Rona E. Pasternak

Sleep after spousal bereavement: A study of recovery from stress ☆

AIM In this study, we compared repeated measures of electroencephalographic (EEG) sleep and subjective sleep quality in nondepressed, spousally bereaved elders and a healthy control group, in order to search for possible psychobiological correlates of bereavement not confounded by concurrent major depression. METHOD Laboratory-based EEG sleep studies and measures of subjective sleep quality (Pittsburgh Sleep Quality Index [PSQI]) were repeated at 3, 6, 11, 18, and 23 months after spousal bereavement in a study group of 27 elderly volunteers. Data were compared with similar measures from a control group of 27 nonbereaved subjects recorded on three occasions 1 year apart. Repeated-measures analysis of variance (ANOVA), using age as a covariate, examined effects due to time on selected variables in the bereaved group, as well as effects due to group, time, and group-by-time interactions in the experimental and control subjects. RESULTS Bereaved and control groups showed consistent differences over time in the phasic measures of rapid eye movement (REM) sleep (higher in bereaved subjects during the first and third REM sleep periods), but were similar on all other EEG sleep measures over the 2 years of observation. The bereaved showed a small decline in the percentage of slow-wave sleep over 2 years, but measures of sleep efficiency, REM latency, and delta sleep ratio were stable and did not differ from values seen in control subjects. Bereaved and control subjects were also similar on subjective sleep quality. CONCLUSION During successful adaptation to the loss of a spouse, and in the absence of major depression, spousal bereavement is associated with elevation in the phasic measures of REM sleep but does not appear to be associated with other physiologic sleep changes typical of major depression when studied at 3 to 23 months after the event. Although this observation does not preclude the possibility of significant sleep disturbance nearer the time of the event, it suggests that preservation of normal sleep following a major negative life event may be an important correlate of the resilience seen in successful aging. The elevation in REM density may provide a psychobiological correlate of bereavement not confounded by concurrent major depression.

The Use of the Hamilton Rating Scale for Depression in Elderly Patients With Cognitive Impairment and Physical Illness

The authors performed a prospective study to assess the impact of cognitive impairment and medical burden on the Hamilton Ratingh Scale for Depression (Ham-D) scores in older psychiatric inpatients. Over 1 year, all patients admitted to an acute-care geriatric psychiatry unit were assessed with an instrument that includes an anchored version of the 17-uten Ham-D. Ham-D scores of 72 patients who met DSM-III-R criteria for a major depressive episode were compared with the scores of 31 patients who did not. The scores of a depressed and nondepressed patients were significantly different on admission but not at discharge. By contrast, the Ham-D scores of 11 depressed patients with a primary dementia did not differ either on admission or at discharge from the scores of 61 depressed patients without dementia. Controlling for psychiatric diagnosis, cognitive impairment had no significant effect on Ham-D scores. Medical burden accounted for less than 6% of the variance in admission Ham-D yields valid ratings of the severity of depressive symptoms in elderly patients with a broad range of cognitive impairment and physical illness.

Medical comorbidity in elderly psychiatric inpatients

A multidisciplinary diagnostic evaluation was performed for 868 older psychiatric inpatients during a 46-month interval. A total of 402 (46%) met DSM-III-R criteria for organic mental disorders, 329 (38%) had mood disorders, 90 (10%) had psychotic disorders, and 47 (5%) had other mental disorders or conditions. Concurrent medical problems were systematically assessed and classified according to ICD-9-CM criteria. The patients suffered from a mean of 5.6 +/- 3.1 (SD) active medical problems (range 0-18). This level of medical comorbidity was significantly greater than that of older psychiatric outpatients and comparable to that of elderly inpatients in general medical hospitals. When the effects of age and education were controlled for, there were no significant differences in mean numbers of medical problems among the four groups of psychiatric inpatients. An association of major depression with diseases of the digestive system was observed and may be related to peripheral autonomic dysregulation.

Personality Disorders in Elderly Inpatients With Major Depression

We studied 154 patients with major depression, with and without personality disorder (PD), consecutively admitted to a geriatric unit and compared their characteristics and responses to acute inpatient treatment. Thirty-seven patients (24%) met DSM-III-R criteria for PD. PD not otherwise specified and dependent PD were the most frequent PD diagnoses, whereas dramatic cluster PDs were rare. Patients with PD were significantly more likely to have had 1) recurrent depression, 2) an earlier age at first episode, and 3) a concurrent anxiety disorder. There was a higher proportion of patients with PD to have 1) never married, 2) separated or divorced, or 3) attempted suicide. During inpatient stays of similar lengths, both groups received similar treatment and improved to a similar and significant extent.

Recruitment Methods for Intervention Research in Bereavement-Related Depression: Five Years' Experience

The authors compared various strategies for recruiting elderly subjects with bereavement-related depression into a randomized clinical trial. Over 5 years, they empaneled 65 patients from a total of 441 subjects screened (14.7%). Response to media advertisements was the single most effective strategy (54% of subjects). Another effective, but labor-intensive, strategy was using letters to bereaved spouses found through newspaper obituaries (14%); another 14% were referred by friends who had seen study advertisements. Information letters to healthcare providers yielded no study participants. Pathways to study participation did not differ as a function of race or gender and did not influence study retention or remission rates. Our experience suggests that successful intake depends on a personal mode of recruitment.

A Naturalistic Study of Trazodone in the Treatment of Behavioral Complications of Dementia

Altered serotonin transmission has been associated with behavioral complications of degenerative dementia. This study examined whether trazodone, a serotonergic antidepressant, may be useful in treating behavioral syndromes associated with dementia. Twenty-two dementia patients with behavioral problems were treated with trazodone (mean daily dose 172 ± 107 mg; mean duration 20 days). Seventy of cognitive impairment and behavioral symptoms were rated using the Mini-Mental State Examination (MMSE), the Global Assessment Scale, the Hamilton Rating Scale for Depression, and the Brief Psychiatric Rating Scale. A global assessment of improvement was made by chart review. Mean scores, with the exception of the MMSE, improved modestly but significantly between admission and discharge. Chart review of target symptoms revealed that 82% of the patients showed moderate-to-marked improvement on discharge, with most able to return to their preadmission residence. Trazodone was generally well tolerated except for occasional mild sedation effects. Results suggest that trazodone may be a useful alternative to neuroleptics or benzodiazepines in treating behavior problems in some demented patients.

Brief Report: Sleep in Bereavement-Related Depression During and After Pharmacotherapy With Nortriptyline:

Our objective was to assess the effects of nortriptyline on electroencephalographic sleep and subjective sleep quality in spousally bereaved, depressed elders. Ten elderly volunteers with bereavement-related major depression had electroencephalographic sleep studies while depressed, after remission of depressive symptoms while still taking nortriptyline, and after nortriptyline discontinuation. Changes in sleep measures over time were compared both within bereaved subjects and with age– and sex-matched healthy controls. Remission of depressive symptoms while still on nortriptyline was associated with improvements in sleep quality (P < .002), rapid eye movement (REM) percent (P < .02), REM latency (P < .05), REM density (P < .05), and delta sleep ratio (P < .05). After discontinuation of nortriptyline, REM percent, REM latency, and delta ratio reverted to pretreatment levels, while sleep efficiency and sleep quality continued to show improvement coincident with sustained clinical remission. These data suggest that nortriptyline may be clinically useful in treating the sleep disturbance of elders with bereavement-related depression and that a double-blind, placebocontrolled, randomized clinical trial is warranted.

The Symptom Profile and Two-Year Course of Subsyndromal Depression in Spousally Bereaved Elders

The authors describe the symptom presentation and clinical course of subsyndromal depression in 20 bereaved elderly persons (mean age = 68.0 years) over a period of 2 years from spousal loss. Clinical ratings on measures of general functioning, depressive symptoms, sleep disturbance, medical burden, social support, and social rhythm stability were contrasted for bereaved subjects with subsyndromal depression, nondepressed bereaved subjects, and control subjects who were neither bereaved nor depressed. Subsyndromally depressed subjects had greater impairment in work and pleasure and more pronounced anxiety. Over follow-up, they showed persistently higher bereavement intensity and were more impaired than nondepressed, bereaved subjects on measures of general functioning, sleep quality, and social support, suggesting that subsyndromally depressed, bereaved persons experience greater functional impairment, worse sleep quality, less perceived interpersonal support, and more intense grieving than non-depressed, bereaved subjects up to 2 years after spousal loss.

Premorbid History of Major Depression and the Depressive Syndrome of Alzheimer's Disease

To test the hypothesis that primary degenerative dementia of the Alzheimer type (PDD-AT) may increase the likelihood of expression of a lifetime vulnerability to the development of depression, the authors compared the premorbid rates of major depression in psychiatric inpatients with dementia, with or without a concurrent syndrome of depression. A premorbid history of major depression was four times more common in patients with the depressive syndrome of PDD-AT than in PDD-AT patients without depression. The authors discuss the significance of these findings for pathophysiologic models and estimates of comorbidity of depression in PDD-AT.

MRI changes in schizophrenia in late life: a preliminary controlled study

The aim of this pilot study was to compare cerebral changes on magnetic resonance imaging (MRI) scans in elderly schizophrenic subjects with those in psychiatric and normal control subjects. We compared the MRIs of 19 subjects with schizophrenia, 19 age- and gender-matched subjects with recurrent major depression, and 19 age- and gender-matched nonpsychiatric control subjects. Deep white matter hyperintensities (DWMH) in right posterior regions were significantly more prominent in the schizophrenic group than in the two comparison groups. Total ratings of MRI abnormalities were significantly related to age in both the normal control and schizophrenic groups, but not in the depressive group. Age of onset was positively associated with total ratings in the depressive group, but not in the schizophrenic group. Thus, a subset of elderly patients with schizophrenia appear to have cerebral white matter abnormalities; such abnormalities may not be confined to late-onset schizophrenia. Systematic MRI studies of early- and late-onset schizophrenia in late life are needed to resolve this question.