Bereavement In Older People

1
Bereavement In Older People

• GERARD BYRNE
• BSc (Med), MBBS (Hons) PhD FRANZCP
• School of Medicine, University of Queensland

gerard.byrne_at_uq.edu.au
2
Definition of Bereavement

• The objective state of having lost someone
  significant as a result of their death

3
Definition of Grief

• The emotional reaction to loss

4
Prevalence of Bereavement in Older People

• By the age of 65 years, over 50 of all women and
  over 10 of all men have been widowed at least
  once
• By the age of 85 years, over 80 of all women and
  over 40 of all men are widowed

5
Medical Morbidity Mortality

• Bereavement is associated with excess all
  causes mortality in men and women (Schaefer et
  al., 1995)
• OR 2.02 (95 CI 1.46 - 2.79)

6
Suicide

• Suicide rates are significantly increased in
  widowed males (Li, 1995)
• RR 3.27 (95 CI 1.29 - 8.32)

7
Bereavement Phenomenology

• Intrusive thoughts
• Distressing thoughts
• Mental images
• Perceptual abnormalities
• Sense of presence
• Yearning or pining
• Searching
• Waves of emotion

• Sense of unreality
• Nostalgia
• Disorganisation
• Crying
• Anxiety
• Depression
• Physical symptoms
• Guilt anger

8
Temporal Diminution in Grief
Bereavement Phenomenology Questionnaire (BPQ)
Score
F(2, 48) 98.78, p lt 0.0001
Byrne Raphael (1994) Psychological Medicine 24
411 - 42
9
Crying


Byrne Raphael (1994) Psychological Medicine 24
411 - 42
10
Hallucinations


Byrne Raphael (1994) Psychological Medicine 24
411 - 42
11
Guilt


Byrne Raphael (1994) Psychological Medicine 24
411 - 42
12
Temporal Diminution in Anxiety
Spielberger State Anxiety Score (STAI-S)
F(1,102) 13.61, p lt 0.001
Byrne Raphael (1997) International Journal of
Geriatric Psychiatry 12 241-251.
13
Psychopathology following Bereavement

• Absent grief (uncommon)
• Prolonged or excessive grief (8.8 _at_ 13mo.)
• Complicated grief
• anxiety disorders (GAD 14.0 _at_ 6 wks)
• depressive disorders (MDD 12.3 _at_ 6wks)
• substance use disorders (hazardous alcohol intake
  18.9 during first 13 mo.)

N 57 widowers response rate 66 mean age 75
years mean MMSE 28
Byrne Raphael (1999) International
Psychogeriatrics 11(1) 67-74. Byrne et al.
(1999) ANZ Journal of Psychiatry 33 740- 747.
14
Prevalence of Depression following Bereavement in
Older People

• 1,047 married persons 39 widowed persons (New
  Haven ECA site) 24 widows 15 widowers (mean
  age 73.4 years)
• DIS interviews within 12 months of spousal
  bereavement
• 12 (30.8) widowed persons 33 (3.2) married
  persons met diagnostic criteria for MDE

Bruce et al. (1990) Am J Psychiatry 147(5)
6087-611
15
Prevalence of Depression following Bereavement in
Older People

• 131 widowed persons aged 65 years (14 of those
  approached)
• DSM-III-R criteria for Major Depressive Episode
  (MDE)
• 2mths 20 7mths 16 13mths 10

Zisook et al. (1993) J Geriatr Psychiatry Neurol
6(3) 137-143
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Syndromal Depression in People Aged 70 years
cohort study

Modified CIDI diagnoses NB newly bereaved (n
223) LTB long term widowed (n 2,113) M
married (n 2,652) D divorced (n 297) NM
never married (n 164)
Turvey et al. (1999) Am J Psychiatry 156(10)
1596-1601
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PsychopathologySuicidal Ideation
6wks
13mths

• Thoughts of death 43.9 15.4
• Wanting to die 12.3 9.6
• Suicidal thoughts 1.8 3.8
• Attempted suicide 0.0 1.9

Byrne Raphael (1999) International
Psychogeriatrics 11(1) 67-74.
18
Pharmacological Treatment of Bereavement-Related
MDEs

• Desipramine (Jacobs et al., 1987)
• Amitriptyline (Davidson et al., 1990)
• Nortriptyline (Pasternak et al., 1991)
• Paroxetine/Nortriptyline (Zygmont et al., 1998)
• Nortriptyline (Reynolds et al., 1999)

RCT Nortriptyline /- IPT vs placebo
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Nortriptyline
remission over 3 years

• 16 week randomised placebo controlled trial of
  nortriptyline interpersonal therapy in
  bereavement related MDE
• N 80
• Mean age 66 years

Reynolds et al. (1999) Am J Psychiatry 156(8)
1177-1181
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Psychosocial Treatments for Bereavement
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Bereavement counselling does it work?

• Professional services and professionally
  supported voluntary and self-help services are
  capable of reducing the risk of psychiatric and
  psychosomatic disorders resulting from
  bereavement.

Parkes (1980) British Medical Journal 281(6232)
3-6
22
Meta-Analysis of Grief Therapy(Allumbaugh
Hoyt, 1999)

• 35 studies (N 2,284)
• 84 female subjects
• modal age 52 yrs
• modal time since loss 27 months
• weighted mean ES 0.43 (95 CI 0.33 - 0.52)
• self-selected subjects did better

Allumbaugh Hoyt (1999) Journal of Counselling
Psychology 46 370-380
23
Limitations of the Meta-Analysis

• Uncontrolled trials included (pre/post
  comparisons given equal status to studies with
  control groups)
• Subjects with normal bereavement mixed in with
  subjects with pathological states
• Modal subject sustained loss 27 months earlier
• Overall methodological quality of the grief
  therapy literature is poor

24
Controlled Treatment Trials

• Raphael (1977) Psychotherapy
• Vachon et al. (1980) Peer Support
• Mawson et al. (1981) Guided Mourning
• Walls Meyers (1985) Group Therapy
• Kleber Brom (1987) Various Therapies
• Marmar et al. (1988) Psychotherapy vs Peer
  Support

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Controlled Treatment Trials

• Sireling et al. (1988) Guided Mourning
• Lieberman Yalom (1992) Group Therapy
• Reynolds et al. (1999) Interpersonal Therapy
• Shear et al. (2005) IPT Complicated Grief
  Therapy
• Kissane et al. (2006) Family-focussed Therapy
• De Groot et al. (2007) CBT for Bereavement
  following Suicide
• Many other uncontrolled studies have been
  reported and many studies (especially
  dissertations) have remained unreported

26
Psychodynamic Psychotherapy

• 200 widows lt 60 years applying for widows
  pensions assessed for vulnerability factors
  within 7 weeks of death of spouse
• 64 at risk widows randomly assigned to
  psychotherapy (N 31) or no intervention (N
  33)
• Mean of 3.4 hours psychotherapy over 3 months

Raphael (1977) Arch Gen Psychiatry 34(12)
1450-1454
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Psychodynamic Psychotherapy
?2 6.22, p lt 0.02
Raphael (1977) Arch Gen Psychiatry 34(12)
1450-1454
28
Peer Support

• 162 widows, median age 52 years, recruited
  through 7 Toronto hospitals in which their
  husbands had died
• Randomly assigned to Widow Support (N 68) or
  no intervention (N 94)
• Widow Support included practical help, supportive
  telephone calls, face to face interviews and even
  small group meetings

Vachon et al. (1980) Am J Psychiatry 137(11)
1380-1384
29
Peer Support

• No significant difference between groups on the
  main outcome measure, the 12-item General Health
  Questionnaire (GHQ)
• No significant difference between groups on
  Intrapersonal Adaptation - a post hoc measure
  with low reliability

Vachon et al. (1980) Am J Psychiatry 137(11)
1380-1384
30
Peer Support
?2 5.37, p 0.02 interpersonal adaptation
Vachon et al. (1980) Am J Psychiatry 137(11)
1380-1384
31
Guided Mourning

• 12 patients with morbid grief were randomly
  assigned to either Guided Mourning (maximal
  exposure N 6) or to a Control Condition
  (maximal avoidance N 6)
• Few differences between groups overall
• At 10 weeks Guided Mourning was better than
  Control on the Texas Inventory of Grief (p lt 0.05)

Mawson et al. (1981) Br J Psychiatry 138 185-193
32
Guided Mourning

• 26 patients with morbid grief were randomised to
  either Guided Mourning (N 14) or to a Control
  Condition (antiexposure N 12)
• Six sessions over 10 weeks
• Few differences between groups overall
• Guided Mourning group did better on a bereavement
  avoidance task

Sireling et al. (1988) Behav Ther 19 121-132
33
Group Psychotherapy

• 78 bereaved spouses were randomised to either
  group psychotherapy (N 58) or to a control
  condition (N 20)
• Group psychotherapy consisted of 8 x 80min
  sessions in a group of approximately 10 members

Lieberman Yalom (1992) Int J Group Psychother
42(1) 117-132
34
Group Psychotherapy

• Overall, there was no multivariate difference
  between the intervention and control group
• No differences between groups on mental health or
  mourning
• Psychotherapy patients exhibited increased
  self-esteem reduced role strain (univariate)

Lieberman Yalom (1992)
35
Various Group Treatments

• 38 widows, mean age 52 years, were assigned
  non-randomly to one of four groups (10 x 90min
  sessions)
• cognitive restructuring (N 10)
• behavioural skills (N 8)
• self-help (N 10)
• wait list control (N 10)

Walls Meyers (1985)
36
Various Group Treatments

• Few treatment effects observed
• Cognitive group did not show cognitive change
• Behavioural group did not show behavioural change
• Self-help group got worse on some measures

Walls Meyers (1985)
37
Various Individual Treatments

• 83 bereaved persons (23 men) mean age 42 years
  assigned non-randomly to one of four treatments
  (15 - 20 sessions)
• trauma desensitisation
• hypnosis therapy
• psychodynamic therapy
• waiting list (N 18)

Kleber Brom (1987)
38
Various Individual Treatments

• Findings difficult to interpret
• Very weak effects for hypnotherapy
  psychodynamic therapy
• Moderate effect for trauma desensitisation on
  measures of intrusion and denial
• Significant risk of Type 1 error

Kleber Brom (1987)
39
Psychotherapy vs Peer Support

• 61 self-selected widows were randomised to either
  brief dynamic psychotherapy (N 31) or to a
  mutual help group treatment (N 30)
• Mean age 58 years
• Widowed between 4 and 36 months
• Psychotherapy 12 sessions 1/wk
• Mutual help 12 x 1.5hr sessions

Marmar et al. (1988)
40
Psychotherapy vs Peer Support

• Both groups improved significantly over time
• Brief psychotherapy was superior for only one
  outcome variable self-reported general symptoms
  on the SCL-90
• Psychotherapy patients were much more likely to
  complete treatment (?2 14.08, p lt 0.001)

Marmar et al. (1988)
41
IPT vs Antidepressant in Bereavement-related MDE

• N 80 bereaved participants with MDE
• Aged 50 years
• 16 week RCT
• Nortriptyline IPT (N 25) Nortriptyline alone
  (N 25) Placebo IPT (N 17) Placebo alone
  (N 22)
• Remission N IPT 69 N 56 P IPT 29 P 45
• No IPT effect in logit model

Reynolds et al. (1999)
42
Complicated Grief Therapy

• IPT (N 46 49 yrs 12 male) vs CGT (N 49
  47yrs 13 male)
• 19 wks treatment
• CGT better than IPT (higher response rate
  faster time to response)

Shear et al. (2005)
43
Family-Focused Grief Therapy

• Palliative care setting
• 81 families randomised to either Family-Focused
  Grief Therapy (53 families 233 individuals) or
  to a Control condition (28 families 130
  individuals)
• Modest effects only for family focused grief
  therapy (less distress at 13 months)
• Greater effects for most affected individuals

Kissane et al. (2006)
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Family CBT for Bereavement following Suicide

• 122 first degree relatives of 70 people who
  committed suicide
• 39 families (68 individuals) allocated to CBT 31
  families (54 individuals) allocated to usual
  care
• No reduction in complicated grief

De Groot et al. (2007)
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Report Card

• Group Therapy ?
• Guided Mourning ?
• Peer Support ?
• Interpersonal Therapy ??
• Psychodynamic Psychotherapy ? ?
• Cognitive Therapy ?
• Family Therapy ?

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Further Reading

• Bowlby, J. (1973) Attachment and loss. Volume II
  Separation, anxiety and anger. London the
  Hogarth Press and the Institute of
  Psychoanalysis.
• Raphael, B. (1983) The Anatomy of Bereavement New
  York Basic Books.
• Jacobs, S. (1993) Pathologic grief maladaptation
  to loss. Washington, D.C. American Psychiatric
  Press.