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@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. 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 Bereavement Phenomenology

8. Temporal Diminution in Grief Bereavement Phenomenology Questionnaire (BPQ) Score F(2, 48) = 98.78, p < 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 < 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% @ 13mo.) • Complicated grief • anxiety disorders (GAD 14.0% @ 6 wks) • depressive disorders (MDD 12.3% @ 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. 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)

27. 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)

28. 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)

29. 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)

30. Report Card • Group Therapy  • Guided Mourning  • Peer Support  • Interpersonal Therapy ? • Psychodynamic Psychotherapy ?  • Cognitive Therapy ? • Family Therapy ?

31. 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.