Bereavement-related Depression Research Articles

The relationship of loneliness with mental health trajectories in bereaved older adults

<h3>Introduction</h3> Losing a loved one often results in acute grief and depressive symptoms. The vast majority of older individuals are resilient and return to normal functioning within a year after a loss. However, a significant minority develop mental health complications, including prolonged grief disorder and bereavement-related depression. This can lead to adverse consequences, including physical and cognitive decline, impairment in global functioning, and early mortality. The contributing factors that increase the likelihood of adverse mental health outcomes in bereaved individuals have not been fully elucidated. This study explores the relationship of loneliness with grief and depressive symptom trajectories in older adults after an attachment loss. <h3>Methods</h3> 45 individuals over age 50 and within 13 months following the death of a loved one completed a comprehensive clinical assessment at the baseline visit (week 0), including the UCLA Loneliness Scale-3, the Inventory of Complicated Grief (ICG), and the Hamilton Depression Rating Scale (HAM-D). All participants completed a 6-month longitudinal study; ICG and HAM-D were completed at weeks 8, 16, and 26 (endpoint). Statistical analyses: Two classes of mixed-effects models, where covariates are fixed effects and patient-specific dependents are random effects, were considered. Cross-sectional models were used to investigate relationships between loneliness and grief and depressive symptoms at baseline. Longitudinal models were used to examine the relationship of baseline loneliness scores with grief and depressive symptoms across the 6-month study duration. In longitudinal models, the interactions between time elapsed since baseline and dynamic measurements (complicated grief and depressive symptom scores) were examined. A hierarchical variance-covariance structure for random effects, informed by clustering of clinical trajectories, was used to determine participant trajectories. Age, gender, days since the loss, and cumulative medical illness rating scale for geriatrics scores were included as covariates in all models. The R statistical software (version 3.6.3) was utilized for data analyses. <h3>Results</h3> Cross-sectionally, loneliness was positively associated with scores on the ICG (p<0.01) and HAM-D (p<0.01) in separate models, after adjusting for covariates. However, the loneliness-ICG relationship was no longer significant when HAM-D was included as a covariate in an extended model (p=0.32). Mediation analyses revealed that the loneliness-ICG relationship was mediated by baseline HAM-D scores. In contrast, the loneliness-HAM-D relationship remained significant even after including ICG as a covariate (p=0.01). Longitudinally, baseline loneliness scores were associated with worsening HAM-D scores over time (p<0.01); this association persisted over 6 months (p<0.01). The loneliness-ICG longitudinal relationship was not significant. Of additional interest were the co-movement patterns expressed by HAM-D and ICG: adults following a C-shaped trajectory for HAM-D scores were likely to demonstrate a similar trajectory with ICG scores. <h3>Conclusions</h3> Loneliness was independently associated with grief and depression symptom severity in older adults following bereavement. However, the baseline loneliness-grief symptom association was mediated by depression. Since loneliness could predict depressive symptom trajectories in older grieving individuals, interventions targeting loneliness may also improve depression outcomes in this study population. Although the co-movement analysis was exploratory (i.e., this was used to inform the structure of the covariance matrix for random effects in analytic models), it has implications for future treatment intervention study designs. <h3>Funding</h3> This research was funded by NIMH grants R01 MH122490 and R21 MH109807 (Goveas); Costigan Family Foundation (Goveas); and UL1TR001436

Clinical features of bereavement-related depression in Japanese elderly: an observational study.

Clinical features of bereavement-related depression in Japanese elderly: an observational study.

MENTAL AND PHYSICAL HEALTH SEQUELAE OF BEREAVEMENT IN OLDER ADULTS: U.S. HEATH AND RETIREMENT STUDY ANALYSIS

Death of a spouse (bereavement) is associated with poor mental and physical health outcomes in older adults. But it is unknown how mental- and physical-health sequelae of bereavement are related and the clinical significance of bereavement-related depression has been questioned. We analyzed US Health and Retirement Study (HRS) data tracking mental and physical health of 36,034 older adults during 1992-2016. Post-bereavement data were available for N=4,985 participants with recorded date of spousal death. We analyzed longitudinal repeated-measures data on survivors’ depression, disease, disability, and mortality. Bereavement effects on depression were immediate, but short-lived, attenuating within the year. In contrast, bereavement effects on physical health and mortality persisted over follow-up. Critically, the magnitude of short-lived effects on depression correlated with the magnitude of longer-lasting effects on disease, disability, and mortality. Results reveal connections between mental and physical health and aging and suggest bereavement-related depression as a biomarker of enduring health risk.

REVIEW OF THE PSYCHOLOGICAL SUPPORT AT COMPLICATED GRIEF BASED ON THE COGNITIVE-BEHAVIOR THERAPY

The article discusses the actual studies concerning the psychological support at complicated grief. The author notes that practitioners and researchers continues debate about the definition, diagnostic criteria and best treatment of the pathopsychological phenomenon that follow the loss of a loved one and usually named as complicated grief. At the present, complicated grief is viewed as a clinical state of a persistent feeling of mourning during, at least, six months with increasing psychosocial disability. Due to many evidences of distinct clinical features for this phenomenon, it was included into the Diagnostic and Statistical Manual for Mental Disorders as a persistent complex bereavement disorder (the condition for further study), and as a new diagnostic category – Prolonged Grief Disorder - is to be added to the International Statistical Classification of Diseases (ICD-11). The article describes the cognitive model of psychological-emotional changes characteristic for people suffering from complicated grief. The cognitive-behavioral model of complicated grief proposes that a traumatic experience of a loss and negative cognition (negative beliefs about Self, life, and the future and threatening interpretations of grief reactions) plays a core role in the development and persistence of emotional problems, so mourners start to avoid social support. The emphasis in the performed analysis is laid on the psychological and psychotherapeutic interventions based on the cognitive-behavioral theory; there are evidences of their effectiveness in dealing with people mourning for deceased. The author summarizes that psychotherapeutic interventions based on the cognitive-behavioral therapy are evidence-based, comprehensive, and methodologically substantiated; they are focused on achieving psychological-emotional stability and returning to normal life. The performed approbation of these methods of intervention have shown lowered intensity of bereavement-related depression, anxiety, traumatic pain and the integration of the traumatic memory of death into a grieving person’s life experience. The cognitive-behavioural model of complicated grief can have wide clinical and psychological practical use, and cognitive-behavioral therapy manuals for dealing with complicated grief (or recommendations based on them) can be proposed as measures of psychotherapeutic and psychosocial support in Ukraine.

Mending the heart and mind during times of loss: A review of interventions to improve emotional well-being during spousal bereavement.

Spousal loss is one of life's greatest stressors. Bereaved spouses are at risk for aberrant cognitive and affective processing. Recent work in psychoneuroimmunology and cognitive neuroscience reveals physiological biomarkers and neural mechanisms underlying acute distress and grief during bereavement that may represent targets for future interventions. We review evidence from existing pharmacological and psychotherapeutic treatment approaches for normal bereavement, complicated grief, and bereavement-related depression. We propose promising future directions, namely the development and empirical validation of novel, personalised cognitive and neurostimulatory interventions to promote adaptive emotion regulation and reduce depressive symptoms following spousal loss. Future work may substantiate which interventions to improve emotional and physical health will be best matched to the needs of a particular surviving spouse.

Assessment and associated features of prolonged grief disorder among Chinese bereaved individuals

BackgroundMost research on the assessment and characteristics of prolonged grief disorder (PGD) has been conducted in Western bereaved samples. Limited information about PGD in Chinese samples exists. This study aims to validate the Chinese version of the Inventory of Complicated grief (ICG), examine the distinctiveness of PGD symptoms from symptoms of bereavement-related depression and anxiety, and explore the prevalence of PGD in a Chinese sample. MethodsResponses from 1358 bereaved Chinese adults were collected through an on-line survey. They completed the Chinese version of ICG and a questionnaire measuring depression and anxiety symptoms. ResultsThe findings indicate that Chinese ICG has sound validity and high internal consistency. The ICG cut-off score for PGD “caseness”in this large Chinese sample was 48. The distinctiveness of PGD symptoms from those of depression and anxiety was supported by the results of the confirmatory factor analysis and the fact that PGD occurred in isolation in the studied sample. The prevalence of PGD was13.9%. ConclusionICG is a valid instrument for use in the Chinese context. Several key characteristics of PGD in Chinese, either different from or comparable to findings in Western samples, may stimulate further research and clinical interest in the concept by providing empirical evidence from an large and influential Eastern country.

The Antidepressant Effect of Hospice: Need for a More Potent Prescription.

The Antidepressant Effect of Hospice: Need for a More Potent Prescription.

Bereavement-related depression: Did the changes induced by DSM-V make a difference? Results from a large population-based survey of French residents

BackgroundDSM-V has been criticized for excessively expanding criteria for bereavement-related depression. The aim of this study was to quantify a potential increase in depression prevalence due to changes in diagnostic criteria and to assess the severity, clinical profile and healthcare use of new cases. MethodsA cross-sectional telephone survey was performed in 2005–2006 in four French regions. Twelve-month prevalence of psychiatric disorders was measured by CIDI-SF. Bereavement was assessed in those who endorsed the gate question to the depression module. Persons with bereavement-related depression according to DSM-IV and DSM-V diagnosis criteria were compared. ResultsOf the 22,138 respondents, 692 were bereaved. The prevalence of depression among those bereaved was 54.2% (95% CI=50.5–57.9) according to DSM-IV and 64.3% (60.7–67.9) according to DSM-V. The overall prevalence of major depression increased from 9.5% (9.1–9.9) with DSM-IV to 9.8% (9.4–10.2) with DSM-V. Cases diagnosed using DSM-IV presented more symptoms than cases diagnosed using DSM-V but clinical features were similar except regarding criterion E׳s symptoms. Healthcare use was similar between the two groups regarding consultations and psychotropic drug prescription. LimitationsSome DSM-IV and DSM-V criteria were difficult to operationalize in the survey. The observed difference in prevalence according to DSM-IV and DSM-V may be reduced when clinical judgment is taken into account. ConclusionsThe overall prevalence of major depression is only marginally increased by the new criteria. However, diagnostic changes increase the prevalence by 10 points among those bereaved. Diagnostic changes do not appear to modify service use.

Primary care providers' bereavement care practices: recommendations for research directions.

Bereaved patients are often seen in primary care settings. Although most do not require formal support, physicians may be called upon to provide support to some bereaved, particularly those with bereavement-related mental health disorders like complicated grief and bereavement-related depression. Research evidence on physician bereavement care is scant. We make recommendations for future research in this area. Literature review focuses on studies conducted between 1996 and 2013 in the United States. Searches of Medline and PsychInfo, along with hand searches of reference sections, were conducted. The limited existing research indicates substantial gaps in the research literature, especially in the areas of primary care physician skill and capacity, patient-level outcomes, and the quality of research methodology. No US studies have focused specifically on care for bereavement-related mental health disorders. We provide recommendations about how to improve research about primary care bereavement care. The primary care sector offers ample opportunities for research on bereavement care. With greater research efforts, there may be improvements to quality of bereavement care in primary care, in general, and also to the accurate detection and appropriate referral for bereavement-related mental health conditions.

Understanding bereavement-related depression: the polemical journey of DSM-5.

This paper will bring you on a polemical journey to understand the issues related in conceptualizing bereavement-related depression. A critical narrative review was carried out to evaluate arguments and controversies surrounding DSM-IV classifications of bereavement exclusion for the diagnosis of major depressive disorder (MDD). Result Available studies that are associated with bereavement exclusion criteria, the open trials and treatments with the implications of such conceptualizations and the current removal of the bereavement exclusion from MDD in DSM-5 were addressed. The review highlights the never-ending polemical journey of conceptualizing any mental disorders, bereavement-related depression included.

Bereavement-related depression in the older adult population: A distinct disorder?

BackgroundBereavement is a phenomenon that shares many symptoms with depression, and that a great number of older adults experience following the loss of a close relative. The objectives of the present study were to (1) determine whether the symptoms of depression reported by bereaved individuals differ from those with non-bereavement minor/major depression (NBRD), (2) assess whether BRD is as persistent during a one year follow-up as compared to NBRD, and (3) identify factors and consequences associated with BRD. MethodsThe data used for this study came from the Longitudinal Study ESA (Study Health of Elders), conducted between 2005 and 2008, using a representative sample (n=2811) of community-dwelling older adults, aged 65 and over. To test our hypothesis, an exploratory latent class analysis and multivariate logistic regression were used. ResultsBRD prevalence among older adults suffering from depression was 39%. BRD individuals report all symptoms of depression, but in lower probabilities, and BRD is as persistent as MDD over 12 months, suggesting that it does not differ from NBRD. The principal factors associated with BRD were widowhood and lower level of education. Individuals with BRD are less likely to consult medical services and be dispensed an antidepressant, compared to NBRD. LimitationsWe have to be cautious when generalizing our findings to individuals with major depression alone, since our results included both minor and major depressions in the same group. ConclusionNo evidence was found that BRD differed from non BRD in terms of depressive symptoms and persistence. The bereavement exclusion criterion in the DSM-IV should be reconsidered.

Distinctiveness of symptoms of prolonged grief, depression, and post-traumatic stress in bereaved children and adolescents

Studies among adults have shown that symptoms of prolonged grief disorder (PGD) are distinct from those of bereavement-related depression and post-traumatic stress-disorder (PTSD). This study was an attempt to replicate this finding in two distinct samples of bereaved children (N = 197; aged 8–12 years) and adolescents (N = 135; 13–18 years), confronted with the death of a parent, sibling or other close relative. Using confirmatory factor analyses, we compared the fit of a one-factor model with the fit of a three-factor model in which symptoms formed three distinct, correlated factors. In both samples, findings showed that the model in which symptoms of PGD, depression, and PTSD loaded on separate factors was superior to a one-factor model and displayed excellent model fit. Summed scores on the PGD, depression, and PTSD items were significantly associated with functional impairment, attesting to the concurrent validity of the PGD, depression, and PTSD factors. The current findings complement prior evidence from adult samples that PGD is a distinct syndrome and suggest that PGD symptoms should be addressed in the assessment and treatment of bereaved children and adolescent seeking help following their loss.

Normal vs. disordered bereavement‐related depression: are the differences real or tautological?

To evaluate whether the DSM distinction between uncomplicated (normal) and complicated (disordered) bereavement-related depression (BRD) has discriminant validity on a range of pathology indicators. The DSM's major depression bereavement exclusion (BE) excludes BRDs from diagnosis when they are uncomplicated (defined by brief duration, non-severe impairment, and lack of certain pathosuggestive symptoms) but classifies all other ("complicated") BRDs as major depression. A previous report seemed to support the uncomplicated/complicated distinction's discriminant validity. However, those arguing for eliminating the BE from DSM-5 dismiss the findings as 'tautological,' attributing the validator differences to definitional biases (e.g. 'uncomplicated' requires 'no suicidal ideation,' yet 'lifetime suicide attempt' was a validator). This study empirically tests whether the uncomplicated/complicated differences are real or tautological. Using National Comorbidity Survey data, confounds between definitional criteria for 'uncomplicated' and pathology validators were identified and corrected by deleting the biasing criteria and recalculating the corresponding validator's outcome. Six validators (interference with life, suicide attempt, melancholic depression, duration, hospitalization, and number of symptoms) were reanalyzed using unbiased definitions for 'uncomplicated.' All still yielded significantly lower pathology levels for uncomplicated BRDs, disconfirming the 'tautology' hypothesis. Regression analysis revealed that 'uncomplicated' offered incremental validity over severity alone in predicting pathology, so 'uncomplicated' cannot be equated with 'mild.' Uncomplicated BRDs' lower pathology validator levels are because of real syndromal differences, not definitional tautologies, supporting the BE's validity.

Pharmacological approaches to the treatment of complicated grief: rationale and a brief review of the literature

Complicated grief (CG) is a common and often under-acknowledged cause of profound impairment experienced after the loss of a loved one. Although both clinical and basic research suggests that pharmacological agents might be of use in the treatment of CG, research on pharmacological approaches to this condition is still scarce. Three open-label trials and one randomized trial on bereavement-related depression suggest that tricyclic antidepressants may be effective, although they may be more efficacious for depressive symptoms than for grief-specific symptoms. Four open-label trials (total number of participants, 50) of selective serotonin reuptake inhibitors (SSRIs) have yielded results, providing very preliminary support that they might be effective in the treatment of CG, both as a standalone treatment and in conjunction with psychotherapeutic interventions. These more recent studies have shown an effect on both depression and grief-specific scales. Furthermore, therapeutic interventions for CG may be more effective in conjunction with SSRI administration. Given the small number of pharmacological studies to date, there is a need for randomized trials to test the potential efficacy of pharmacological agents in the treatment of CG.

Recurrence of Depression After Bereavement-Related Depression

The DSM-IV diagnostic criteria for major depressive disorder exclude bereavement-related depressive episodes that are brief and lack certain severe symptoms and are thus better explained as normal grief responses. However, the DSM-5 Task Force proposes to eliminate this exclusion because of a lack of evidence that such episodes differ relevantly from standard major depression. Using the two-wave longitudinal Epidemiologic Catchment Area Study, we compared 1-yr depression recurrence rates at wave 2 of four groups at wave 1 baseline: (1) those with no history of depressive disorder (n = 18,239), (2) those who had only lifetime excludable bereavement-related depression (n = 25), (3) those with brief-episode (≤ 2 months duration) lifetime standard depressive disorder (n = 446), and (4) those with nonbrief lifetime standard depressive disorder (n = 581). The recurrence rate in the excludable-depression group (3.7%) was not significantly different from the no-history group (1.7%) but was significantly and substantially lower than in the brief and nonbrief standard depression groups (14.4% and 16.2%, respectively). These findings confirm findings reported by Mojtabai (Arch Gen Psychiatry 68:920-928, 2011) using a different data set and time frame and thus substantially strengthen the support for the validity of bereavement exclusion and for its preservation in the DSM-5.

THE BEREAVEMENT EXCLUSION AND DSM-5

Pre-DSM-III (where DSM is Diagnostic and Statistical Manual), a series of studies demonstrated that major depressive syndromes were common after bereavement and that these syndromes often were transient, not requiring treatment. Largely on the basis of these studies, a decision was made to exclude the diagnosis of a major depressive episode (MDE) if symptoms could be "better accounted for by bereavement than by MDE" unless symptoms were severe and very impairing. Thus, since the publication of DSM-III in 1980, the official position of American Psychiatry has been that recent bereavement may be an exclusion criterion for the diagnosis of an MDE. This review article attempts to answer the question, "Does the best available research favor continuing the 'bereavement exclusion' (BE) in DSM-5?" We have previously discussed the proposal by the DSM-5 Mood Disorders Work Group to remove the BE from DSM-5. Prior reviews have evaluated the validity of the BE based on studies published through 2006. The current review adds research studies published since 2006 and critically examines arguments for and against retaining the BE in DSM-5. The preponderance of data suggests that bereavement-related depression is not different from MDE that presents in any other context; it is equally genetically influenced, most likely to occur in individuals with past personal and family histories of MDE, has similar personality characteristics and patterns of comorbidity, is as likely to be chronic and/or recurrent, and responds to antidepressant medications. We conclude that the BE should not be retained in DSM-5.

The Phenomenology and Course of Depression in Parentally Bereaved and Non-Bereaved Youth

To compare the phenomenology and course of bereavement-related depression to depression that occurred later in the course of bereavement and to depression in non-bereaved youth. This sample is drawn from a cohort of parentally bereaved youth and non-bereaved controls followed for approximately 5 years. Three groups of depressed youth were compared with respect to symptoms, severity, duration, risk for recurrence, and correlates and risk factors: (1) a group with bereavement-related depression (BRD, n = 42), with the onset of a depressive episode within the first 2 months after parental loss; a group with later bereavement depression (LBD, n = 30), with onset at least 12 months after parental loss; and a non-bereaved control group with depression (CD, n = 30). BRD episodes were similar to LBD and CD with respect to number of symptoms, severity, functional impairment, duration, risk for recurrence, and most risk factors and correlates. BRD, compared with both CD and LBD, were younger, exposed to fewer life events, and less likely to have experienced feelings of worthlessness. Also, caregivers of BRD showed higher rates of depression and post-traumatic stress disorder at the time of the depression compared with each of the other two groups. BRD is similar to both LBD and CD in phenomenology, course, and risk factors, supporting a diagnostic and therapeutic approach to BRD similar to that for non-bereavement-related depressions. In the bereaved child who presents with depression shortly after parental death, the clinician should also be alert to caregiver depression and post-traumatic stress disorder.

Associations Between Prolonged Grief Disorder, Depression, Posttraumatic Stress Disorder, and Anxiety in Rwandan Genocide Survivors

A number of studies have demonstrated that symptoms of prolonged grief disorder (PGD) represent a symptom cluster distinct from bereavement-related depression, anxiety, and posttraumatic stress disorder (PTSD). The aim of the present study was to confirm and extend these findings using the most recent criteria defining PGD. The authors interviewed a total of 400 orphaned or widowed survivors of the Rwandan genocide. The syndromes were strongly linked to each other with a high comorbidity. Principal axis factoring resulted in the emergence of 4 different factors. The symptoms of depression, along with the cognitive, emotional, and behavioral symptoms of PGD, loaded on the first factor, symptoms of anxiety on the second factor, symptoms of PTSD on the third factor, and the separation distress symptoms of PGD on the fourth factor. This indicates that the concept of PGD includes symptoms that are conceptually related to depression. However, the symptom cluster of separation distress presents a grief-specific dimension that may surface unrelated to depressive symptoms.

Validity of the bereavement exclusion to major depression: does the empirical evidence support the proposal to eliminate the exclusion in DSM-5?

The DSM-IV major depression “bereavement exclusion” (BE), which recognizes that depressive symptoms are sometimes normal in recently bereaved individuals, is proposed for elimination in DSM-5. Evidence cited for the BE's invalidity comes from two 2007 reviews purporting to show that bereavement-related depression is similar to other depression across various validators, and a 2010 review of subsequent research. We examined whether the 2007 and 2010 reviews and subsequent relevant literature support the BE's invalidity. Findings were: a) studies included in the 2007 reviews sampled bereavement-related depression groups most of whom were not BE-excluded, making them irrelevant for evaluating BE validity; b) three subsequent studies cited by the 2010 review as supporting BE elimination did examine BE-excluded cases but were in fact inconclusive; and c) two more recent articles comparing recurrence of BE-excluded and other major depressive disorder cases both support the BE's validity. We conclude that the claimed evidence for the BE's invalidity does not exist. The evidence in fact supports the BE's validity and its retention in DSM-5 to prevent false positive diagnoses. We suggest some improvements to increase validity and mitigate risk of false negatives.

Recent trends in the treatment of prolonged grief

Treatment for prolonged grief has been controversial. However, recent studies have clarified several key issues, offering important guidance to clinicians. This review summarizes the most recent evidence on the efficacy of grief treatments, moderators of treatment response, and new treatment approaches. Recent research findings highlight that grief therapy is efficacious when targeted to adult and child grievers with persistent and elevated levels of distress. However, when grief therapy is applied as a universal intervention, it has minimal to no benefits, either for adults or for children. Earlier intervention for children is associated with greater efficacy. In recent studies, therapies employing cognitive-behavioral techniques, such as cognitive restructuring and exposure, have shown particularly robust effects in ameliorating grief symptoms. Other intervention approaches, including pharmacotherapy, internet-based, family-based, and preventive, have shown initial promise, but insufficient data exist to validate their efficacy to date. Prolonged grief, a pattern of persistent and elevated distress following a loss, is increasingly recognized as an independent form of psychopathology that is responsive to treatment. Therapies that employ cognitive-behavioral techniques are efficacious in ameliorating the symptoms of prolonged grief and should be more widely used. However, grief therapy should not be deployed as a blanket intervention for all grievers. Antidepressant medication may serve a useful adjunctive role in grief therapy completion and in reducing bereavement-related depression.