Bupropion sustained release for bereavement: results of an open trial.

OBJECTIVE: The present study was conducted to assess whether DSM-IV-defined bereavement responds to bupropion sustained release (SR). METHOD: Twenty-two subjects who had lost their spouses within the previous 6 to 8 weeks and who met DSM-IV symptomatic/functional criteria for a major depressive episode were evaluated. Subjects completed the Hamilton Rating Scale for Depression (HAM-D), the Clinical Global Impressions scale, the Texas Revised Inventory of Grief, and the Inventory of Complicated Grief at baseline and follow-up. Subjects were treated with bupropion SR, 150 to 300 mg/day, for 8 weeks. RESULTS: Improvement was noted in both depression and grief intensity. For the intent-to-treat group. 59% experienced a reduction of > or = 50% on HAM-D scores. The correlations between changes in the HAM-D scores and the grief scale scores were high, ranging from 0.61 (p = .006) to 0.44 (p = .054). CONCLUSION: Major depressive symptoms occurring shortly after the loss of a loved one (i.e., bereavement) appear to respond to bupropion SR. Treatment of these symptoms does not intensify grief; rather, improvement in depression is associated with decreases in grief intensity. The results of this study challenge prevailing clinical wisdom that DSM-IV-defined bereavement should not be treated. Larger, placebo-controlled studies are indicated.

The psychological and physical health of hospice caregivers.

This study explores the psychological distress of caring for a dying family member and examines the differences in depression, anxiety, health, social and occupational functioning, and social support among hospice caregivers and community controls. It compares psychological functioning of spousal and adult child hospice caregivers. Caregivers of terminally ill hospice patients were assessed prior to death as a part of a longitudinal bereavement study. Caregivers reported experiencing higher levels of depression, anxiety, anger, and health problems than controls. Hospice caregiving was associated with deterioration in physical health and in social and occupational functioning. The comparisons between adult children and spouse caregivers revealed that levels of psychological and physical morbidity were very similar for the two generations of caregivers. An awareness of distress symptoms among hospice caregivers could lead to timely proactive clinical intervention that may prevent bereavement complications.

PTSD following bereavement.

Until quite recently, the only stressor considered consistent with the diagnosis of PTSD was a catastrophic, out of the ordinary, trauma that almost anyone could be expected to have a severe reaction to. Thus, PTSD was considered relatively rare among non-military populations. More recently, epidemiologic surveys have suggested that PTSD may be much more prevalent than heretofore recognized, and the DSM-IV has opened the door to a much larger variety of stressors (the "A" criterion). Yet, bereavement is not considered the type of stressor capable of producing PTSD. In this study, 350 newly bereaved widows and widowers were assessed for the prevalence of PTSD, its chronicity, comorbidity, and consequences. The diagnosis of PTSD was made on the basis of questionnaire items approximating the DSM-IV criteria for PTSD. At 2 months after the spouse's death, 10% of those whose spouses died after a chronic illness met criteria for PTSD, 9% of those whose spouses died unexpectedly met criteria, and 36% of those whose spouses died from "unnatural" causes (suicide or accident) had PTSD. Symptoms tended to be chronic in at least 40% of the subjects, almost always were associated with comorbid depression, and created substantial morbidity. The results suggested that PTSD may occur after bereavement, and, by extension, other stressors not recognized by official diagnostic systems. The "A" criterion needs further examination.

The many faces of depression following spousal bereavement.

While it is becoming increasingly clear that mood disorders tend to be chronic, intermittent and/or recurrent conditions with different manifestations over time, little is known of the variability or course of mood disorders that are associated with severe psychosocial stress. This paper reports on the prevalence and course of major, minor, and subsyndromal depressions in 328 widows and widowers followed prospectively from 2 to 25 months following one of the most disruptive of all naturally occurring stressors, spousal bereavement. The results are consistent with the following conclusions: (1) past major depression (prior to the death) predicts an increased risk for major depression following bereavement; (2) membership in any of the unipolar subgroups, in turn, predicts future depression throughout the unipolar depressive spectrum; (3) subsyndromal and minor depression stand between major depression, on the one hand, and no depression, on the other, in terms of their effects on overall adjustment to widowhood. Thus, the results support the validity of subsyndromal depression, and that the three subgroups (major, minor and subsyndromal depression) are pleiomorphic manifestations of the same unipolar depression disorder.

Dating and remarriage over the first two years of widowhood.

In this study we examined the following: (1) frequencies of remarrying or becoming romantically involved for widows and widowers during the first 2 years of widowhood; (2) attitudes toward dating and remarriage among the recently widowed, and their evolution; (3) identifiable factors which predict the development of new romances, such as sex, age, income, and level of education; and (4) the psychological well-being of those widows and widowers involved in romances compared to those who were not. The San Diego Widowhood Project was a prospective study in which 249 widows and 101 widowers who were identified through San Diego County death certificates completed detailed questionnaires 2, 7, 13, 19, and 25 months after their spouses' deaths. The main outcome measures for this study were marital and romance status, attitudes toward romance at several time points, demographic predictors of romance status, and self-reported measures of psychological well-being. By 25 months after the spouse's death 61% of men and 19% of women were either remarried or involved in a new romance. Women expressed more negative feelings about forming new romantic relationships. Younger age was a predictor of becoming involved in a new romance for women, and higher monthly income and level of education were predictors for men. Greater psychological well-being was highly correlated with being remarried or in a new romance 25 months after the spouse's death. It may be helpful for family, friends, and therapists to know that dating and remarriage are common and appear to be highly adaptive behaviors among the recently bereaved.

Bereavement, depression, and immune function.

This study evaluates whether recently widowed women who fulfill criteria for a depressive syndrome differ in their immune responses from widows who do not. Twenty-one middle-aged widows who had lost their spouses 2 months before the initial evaluation and 21 demographically matched married women were evaluated at approximately 6-month intervals for 13 months. Evaluations consisted of diagnostic interviews using the Schedule for Affective Disorders and Schizophrenia, Hamilton Rating Scale for Depression, and Beck Depression Inventory. Immune function was measured by total lymphocyte counts, natural killer (NK) cell activity, mitogen responsiveness to concanavalin A, and T-cell subsets. There were no statistically significant differences on any of the immune measures between the entire cohort of widows and control subjects. However, the subset of widows who met DSM-III-R criteria for major depressive syndromes demonstrated impaired immune function (lower NK cell activity and lower mitogen stimulation) compared with those who did not meet criteria for major depression. This study suggests a relationship between impaired immune function and depression in women experiencing the stress of bereavement.

The spectrum of depressive phenomena after spousal bereavement.

BACKGROUND: Major depressive syndromes have been found to be prevalent, disabling, and often persistent during the stress of bereavement. To add to the burden of mood changes associated with bereavement, a substantial number of bereaved individuals may suffer from depressive symptoms that do not quite equal the requisite number to meet criteria for a major depressive episode, but which also may be quite disabling, if not be actual forerunners of major depression. This study evaluates the frequency, morbidity, and stability of subsyndromal symptomatic depressions. METHOD: 350 widows and widowers were evaluated for depressive symptoms and syndromes at 2, 13, and 25 months after the death of their spouse. An additional 126 demographically similar men and women also were evaluated. In addition to the presence of a number of depressive symptoms, a number of outcome measures were obtained: use of antidepressant medication, self-perceived physical health, satisfaction with work performance, number of days of social activity per month, self-rated adjustment to widow-hood, satisfaction with ongoing interpersonal relationships, and development of a new relationship. RESULTS: Both symptomatic major depression (SMD) syndromes and subsyndromal symptomatic depression (SSD) were prevalent throughout the first 2 years of widowhood. More than one third of subjects with SSD 2 months after their spouse's death either continue to have SSD after the first full year of bereavement (28%) or worsen (9%) during that time. On most outcome measures, subjects with SSD stand between subjects with no depression and those with SMD and are significantly more likely than euthymic subjects to complain of poor physical health, be dissatisfied with their work performance, and refrain from social activity; they show a statistical trend for more disturbed ongoing relationships with friends and to be less likely to be involved in a new romantic relationship. CONCLUSION: Although heretofore relatively unrecognized, SSDs are prevalent, often persist, and are associated with substantial morbidity in widows and widowers during the first 2 years of bereavement.

Reported suicidal behavior and current suicidal ideation in a psychiatric outpatient clinic.

One thousand consecutive intakes at an outpatient psychiatric clinic were screened for past suicide attempts and present suicidal ideation and diagnosed using DSM-III-R criteria. A full range of thoughts about death and suicide were prevalent in all diagnostic groups. Over one-third of patients with major depression and borderline personality disorder had actual plans to kill themselves, and over two-thirds of patients with borderline personality disorder had made one or more suicide attempts.

Uncomplicated bereavement.

BACKGROUND: This paper evaluates the validity of the distinction between the depressive syndrome associated with uncomplicated bereavement and major depression by following the course, associated symptoms, and impairment associated with depressive episodes occurring in bereaved widows and widowers. METHODS: Two hundred fifty-nine widows/widowers were interviewed and completed the San Diego Widowhood Questionnaire at 2, 13, and 25 months after the deaths of their spouses. Subjects were diagnosed as depressed or not depressed on the basis of DSM-III-R criteria. RESULTS: Fifty-nine (23%) of subjects met symptomatic criteria for a major depressive syndrome at 2 months. Because of the close proximity to the death, the symptoms in these 59 subjects were considered to represent "uncomplicated bereavement" rather than major depression. Compared with widows/widowers who did not manifest an early depressive syndrome, the "depressed" group was more likely to have past or family histories of major depression, present treatment with antidepressant medication, feelings of worthlessness and suicidal ideation, poor health and job satisfaction, and major depression 1 and 2 years later. CONCLUSION: When a full depressive syndrome is present soon after the death of a spouse, the symptoms may often be prolonged and associated with substantial morbidity. We recommend that future conceptualizations of uncomplicated bereavement exclude persons with major depressive episodes.

Aging and bereavement.

This paper compares the grief responses of widows and widowers of different age groups over the 1st year of bereavement. The results strongly suggest that older widows and widowers perceive themselves as adjusting better to their loss and suffering from less depression and fewer anxiety symptoms than their younger counterparts. Furthermore, the oldest widows/widowers demonstrate the most consistent improvement in their levels of distress over time. Thus, when it comes to coping, older persons are not at the disadvantage that certain stereotypes and "clinical wisdoms" have previously suggested. Seniors are every bit as adaptive and able to cope with the severest forms of stress as anyone else, and they are, if anything, less prone to depression than are younger individuals.

Early psychological reaction to the stress of widowhood.

As part of an ongoing panel study, we evaluated 350 widows and widowers at 2 and 7 months following the loss of their spouses. In general, no consistent progression of grief resolution was noted. At 7 months, grief-specific feeling states remain remarkably similar to what they were at 2 months. Anxiety levels remain high and change little from 2 to 7 months. When changes do occur, they are not unidirectional. For example, subjects are about as likely to increase as to decrease their drinking or smoking. Furthermore, depression scores at month 2 correlate well with depression and anxiety scores at month 7. Over 50% of the subjects were depressed at some time during the study period, but the depression could initially manifest itself at any time during this period. Despite the presence of psychological distress in a significant minority, most bereaved individuals report good health, satisfactory work performance and good adjustment to widowhood.

Depression through the first year after the death of a spouse.

OBJECTIVE: This study assesses the frequency of depressive syndromes during the first 13 months after the death of a spouse. METHOD: Men and women whose spouses had recently died were identified through death certificate records. These subjects completed a multidimensional questionnaire and were interviewed 7-8 weeks (2 months) after the death. Follow-up questionnaires were completed 7 and 13 months after the death. The questionnaires contained specific items corresponding to DSM-III-R criteria for depressive episodes as well as other widely used measures of depressive symptoms such as the Zung Depression Scale and the Hopkins Symptom Checklist. RESULTS: Eighty-four (24%) of 350 widows and widowers met criteria for depressive episodes at 2 months, 72 (23%) of 308 did so at 7 months, and 46 (16%) of 286 did so at 13 months. At each time period, the prevalence was substantially higher than the 4% rate of depressive episodes observed in a comparison group of 126 subjects whose spouses were still living. Widows and widowers most likely to meet criteria for depressive episodes 13 months after the bereavement were younger, had past histories of major depression, were still grieving 2 months after the loss, and met DSM-III-R criteria for depressive episodes 2 and/or 7 months after the death. CONCLUSIONS: Depressive episodes are common after the death of a spouse. Clinicians should maintain a high index of suspicion for the possibility of depression, particularly in young widows and widowers who have a past history of depression or who experience a full depressive syndrome soon after the loss.

Anxiety and bereavement.

The results reported here support the observations that anxiety symptoms are prevalent, often severe, and may last through at least the first seven months of bereavement. In addition, many widows and widowers are prescribed, or take on their own, medications geared to attenuate the discomfort of these symptoms. A preliminary profile of persons most likely to suffer substantial and relatively prolonged anxiety after the stress of widowhood includes: someone who is young, female and experiences a loss of income related to the death; someone who lacks social support; and someone who experiences acute grief, a depressive syndrome and anxiety symptoms at the end of two months. We hope to build on this profile over time, so that vulnerable individuals might be identified and offered early intervention.

Predictors of psychological reactions during the early stages of widowhood.

In conclusion, this preliminary study of 2-month outcome to spousal bereavement found (1) most widows and widowers had social supports and lack of such supports was not related to outcome; (2) a clinical depressive syndrome was common, and a history of past depressions was associated with poor outcome; (3) more subjects increased alcohol consumption and cigarette use after their loss than decreased their use, but a past history of problems with alcohol was not related to outcome; (4) female, younger, and poorer survivors had the worst outcomes; (5) more disturbed marital relationships correlated highly with poor outcomes; (6) when the deceased spouse died without warning and without a prolonged illness, the survivor was more apt to have a difficult adjustment; and (7) the continued presence of active grief was associated with increased levels of anxiety, somatization, interpersonal sensitivity, and depression. Finally, the results of the study show that self-rated overall adjustment is highly correlated with other, standardized psychometric scale scores as well as with grief-specific affects. Assessing global adjustment may, therefore, be a simple, time-efficient, yet meaningful area of inquiry in clinical situations. This is the first in a series of studies on this widowed population. Future reports will focus on other dimensions of widowhood, changes over long-term follow-up, and the validity and reliability of the Widowhood Questionnaire.

The dexamethasone suppression test in acute grief.

Nineteen recently widowed women and men were given diagnostic interviews, psychometric evaluations, and dexamethasone suppression tests (DSTs). While 58% of the subjects (N = 11) met Research Diagnostic Criteria for depression, only 16% (N = 3) were nonsuppressors on the DST. In this population, nonsuppression was related more to levels of anxiety than to depression.

Time course of spousal bereavement.

This article reports the results of a survey on 300 widows and widowers who experienced spousal bereavement weeks to years prior to the study, and discusses the symptoms, syndromes, and behaviors seen at various time intervals. Although the reactions to widowhood were highly variable and individual, it was clear that for many widows and widowers, the time course of grief was much more prolonged than generally expected. Dysphoric feelings, symptoms, and behaviors were most frequent during the first year of bereavement, but often remained present even four or more years after the death. In particular, anger, guilt, depression, and anxiety tended to diminish over time, but not to statistically significant degrees. Many widows and widowers never fully accepted the fact of their spouses' deaths and maintained a continuing relationship with their deceased spouses, in their own ways, indefinitely. The implications of these findings and directions for future research are discussed.