CRD summary

This review found that cognitive-behavioural therapy based interventions provided significant benefits for bereaved adults compared with non-cognitive-behavioural strategies and no treatment. Limitations in the reporting of the review, minimal evaluation of study quality, and lack of information on the outcomes in the included studies mean that the degree to which the authors' conclusions are reliable is unclear.

Authors' objectives

To evaluate the degree to which cognitive-behavioural therapy (CBT) interventions alleviate bereavement-related distress compared with non-CBT interventions and no treatment.

Searching

PsycINFO, PsycARTICLES, MEDLINE and Dissertation Abstracts were searched. Search terms were reported. References of identified studies and existing narrative reviews were checked for additional studies.

Study selection

Studies that compared cognitive-behavioural therapy (CBT)-based interventions (described as cognitive or behavioural or CBT) to non-CBT interventions or no therapy in bereaved individuals were eligible for inclusion. Studies were required to provide quantitative information to allow calculations of effect sizes

In the included studies, all the participants were adults, treated individually or in a group format, including family groups; their average age was 46.8 years (range 37 to 55 years). Most of the bereaved were women, and the average length of time since the bereavement was 33.3 months (range seven to 36 months). The mean number of sessions for all interventions was 11 sessions (range four to 20 sessions). The CBT techniques used in the interventions principally involved cognitive restructuring and exposure treatments, with other treatments (including behavioural activation, psycho-education, relaxation training, self-monitoring exercises, social skill training and other between-session practice assignments). Non-CBT interventions included supportive counselling, brief psychodynamic psychotherapy, avoidance or anti-exposure therapy, standard of care interventions, emotion-focused counselling, and the use of self-help or social systems support groups. Outcome measures included five domains of bereavement-related distress: grief, depression, anxiety, trauma, general distress, and other outcomes. The studies were undertaken by psychology and psychiatry researchers.

The reviewers did not state how studies were selected.

Assessment of study quality

The reviewers did not state that they assessed study quality, but random assignment and the percentage of total attrition were noted.

Data extraction

The measurements of therapeutic outcomes from post-treatment, and at the last point of outcome evaluation, in each study were converted to a Cohen's d-statistic to estimate effect sizes. The Hedges correction formula was applied to all the effect sizes reported in the review because of potential overestimation of effects derived from studies with small sample sizes.

The reviewers did not state how the data extraction was performed.

Methods of synthesis

Effect sizes were averaged across all outcome measures using a random-effects model to provide an aggregate effect size. Pooled effect sizes were also calculated for each of the outcome measures, with corresponding 95% confidence intervals (CIs). The Q-statistic was used to evaluate heterogeneity between effect sizes.

Results of the review

Eleven studies (n=1,113) were included in the review. Random assignment to treatment occurred in 10 studies. There were 14 comparisons of CBT and non-CBT interventions; six studies had a no-treatment control group. The mean total attrition was 18.9%.

Overall, the CBT-based interventions were shown to provide greater overall benefit than non-CBT interventions both at post-treatment (aggregated effect size 0.27, 95% CI 0.09 to 0.44; nine studies) and after follow-up (aggregated effect size 0.25, 95% CI 0.05 to 0.46). When the results were adjusted for researcher allegiance, there were no significant differences in the effectiveness of the interventions. CBT-based interventions were also found to elicit statistically significant overall benefits compared with no-treatment control groups immediately post-treatment (aggregate effect size 0.38, 95% CI 0.09 to 0.67), but the differences between groups was not significant at follow-up.

Significant benefits were found with CBT-based therapies compared witho non-CBT intervention groups for the five domains of grief (four studies), depression (five studies), anxiety (five studies), trauma (two studies) and general distress (five studies) at post-treatment, but by the end of the follow-up period the differences between groups remained significant only for the outcomes depression (three studies) and anxiety (three studies).

Compared with no-treatment control groups significant differences were observed in favour of CBT-based treatment for the domains depression (three studies), anxiety (three studies) and trauma (two studies) at post-treatment, but there were no differences between the groups at follow-up.

There was no statistically significant heterogeneity reported between effect sizes at post-treatment or follow-up.

Authors' conclusions

Findings from the review provided preliminary evidence for the benefit of cognitive behavioural therapy-based interventions for bereaved persons, but also highlighted the importance of studying the relative efficacy of different cognitive behavioural change strategies, as well as treatments from different therapeutic orientations.

CRD commentary

The review addressed a clear question. Criteria for the inclusion of studies in the review were stipulated. Appropriate databases were searched, but it was unclear if there were any language restrictions, which meant there was a risk of language bias. There were few attempts to identify unpublished literature. There were no steps reported to minimise errors or bias at any stage of the review process.

There was no systematic assessment of methodological quality, so the reliability of the included studies was unknown. There was a lack of information on the included studies, particularly in terms of the outcome measures used. Therefore, the extent to which pooling of the studies was appropriate was unknown, particularly the pooling of all the results to produce an aggregate outcome of overall benefit.

Limitations in the reporting of the review, minimal evaluation of study quality, and lack of information on the outcomes in the included studies mean that the the degree to which the authors' conclusions are reliable is unclear.

Implications of the review for practice and research

Practice: The authors stated that it may be helpful to supplement CBT-based therapy with other therapeutic approaches for bereaved people, as interventions that can simultaneously address unhelpful cognitions and behaviours, as well as the relational and emotional dimensions of grief could meet a broader range of therapeutic needs and perhaps generate better outcomes.

Research: The authors stated that further research is required to determine which therapeutic factors of CBT are the most helpful for bereaved individuals. In addition, the comparative efficacy of both CBT and non-CBT methods, and interventions incorporating both treatment types should be evaluated. Investigations are also required in terms of the inclusion of only severely distressed populations.

Funding

Not stated.

Bibliographic details

Currier JM, Holland JM, Neimeyer RA. Do CBT-based interventions alleviate distress following bereavement? A review of the current evidence International Journal of Cognitive Therapy 2010; 3(1): 77-93.

Original Paper URL

http://guilfordjournals.com/GPI/doi/abs/10.1521/ijct.2010.3.1.77

Indexing Status

Subject indexing assigned by CRD

MeSH

Bereavement; Cognitive Therapy; Grief; Humans

AccessionNumber

12010003749

Database entry date

22/12/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.