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Bereavement In Older People. GERARD BYRNE BSc (Med), MBBS (Hons) PhD FRANZCP School of Medicine, University of Queensland. gerard.byrne@uq.edu.au. Definition of Bereavement. The objective state of having lost someone significant as a result of their death. Definition of Grief.

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bereavement in older people

Bereavement In Older People

GERARD BYRNE

BSc (Med), MBBS (Hons) PhD FRANZCP

School of Medicine, University of Queensland

gerard.byrne@uq.edu.au

definition of bereavement
Definition of Bereavement
  • The objective state of having lost someone significant as a result of their death
definition of grief
Definition of Grief
  • The emotional reaction to loss
prevalence of bereavement in older people
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
medical morbidity mortality
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)
suicide
Suicide
  • Suicide rates are significantly increased in widowed males (Li, 1995)
    • RR = 3.27 (95% CI: 1.29 - 8.32)
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

Bereavement Phenomenology
temporal diminution in grief
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

crying
Crying

%

%

Byrne & Raphael (1994) Psychological Medicine 24: 411 - 42

hallucinations
Hallucinations

%

%

Byrne & Raphael (1994) Psychological Medicine 24: 411 - 42

guilt
Guilt

%

%

Byrne & Raphael (1994) Psychological Medicine 24: 411 - 42

temporal diminution in anxiety
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.

psychopathology following bereavement
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.

prevalence of depression following bereavement in older people
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

prevalence of depression following bereavement in older people15
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

syndromal depression in people aged 70 years cohort study
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

psychopathology suicidal ideation
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.

pharmacological treatment of bereavement related mdes
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

nortriptyline
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

bereavement counselling does it work
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

meta analysis of grief therapy allumbaugh hoyt 1999
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

limitations of the meta analysis
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
controlled treatment trials
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
controlled treatment trials25
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
ipt vs antidepressant in bereavement related mde
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)

complicated grief therapy
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)

family focused grief therapy
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)

family cbt for bereavement following suicide
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)

report card
Report Card
  • Group Therapy 
  • Guided Mourning 
  • Peer Support 
  • Interpersonal Therapy ?
  • Psychodynamic Psychotherapy ? 
  • Cognitive Therapy ?
  • Family Therapy ?
further reading
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.