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Understanding the impact of complicated grief on combat related posttraumatic stress disorder, guilt, suicide, and functional impairment in a clinical trial of post-9/11 service members and veterans.

  • Simon, Naomi M1, 2
  • Hoeppner, Susanne S1, 3
  • Lubin, Rebecca E2
  • Robinaugh, Donald J1, 3
  • Malgaroli, Matteo2
  • Norman, Sonya B4, 5, 6, 7
  • Acierno, Ron8, 9
  • Goetter, Elizabeth M1, 3
  • Hellberg, Samantha N1
  • Charney, Meredith E1, 3
  • Bui, Eric1, 3
  • Baker, Amanda W1, 3
  • Smith, Erin10, 11
  • Kim, H Myra10, 12
  • Rauch, Sheila A M13, 14
  • 1 Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.
  • 2 Department of Psychiatry, New York University School of Medicine, New York, New York.
  • 3 Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.
  • 4 National Center for PTSD, White River Junction, Vermont.
  • 5 Mental Health Service Line, Veterans Affairs San Diego Healthcare System, San Diego, California.
  • 6 School of Medicine, University of California, San Diego, California.
  • 7 Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, California.
  • 8 Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.
  • 9 College of Nursing, Medical University of South Carolina, Charleston, South Carolina.
  • 10 VA Ann Arbor Healthcare System, Ann Arbor, Michigan.
  • 11 Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.
  • 12 Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan.
  • 13 Mental Health Service Line, Veterans Affairs Atlanta Healthcare System, Decatur, Georgia. , (Georgia)
  • 14 Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia. , (Georgia)
Published Article
Depression and anxiety
Publication Date
Jan 01, 2020
DOI: 10.1002/da.22911
PMID: 31916660


Complicated grief (CG) is a bereavement-specific syndrome distinct from but commonly comorbid with posttraumatic stress disorder (PTSD). While bereavement is common among military personnel (Simon et al., 2018), there is little research on the impact of CG comorbidity on PTSD treatment outcomes. To evaluate the impact of comorbid CG on PTSD treatment outcomes we analyzed data from a randomized trial comparing prolonged exposure, sertraline, and their combination in veterans with a primary diagnosis of combat-related PTSD (n = 194). Assessment of PTSD, trauma-related guilt, functional impairment, and suicidal ideation and behavior occurred at baseline and weeks 6, 12, and 24 during the 24-week trial. CG was associated with lower PTSD treatment response (odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.12, 0.69], p = 0.005) and remission (OR = 0.28, 95% CI [0.11, 0.71], p = 0.007). Those with CG had greater severity of PTSD (p = 0.005) and trauma-related guilt (<0.001) at baseline and endpoint. In addition, those with CG were more likely to experience suicidal ideation during the study (CG: 35%, 14/40 vs. no CG 15%, 20/130; OR = 3.01, 95% CI [1.29, 7.02], p = 0.011). Comorbid CG is associated with elevated PTSD severity and independently associated with poorer endpoint treatment outcomes in veterans with combat-related PTSD, suggesting that screening and additional intervention for CG may be needed. © 2020 Wiley Periodicals, Inc.

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