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Bereavement In Older People

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Title: 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
16
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
17
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
19
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
20
Psychosocial Treatments for Bereavement
21
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

25
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
27
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)
44
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)
45
Report Card
  • Group Therapy ?
  • Guided Mourning ?
  • Peer Support ?
  • Interpersonal Therapy ??
  • Psychodynamic Psychotherapy ? ?
  • Cognitive Therapy ?
  • Family Therapy ?

46
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.
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