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. Author manuscript; available in PMC: 2014 Jul 1.
Published in final edited form as: Death Stud. 2013 Oct 18;38(6):381–386. doi: 10.1080/07481187.2013.766658

CAN A FUNCTION-BASED THERAPY FOR SPOUSALLY BEREAVED SENIORS ACCRUE BENEFITS IN BOTH FUNCTIONAL AND EMOTIONAL DOMAINS?

Marissa K Pfoff 1, Joette R Zarotney 2, Timothy H Monk 2,*
PMCID: PMC3970179  NIHMSID: NIHMS458847  PMID: 24666144

Abstract

Late-life spousal bereavement has detrimental effects in daily functioning and emotional distress. This study tested the hypothesis that a therapy based exclusively upon functioning issues (sleep and daily lifestyle regularity) would accrue benefits in both functional and emotional domains. A comparison was made with a control therapy which concentrated on emotional issues, and specifically avoided discussing sleep or lifestyle regularity. Thirty-eight spousally bereaved seniors were randomly assigned to either functional or control therapy. Assessments were made before, during and after a 6-month, 10-session individual therapy. The functional therapy assisted in both functional and emotional domains and the hypothesis was confirmed.

Keywords: Bereavement, Sleep, Depression, Aging, Therapy

Introduction

Spousal bereavement is a devastating, life-altering event that becomes more likely with advancing age (Harlow et al., 1991; Prigerson et al., 1994). Immediately after the loss of a close loved one, the individual experiences a period of acute grief that generally includes intrusive thoughts, intense emotional distress, and withdrawal from normal daily activities (Ott et al., 2007). This period, along with the chronic grief experience that follows, may vary in length and intensity from individual to individual and often resembles clinical depression (Carr et al., 2000). About 15 to 30% of spousally bereaved adults experience clinically diagnosed depression in first year after bereavement (Zisook & Shuchter, 1993). Even bereaved persons with subclinical levels of depressive symptoms may suffer extensively, for they have a greater likelihood of functional impairment, poorer health, more physician visits and mental health counseling, and increased use of antidepressants than do non-bereaved individuals (Pasternak et al., 1992; Prigerson et al., 1994; Thompson et al., 1991).

One way the grieving process can be conceptualized is using two domains: functional impairment and emotional distress. Functional impairment can be caused by a number of factors. Bereaved older adults are often unable to concentrate on and effectively perform normal activities of daily living during the post-loss time period. They may experience sleep disruption, reduced financial security, less freedom of action, and decreased perceived personal safety, all of which can secondarily affect impaired daily functioning (Mendes de Leon et al., 1994; Harlow et al., 1991). Additionally, they may have difficulty learning to perform new tasks routinely performed by their deceased spouse (e.g., balancing a check book, doing laundry). All of these impairments can adversely affect bereaved adults in their daily lives, and need to be ameliorated.

Emotional distress is also a powerfully debilitating aspect of spousal bereavement (Ott et al., 2007). Although the symptoms of bereaved persons may not meet criteria necessary for a formal diagnosis of major depression, bereavement is frequently and persistently accompanied by anhedonia, anxiety, mild feelings of self-deprecation, sadness, and other dysphoric moods (Harlow et al., 1991; Thompson et al., 1991). Bereaved individuals often experience intrusive thoughts, yearning, pining, and feelings of grief, sometimes for months following the bereavement event (Clayton, 1990). Emotional distress can also affect functional impairment, for example impairing concentration and desire to perform activities of daily living. Conversely, functional impairment can lead to heightened emotional distress by reinforcing feelings of helplessness and self-deprecation, thus further triggering the emotional response of grief. Consequently, effective treatment for bereaved individuals should ideally both decrease emotional distress and improve functioning (Frank et al., 1997b; Shear, 2009). There is a current gap in the literature as to whether therapies that concentrate solely on functional issues can also be of benefit in the emotional domain. The present study sought to fill that gap.

Sleep disruption is a frequent functional impairment after spousal bereavement (Pasternak et al., 1992; Reynolds et al., 1992). Moreover, increased lifestyle regularity protects against depression in spousally bereaved seniors (Prigerson et al., 1996), presumably by strengthening circadian rhythms. The present study thus compared Functional Therapy (FT) concentrating on behavioral prescriptions regarding sleeping habits and daily lifestyle regularity to a non-prescriptive Control Therapy (CT), which concentrated on emotional issues, and specifically avoided discussing issues related to sleep or lifestyle regularity.

Method

Participants

A total of 38 participants (30 women, 8 men aged 60 – 84, mean 72.0 (SD = 6.9) were studied at least two months after spousal bereavement (range 76 to 498 days, mean 220 days, SD = 86 days). Participants were recruited by advertisements, flyers, personal contact and presentations at senior centers, funeral homes and churches. Once recruited, the project coordinator (JRZ) developed a strong relationship with each participant and guided them through the entire protocol. As detailed in the Appendix, the two treatment groups did not significantly differ on any variable at baseline (T1).

Materials

The Texas Revised Inventory of Grief [TRIG] (Faschingbauer et al., 1987), a standard method for evaluating grief (Boelen & van den, 2008; Dillen et al., 2008), comprises 21 first-person statements regarding the participant’s responses regarding various aspects of grief-related depression, each scored on a 5-point scale (completely false to completely true). Higher scores indicate more grief. The TRIG has been used successfully in older adults (Reynolds et al., 1997).

The Hamilton Rating Scale for Depression [HRSD] (Hamilton, 1960), the standard clinician assessing various symptoms of depression, comprises 21 questions, some scored from 0 to 2 and others from 0 to 4. Higher scores represent more severe symptoms of depression. It has been shown to be valid in older age groups (Reynolds, III et al., 1993).

The Pittsburgh Sleep Diary (PghSD) [14 night average] (Monk et al., 1994b) is a widely used, detailed sleep diary. The PghSD has one section completed in the evening describing events during the day, and another in the morning gleaning details regarding the previous night’s sleep. In addition to sleep timing, these details include time taken to fall asleep and amount of unwanted wakefulness during the night, allowing calculation of Time Spent Asleep (TSA) and Sleep Efficiency (SE). The morning section ends with three 100mm visual analogue scale ratings: Sleep quality (QUAL), alertness on awakening (ALERT) and mood (calm versus tense) on awakening (MOOD). The participant places a mark on the line to denote their current rating on that morning. The score used is the distance in mm between the mark and the left end of the line. Most research using the PghSD has been studying older adults, confirming its usefulness in such samples (e.g., Monk et al., 1991; Monk et al., 2006).

The Pittsburgh Sleep Quality Index (PSQI) score (Buysse et al., 1991), widely used for measuring sleep quality comprises 18 questions that yield a whole number total score ranging between 0 and 21, with higher scores representing more sleep problems. A score above 5 indicates poor sleep quality. The PSQI has been shown to be a useful instrument in older adult populations (Monk et al., 1991; Monk et al., 2011).

Procedure

Prior to the first therapy session, all participants received medical, psychiatric, and sleep screening. Medical screening included a complete medical history and physical examination, review of current medical records from participants’ personal physicians, and a routine laboratory panel (complete blood count, electrolytes, blood glucose, blood urea nitrogen, creatinine, liver function tests, thyroid function tests, urinalysis, and electrocardiogram). We included only participants with stable, non-acute chronic medical problems, such as well-controlled hypertension or hypothyroidism. Potential participants with acute symptoms warranting treatment were not included until a stable treatment regimen had been implemented. Psychiatric screening included the Structured Clinical Interview for DSM-IV. Participants were also required to score 24 or greater on the Folstein Mini-mental State Examination (Folstein et al., 1975) to exclude participants with dementia.

Sleep Screening included one recorded night of sleep (full montage polysomnography with oximetry) to rule out participants with an Apnea Hypopnea Index >30. Participants were also required to have sleep problems (as defined by a PSQI >6, or sleep efficiency <90). All potential participants had sleep complaints as so defined.

Participants were randomly assigned to FT (13 women, 5 men) or CT (17 women, 3 men). Both therapies involved 10 one-on-one therapy sessions spread over 6 months: weekly for the first month, every two weeks for the second month, and monthly for the next four months. The study coordinator (JRZ) facilitated all visits. Evaluations were given at baseline (T1), at three months (T2), and at six months (T3). There were 36-hour laboratory evaluations of sleep and circadian rhythms at T1 and T3 which are described elsewhere (Monk et al., 2008). At T1, T2 and T3 there was a 2-week field evaluation using the PghSD; other variables were also collected at these time points.

Therapists were three Master’s or Doctorate level trained therapists who between them gave both FT and CT. A therapist not giving the therapy performed the HRSD interview, so that the rater could be blind to treatment assignment. Much care was taken at each therapy session to ensure that no participant showed any signs of suicidal ideation, and/or needed immediate psychiatric help. Only one participant triggered the need to be seen by a psychiatrist, and this did not require removal from the study.

Functional Therapy (FT )was based upon Social Rhythm Therapy (Frank et al., 1995; Frank et al., 1997a) [but without Interpersonal Psychotherapy], augmented by education in healthy sleep practices (Buysse et al., 2007). The FT group attended one-on-one therapy sessions at which a therapist discussed a weekly activity diary. For the week before each session, the participant was required to complete a a diary of 17 daily events and the time at which they occurred (Monk et al., 1990). FT therapists taught healthy sleep practices as well as factors and behaviors influencing sleep (Buysse et al., 2007). Each therapy session started with a brief questionnaire regarding recent events that may have influenced lifestyle regularity, and ended with a Beck Depression Inventory. The main body of the session followed the SRT treatment manual involving steps towards a more regular and active lifestyle. The therapist and participant developed and set goals to increase the events completed and the regularity with which these events were done, as well as implementing healthy sleep practices, and reviewed progress made.

Control Therapy (CT) covered the occurrence and triggers of grief attacks, and was adapted from treatment for panic disorders (Shear et al., 2001; Shear & Weiner, 1997; Shear et al., 1994). Each session started with a brief questionnaire regarding recent events that may have influenced their level of grief, and ended with a Beck Depression Inventory. For the week before each session, the participant was required to complete a grief diary including the nature and frequency of particular grief triggers (times, places and events). The main body of the session followed the Emotion Focused Treatment manual as modified for bereavement (Shear et al., 2001), involving steps towards identifying the events that trigger grief attacks and exploring the emotions that result in a reflective listening approach.

Prior to statistical testing, the data were examined for normality and checked for outliers (none were found). HRSD Score, TRIG score and SE were transformed logarithmically for statistical analyses. The statistical models included covariates of age, gender and time since loss (none achieved significance).

Results

The 2 (Therapy Group) x 3 (Time) ANOVAs yielded a main effect of time on three emotion variables (TRIG, MOOD, and ALERT) and two function variables (PSQI and QUAL). In all cases, both therapy groups improved over time (i.e., lower TRIG and PSQI scores, higher QUAL, MOOD and ALERT scores) (Table 1).

Table 1.

Average +/− standard deviation for 4 emotion variables (denoted by *) and 4 function variables at T1, T2 and T3.

Variable T1 (FT) T2 (FT) T3 (FT) T1 (CT) T2 (CT) T3 (CT)
TRIG* ▼ 56 +/− 13 48 +/− 13 49 +/− 18 59 +/− 15 49 +/− 12 48 +/− 12
HRSD* ▼ 7.7 +/− 4.9 3.8 +/− 3.7 4.2 +/− 4.1 5.9 +/− 4.5 5.2 +/− 3.4 5.8 +/− 4.4
MOOD* ▲ 70 +/− 20 73 +/− 16 73 +/− 15 71+/− 13 75 +/− 12 77 +/− 11
ALERT* ▲ 69 +/− 18 72 +/− 14 73 +/− 14 69 +/− 16 74 +/− 13 76 +/− 12
PSQI ▼ 6.9 +/− 4.2 5.1 +/− 2.5 4.1 +/− 2.6 6.9 +/− 3.6 6.4 +/− 3.9 5.3 +/− 3.0
QUAL ▲ 64 +/− 20 70 +/− 15 70 +/− 15 67 +/− 14 72 +/− 12 73.2 +/− 9.4
TSA ▲ 361 +/− 61 403 +/− 55 412 +/− 52 394 +/− 63 419 +/− 61 400 +/− 66
SE (%) ▲ 85.0 +/− 6.7 86.4 +/− 8.5 85 +/− 11 83.8 +/− 6.6 83 +/− 12 88.2 +/− 6.6
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Key: FT denotes Functional Therapy; CT denotes Control Therapy; TRIG denotes Texas Revised Inventory for Grief; HRSD denotes Hamilton Rating Scale for Depression; MOOD and ALERT represent 100mm visual analogue scale ratings of mood and alertness; PSQI denotes Pittsburgh Sleep Quality Index; TSA denoted Time Spent Asleep; SE denotes Sleep Efficiency; T1, T2 and T3 denote the three time points; ▲ denotes increase good; ▼ denotes increase bad.

Also, there was a significant group-by-time interaction on one emotion variable (HRSD) and two function variables (TSA and SE). For all variables, the FT group showed better improvements over time (i.e., lower HRSD scores, higher TSA and SE values) than those of the CT group.

Discussion

The study confirmed the hypothesis that therapy which emphasizes sleep could accrue benefits in both sleep and depression. Functional therapies may be more easily administered and/or more acceptable to the bereaved senior than emotion-based ones. Thus, the present results may open new therapeutic avenues for some spousally bereaved seniors.

Prior research suggests that emotion-based interventions such as cognitive behavioral therapy and interpersonal psychotherapy can reduce the incidence of depressive disorders in at-risk individuals, such as the bereaved (Cuijpers et al., 2008). However, it was noteworthy that in our study better improvement occurred with Functional Therapy. Programs directed at spousally bereaved individuals, including self-help groups and function-based therapies to improve post-bereavement adaptation, have been shown to improve functional outcomes, but their effect on emotion variables has not been well substantiated (Schoevers et al., 2006). Our study suggests that function therapy may result in improvements in both emotion and function variables; thus filling that gap in the literature.

It is noteworthy that none of the covariates (age, gender, time since loss) showed a significant effect. The absence of statistical significance in the time since loss covariate suggests that the improvements in emotion variables and sleep quality function variables over time observed for FT and CT were not due simply to the increased time since loss from T1 through T2 to T3. That conclusion could only be answered definitively, though, with a no-treatment control group (see below).

Of necessity, the current study had a number of shortcomings. The investigation had a relatively small number of participants, and consequently the results from the study must be considered preliminary. The study participants were not blind to treatment group assignment. Participants were able to deduce which therapy they were placed in based on the types of topics that were covered during therapy. Informed consent had required that the two therapies be described to the participants at the start of the study. Depression score raters were, however, blind to therapy assignment.

As noted above, there was (because of both ethical and financial considerations) no “wait-list” control group or a placebo treatment group focusing on issues unrelated to bereavement (e.g., diet). Ethical issues were particularly salient in the latter since we were concerned about the risk of major depression and/or suicide. Monitoring of these issues would seem out of place in a placebo therapy.

Functional impairments related to sleep disturbance are common in bereaved older adults, and effective therapies to improve sleep in the bereaved population need to be developed and studied (Monk et al., 2008). The current study is the first of its kind to employ a function therapy modeled after social rhythm therapy with sleep hygiene instruction in the treatment of spousally bereaved older adults. It provides evidence supporting the use of function therapy to help seniors recover from the emotional distress and sleep disturbances that accompany the loss of a spouse. As noted above, spousal bereavement is often the most devastating event a person ever experiences. The present results can inform treatment and counseling decisions to help older women and men pass through this very difficult phase in their life.

Conclusions

Function-based therapies may help spousally bereaved seniors in both emotional and functional domains.

Table 2.

ANOVA Results: Main Effect of Time (T1, T2, T3).

Post-hoc Variable Type Variable F-Statistic P-value
T1>T2,T3 Emotion TRIG ▼ F (2,64) = 18.94 p<0.01 **
T1<T3 Emotion MOOD ▲ F (2,70) = 3.52 p=0.04 *
T1<T2,T3 Emotion ALERT ▲ F (2,70) = 5.78 p<0.01 **
T1>T2>T3 Function PSQI ▼ F (2,65) = 11.50 p<0.01 **
T1<T2,T3 Function QUAL ▲ F (2,70) = 6.59 p<0.01 **
T1>T2,T3 Emotion HRSD ▼ F (2,68) = 5.10 p<0.01 **
T1<T2,T3 Function TSA ▲ F (2,70) = 10.86 p<0.01 **
T1<T2,T3 Function SE ▲ F (2,70) = 6.92 p<0.01 **
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Key:

*

denotes p<0.05,

**

denotes p<0.01. TRIG denotes Texas Revised Inventory for Grief; QUAL, MOOD and ALERT represent 100mm visual analogue scale ratings of sleep quality, mood and alertness; PSQI denotes Pittsburgh Sleep Quality Index; HRSD denotes Hamilton Rating Scale for Depression; TSA denoted Time Spent Asleep; SE denotes % Sleep Efficiency; T1, T2 and T3 denote the three time points; ▲ denotes increase good; ▼ denotes increase bad.

Table 3.

ANOVA Results: Therapy group (ET, CT) x Time (T1, T2, T3) interaction for variables showing a significant interaction.

Significant post-hoc comparisons Variable Type Variable F-Statistic P-value
FT<CT, T1>T2,T3 Emotion HRSD▼ F (2,68) = 3.27 p=0.04 *
FT>CT, T1<T2 Function TSA ▲ F (2,70) = 3.74 p=0.03 *
FT>ET, T1<T3 Function SE ▲ F (2,70) = 5.56 p<0.01 **
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Key:

*

denotes p<0.05,

**

denotes p<0.01; HRSD denotes Hamilton Rating Scale for Depression; TSA denoted Time Spent Asleep; SE denotes % Sleep Efficiency; FT denotes Functional Therapy; CT denotes Control Therapy; T1, T2 and T3 denote the three time points; ▲ denotes increase good; ▼ denotes increase bad.

Acknowledgments

Special thanks are owed to Ms. Jean Miewald and Ms. Amy Begley for data processing and statistical help, to the study psychiatrists Drs. M. Katherine Shear and Douglas E. Moul, and to our grief therapists (Dr. Valerie Richards, Dr. Karen Woodall, and Ms. Rose Zingrone). Gratitude is also owed to our subjects for their gracious cooperation at a very difficult time in their lives. This work was primarily supported by NIA program project grant P01 AG 20677. Other support was provided by AG 13396 and a summer fellowship to the first author (NIH T32 HL082610-05 Translational Research Training in Sleep Medicine, P.I. D.J. Buysse MD). The views expressed in this paper do not necessarily reflect those of the University of Pittsburgh or the funding agencies.

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