmond Patton’s in his analysis of expressions of grief on twitter, Dr. Sapana Patel in studying prolonged grief in a primary care medical practice and Dr. Noam Schneck in his collaboration with computer scientists to study unconscious processes in grief.
We continued work to establish formal diagnostic criteria. A further analysis of themilitary bereaved family data was published by Dr. Cozza.
Successful field testing of the criteria proposed by the 2019 Workshop panel enabled the diagnosis to move forward for final approval which was obtained in the fall of 2021. The criteria were released formally in DSM-5 TR in March of 2022. Drs. Prigerson, Reynolds and myself wrote a paper introducing the new criteria.
We initiated work in several new directions in response to the COVID pandemic. We remained focused, as always, on understanding, recognizing and supporting people whose prolonged grief is stopping them from thriving in their own life. We want to share what we have learned in a way that is meaningful to clinicians as well as bereaved people, their family and friends.
Drs. Kozak and Shear obtained a COVID-related supplement to our Online Training in Prolonged Grief treatment to be used to develop a patient-facing tutorial. This tutorial was designed to be used by a therapist to enhance the effectiveness of PGT.
We also completed a pilot study of our therapist training tutorial. We had a very large response to our recruitment of therapists to participate in this study (n=238) and most (n=183) completed the 11 module tutorial saying they found it helpful and interesting. We also found evidence of significant learning as a result of taking this tutorial.
In response to an invitation to develop a prolonged grief project for Columbia University’s World Project initiative, we partnered with Rev. Dr. Johnnie Green from Mobilizing Preachers and the Community(MPAC), a Black activist group in Harlem, Dr. Desmond Patton and his Safelab at CSSW and Postdoctoral Fellow, Dr. Henry Willis, to develop a project in which we conducted focus groups with community leaders, both senior and youth, to increase understanding and connection with Harlem community experiences of loss and grief during covid and beyond. Our goal was to modify our existing digital GriefCare app to focus on GriefCare for Harlem and to add information to our therapist tutorial on PGT that can increase cultural sensitivity in providing this treatment.
We continue to analyze data from our randomized controlled trials including an important re-analysis that shows that the treatment we studied has good efficacy in study participants who met the DSM-5 criteria.
Visiting Scholar Franziska Lechsner-Meichsner examined possible mediators in our study of older adults. Natalia Skritskaya analyzed changes in prolonged grief cognitions after prolonged grief treatment and Kristin Szuhany examined the impact of sleep on prolonged grief severity and outcomes.
Peter Na, a Postdoctoral fellow at our NYU site, analyzed PTSD symptoms among participants in our 4-site collaborative treatment study. This work revealed that the great majority of our participants (83%), including those who were bereaved by natural causes, endorsed symptoms on a self-report questionnaire, above the cut score for PTSD. These symptoms showed a robust response to PGT.
Dr. Naomi Simon organized a special issue of the journal Depression and Anxiety focused on prolonged grief. Our group submitted summary papers on the diagnosis and treatment of this condition.
We continue to work with colleagues doing their own grief research.