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. 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 F(2, 48) = 98.78, p < 0.0001 Bereavement Phenomenology Questionnaire (BPQ) Score 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. Psychopathology Suicidal Ideation Thoughts of death43.9%15.4% Wanting to die12.3%9.6% Suicidal thoughts1.8%3.8% Attempted suicide0.0%1.9% 6wks13mths 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 16 week randomised placebo controlled trial of nortriptyline & interpersonal therapy in bereavement related MDE N = 80 Mean age ~ 66 years % remission over 3 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 < 60 years applying for widow’s 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 < 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 < 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 < 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.