Showing papers by "Naomi M. Simon published in 2016"

Optimizing Treatment of Complicated Grief: A Randomized Clinical Trial.

Abstract: Importance To our knowledge, this is the first placebo-controlled randomized clinical trial to evaluate the efficacy of antidepressant pharmacotherapy, with and without complicated grief psychotherapy, in the treatment of complicated grief. Objective To confirm the efficacy of a targeted complicated grief treatment (CGT), determine whether citalopram (CIT) enhances CGT outcome, and examine CIT efficacy without CGT. Design, Setting, and Participants Included in the study were 395 bereaved adults who met criteria for CG recruited from March 2010 to September 2014 from academic medical centers in Boston, Massachusetts; New York, New York; Pittsburgh, Pennsylvania; and San Diego, California. Co-occurring substance abuse, psychosis, mania, and cognitive impairment were exclusionary. Study participants were randomized using site-specific permuted blocks stratified by major depression into groups prescribed CIT (n = 101), placebo (PLA; n = 99), CGT with CIT (n = 99), and CGT with PLA (n = 96). Independent evaluators conducted monthly assessments for 20 weeks. Response rates were compared under the intention-to-treat principle, including all randomized participants in a logistic regression with inverse probability weighting. Interventions All participants received protocolized pharmacotherapy optimized by flexible dosing, psychoeducation, grief monitoring, and encouragement to engage in activities. Half were also randomized to receive manualized CGT in 16 concurrent weekly sessions. Main Outcomes and Measures Complicated grief–anchored Clinical Global Impression scale measurments every 4 weeks. Response was measured as a rating of “much improved” or “very much improved.” Results Of the 395 study participants, 308 (78.0%) were female and 325 (82.3%) were white. Participants’ response to CGT with PLA vs PLA (82.5% vs 54.8%; relative risk [RR], 1.51; 95% CI, 1.16-1.95; P = .002; number needed to treat [NNT], 3.6) suggested the efficacy of CGT, and the addition of CIT did not significantly improve CGT outcome (CGT with CIT vs CGT with PLA: 83.7% vs 82.5%; RR, 1.01; 95% CI, 0.88-1.17; P = .84; NNT, 84). However, depressive symptoms decreased significantly more when CIT was added to treatment (CGT with CIT vs CGT with PLA: model-based adjusted mean [standard error] difference, −2.06 [1.00]; 95% CI, −4.02 to −0.11; P = .04). By contrast, adding CGT improved CIT outcome (CIT vs CGT with CIT: 69.3% vs 83.7%; RR, 1.21; 95% CI, 1.00-1.46; P = .05; NNT, 6.9). Last, participant response to CIT was not significantly different from PLA at week 12 (45.9% vs 37.9%; RR, 1.21; 95% CI, 0.82-1.81; P = .35; NNT, 12.4) or at week 20 (69.3% vs 54.8%; RR, 1.26; 95% CI, 0.95-1.68; P = .11; NNT, 6.9). Rates of suicidal ideation diminished to a substantially greater extent among participants receiving CGT than among those who did not. Conclusions and Relevance Complicated grief treatment is the treatment of choice for CG, and the addition of CIT optimizes the treatment of co-occurring depressive symptoms. Trial Registration clinicaltrials.gov Identifier:NCT01179568

The role of avoidance in complicated grief: A detailed examination of the Grief-Related Avoidance Questionnaire (GRAQ) in a large sample of individuals with complicated grief

Abstract: Grief-related avoidance is a significant component of complicated grief, yet has rarely been formally measured in a validated fashion. Further, more work is needed to understand the impact of grief-related avoidance on symptom severity and functional impairment among individuals with complicated grief (CG). The Grief-Related Avoidance Questionnaire (GRAQ; Shear, Monk et al. 2007) was created to assess grief-related avoidance and the present analysis aimed to further develop this measure and construct by confirming the GRAQ’s psychometric properties and examining loss-related predictors of avoidance. In a sample of 393 adults with CG, we found the GRAQ had high internal consistency, with a Cronbach’s alpha of 0.89 and good convergent validity. While the EFA results suggest that the GRAQ may be unidimensional, a 3-factor model generally corresponded with the findings by (Shear, Monk et al. 2007), which suggested the presence of 3 subscales. Loss-related variables age, relationship to the deceased, a...

Providers' perspectives of factors influencing implementation of evidence-based treatments in a community mental health setting: A qualitative investigation of the training-practice gap.

Abstract: This study aims to elucidate relations between provider perceptions of aspects of the consolidated framework for implementation research (Damschroder et al., 2009) and provider attitudes toward the implementation of evidence-based treatments (EBTs) in an ethnically diverse community health setting. Guided by directed content analysis, we analyzed 28 semistructured interviews that were conducted with providers during the pre-implementation phase of a larger implementation study for cognitive processing therapy for posttraumatic stress disorder (Resick et al., 2008). Our findings extend the existing literature by also presenting provider-identified client-level factors that contribute to providers' positive and negative attitudes toward EBTs. Provider-identified client-level factors include the following: client motivation to engage in treatment, client openness to EBTs, support networks of family and friends, client use of community and government resources, the connection and relationship with their therapist, client treatment adherence, client immediate needs or crises, low literacy or illiteracy, low levels of education, client cognitive limitations, and misconceptions about therapy. These results highlight the relations between provider perceptions of their clients, provider engagement in EBT training, and subsequent adoption of EBTs. We present suggestions for future implementation research in this area. (PsycINFO Database Record

Yearning and Its Measurement in Complicated Grief

Abstract: Persistent intense yearning for the deceased is a core clinical feature of complicated grief (CG) that distinguishes it from other mental disorders that develop following loss. The Yearning in Situations of Loss Scale (YSL) is a recently developed assessment of yearning. To assess the psychometric properties of the YSL in those with CG, we administered the YSL, Inventory of Complicated Grief, and Quick Inventory of Depression Symptomatology to 303 treatment-seeking bereaved adults with CG. Our results suggest the YSL is a reliable assessment with acceptable convergent and discriminant validity as a measure of yearning in those with CG.

Delivering Cognitive Processing Therapy in a Community Health Setting: The Influence of Latino Culture and Community Violence on Posttraumatic Cognitions

Abstract: Despite the applicability of cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) to addressing sequelae of a range of traumatic events, few studies have evaluated whether the treatment itself is applicable across diverse populations. The present study examined differences and similarities among non-Latino, Latino Spanish-speaking, and Latino English-speaking clients in rigid beliefs-or "stuck points"-associated with PTSD symptoms in a sample of community mental health clients. We utilized the procedures of content analysis to analyze stuck point logs and impact statements of 29 participants enrolled in a larger implementation trial for CPT. Findings indicated that the content of stuck points was similar across Latino and non-Latino clients, although fewer total stuck points were identified for Latino clients compared to non-Latino clients. Given that identification of stuck points is central to implementing CPT, difficulty identifying stuck points could pose significant challenges for implementing CPT among Latino clients and warrants further examination. Thematic analysis of impact statements revealed the importance of family, religion, and the urban context (e.g., poverty, violence exposure) in understanding how clients organize beliefs and emotions associated with trauma. Clinical recommendations for implementing CPT in community settings and the identification of stuck points are provided.

Working memory capacity is associated with optimal adaptation of response bias to perceptual sensitivity in emotion perception.

Abstract: Emotion perception, inferring the emotional state of another person, is a frequent judgment made under perceptual uncertainty (e.g., a scowling facial expression can indicate anger or concentration) and behavioral risk (e.g., incorrect judgment can be costly to the perceiver). Working memory capacity (WMC), the ability to maintain controlled processing in the face of competing demands, is an important component of many decisions. We investigated the association of WMC and anger perception in a task in which "angry" and "not angry" categories comprised overlapping ranges of scowl intensity, and correct and incorrect responses earned and lost points, respectively. Participants attempted to earn as many points as they could; adopting an optimal response bias would maximize decision utility. Participants with higher WMC more optimally tuned their anger perception response bias to accommodate their perceptual sensitivity (their ability to discriminate the categories) than did participants with lower WMC. Other factors that influence response bias (i.e., the relative base rate of angry vs. not angry faces and the decision costs and benefits) were ruled out as contributors to the WMC-bias relationship. Our results suggest that WMC optimizes emotion perception by contributing to perceivers' ability to adjust their response bias to account for their level of perceptual sensitivity, likely an important component of adapting emotion perception to dynamic social interactions and changing circumstances. (PsycINFO Database Record

Staying Strong With Schools: A Civilian School-Based Intervention to Promote Resilience for Military-Connected Children.

Abstract: Since September 11, 2001, over 2 million U.S. service members have been deployed to Iraq or Afghanistan, resulting in hundreds of thousands of military-connected children (MCC) having experienced a parental deployment. Although parental deployments have significantly burdened these children, few evidence-based interventions designed to support their resilience to these stressors are available. To address this gap, we developed a civilian school-based intervention to promote resilience in MCC living in the community. Our intervention, Staying Strong With Schools (SSWS), aims to deliver: a training to all school professionals early in the school year to educate them about challenges for children and families experiencing parental deployment and signs of deployment-related distress; and a year-long training for the school guidance counselor who coordinates communication and provides psychosocial support to MCC within the school community. We piloted SSWS in two civilian elementary schools and found p...

Stigma and Health Services Use Among Veterans and Military Personnel

Abstract: Despite high rates of physical and mental health difficulties, veterans have low rates of health service utilization. Among other barriers to accessing needed treatment, stigma is associated with poorer quality of healthcare and lower intentions to seek treatment for health concerns. Healthcare-related stigma is prevalent among veterans and includes privacy concerns and a variety of personal beliefs regarding mental illness and treatment that deter them from seeking services. Despite efforts targeted toward reducing stigma, progress in this area has been limited, and increasing access to needed physical and mental healthcare among veterans and service members remains a persistent concern. This chapter explores the various stigma faced by today’s veterans, synthesizes the extant research on stigma-reducing strategies, and provides our recommendations for future directions. Avenues for future work include the development of prospective research designs to more completely examine the impact of stigma on service use, the development of novel approaches to interventions that expand upon existing models, and a focus on normalizing health and treatment seeking in military settings.

The Influence of Anxiety Sensitivity on a Wish to Die in Complicated Grief.

Abstract: Individuals with complicated grief are at elevated risk of suicidal thoughts. Anxiety sensitivity has recently emerged as a risk factor of suicide. This study aimed to investigate a possible association between anxiety sensitivity and a wish to die in individuals with complicated grief. Participants were evaluated for participation in a treatment study and completed an ancillary questionnaire-based study. Participants were 51 bereaved adults evaluated (age: mean, 54 [SD, 13.6] years; 78% [n = 40] women). Logistic regression was used to examine the relationship between anxiety sensitivity and a wish to die. Overall, anxiety sensitivity was associated with a wish to die at the level of a medium effect size, although it did not reach statistical significance. The anxiety sensitivity social concerns subscale was significantly associated with a wish to die. These findings add to a growing literature implicating anxiety sensitivity in reporting a wish to die.

Evaluating Strategies for Combining Pharmacotherapy with Cognitive Behavioral Therapy

Abstract: This chapter provides an overview of the rationale for combining cognitive-behavioral therapies and pharmacologic treatments. Relevant research literature is presented across a range of disorders including anxiety and related disorders, mood disorders, eating disorders, schizophrenia, and substance use disorders. In addition, practical considerations are discussed related to how the combination approach may be utilized and applied in clinical practice including a case example to highlight how a combination approach may be completed successfully in a clinical setting. Finally, novel treatment approaches are discussed as a means of highlighting future directions for the use of combined treatments.