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JAMA NEWS RELEASES
(Embargoed for Release: 3 p.m. CT, Tuesday, May 31, 2005)

JAMA NEWS RELEASES

   NEWLY DEVELOPED TREATMENT FOR SEVERE GRIEF SHOWN MORE EFFECTIVE THAN STANDARD THERAPY

   PRACTICE OF DEFENSIVE MEDICINE WIDESPREAD AMONG PHYSICIANS IN SPECIALTIES AT HIGH RISK OF LAWSUITS

   LOCATION, ACCESS TO TRAUMA CENTERS OFTEN INADEQUATE, INEFFICIENT

JAMA REPORT (VIDEO NEWS RELEASE SCRIPT)

   VIDEO: Windows Media | Quicktime

   NEW THERAPY CAN SUCCESSFULLY TREAT SYNDROME CALLED ‘COMPLICATED GRIEF’

INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED.

TV Note: This week's JAMA video news release is on treating complicated grief. The release will be fed Tuesday, May 31, from 9:00 - 9:30 a.m. ET on Intelsat America 6 (formerly Telstar 6), Transponder 11 (C-Band) and from 2:00 - 2:30 p.m. ET on Intelsat America 6, Transponder 11 (C-Band). For more information, call 312/464-JAMA (5262).

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Embargoed for Release: 3 p.m. CT, TUESDAY, May 31, 2005
Media Advisory: To contact Katherine Shear, M.D., call Lisa Rossi at 412-647-3555. To contact editorialist Richard M. Glass, M.D., call Jim Michalski at 312-464-5785.

CHICAGO—A recently developed method for treating complicated grief, which includes discussing certain aspects of the death of a loved one, was found more effective than a standard therapy for depression, according to a study in the June 1 issue of JAMA.

Many physicians are uncertain about how to identify bereaved individuals who need treatment, and what treatments work for bereavement-related mental health problems, according to background information in the article. Bereavement-related major depressive disorder (MDD) is a well-recognized consequence of loss. Complicated grief also occurs in the aftermath of loss but is different from depression. Key features of complicated grief, persisting more than 6 months after the death of a loved one, include (1) a sense of disbelief regarding the death; (2) anger and bitterness over the death; (3) recurrent pangs of painful emotions, with intense yearning and longing for the deceased; and (4) preoccupation with thoughts of the loved one, often including distressing intrusive thoughts related to the death.

Complicated grief is a source of significant distress and impairment and is associated with a range of negative health consequences, but the results of existing treatments for it have been disappointing. Prevalence rates are estimated at approximately 10 percent to 20 percent of bereaved persons. Approximately 2.5 million people die yearly in the United States. Estimates suggest each death leaves an average of 5 people bereaved, suggesting that more than 1 million people per year are expected to develop complicated grief in the United States.

Given observations regarding the specificity and clinical significance of complicated grief symptoms, including the lack of response to standard treatments for depression, the researchers developed a targeted complicated grief treatment (CGT). They modified standard interpersonal psychotherapy (IPT) for grief-related depression to include cognitive-behavioral therapy-based techniques for addressing trauma and working with loss-specific distress.

Katherine Shear, M.D., of the University of Pittsburgh School of Medicine, Pittsburgh and colleagues examined whether CGT would be superior to IPT with respect to overall response rates and time to response and if CGT would produce greater resolution of complicated grief symptoms than IPT. The study included 83 women and 12 men aged 18 to 85 years recruited through professional referral, self-referral, and media announcements who met criteria for complicated grief. The study was conducted at a university-based psychiatric research clinic as well as a satellite clinic in a low-income African American community between April 2001 and April 2004. Participants were randomly assigned to receive interpersonal psychotherapy (n = 46) or complicated grief treatment (n = 49); both were administered in 16 sessions during an average interval of 19 weeks per participant.

IPT included identifying and reviewing symptoms, focusing on grief. The IPT therapist helped patients arrive at a more realistic assessment of the relationship with the deceased, addressing both its positive and negative aspects, and encouraged the pursuit of satisfying relationships and activities. Treatment gains were reviewed, plans were made for the future, and feelings about ending treatment were discussed.

CGT included a discussion of grief and loss and personal life goals, entailing both restoration of a satisfying life and adjustment to the loss. Similar to IPT, the last phase focused on review of progress, plans for the future, and feelings about ending treatment. In contrast to IPT, however, traumalike symptoms were addressed using procedures for retelling the story of the death and exercises entailing confrontation with avoided situations. The therapist tape-recorded the story and the patient was given the tape to listen to at home. Distress related to the loss (e.g., yearning and longing, reveries, fears of losing the deceased forever) was targeted using techniques to promote a sense of connection to the deceased. These included an imagined conversation with the deceased and completion of a set of memories questionnaires, primarily focused on positive memories, though also inviting reminiscence that was negative. The patient was asked to imagine that he/she could speak to the person who died and that the person could hear and respond. The patient was invited to talk with the loved one in an imagined conversation and then to take the role of the deceased and answer.

The researchers found that both treatments produced improvement in complicated grief symptoms. The response rate was greater for complicated grief treatment (51 percent) than for interpersonal psychotherapy (28 percent) and time to response was faster for complicated grief treatment.

"In summary, we conducted the first randomized controlled trial of therapy targeting symptoms of complicated grief. We found better response to CGT compared with IPT, which is a proven efficacious psychotherapy for depression. Similarity of Inventory of Complicated Grief scores across age, cultural, and death-related variables supports the diagnostic validity of the syndrome. Our treatment findings suggest that complicated grief is a specific condition in need of a specific treatment. More research is needed to confirm our findings, to test potential moderators of treatment response, and to improve treatment acceptance," the authors write.
(JAMA. 2005;293:2601-2608. Available post-embargo at jama.com)

Editor's Note: This work was supported by grants from the National Institute of Mental Health (NIMH). Dr. Shear has received financial support from Pfizer and Forest Pharmaceuticals. Co-author Ellen Frank, Ph.D., has received financial support from Pfizer, Pfizer Italia, Eli Lilly, Forest Research Institute, and the Pittsburgh Foundation.

EDITORIAL: IS GRIEF A DISEASE? SOMETIMES.

In an accompanying editorial, Richard M. Glass, M.D., Deputy Editor, JAMA, Chicago, comments on the findings by Shear et al.

"The results of the Shear et al study, while interesting and provocative, obviously leave a number of unanswered questions about complicated grief and its treatment. Although CGT was shown to be superior to IPT, a finding of particular relevance to the distinction of complicated grief from depressive disorder in view of IPT's demonstrated efficacy for MDD, the 51 percent response rate could be viewed as disappointing. Does that indicate a need for improvements in the treatment procedures or perhaps a need for longer duration of treatment? Do the psychological demands that the CGT exposure techniques place on patients mean that its acceptability and effectiveness will be limited in nonresearch clinical practice?" "The question of whether this condition should be an officially recognized mental disorder separate from MDD and posttraumatic stress disorder (PTSD) is an important issue for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, currently planned for publication by the American Psychiatric Association in 2012. It is clear that awareness about depression is important for all physicians. Is that also true about complicated grief, since patients and families almost certainly consult primary care physicians about the persisting symptoms and dysfunction associated with it?

"A concern that some might raise is that the concept of complicated grief as a disorder warranting treatment is yet another example of the medicalization of various aspects of the human condition. The available evidence that distinguishes complicated grief from normal grief and also from MDD and PTSD appears to provide a compelling response to that concern. Thus, the answer to the question 'Is grief a disease?' is 'sometimes.' The painful process of normal grief following bereavement certainly warrants sympathy and concern, along with the support of family and friends. Complicated grief warrants more research about effective ways to prevent and treat it," Dr. Glass concludes.
(JAMA. 2005;293:2658-2660. Available post-embargo at jama.com)

For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.

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Embargoed for Release: 3 p.m. CT, TUESDAY, May 31, 2005
Media Advisory: To contact David M. Studdert, L.L.B., Sc.D., M.P.H., call Kevin Myron at 617-432-3952. To contact the corresponding author of the second study, William M. Sage, M.D., J.D., call Barbara Beck at 215-209-3076. To contact editorialist Peter P. Budetti, M.D., J.D., call Jerri Culpepper at 405-325-1701.

PRACTICE OF DEFENSIVE MEDICINE WIDESPREAD AMONG PHYSICIANS IN SPECIALTIES AT HIGH RISK OF LAWSUITS

CHICAGO—More than 90 percent of surveyed physicians in Pennsylvania reported defensive medicine practices such as over-ordering of diagnostic tests, unnecessary referrals and avoidance of high-risk patients, according to a study in the June 1 issue of JAMA.

Defensive medicine is a deviation from sound medical practice that is induced primarily by a threat of malpractice suits, according to background information in the article. Defensive medicine has been reported widely in the United States and abroad. However, its prevalence and characteristics remain controversial.

According to the article, defensive medicine may supplement care (e.g., additional testing or treatment), replace care (e.g., referral to another physician or health facility), or reduce care (e.g., refusal to treat particular patients). Some practices, described as "assurance behavior" (sometimes called "positive" defensive medicine), involve supplying additional services of marginal or no medical value with the aim of reducing adverse outcomes, deterring patients from filing malpractice claims, or persuading the legal system that the standard of care was met. Other practices, described as "avoidance behavior" (sometimes called "negative" defensive medicine), reflect physicians' efforts to distance themselves from sources of legal risk. Defensive medicine, particularly avoidance behavior, encompasses both day-to-day clinical decisions affecting individual patients and more systematic alterations of scope and style of practice.

David M. Studdert, L.L.B., Sc.D., M.P.H., of the Harvard School of Public Health, Boston, and colleagues conducted a study to determine whether during a more volatile period in malpractice insurance markets, physicians' uncertainty about the costs and availability of coverage may induce a wider array of defensive practices, affecting not only the cost of health care but also its accessibility and quality. In May 2003, the researchers surveyed Pennsylvania physicians in six specialties at high risk of malpractice claims about the frequency and nature of their defensive practices. The specialties were emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology.

A total of 824 physicians (65 percent) completed the survey. Nearly all (93 percent) reported practicing defensive medicine. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation was very common (92 percent). Among practitioners of defensive medicine who detailed their most recent defensive act, 43 percent reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents' lack of confidence in their malpractice insurance and perceived burden of insurance premiums.

"Higher levels of defensive medicine are part of the social costs of instability in the malpractice system. The most frequent form of defensive medicine, ordering costly imaging studies, seems merely wasteful, but other defensive behaviors may reduce access to care and even pose risks of physical harm. Because both obstetrics and breast cancer detection are high-liability fields, women's health may be particularly affected," the authors write.

"Efforts to reduce defensive medicine should concentrate on educating patients and physicians regarding appropriate care in the clinical situations that most commonly prompt defensive medicine, developing and disseminating clinical guidelines that target common defensive practices, and reducing the financial and psychological vulnerability of individual physicians in high-risk specialties to shocks to the liability system," the researchers conclude.
(JAMA. 2005;293:2609-2617. Available post-embargo at jama.com)

Editor's Note: This study was funded by a grant from the Pew Charitable Trusts as part of the Project on Medical Liability in Pennsylvania.

TORT REFORM ASSOCIATED WITH INCREASE IN PHYSICIAN SUPPLY

States that enacted malpractice reforms had an increase in their overall supply of physicians, according to a study in the June 1 issue of JAMA.

Debates about medical malpractice have recurring themes, with tort reformers emphasizing the threat that liability crises pose to the cost and availability of medical services and tort defenders emphasizing the importance of liability to medical quality, according to background information in the article. Effects on access to health care are of particular concern during "malpractice crises," when rising liability insurance premiums and uncertain coverage are said to induce physicians to avoid high-risk patients or procedures, relocate to other communities, or leave practice altogether. Even between such crises, however, malpractice climate remains one of many factors determining how many physicians enter the medical profession, what specialties they choose, and where they practice.

Daniel P. Kessler, Ph.D., J.D., of the Stanford University Graduate School of Business, Hoover Institution, and the National Bureau of Economic Research, Stanford, Calif., and colleagues investigated whether and how liability pressure affects long-term trends in physician supply from state to state. The researchers used data from the American Medical Association's Physician Masterfile on the number of physicians in active practice in each state for each year from 1985 through 2001, and matched this with data on state tort laws and state demographic, political, population, and health care market characteristics.

The researchers found that the adoption of "direct" malpractice reforms that reduce the size of awards (such as caps on damages) led to greater growth in the overall supply of physicians. Three years after adoption, direct reforms increased physician supply by 3.3 percent, controlling for fixed differences across states, population, states' health care market and political characteristics, and other differences in malpractice law. Direct reforms had a larger effect on the supply of nongroup vs. group physicians, on the supply of most (but not all) specialties with high malpractice insurance premiums, on states with high levels of managed care, and on supply through retirements and entries than through the propensity of physicians to move between states. Direct reforms had similar effects on less experienced and more experienced physicians.
(JAMA. 2005;293:2618-2625. Available post-embargo at jama.com)

Editor's Note: This work was supported by the Project on Medical Liability in Pennsylvania funded by The Pew Charitable Trusts.

EDITORIAL: TORT REFORM AND THE PATIENT SAFETY MOVEMENT - SEEKING COMMON GROUND

In an accompanying editorial, Peter P. Budetti, M.D., J.D., of the University of Oklahoma Health Sciences Center, Oklahoma City, discusses the studies on defensive medicine and tort reform in this week's issue of JAMA.

"Perhaps the foremost lesson emerging from the work of Studdert et al and Kessler et al is that medicine's 30-year pursuit of piecemeal tort reform has had some results, but not all the consequences have been positive and serious problems with the quality of medical care have not been ameliorated. While some physicians apparently prefer to practice in states that have enacted certain liability law changes, the tort system still seems to engender perverse behaviors such as widespread, sometimes serious, and often costly deviations from accepted medical practice, and internal self-monitoring by the medical profession evidently permits such behavior to occur on a large scale. Most important, the pattern of tort reforms pursued to date has not led to innovative legal approaches that serve both the profession and patients by tying liability law restructuring to systemic, evidence-based changes in medical practice that ensure adherence to not deviate from good medical care."

"What is needed is to link new approaches to legal accountability with mandatory active participation in advanced, systematic measures to ensure high-quality care. Plaintiffs' attorneys, physicians, and patient safety proponents need to work toward achieving their stated central motivation (i.e., protecting patients from medical errors and fairly compensating the unfortunate few who nevertheless sustain avoidable injuries). Even as states continue to reform tort law and the patient safety movement makes progress toward its goals, health care generates large numbers of avoidable injuries from medical errors-most of which the legal system fails to compensate. Regardless of how fanciful this may sound in the face of entrenched contrary experience, now is the time for the disparate and opposing forces to find a way to focus together on 'the large number of patients who die unnecessarily each year from medical errors' rather than a continuance of actions reflecting the visceral antipathy of many physicians and lawyers to one another," Dr. Budetti writes.
(JAMA. 2005;293:2660-2662. Available post-embargo at jama.com)

Editor's Note: Dr. Budetti is serving as a paid expert in a lawsuit against a number of health maintenance organizations in which his contribution is focused on issues related to medical necessity and also is performing malpractice-related research funded by the Henry J. Kaiser Family Foundation.

For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.

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Embargoed for Release: 3 p.m. CT, TUESDAY, May 31, 2005
Media Advisory: To contact Charles C. Branas, Ph.D., call Karen Kreeger at 215-349-5658.

LOCATION, ACCESS TO TRAUMA CENTERS OFTEN INADEQUATE, INEFFICIENT

CHICAGO—Nearly 50 millions Americans do not have access to a level I or II trauma center within an hour if they were to be seriously injured, according to a study in the June 1 issue of JAMA.

Despite the growing number of trauma centers over the past decade, studies indicate that their geographic distribution varies widely across states, according to background information in the article. These studies suggest that residents in many parts of the country are without timely access to trauma centers that could save their lives. In other parts of the country, there are possibly too many trauma centers that may lead to inefficiencies, reduced quality of care, and lower patient volumes per center.

Charles C. Branas, Ph.D., from the University of Pennsylvania School of Medicine, Philadelphia, and colleagues used information from two national databases to estimate U.S. residents' access to level I, II, and III trauma centers by ground ambulance or helicopter within 45 and 60 minutes. "Level I and II trauma centers provide comprehensive care for the most critically injured patients and have immediate availability of trauma surgeons, anesthesiologists, and certain other physician specialists," the article states. "Level III centers provide prompt assessment, resuscitation, surgery, and stabilization, with transfer to a level I or II center when indicated."

The researchers found that an estimated 69.2 percent and 84.1 percent of U.S. residents had access to a level I or II trauma center within 45 and 60 minutes, respectively. Residents in the northeastern region of the U.S. had the greatest access to level I and II centers within 45 and 60 minutes, with accessibility at 85.8 percent and 96.9 percent, respectively. The 46.7 million people who did not have access within an hour of trauma care generally lived in rural areas, while the 42.8 million people who had access to 20 or more level I or II trauma centers within an hour lived mostly in urban areas. Only about ten percent and 25 percent of U.S. land area was located within 45 and 60 minutes, respectively, of a level I or II trauma center.

"Judiciously selecting trauma centers based on geographic need, appropriately locating medical helicopter bases, and establishing formal agreements for sharing trauma care resources across states should be considered to improve access to trauma care in the United States," the authors conclude.
(JAMA. 2005;293:2626-2633. Available post-embargo at jama.com)

Editor's Note: This work was supported in part by the American Trauma Society Trauma Information and Exchange Program, a grant from the Agency for Healthcare Research and Quality, and a grant from the Centers for Disease Control and Prevention's Center for Injury Prevention and Control.

For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.

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JAMA REPORTS

VIDEO: Windows Media | Quicktime

NEW THERAPY CAN SUCCESSFULLY TREAT SYNDROME CALLED ‘COMPLICATED GRIEF’

VIDEO:
B-ROLL
Heather doing dishes in her kitchen
Picture of Renee in dance pose

AUDIO:
THERE WAS A TIME WHEN EVEN DOING THE DISHES WAS TOO MUCH FOR HEATHER CHATTERJEE (CHA-ter-jee). SHE WAS TOO DEBILITATED BY GRIEF, AFTER HER 19-YEAR OLD DAUGHTER RENEE DIED IN AN ACCIDENT.

VIDEO:
SOT/FULL
@ :11
Super: Heather Chatterjee
Grieving daughter’s death
Runs :27

AUDIO:
"(Crying) There’s no sadness or loneliness or any emotion that you can feel that describes the agony. It becomes physical pain, it becomes debilitating. It’s the yearning and the longing."

VIDEO:
Picture of Renee sitting in chair

AUDIO:
WHEN THIS KIND OF GRIEF LASTS BEYOND SIX MONTHS, IT’S CALLED COMPLICATED GRIEF.

VIDEO:
SOT/FULL
@ :42
Super: Katherine Shear, M.D.
Univ. of Pittsburgh School of Medicine
Runs :09

AUDIO:
"Complicated grief is a newly defined syndrome and there wasn’t any treatment for it so we developed a treatment and tested it."

VIDEO:
B-ROLL
Dr. Shear working at desk
GFX/COVER

AUDIO:
DR. KATHERINE SHEAR FROM UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE LED THE STUDY, WHICH APPEARS IN JAMA, THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.

VIDEO:
SOT/FULL
Katherine Shear, M.D.
Univ. of Pittsburgh School of Medicine
Runs :13

AUDIO:
"People who got complicated grief treatment were much more likely to tell us that the treatment made a very dramatic difference in their symptoms and sometimes they even said that basically the treatment had changed their lives."

VIDEO:
B-ROLL
Heather with therapist
Tape recorder
Heather with therapist

AUDIO:
THEY ALSO SAW RESULTS SOONER THAN THOSE WHO RECEIVED A STANDARD THERAPY. COMPLICATED GRIEF TREATMENT TARGETS BOTH ACCEPTING LOSS AND FOCUSING ON THE PATIENT’S OWN PERSONAL LIFE GOALS. THE TREATMENT INCLUDES "REVISITING" --TAPE RECORDING THE PATIENT TELLING THE STORY OF THE LOVED ONE’S DEATH. THE PATIENT LISTENS TO THE STORY DAILY, TO HELP LESSEN THE INTENSITY OF EMOTION. THE PATIENT ALSO TELLS THE LOVED ONE THINGS THEY DIDN’T GET TO HEAR IN LIFE.

VIDEO:
NAT SOT UP FULL FOR :02

AUDIO:
"Sound of Heather coming into room"

VIDEO:
B-ROLL
Heather looking at photo album
Picture of her three children

AUDIO:
IT’S BEEN TWO YEARS SINCE RENEE DIED. HEATHER CAN NOW FIND JOY IN HER OTHER TWO CHILDREN. SHE SAYS HER TREATMENT FOR COMPLICATED GRIEF MADE ALL THE DIFFERENCE.

VIDEO:
SOT/FULL
Heather Chatterjee
Grieving daughter’s death
Runs :09

AUDIO:
"I did get through it and I’m still going through it and it’s something that will be with me for the rest of my life. But it’s okay, I can go on now."

VIDEO:
B-ROLL
Picture of Renee in dance pose

AUDIO:
THIS IS MAVIS PRALL WITH THE JAMA REPORT.