Prospective study of early bereavement on psychological and behavioural cardiac risk factors

Impact of hospitalisation on behavioural and physiological stress responses associated with cardiovascular risk in visiting family members

BACKGROUND

The hospitalisation of a patient in intensive care impacts the psychological health of family members, with a high prevalence of anxiety, depression, and post-traumatic stress symptoms reported among families of critically ill patients. Understanding of the behavioural and physiological impact is limited and presents a new area of focus.

OBJECTIVES

The objective of this study was to evaluate behavioural and physiological stress responses of visiting family members following hospitalisation of their adult relative.

METHODS

Prospective longitudinal evaluation included 40 family members of adult patients with admission to intensive or coronary care in a large tertiary care metropolitan hospital. Assessments were conducted at three timepoints: in-hospital within 1 week of admission and 2 weeks and 3 months post discharge. Assessments included duration and quality of sleep (self-reported and actigraphy measured), physical activity, dietary and alcohol patterns, resting heart rate and blood pressure, and morning blood cortisol and lipid levels. Assessment of a reference group of 40 non-hospital-exposed control participants was also conducted.

RESULTS

At the in-hospital assessment, study participants reported lower sleep time, altered 24-h physical activity patterns, reduced dietary and alcohol intake, and higher systolic and diastolic blood pressure than a nonhospitalised reference group. Compared to in-hospital assessment, these altered behavioural and physiological responses improved over time except for systolic blood pressures which remained unchanged at 3 months post family member discharge.

CONCLUSION

Hospitalisation is associated with altered behavioural and physiological responses in family members. These findings contribute to understanding of the impact of unexpected hospitalisation on family members' cardiovascular risk factors and provide insights into potential mechanisms for the proposed increased risk during this time. Elevated systolic blood pressure at 3 months post discharge suggests a prolonged cardiovascular stress response in many family members of critical care patients that requires further study, with a focus on contributing and potential modifiable factors.

Grieving as a form of learning: Insights from neuroscience applied to grief and loss

Recent grief research suggests that the influential cognitive stress theory should be updated with evidence from cognitive neuroscience. Combining human and animal neuroscience with attachment theory, we propose that semantic knowledge of the everlasting nature of the attachment figure and episodic, autobiographical memories of the death are in conflict, perhaps explaining the duration of grieving and generating predictions about complications in prolonged grief disorder (PGD). Our gone-but-also-everlasting model emphasizes that grieving may be a form of learning, requiring time and experiential feedback. Difficulties before loss, such as spousal dependency or pre-existing hippocampal volume, can prolong learning and predict PGD. Complications such as avoidance, rumination, and stress-induced hippocampal atrophy may also develop after loss and create functional or structural mechanisms predicting PGD.

The brain oxytocin and corticotropin-releasing factor systems in grieving mothers: What we know and what we need to learn

The bond between a mother and her child is the strongest bond in nature. Consequently, the loss of a child is one of the most stressful and traumatic life events that causes Prolonged Grief Disorder in up to 94 % of bereaved parents. While both parents are affected, mothers are of higher risk to develop mental health complications; yet, very little research has been done to understand the impact of the loss of a child, stillbirth and pregnancy loss on key neurobiological systems. The emotional impact of losing a child, e.g., Prolonged Grief Disorder, is likely accompanied by dysregulations in neural systems important for mental health. Among those are the neuropeptides contributing to attachment and stress processing. In this review, we present evidence for the involvement of the brain oxytocin (OXT) and corticotropin-releasing factor (CRF) systems, which both play a role in maternal behavior and the stress response, in the neurobiology of grief in mothers from a behavioral and molecular point of view. We will draw conclusions from reviewing relevant animal and human studies. However, the paucity of research on the tragic end to an integral bond in a female's life calls for the need and responsibility to conduct further studies on mothers experiencing the loss of a child both in the clinic and in appropriate animal models.

Death of an offspring and parental risk of ischemic heart diseases: A population-based cohort study

BACKGROUND

The death of a child is an extreme life event with potentially long-term health consequences. Knowledge about its association with ischemic heart diseases (IHDs) and acute myocardial infarction (AMI), however, is very limited. We investigated whether the death of an offspring is associated with the risk of IHD and AMI.

METHODS AND FINDINGS

We studied parents of live-born children recorded in the Danish (1973 to 2016) and the Swedish (1973 to 2014) Medical Birth Registers (n = 6,711,952; mean age at baseline 31 years, 53% women). We retrieved information on exposure, outcomes, and covariates by linking individual-level information from several nationwide registers. We analyzed the abovementioned associations using Poisson regression. A total of 126,522 (1.9%) parents lost at least 1 child during the study period. Bereaved parents had a higher risk of IHD and AMI than the nonbereaved [incidence rate ratios (IRRs) (95% confidence intervals (CIs)): 1.20 (1.18 to 1.23), P < 0.001 and 1.21 (1.17 to 1.25), P < 0.001, respectively]. The association was present not only in case of losses due to CVD or other natural causes, but also in case of unnatural deaths. The AMI risk was highest in the first week after the loss [IRR (95% CI): 3.67 (2.08 to 6.46), P < 0.001], but a 20% to 40% increased risk was observed throughout the whole follow-up period. Study limitations include the possibility of residual confounding by socioeconomic, lifestyle, or health-related factors and the potentially limited generalizability of our findings outside Scandinavia.

CONCLUSIONS

The death of an offspring was associated with an increased risk of IHD and AMI. The finding that the association was present also in case of losses due to unnatural causes, which are less likely to be confounded by cardiovascular risk factors clustering in families, suggests that stress-related mechanisms may also contribute to the observed associations.

Acute and long-term grief reactions and experiences in parentally cancer-bereaved teenagers

Background

Previous research shows that many cancer-bereaved youths report unresolved grief several years after the death of a parent. Grief work hypothesis suggests that, in order to heal, the bereaved needs to process the pain of grief in some way. This study explored acute grief experiences and reactions in the first 6 months post-loss among cancer-bereaved teenagers. We further explored long-term grief resolution and potential predictors of having had “an okay way to grieve” in the first months post-loss.

Methods

We used a population-based nationwide, study-specific survey to investigate acute and long-term grief experiences in 622 (73% response rate) bereaved young adults (age > 18) who, 6–9 years earlier, at ages 13–16 years, had lost a parent to cancer. Associations were assessed using bivariable and multivariable logistic regression.

Results

Fifty-seven per cent of the participants reported that they did not have a way to grieve that felt okay during the first 6 months after the death of their parent. This was associated with increased risk for long-term unresolved grief (odds ratio (OR): 4.32, 95% confidence interval (CI): 2.99–6.28). An association with long-term unresolved grief was also found for those who reported to have been numbing and postponing (42%, OR: 1.73, 95% CI: 1.22–2.47), overwhelmed by grief (24%, OR: 2.02, 95% CI: 1.35–3.04) and discouraged from grieving (15%, OR: 2.68, 95% CI: 1.62–4.56) or to have concealed their grief to protect the other parent (24%, OR: 1.83, 95% CI: 1.23–2.73). Predictors of having had an okay way to grieve included being male, having had good family cohesion, and having talked about what was important with the dying parent.

Conclusion

More than half of the cancer-bereaved teenagers did not find a way to grieve that felt okay during the first 6 months after the death of their parent and the acute grief experiences and reaction were associated with their grief resolution long-term, i.e. 6–9 years post-loss. Facilitating a last conversation with their dying parent, good family cohesion, and providing teenagers with knowledge about common grief experiences may help to prevent long-term unresolved grief.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00758-7

Psychological responses and coping behaviour of visiting family members during and following unplanned hospital admission

AIMS

To describe the psychological symptoms and coping behaviours of visiting family members following the unplanned hospitalisation of their relative.

BACKGROUND

Hospitalisation of a patient is recognised as a stressful time for visiting family members, who experience psychological morbidity and elevated health risk.

DESIGN

This prospective longitudinal evaluation included 40 family members of patients with unplanned admission to coronary or intensive care. Assessments were conducted at 3 timepoints: in-hospital within 1 week of admission and again at 2 weeks and 3 months post-discharge. Measures included symptoms of anxiety, depression, and anger, coping strategies and social support. This paper adhered to STROBE guidelines.

RESULTS

At the initial in-hospital assessment study participants reported higher anxiety, depression and anger symptoms levels compared to community matched control participants. Compared to in-hospital assessment, anxiety and depression levels were lower at 2 weeks and 3 months following hospital discharge. The use of active coping and the use of religion during early hospitalisation were associated with higher anxiety and depression symptoms at 3 months post-discharge. Conversely, use of instrumental support (getting help and advice from others), planning and venting during early hospitalisation were associated with lower depression symptoms at 3 months. Venting during the hospitalisation period was also associated with lower anxiety symptoms at 3 months.

CONCLUSION

Results demonstrate the significant psychological impact of unplanned hospitalisation on visiting family members both during and following hospitalisation. The finding that prolonged psychological response is associated with individual coping strategies employed in the early hospitalised period informs potential preventative approaches for family members at risk of prolonged psychological morbidity following hospitalisation of their loved one.

RELEVANCE TO CLINICAL PRACTICE

The reported psychological impact of hospitalisation on family members provides a strong imperative for nurses and health professionals to provide early individualised support to reduce the risk of long-term psychological morbidity.

The longitudinal association of actigraphy-estimated sleep with grief in middle-aged and elderly persons

Most people experience grief after a loss, about 10% develop complicated grief, often accompanied by sleep complaints. Yet, the role of objectively estimated poor sleep remains unclear. Therefore, we assessed the cross-sectional and longitudinal association of actigraphy-estimated sleep with grief. We included 1,776 participants (mean age: 61.8 ± 8.9 years, 55% women) of a prospective population-based cohort. Of 1,471 participants (83%) repeated measures of grief were available (median follow-up 6 years, inter quartile range 5.6-6.3). At baseline, sleep was objectively estimated using actigraphy (mean duration 6.0 ± 0.8days). At baseline and follow-up, participants were asked about significant losses and completed the Dutch Inventory of Complicated Grief (17 items, cut-off ≥22). At baseline 1,521 (86%) participants experienced no grief, 44 (2%) acute grief (<6 months, any grief score), 158 (9%) non-complicated grief (≥6 months, grief score<22), and 53 (3%) complicated grief (≥6 months, grief score≥22). In those indicating any grief (n = 255), low sleep efficiency (B = -0.16, 95%CI = -0.30;-0.02), long sleep onset latency (B = 0.07, 95%CI = 0.01; 0.14), and long wake after sleep onset (B = 0.06, 95%CI = 0.01; 0.10) were cross-sectionally associated with more grief symptoms. Over time, those with a short total sleep time (OR = 0.59, 95%CI = 0.39; 0.91), low sleep efficiency (OR = 0.95, 95%CI = 0.91; 0.99), long sleep onset latency (OR = 1.02, 95%CI = 1.00; 1.04), and long wake after sleep onset (OR = 1.02, 95%CI = 1.00; 1.03) at baseline more often experienced complicated grief than non-complicated grief at follow-up. This study suggests that objectively estimated poor sleep is associated with grief over time. Poor sleep might not only accompany grief, but also be a risk factor for developing complicated grief after a loss.

Loneliness, Circulating Endocannabinoid Concentrations, and Grief Trajectories in Bereaved Older Adults: A Longitudinal Study

Background: Loneliness is one of the most distressing grief symptoms and is associated with adverse mental health in bereaved older adults. The endocannabinoid signaling (ECS) system is stress-responsive and circulating endocannabinoid (eCB) concentrations are elevated following bereavement. This study examined the association between loneliness and circulating eCB concentrations in grieving older adults and explored the role of eCBs on the association between baseline loneliness and grief symptom trajectories. Methods: A total of 64 adults [grief with high loneliness: n = 18; grief with low loneliness: n = 26; and healthy comparison (HC): n = 20] completed baseline clinical assessments for the UCLA loneliness scale. In grief participants, longitudinal clinical assessments, including the Inventory of Complicated Grief and 17-item Hamilton Depression Rating scales, were collected over 6 months. Baseline circulating eCB [N-arachidonoylethanolamine (AEA) and 2-arachidonoylglycerol (2-AG)] concentrations were quantified in the serum using isotope dilution, liquid chromatography-mass spectrometry; cortisol concentrations were measured in the same samples using radioimmunoassay. Results: Circulating AEA concentrations were higher in severely lonely grieving elders than in HC group; cortisol concentrations were not different among the groups. Cross-sectionally, loneliness scores were positively associated with AEA concentrations in grievers; this finding was not significant after accounting for depressive symptom severity. Grieving individuals who endorsed high loneliness and had higher 2-AG concentrations at baseline showed faster grief symptom resolution. Conclusions: These novel findings suggest that in lonely, bereaved elders, increased circulating eCBs, a reflection of an efficient ECS system, are associated with better adaptation to bereavement. Circulating eCBs as potential moderators and mediators of the loneliness-grief trajectory associations should be investigated.

Parental mortality following the loss of a child to a drug-related death

BACKGROUND

The drug-related death of a child has been linked to higher prevalence of complicated grief and mental health problems than bereavement by other causes of death. Whether this leads to an increased risk of mortality following the loss has not yet been examined.

METHODS

Employing register data covering the years 1986-2015 and encompassing the entire Norwegian population, parents with at least one child aged 15 or older were analyzed using Cox regression. Drug-death bereaved parents were compared with both non-bereaved parents and parents bereaved by other causes of death.

RESULTS

Parents bereaved by a drug-related death generally had a higher natural cause mortality throughout the follow-up. Drug-death bereaved parents had a particularly high external cause mortality in the first 2 years subsequent to bereavement when compared with non-bereaved parents (mothers: hazard ratio 4.82, 95% CI = 3.11-7.47; fathers: hazard ratio 2.50, 95% CI = 1.57-3.97). There was also an elevated, but significantly lower mortality risk from external causes 2 to 10 years subsequent to bereavement. This indicates that the associations observed are not solely due to selection.

CONCLUSIONS

Parents bereaved by the drug-related death of a child had a higher mortality than both non-bereaved parents and parents bereaved by other causes of death. Drug-death bereaved parents had particularly high external cause mortality. Our results indicate that losing a child to a drug-related death is associated with adverse health outcomes and that these might be more severe than bereavement due to other causes of death.

Neuroendocrine mechanisms of grief and bereavement: A systematic review and implications for future interventions

Bereavement is associated with many negative behavioural, psychological and physiological consequences and leads to an increased risk of mortality and morbidity. However, studies specifically examining neuroendocrine mechanisms of grief and bereavement have yet to be reviewed. This systematic review is a synthesis of the latest evidence in this field and aims to draw conclusions about the implications of neurobiological findings on the development of new interventions. PRISMA guidelines for systematic reviews were used to search for articles assessing neuroendocrine correlates of grief. Findings were qualitatively summarised. The National Heart, Lung, and Blood Institute Study Assessment Tool was used to assess the quality of the included studies. Out of 460 papers, 20 met the inclusion criteria. However, most were of fair quality only. As a neuroendocrine marker, the majority of the studies reported cortisol as the outcome measure and found elevated mean cortisol levels, flattened diurnal cortisol slopes and higher morning cortisol in bereaved subjects. Cortisol alterations were moderated by individual differences such as emotional reaction to grief, depressive symptoms, grief severity, closeness to the deceased and age or gender. Research on neuroendocrine mechanisms of grief is still in its early stages regarding grief measures and the use and timing of neuroendocrine assessments. Most of the studies focus on cortisol as outcome, and only limited data exist on other biomarkers such as oxytocin. Future research might consider assessing a broader range of neuroendocrine markers and use longitudinal designs with a focus on the psychobiological reactions to loss. Based on this, individually tailored psychosocial interventions, possibly in the palliative care context, might be developed to prevent prolonged grief disorder.

Sleep disturbances in bereavement: A systematic review

Severe, persistent and disabling grief occurs among a sizable minority experiencing bereavement, with diagnostic manuals newly including complicated grief (CG) disorders. Sleep disturbances/disorders have been established as worsening affective and stress-related conditions. However, the role of sleep difficulties in bereavement and CG has not received similar scientific attention. We therefore conducted a systematic review with narrative syntheses on this topic to clarify the role of sleep in bereavement (PROSPERO: CRD42018093145). We searched PubMed, Web of Science and PsychInfo for peer-reviewed English-language articles including (at least one) bereaved sample and sleep disturbance measure. We identified 85 articles on 12.294 participants. We answered seven pre-defined research questions demonstrating: high prevalence of sleep disturbances in bereavement; positive associations of grief intensity with sleep difficulties; preliminary indications of risk factors of post-loss sleep disturbance; higher prevalence of sleep disturbances in CG, enhanced by psychiatric comorbidity (i.e., depression); and initial evidence of causal relationships between (complicated) grief and sleep. Grief therapy partly improves sleep difficulties, yet no intervention studies have specifically targeted sleep problems in bereaved persons. Causal relationships between sleep and grief require further examination in intensive longitudinal investigations, including randomized trials, thereby clarifying whether treating sleep problems enhances CG treatment effects.

The effect of metoprolol and aspirin on cardiovascular risk in bereavement: A randomized controlled trial

BACKGROUND

Bereavement is associated with an increased risk of cardiovascular disease; however, no reports exist of interventions to reduce risk. In a randomized, double-blind, placebo-controlled trial of 85 recently bereaved participants, we determined whether β-blocker (metoprolol 25 mg) and aspirin (100 mg) reduce cardiovascular risk markers and anxiety, without adversely affecting bereavement intensity.

METHODS

Participants were spouses (n = 73) or parents (n = 12) of deceased from 5 hospitals in Sydney, Australia, 55 females, 30 males, aged 66.1 ± 9.4 years. After assessment within 2 weeks of bereavement, subjects were randomized to 6 weeks of daily treatment or placebo, and the effect evaluated using ANCOVA, adjusted for baseline values (primary analysis).

RESULTS

Participants on metoprolol and aspirin had lower levels of home systolic pressure (P = .03), 24-hour average heart rate (P < .001) and anxiety (P = .01) platelet response to arachidonic acid (P < .001) and depression symptoms (P = .046) than placebo with no difference in standard deviation of NN intervals index (SDNNi), von Willebrand Factor antigen, platelet-granulocyte aggregates or bereavement intensity. No significant adverse safety impact was observed.

CONCLUSIONS

In early bereavement, low dose metoprolol and aspirin for 6 weeks reduces physiological and psychological surrogate measures of cardiovascular risk. Although further research is needed, results suggest a potential preventive benefit of this approach during heightened cardiovascular risk associated with early bereavement.

Grief: A Brief History of Research on How Body, Mind, and Brain Adapt

OBJECTIVE

Using an integrative view of psychology, neuroscience, immunology, and psychophysiology, the present review of literature curates the findings that have had an impact on the field of bereavement research and shaped its development.

METHODS

Beginning with pivotal systematic descriptions of medical and psychological responses to the death of a loved one by Lindemann in the mid-1940s, this selective review integrates findings in bereavement research from studies that investigate medical outcomes after loss, their psychological predictors, and biopsychosocial mechanisms.

RESULTS

Morbidity and mortality after the death of a loved one have long been a topic of research. Early researchers characterized somatic and psychological symptoms and studied immune cell changes in bereaved samples. More recent research has repeatedly demonstrated increased rates of morbidity and mortality in bereaved samples, as compared with married controls, in large epidemiological studies. Recent developments also include the development of criteria for prolonged grief disorder (also termed complicated grief). Newer methods, including neuroimaging, have observed that the greatest impact of the death of a loved one is in those who have the most severe psychological grief reactions. Research addressing the mechanisms tying bereavement to medical outcomes is relatively scarce, but differences in rumination, in inflammation, and in cortisol dysregulation between those who adapt well and those who do not have been offered with some evidence.

CONCLUSIONS

Recommendations to propel the field forward include longitudinal studies to understand differences between acute reactions and later adaptation, comparing samples with grief disorders from those with more typical responses, and integrating responses in brain, mind, and body.

Animal models of social stress: the dark side of social interactions

Social stress occurs in all social species, including humans, and shape both mental health and future interactions with conspecifics. Animal models of social stress are used to unravel the precise role of the main stress system - the HPA axis - on the one hand, and the social behavior network on the other, as these are intricately interwoven. The present review aims to summarize the insights gained from three highly useful and clinically relevant animal models of psychosocial stress: the resident-intruder (RI) test, the chronic subordinate colony housing (CSC), and the social fear conditioning (SFC). Each model brings its own focus: the role of the HPA axis in shaping acute social confrontations (RI test), the physiological and behavioral impairments resulting from chronic exposure to negative social experiences (CSC), and the neurobiology underlying social fear and its effects on future social interactions (SFC). Moreover, these models are discussed with special attention to the HPA axis and the neuropeptides vasopressin and oxytocin, which are important messengers in the stress system, in emotion regulation, as well as in the social behavior network. It appears that both nonapeptides balance the relative strength of the stress response, and simultaneously predispose the animal to positive or negative social interactions.

Communication Disparity Between the Bereaved and Others: What Hurts Them and What Is Unhelpful? A Nationwide Study of the Cancer Bereaved

CONTEXT

The importance of communication between the cancer bereaved and others has been emphasized, but little is known about the more problematic aspects of this communication such as "unhelpful communication."

OBJECTIVES

The aim of this study was to establish which types of communication are perceived by the bereaved to be unhelpful.

METHODS

We conducted a cross-sectional, anonymous, nationwide survey at 103 certified hospice facilities/palliative care units in Japan.

RESULTS

A total of 630 (63%) bereaved responded. Over 60% of the bereaved experiencing such communication considered it to be unhelpful, with the most unhelpful communication being "They emphasized the positive aspects of death." Thirteen items related to communication were separated into two factors ("advice for recovery" and "comments on cancer") by factor analysis. "Comments on cancer" were more unhelpful to them and were more often provided by those around them. With regard to "advice for recovery," losing a spouse was a stronger predictor with a higher odds ratio for communication distress than losing a parent (odds ratio, 5.34; 95% CI, 1.63-17.57).

CONCLUSION

A number of the bereaved have experienced unhelpful communication regarding advice on dealing with bereavement and cancer. To prevent putting an unnecessary burden on the bereaved with such unhelpful communication, it is essential to understand problematic aspects. Even when people have no intention of hurting the bereaved, some communication may do so. Communication with the bereaved is also a core clinical skill required by health professionals, and further efforts are required to support the grieving process.

The bidirectional relationship between sleep duration and depression in community-dwelling middle-aged and elderly individuals: evidence from a longitudinal study

BACKGROUND

There are several studies that have focused on the relationship between sleep duration and depression, however, only a few prospective studies have centered on the bidirectional relationship between them. This four-year longitudinal study aimed to identify the association between sleep duration and depression in community-dwelling mid-age and elderly individuals.

METHODS

10,704 participants from the China Health and Retirement Longitudinal Study (CHARLS) were included for baseline and four-year follow up. Of these individuals, 7866 and 2956 were used to identify the effects of sleep duration on onset and recurrent depression respectively. 4504 individuals with normal sleep duration at baseline were included to examine the effects of depression on changes of sleep time. The 10-item version of the Centre for Epidemiological Studies Depression scale (CESD-10) was used to access depressive symptoms, as well sleep duration was self-reported.

RESULTS

Participants with short sleep duration (<5 and 5-6 h) had a higher risk of depression onset (OR 1.69 [1.36-2.11], 1.48 [1.19-1.84]) and recurrent depression (OR 1.44 [1.12-1.86], 1.32 [1.00-1.74]) compared to participants with normal sleep durations (7-8 h). Long sleep durations (>9 h) had no significant risks for depression. Males and the elderly (over 60 years-old) were more sensitive to short sleep durations and experienced a higher incidence of depression. Individuals with depression were more likely to have short sleep durations instead of long ones (RRR 1.20 [1.02-1.43]).

CONCLUSIONS

The present study identified the bidirectional relationship between sleep duration and depression. Short sleep durations were a risk factor for the onset and recurrent depression. Conversely, depression induced short sleep durations rather than excessive sleep durations. Future studies need to focus on identifying the mechanism between sleep duration and depression, and develop additional evidence-based cost-effective interventions to prevent depression and sleep problems.

Widowhood and severity of coronary artery disease: a multicenter study

OBJECTIVES

The aim of this study was to assess the association of widowhood with the severity and extent of coronary artery disease (CAD), and whether it is modified by sex or socioeconomic status.

PATIENTS AND METHODS

A total of 1068 patients undergoing coronary angiography at five centers in Saudi Arabia and the United Arab Emirates were included in the study. CAD was defined as more than 70% lumen stenosis in a major epicardial vessel or more than 50% in the left main coronary artery. Multivessel disease was defined as more than one diseased vessel.

RESULTS

Of 1068 patients, 65 (6%) were widowed. Widowed patients were older (65±15 vs. 59±12), more likely to be female (75 vs. 25%), less likely to be smokers (18 vs. 47%), of lower economic and education status, and more likely to have undergone coronary angiography for urgent/emergent indications (75 vs. 61%) (P<0.05 for all). There was a significant association between widowhood and the number of coronary arteries with more than 70% lumen stenosis. Consequently, such a high degree of lumen stenosis in those who were widowed was more likely to require coronary artery bypass graft surgery (38 vs. 16%; P<0.01). After adjusting for baseline differences, widowhood was associated with a significantly higher odds of CAD [adjusted odds ratio (OR) 3.6; 95% confidence interval (CI) 1.2-10.5] and multivessel disease (adjusted OR 4.6; 95% CI 2.2-9.6), but not left main disease (adjusted OR 1.3; 95% CI 0.5-3.1). All associations were consistent in men and women and not modified by age, community setting (urban vs. rural), employment, income, or educational levels (Pinteraction>0.1 for all).

CONCLUSION

Widowhood is associated with the severity and extent of CAD. The association is not modified by sex or socioeconomic status.

Blocking metabotropic glutamate receptor subtype 5 relieves maladaptive chronic stress consequences

Etiology and pharmacotherapy of stress-related psychiatric conditions and somatoform disorders are areas of high unmet medical need. Stressors holding chronic plus psychosocial components thereby bear the highest health risk. Although the metabotropic glutamate receptor subtype 5 (mGlu5) is well studied in the context of acute stress-induced behaviors and physiology, virtually nothing is known about its potential involvement in chronic psychosocial stress. Using the mGlu5 negative allosteric modulator CTEP (2-chloro-4-[2-[2,5-dimethyl-1-[4-(trifluoromethoxy)phenyl]imidazol-4yl]ethynyl]pyridine), a close analogue of the clinically active drug basimglurant - but optimized for rodent studies, as well as mGlu5-deficient mice in combination with a mouse model of male subordination (termed CSC, chronic subordinate colony housing), we demonstrate that mGlu5 mediates multiple physiological, immunological, and behavioral consequences of chronic psychosocial stressor exposure. For instance, CTEP dose-dependently relieved hypothalamo-pituitary-adrenal axis dysfunctions, colonic inflammation as well as the CSC-induced increase in innate anxiety; genetic ablation of mGlu5 in mice largely reproduced the stress-protective effects of CTEP and additionally ameliorated CSC-induced physiological anxiety. Interestingly, CSC also induced an upregulation of mGlu5 in the hippocampus, a stress-regulating brain area. Taken together, our findings provide evidence that mGlu5 is an important mediator for a wide range of chronic psychosocial stress-induced alterations and a potentially valuable drug target for the treatment of chronic stress-related pathologies in man.

Relief from detrimental consequences of chronic psychosocial stress in mice deficient for the metabotropic glutamate receptor subtype 7

Chronic stress-related psychiatric conditions and comorbid somatic pathologies are an enormous public health concern in modern society. The etiology of these disorders is complex, with stressors holding a chronic and psychosocial component representing the most acknowledged risk factor. During the last decades, research on the metabotropic glutamate receptor (mGlu) system advanced dramatically and much attention was given to the role of the metabotropic glutamate receptor subtype 7 (mGlu7) in acute stress-related behavior and physiology. However, virtually nothing is known about the potential involvement of mGlu7 in chronic psychosocial stress-related conditions. Using the chronic subordinate colony housing (CSC, 19 days) in male mice, we addressed whether central mGlu7 is altered upon chronic psychosocial stressor exposure and whether genetic ablation of mGlu7 interferes with the multitude of chronic stress-induced alterations. CSC exposure resulted in a downregulation of mGlu7 mRNA transcript levels in the prefrontal cortex, a brain region relevant for stress-related behaviors and physiology. Interestingly, mGlu7 deficiency relieved multiple chronic stress-induced alterations including the CSC-induced anxiety-prone phenotype; mGlu7 ablation also ameliorated CSC-induced physiological and immunological consequences such as hypothalamo-pituitary-adrenal (HPA) axis dysfunctions and colonic inflammation, respectively. Together, our findings provide first evidence for the involvement of mGlu7 in a wide range of behavioral and physiological alterations in response to chronic psychosocial stressor exposure. Moreover, the stress-protective phenotype of genetic mGlu7 ablation suggests mGlu7 pharmacological blockade to be a relevant option for the treatment of chronic stress-related emotional and somatic dysfunctions. This article is part of the Special Issue entitled 'Metabotropic Glutamate Receptors, 5 years on'.

Family member deaths across adulthood predict Alzheimer's disease risk: The Cache County Study

OBJECTIVES

Parental death during childhood, and offspring and spouse death during adulthood have individually been associated with faster cognitive decline and higher Alzheimer's disease (AD) risk in late life. However, the cumulative effect of childhood and adulthood family deaths on AD risk among different age cohorts has not been studied.

METHODS

To examine these associations, this prospective cohort study uses a population-based sample of 4545 initially non-demented participants (56.7% female; age M = 75.0/SD = 6.9 years) observed at four triennial waves, linked with objective Utah Population Database data on cumulative mother, father, sibling, spouse, and offspring death experienced during childhood and adulthood. Cox regression modeled survival time from baseline interview to AD onset, as a function of family deaths during childhood or adulthood, among different age groups, along with gender and presence of ε4 allele at apolipoprotein E (APOE) polymorphic genetic locus.

RESULTS

Age group significantly moderated the relationship between family death and AD; among persons aged 65-69 years at baseline (children of the Great Depression), those exposed to 3-4 deaths and 5+ deaths during adulthood exhibited a doubling of AD risk (adjusted hazard ratio, aHR = 2.25, p = .038, and aHR = 2.72, p = .029), while among persons aged 80 years and older, those exposed to 3-4 deaths during adulthood exhibited lower AD risk (HR = 0.539, p = 0.014). In a combined model of childhood and adulthood deaths, these findings persisted.

CONCLUSIONS

Results suggest a cohort effect in the link between family member deaths during adulthood and AD risk later in life.

Mortality After Bereavement: The Role of Cardiovascular Disease and Depression

OBJECTIVES

Late-life bereavement is associated with an increased risk of mortality. This study assesses the associations among bereavement, cardiovascular disease (CVD), and depressive symptoms on mortality in older men and women.

METHODS

We examined data from the Cardiovascular Health Study, a prospective population-based cohort study of older adults. We compared mortality in those who became bereaved from 1989 to 1999 (n = 593) to an age- and sex-matched sample of individuals who remained married (n = 593). Cox regression was used to examine the association between bereavement and 3-year all-cause mortality and whether or not the association differed by sex, presence of CVD, or postbereavement depressive symptoms.

RESULTS

One hundred ninety-nine (16.8%) individuals died. There was no association of bereavement with mortality (hazard ratio [HR] = 0.98 [0.74-1.30]). However, there were significant interaction effects of bereavement with participant sex (p < .001) and CVD (p = .010). Bereavement decreased the risk of mortality in women (HR = 0.67 [0.46-0.97]) and increased the risk of mortality in men (HR = 1.77 [1.14-2.75]). Within sex, the association of bereavement with mortality differed according to CVD status. The reduced risk of mortality associated with bereavement in women was only observed in women with CVD, and the increased risk in men was only observed in men without CVD. High levels of depressive symptoms attenuated the relation between bereavement and mortality in men without CVD.

CONCLUSIONS

The relation between bereavement and mortality was different in men and women and varied by CVD status. Bereavement decreased mortality in women with CVD and increased mortality in men without CVD.

Suicide loss, changes in medical care utilization, and hospitalization for cardiovascular disease and diabetes mellitus

AIMS

The impact of suicide loss on family members' cardiometabolic health has little been evaluated in middle-aged and elderly people. We investigated the effect of suicide loss on risks for cardiovascular disease (CVD) and diabetes mellitus (DM) in suicide completers' family members using a national representative comparison group.

METHODS AND RESULTS

The study subjects were 4253 family members of suicide completers and 9467 non-bereaved family members of individuals who were age and gender matched with the suicide completers in the Republic of Korea. National health insurance data were used to identify medical care utilization during the year before and after a suicide loss. A recurrent-events survival analysis was performed to estimate the hazard ratios (HRs) of hospitalizations for CVD, DM, or psychiatric disorders, after adjusting for age, residence, and socioeconomic status. Among subjects without a past history of CVD, DM, or psychiatric disorders, the increased risks of recurrent hospitalizations were observed for CVD [HR 1.343, 95% confidence interval (CI) 1.001-1.800 in men; HR 1.240, 95% CI 1.025-1.500 in women] and DM (HR 2.238, 95% CI 1.379-3.362 in men; HR 1.786, 95% CI 1.263-2.527 in women). In subjects with a past history of CVD, DM, or psychiatric disorders, the number of medical care visits decreased after a suicide loss, and suicide completers' family members showed lower rates of hospitalization for CVD and DM than the comparison group.

CONCLUSION

Compared with non-bereaved family members, suicide completers' family members without a past history of CVD, DM, or psychiatric disorder showed a high risk of hospitalization for those conditions.

SLEEP DURATION AND DEPRESSION AMONG ADULTS: A META-ANALYSIS OF PROSPECTIVE STUDIES

BACKGROUND

Results from longitudinal studies on sleep duration and incidence of depression remain controversial.

METHODS

PubMed and Web of Science updated on October 22, 2014 were searched for eligible publications. Pooled relative risks (RRs) with 95% confidence interval (CI) were calculated using a random-effects model.

RESULTS

Seven prospective studies were included, involving 25,271 participants for short sleep duration and 23,663 participants for long sleep duration. Compared with the normal sleep duration, the pooled RR for depression was 1.31 (95% CI, 1.04-1.64; I(2) = 0%) for the short sleep duration overall. For long sleep duration, the pooled RR was 1.42 (95% CI, 1.04-1.92; I(2) = 0%). The associations between short or long sleep duration and risk of depression did not substantially change in sensitivity and subgroup analyses. No evidence of publication bias was found.

CONCLUSION

This meta-analysis indicates that short and long sleep duration was significantly associated with increased risk of depression in adults.

Missing memories of death: Dissociative amnesia in the bereaved the day after a cancer death

Objective:

The death of a loved one is one of the most stressful events of life, and such stress affects the physical and psychological well-being of the bereaved. Dissociative amnesia is characterized by an inability to recall important autobiographical information. Dissociative amnesia in the bereaved who have lost a loved one to cancer has not been previously reported. We discuss herein the case of a patient who developed dissociative amnesia the day after the death of here beloved husband.

Method:

A 38-year-old woman was referred for psychiatric consultation because of restlessness and abnormal behavior. Her 44-year-old husband had died of pancreatic cancer the day before the consultation. On the day of the death, she looked upset and began to hyperventilate. The next day, she behaved as if the deceased were still alive, which embarrassed her family. At her initial psychiatric consultation, she talked and behaved as if her husband was still alive and in the hospital.

Results:

Her psychiatric features fulfilled the DSM–V criteria for dissociative amnesia. The death of her husband had been very traumatic for her and was considered to have been one of the causes of this dissociation.

Significance of Results:

This report adds to the list of psychiatric symptoms in the bereaved who have lost a loved one to cancer. In an oncology setting, we should consider the impact of death, the concomitant defense mechanisms, and the background of the families.

The nature of death, coping response and intensity of bereavement following death in the critical care environment

INTRODUCTION

Bereavement, defined as the situation of having recently lost a significant other, is recognised as one of life's greatest stressors and may lead to decrements in health status, psychological morbidity and excess risk of mortality.

AIM

The aim of this study was firstly to describe the relationships between the nature of death and bereavement intensity following death in the adult critical care environment and secondly to examine the modifying effects of coping responses on intensity of bereavement reaction.

METHOD

Prospective evaluation of the impact of the nature of death and coping responses on bereavement intensity. 78 participants completed a nature of death questionnaire within 2 weeks of bereavement and at 3 and 6 months completed the Core Bereavement Items Questionnaire (CBI-17) and Brief COPE Inventory.

RESULTS

At 6 months, univariate variables significantly associated with bereavement intensity were: being unprepared for the death (p<0.001), a drawn out death (p<0.001), a violent death (p=0.007) and if the deceased appeared to suffer more than expected (p=0.03). Multivariate analysis revealed being unprepared for the death appears to account for these relationships. Regarding coping, there were significant increases from 3 to 6 months in both acceptance scales (p=0.01) and planning (p=0.02) on The Brief COPE Inventory. Greater use of emotional support (p=0.02), self-blame (0.003) and denial (p<0.001) were multivariate variables associated with higher bereavement intensity at 6 months.

CONCLUSION

The results from this evaluation provide insight into the impact of bereavement after death in the critical care environment and inform potential preventative approaches at the time of death to reduce bereavement intensity.

Depression and antidepressant use moderate association between widowhood and Alzheimer's disease

OBJECTIVE

In recent decades, biological evidence has implicated chronic stress in the etiology of Alzheimer's disease (AD). As a result, the relationship between widowhood, one of the most stressful life events, and AD has also received attention. This study extends this literature by investigating whether depression, which may indicate proneness to distress, and antidepressant use, which can protect against hippocampal shrinkage, moderate the relationship between widowhood and increased risk for AD.

METHODS

To investigate this, this study utilized data from the Cache County Memory Study, a large population-based epidemiological study of AD, and the Utah Population Database, one of the world's foremost linked genealogical databases, to regress AD on the interaction between widowhood and history of depression and antidepressant use.

RESULTS

In Cox regression analyses, history of depression and antidepressant use moderated the association between widowhood and AD (p = 0.007 and p = 0.006, respectively), in that widowhood was associated with 73% and 94% increased hazard of AD among those reporting depression (hazard ratio [HR] = 1.73, 95% confidence interval [CI]: 1.001 to 2.99) and those reporting antidepressant use (HR = 1.94, 95% CI: 1.13 to 3.33). A significant three-way interaction between widowhood, depression, and antidepressant use was also found (p = 0.02), showing depression to moderate the association between widowhood and AD only among those not using antidepressants (p = 0.02).

CONCLUSIONS

These findings advance clinical and scientific knowledge concerning the effects of widowhood on risk for AD and underscore the importance of depression and antidepressant use in understanding vulnerability to and protection from these effects.

The complexities of recruiting bereaved family members into a research study in the critical care environment: a discussion paper

Research on the effects of stressful events on human health and wellbeing has progressed in recent years. One such stress, bereavement, is considered one of life's greatest stresses, requiring significant readjustment. The Cardiovascular Risk in Bereavement study (CARBER) investigated in detail cardiovascular risk factors during the first weeks following the death of a partner or adult child in the critical care environment. The purpose of this paper is to explore the once held perception that the bereaved population should not be involved in research, using an actual illustrative project. The paper specifically focuses on the challenges regarding acceptability and feasibility of recruitment of recently bereaved individuals from the critical care environment. The question of whether bereaved individuals have capacity to consent to involvement in research immediately after loss is considered. The appropriateness of asking newly bereaved individuals to participate in research immediately after the death of their relative is also discussed. The work of the research team demonstrates that early recruitment of bereaved family members into a research project is feasible and acceptable to participants, especially when a multidisciplinary collaborative approach is employed and a personal mode of recruitment used.

Mortality From myocardial infarction after the death of a sibling: a nationwide follow-up study from Sweden

Background

Death of a sibling represents a stressful life event and could be a potential trigger of myocardial infarction (MI). We studied the association between loss of an adult sibling and mortality from MI up to 18 years after bereavement.

Methods and Results

We conducted a follow‐up study for Swedes aged 40 to 69 years between 1981 and 2002, based on register data covering the total population (N=1 617 010). Sibling deaths could be observed from 1981 and on. An increased mortality rate from MI was found among women (1.25 CI 1.02 to 1.54) and men (1.15 CI 1.03 to 1.28) who had experienced death of an adult sibling. An elevated rate some years after bereavement was found among both women (during the fourth to sixth half‐years after the death) and men (during the second to sixth half‐years after the death), whereas limited support for a short‐term elevation in the rate was found (during the first few months since bereavement). External causes of sibling death were associated with increased MI mortality among women (1.54 CI 1.07 to 2.22), whereas nonexternal causes showed associations in men (1.23 CI 1.09 to 1.38). However, further analyses showed that if the sibling also died from MI, associations were primarily found among both women (1.62 CI 1.00 to 2.61) and men (1.98 CI 1.59 to 2.48).

Conclusions

Our study provided the first large‐scale evidence for mortality from MI associated with the death of a sibling at an adult age. The fact that findings suggested associations primarily between concordant causes of death (both died of MI) could indicate genetic resemblance or shared risk factors during childhood. Future studies on bereavement should carefully deal with the possibility of residual confounding.

Physiological correlates of bereavement and the impact of bereavement interventions

The death of a loved one is recognized as one of life's greatest stresses, with reports of increased mortality and morbidity for the surviving spouse or parent, especially in the early months of bereavement. The aim of this paper is to review the evidence to date to identify physiological changes in the early bereaved period, and evaluate the impact of bereavement interventions on such physiological responses, where they exist. Research to date suggests that bereavement is associated with neuroendocrine activation (cortisol response), altered sleep (electroencephalography changes), immune imbalance (reduced T-lymphocyte proliferation), inflammatory cell mobilization (neutrophils), and prothrombotic response (platelet activation and increased vWF-ag) as well as hemodynamic changes (heart rate and blood pressure), especially in the early months following loss. Additional evidence suggests that bereavement interventions have the potential to be of value in instances where sleep disturbance becomes a prolonged feature of complicated grief, but have limited efficacy in maintaining immune function in the normal course of bereavement.

Effect of early bereavement on heart rate and heart rate variability

Early bereavement is associated with increased cardiovascular events. The mechanism, however, has not been well studied. We assessed whether bereavement is associated with an increased heart rate (HR) and decreased heart rate variability that might contribute to increased cardiovascular risk. A total of 78 bereaved spouses and parents (55 women and 23 men; aged 34 to 87 years, mean 65) were studied with 24-hour Holter monitoring within 2 weeks of bereavement (acute) and at 6 months. Their findings were compared to those from a nonbereaved reference group (52 women and 27 men) aged 33 to 91 years (mean 63.6). All participants were in sinus rhythm. We assessed the mean HR, atrial and ventricular arrhythmias, and both time and frequency domain heart rate variability measures. Acute bereavement was associated with increased 24-hour HR (mean ± SE, 75.1 ± 1.1 vs 70.7 ± 1.0; p = 0.004) and reduced heart rate variability, as indicated by lower standard deviation of the NN intervals index (median 45.4 vs 49.9, p = 0.017), total power (7.78 ± 0.10 vs 8.02 ± 0.09, p = 0.03), very low frequency (7.23 ± 0.09 vs 7.44, p = 0.046) and low frequency (5.76 ± 0.12 vs 6.16 ± 0.09, p = 0.01). At 6 months, the bereaved had a significantly lower HR (p = 0.001) and increased standard deviation of the NN intervals index (p = 0.02), square root of the mean square of differences of successive intervals (p = 0.045), number of interval differences of successive NN intervals >50 ms divided by the number of NN intervals (p = 0.039), low-frequency power (p = 0.02), and high frequency (p = 0.002) compared to the initial acute levels. In conclusion, the present study, the first to report 24-hour HR monitoring in the early weeks of bereavement, has demonstrated increased HR and altered autonomic function that might contribute to the increased cardiovascular events in early bereavement.

Alcohol use in the first three years of bereavement: a national representative survey

Background

Earlier results concerning alcohol consumption of bereaved persons are contradictory. The aim of the present study was to analyze the relationship between bereavement and alcohol consumption accounting for time and gender differences on a nationally representative sample from Hungary ("Hungarostudy Epidemiological Panel Survey", N = 4457)

Methods

Drinking characteristics of mourning persons (alcohol consumption, dependence symptoms, and harmful consequences of alcohol use) in the first three years of grief were examined among persons between 18-75 years using the Alcohol Use Disorders Identification Test (AUDIT).

Results

Men bereaved for one year scored higher on two dimensions of AUDIT (dependence symptoms and harmful alcohol use), while men bereaved for two years scored higher on all three dimensions of AUDIT compared to the non-bereaved. The rate of men clinically at-risk concerning alcohol consumption among the non-bereaved is 12.9%, and among men bereaved for one year is 18.4% (a non-significant difference), while 29.8% (p < 0.001, OR = 2,781) among men bereaved for two years. However, men bereaved for three years did not differ from the non-bereaved in their drinking habits. In case of bereaved women, again no difference was found with respect to alcohol use compared to the non-bereaved.

Conclusion

Among bereaved men, the risk of alcohol related problems tends to be higher, which can be shown both among men bereaved for one year as well as men bereaved for two years. Considering the higher morbidity and mortality rates of bereaved men, alcohol consumption might play a mediator role. These facts draw attention to the importance of prevention, early recognition, and effective therapy of hazardous drinking in bereaved men.

Risk of acute myocardial infarction after the death of a significant person in one's life: the Determinants of Myocardial Infarction Onset Study

BACKGROUND

Acute psychological stress is associated with an abrupt increase in the risk of cardiovascular events. Intense grief in the days after the death of a significant person may trigger the onset of acute myocardial infarction (MI), but this relationship has not been systematically studied.

METHODS AND RESULTS

We conducted a case-crossover analysis of 1985 participants from the multicenter Determinants of Myocardial Infarction Onset Study interviewed during index hospitalization for an acute MI between 1989 and 1994. We compared the observed number of deaths in the days preceding MI symptom onset with its expected frequency based on each patient's control information, defined as the occurrence of deaths in the period from 1 to 6 months before infarction. Among the 1985 subjects, 270 (13.6%) experienced the loss of a significant person in the prior 6 months, including 19 within 1 day of their MI. The incidence rate of acute MI onset was elevated 21.1-fold (95% confidence interval, 13.1-34.1) within 24 hours of the death of a significant person and declined steadily on each subsequent day. The absolute risk of MI within 1 week of the death of a significant person is 1 excess MI per 1394 exposed individuals at low (5%) 10-year MI risk and 1 per 320 among individuals at high (20%) 10-year risk.

CONCLUSIONS

Grief over the death of a significant person was associated with an acutely increased risk of MI in the subsequent days. The impact may be greatest among individuals at high cardiovascular risk.

Haemodynamic changes during early bereavement: potential contribution to increased cardiovascular risk

BACKGROUND

bereavement is associated with increased cardiovascular risk, particularly in surviving spouses and parents, however the mechanism is not well understood due to limited studies. The purpose of this study was to evaluate haemodynamic changes (blood pressure (BP) and heart rate (HR)), that may contribute to increased cardiac risk in early bereavement.

METHODS

we enrolled 80 bereaved individuals and 80 non-bereaved as a reference group. Twenty-four hour ambulatory blood pressure monitoring was performed within two weeks (acute assessment) and at six months following bereavement.

RESULTS

compared to the non-bereaved, the acutely bereaved had higher 24-hour systolic BP (mean (SE) 130.3 (1.5) vs 127.5 (1.4)mmHg, p=0.03), higher daytime systolic BP (135.6 (1.5) vs 131.6 (1.4)mmHg, p=0.02) and higher daytime systolic load (median % 39.0 vs 29.3, p=0.02). By six months the BP of the bereaved tended to be lower than acute measures. This difference was significant amongst those not taking BP lowering medications for 24-hour systolic BP (126.5 (2.4) vs 129.7 (2.3)mmHg, p=0.04), daytime systolic BP (129.8 (2.1) vs 133.9 (2.0)mmHg, p=0.01) and daytime diastolic pressure (76.7 (1.0) vs 78.9 (0.9)mmHg, p=0.03). Twenty-four hour heart rate was also higher acutely in the bereaved compared with the reference group (74.0 (1.2) vs 71.7 (0.9) b/min, p=0.02); at six months heart rate in the bereaved had fallen to non-bereaved levels (70.4 (0.09), p=0.02).

CONCLUSION

early bereavement is associated with increased systolic blood pressure and heart rate. These haemodynamic changes may contribute to a time-limited increase in cardiovascular risk.