Overview: Prevalence of PGD in returning Veterans of Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn (OND) appears to equal that of PTSD (Bolen et al., 2007). This is not altogether surprising, given that loss of life is widespread in most combat theatres. Moreover, combat Veterans experience a 'Dual Burden' of (a) loss and (b) trauma exposure (Iverson et al., 2005; Papa, Neria, & Litz, 2008) in which the potentially added negative impact of repeated significant life threat combines with loss of close attachment and support to cause impairment. Indeed, fully 21.3% of a sample of OIF/OEF Veterans reported significant difficulty coping with grief over combat death; and those who reported difficulty coping with grief were 2.4 times as likely to report health problems, and significantly more likely to report both missing work and increasing medical care use. Even more striking was the finding that effects of grief were independent of either PTSD or Depression, in that, after controlling for both PTSD and MDD, risk of reporting poor health was doubled among those reporting high grief (Toblin et al., 2012). Unfortunately, treatments for grief in Veterans remain understudied. Our research group has recently completed pilot work on an innovative, technology-leveraged treatment protocol for PGD that combines Behavioral Activation with Therapeutic Exposure and appears readily applicable to the Veteran and Military populations. We propose to evaluate this intervention through a repeated measures randomized controlled trial design (pre-treatment, post-treatment, 3 & 6 month follow-up) in order to compare it to the treatment most commonly offered to Veterans with PGD: Cognitive Restructuring and Supportive Grief Counseling (as outlined by the VA / DoD Iraq War Clinician Guide, 2nd ed.) (Pivar, 2007). Both treatments will be delivered over 5 sessions in which sessions 2, 3, and 4 of both treatments will be delivered via televideo to Veterans' homes to increase contextual relevance of treatment components. Measures will cover clinical outcomes, process outcomes, and cost outcomes in order to assess relative effectiveness of treatment across multiple parameters. Participants will be Veterans of OIF/OEF/OND who meet PGD cutoff criteria but do not meet criteria for PTSD (as a 5 session intervention is not considered appropriate for this diagnostic group). This study has the following Specific Aims: (1) To compare the efficacy of BATE-G vs. Cognitive Restructuring and Supportive Grief Counseling in terms of PGD and psychological outcomes in 140 OIF/OEF/OND Veterans, aged 21 years and older, who meet criteria for PGD. (2) To evaluate BATE-G with respect to its relative effects on increasing the frequency of community based reinforcing activities. (3) To evaluate BATE-G with respect to its relative effects on distal treatment targets, including perceived social support and health-related functioning. The following are the study Hypotheses: (1) BATE-G will be more effective than Cognitive Restructuring and Supportive Grief Counseling in reducing symptoms of PGD, both at post-treatment and follow-up. Moreover, BATE-G will be more effective in reducing acute emotional distress and preventing long-term emotional distress in terms of general depression and anxiety symptoms. (2) BATE-G will result in increased frequency of completed positively reinforcing, community-based events when compared to Cognitive Restructuring and Supportive Grief Counseling. (3) BATE-G will result in greater improvements in perceived social support and health. Note: this project is the first evidence-based treatment for PGD in military populations, thus addressing a significant service gap.
The 'dual burden' of (a) loss of a fellow service member in the context of (b) experiencing repeated extreme life threat is unique to military combat personnel and a core characteristic of combat-related Prolonged Grief Disorder (PGD), a disorder as prevalent as Post-traumatic stress disorder and associated with functional impairment, disability, and suicidality. Effective treatments for depression and PTSD have proven less than adequate in treating PGD when each is offered in isolation; and simply combining these 12-16 week treatment regimens into a 24-36 week treatments is not a viable approach, particularly with a population predisposed to avoiding extended mental health care. The proposed project addresses the need for a Veteran/ military specific treatment of PGD, and uses technology to deliver this treatment in a format that is far more likely to be accepted by military personnel and Veterans. This study will impact clinical practice by providing the first evidence for effective treatment PGD in Veterans.
