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Project HEAL:

Using a Web-based Intervention to

Prevent Prolonged Grief Disorder

Project HEAL is funded by the National Institute of Mental Health and

is a collaboration of Boston University, VA Boston Healthcare System, and

DFCI.

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Presentation Aims

Introduce Prolonged Grief Disorder (PGD)

Describe R34 NIMH-funded study

Report preliminary findings of R34

Future directions for military applications

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Grief is a normal reaction but…

Lindemann (1944) observed two groups of bereaved

‘Normal’ grief

‘Morbid’ grief

Researchers have continued to study ‘morbid’ grief

Past terms: traumatic grief, complicated grief

Current term: prolonged grief disorder (PGD)

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Prolonged Grief Disorder (PGD)

Sustained and impairing:

Longing and yearning for the lost person

Trouble accepting the loss

Difficulty trusting others

Anger or bitterness about the loss

Unease about moving on with life

Role confusion or diminished sense of self

Hopelessness and meaningless about the future

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PGD UG

Strong yearning 0.74 Missing the person 0.55

Trouble accepting the loss 0.62 Pain memory recall 0.55

Inability to trust others 0.55 Hiding tears 0.25

Bitterness or anger 0.72 Can’t avoid thoughts 0.51

Numbness/detachment 0.81 Reminders 0.46

Life is empty or meaningless 0.79 Constant need to cry 0.49

Future is bleak 0.77

Feeling agitated 0.65

PGD is different than uncomplicated grief

(UG) (Boelen & van den Bout, 2008)

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PGD UG

Anxiety 0.67*** 0.04

Depression 0.62*** 0.10

Social functioning -0.56*** -0.07

Mental health -0.61*** -0.12

Energy/fatigue -0.53*** -0.07

General health perception -0.42*** -0.06

***P<0.001

PGD is different than UG (Boelen & van den Bout, 2008)

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Incidence and consequences

A significant minority of individuals experience PGD (Latham & Prigerson, 2004).

Approximately 1 million people in the US experience PGD every year

Rates range between 10% to 50% depending on circumstance of the

death

PGD is associated with functional impairment, physical

and mental health morbidity, lost productivity,

suicide and fewer quality-adjusted life years (Lichtenthal, Cruess, & Prigerson, 2004).

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PGD has been shown to be different than bereavement-

related depression, anxiety, and PGD (Boelen et al., 2000)

PGD has its own course and risk factors (Prigerson et al., in

1999)

Is PGD different than other disorders?

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Treatments targeting PGD

Ryan and colleagues (1999) compared effectiveness of anti-

depressants and IPT for prolonged grief symptoms

No changes in grief symptoms

Three randomized controlled trials have demonstrated the

superiority of cognitive-behavioral treatments (CBT) (Shear et

al., 2005; Wagner et al. 2006; Boelen et al., 2007).

All have used some combination of exposure and cognitive

restructuring techniques.

Is exposure necessary to treat PGD?

• Some may not be willing to engage in exposure

• PGD is unique to PTSD

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When should we intervene?

A diagnosis of PGD is applied six months after

the loss

Yet, prior to six months, if symptoms and impairment

are high, indicated prevention strategies should be

considered to prevent PGD

To date, there have been no studies examining

indicated prevention interventions for PGD

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R34 NIMH-Funded Trial Developed an intervention that:

Filled a care-gap • Most bereaved at risk for PGD or have a diagnosis of PGD do not get

expert care

Addressed barriers to care • Use professionally assisted Web-based care (more effective than 100%

self-management)

Focused on core functional impairment

• Psychological and behavioral disengagement from one’s present life

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HEAL Intervention Healthy Experiences After Loss

Web-based CBT

Promotes reengagement (self-care activities) and

reconnection with supports

3 logins per week for 6 weeks

Study therapist monitors adherence and

addresses questions or clinical issues (when

necessary)

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Pilot Study

Recruiting caretakers and close family members

of Dana-Farber Cancer Institute (DFCI) patients who

died in the last 3 to 6 months

Participants are randomized to immediate treatment or

6-week delayed treatment. Complete assessments at baseline, post-treatment and at

6-week and 3-month follow-ups

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Preliminary Findings

Fourteen participants have completed the intervention and post-

treatment assessment

We have found significant improvements for:

Prolonged grief symptoms (d =1.56)

Depression symptoms (d = 1.19)

PTSD symptoms (d=1.29)

Anxiety symptoms (d=0.80)

Negative cognitions about grief and bereavement (d =

1.29)

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Feedback from Participants

“Very doable and accessible; liked flexibility of it.”

“…it was a steadying factor in my turbulent life.”

“I know I will be mourning [my wife's] passing for a very

long time, probably forever, but I am back to the

point where life is more ‘normal’ and I am certainly

starting to enjoy things again.”

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Future Directions

Submit a R01 application to conduct a multi-site, three-

arm randomized controlled trial of HEAL

as a PGD-indicated prevention Compare HEAL to:

• On-line grief-processing intervention

• Treatment-as-usual condition

Adapt HEAL for military settings

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Can HEAL be useful in the military?

“Bereavement operates on many levels: for friends who

have been injured or killed, limbs, dreams, potential,

Marine Corps career "…

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Military Loss Sudden deaths may generate emotional reactions

that cause adjustment issues and impairment

There is a need to assess those who have

experienced loss and provide support when

necessary CDR McCaughey, MC, USN (1984). Bereavement: Intervention

Following an Accident involving Multiple Deaths and No Survivors

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Military Loss Those who use persistent avoidance showed the

most dysfunction Bartone & Wright (1990) Grief and Group Recovery Following a

Military Air Disaster

Those unable to access natural supports may be at

risk for grief-related problems Tyler & Gifford (1991) Fatal Training Accidents: The Military Unit as a

Recovery Context

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Traumatic loss poses a high risk for PGD

Deaths Wounded

OIF 4409 31,922

OEF 1895 15,438

OND 66 301

Total 6370 47,661

U.S. Department of Defense Casualty Status (as of 3/7/2012)

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Military Loss

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Survey of soldiers found that more than 20% reported difficulty coping with grief (Toblin, Riviere, Thomas, Adler, Kok, & Hoge, 2012)

Grief associated with negative physical health and occupational impairment

Service members are likely dealing with co-morbid

problems For example: feelings of guilt and shame, PTSD, depression, and other

trauma-related problems

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Military Loss

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Trauma- and grief-related problems are associated with:

Poor physical health (Schnurr & Spiro,1999; Caserta, Lund,

& Obray, 2004)

Social disconnection, which is associated with

further morbidity and mortality (Uchino, Cacioppo, &

Kiecolt-Glaser, 1996)

Military Loss

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Would a program like HEAL be useful for military

populations?

What would be helpful to target? Loss? Other trauma-related issues?

What would be the best use of Web-based

strategies? Stand alone self-management

Supplement to clinical treatment: Before treatment starts? As

booster sessions? As relapse prevention?

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Moving forward…

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Thank you!

Any Questions?