anxiety among widowed elders: is it distinct from depression and grief?
TRANSCRIPT
ANXIETY2:1-12 (1996)
ANXIETY AMONG WIDOWED ELDERS: Is IT DISTINCT FROM DEPRESSION AND GRIEF?
Holly G. Prigerson, M. Katherine Shear, Jason T. Newsom, Ellen Frank, Charles E Reynolds 111, Paul K. Maciejewski, Patricia R. Houck, Andrew J. Bierhals, and David J. Kupfer
The purpose of this study was to test the validity and utility of distingrcishing symptoms of anxiety f i o m those of depression and grief in recently spousally bereaved elders. We also examined pathways f i o m baseline (six months or less post-spousal death) to follow-up (12 and 18 months post-death) levels of anxi- ety, depression and grief-related symptoms. Baseline and follow -up data were available $-om S6 recently widowed elderly subjects recruited fo r a n investiga- tion of physiological changes in bereavement. Confirmatory factor analyses in- dicated that a model in which anxiety was specified as a third factor, apart f i o m depression and grief factors, f i t the data well and signzj?cantly better than either the one or two factor models. Path analyses revealed that both baseline severity of grief and anxiety had significant lagged efiects and pre- dicted follow-up severity of depression. Symptoms of anxiety appeared distinct Ji-om those of depression and grief; and the anxiety, depression and gr'effac- tors dzgerentially predicted subsequent ymptomatology. These findings suggest a need f o r more specific identification and treatment of anxiety, depression and grief symptoms within the context of late-life spousal bereavement. Anxiety 2:l-12 (1996). o 1996 Wiley-Liss, Inc.
Key words: bereavement, geriatrics, death, nosology, psychological trauma, mood disorders, separation anxiety
INTRODUCTION Symptoms of anxiety are common in reaction to stressful life events in general, and to bereavement in particular. Several studies have shown that anxiety dis- orders tend to occur after recent life events (Barrett, 1981; Blazer et al., 1987; Finlay-Jones and Brown, 1981; Uhlenhuth and Paykel, 1973). Other studies have shown that approximately 50% of the cases of panic disorder occur following significant losses and separations (Breier et al., 1986; Klein, 1964; Raskin et al., 1982). The few studies that have specifically exam- ined anxiety as a consequence of bereavement have re- vealed that widowed individuals report a greater number of anxiety-related symptoms (Bornstein et al., 1973; Parkes, 1970; Parkes and Weiss, 1983) and are at hei htened risk of anxiety disorders compared to non-
wives of myocardial infarction patients, and women seekin shelter (Surtees and Miller, 1994). A recent
wi C F owed controls (lacobs et al., 1990; Parkes, 1964),
study B ound that 44% of bereaved spouses in a commu-
0 1996 WILEY-LISS, INC.
nity sample reported at least one type of anxiety disorder during the first year of bereavement (lacobs et al., 1990). Thus, both symptomatic and diagnosable anxiety disor- ders have been shown to follow the loss of one's spouse.
Much has been written about the distinctiveness of the symptoms of anxiety and depression in general
The Clinical Research Center for Late Life Mood Disorders, Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic (H.G.P., M.K.S., E.F., C.F.R., P.R.H., A.J.B., D.J.K.); the University Center for Social and Urban Research, University of Pitts- burgh (J.T.N.); and the Mechanical Engineering Department, University of Pittsburgh (P.K.M.), Pittsburgh, Pennsylvania.
Received for publication February 16, 1995; revised May 27, 1995; accepted July 11,1995.
Address reprint requests to Dr. Holly G. Prigerson, Room 754 Bellefield Towers, 3811 OHara Street, Pittsburgh, PA 15213.
2 Prigerson et al.
(e.g., Coryell et al., 1983; Harris et al., 1983; Mount- joy and Roth, 198Za, b; Prusoff and Kierman, 1974; Watson and Clark, 1984; Watson et al., 1988). For ex- ample, researchers such as Coryell et al. (1953) have found anxiety and depressive disorders to differ sig- nificantly from each other in their course over time and on the basis of family data. Genetic data also sup- port the independence of anxiety and depression (Crowe et al., 1983; Harris et al., 1983). Other re- searchers, however, such as Angst and Dobler-Mikola (1985) and Vanvalkenburg et al. (1983) have found evi- dence which supports a “unitarian” or “continuum” hypothesis, whereby “depression and anxiety disorders are hardly distinguishable, and . . . the overlap group with both diagnoses must be just more severely af- fected” (pp. 183). Similarly, Watson and his colieagues (1984, 1988) argue that measures of fear, hostility, anxiety, sadness and loneliness form a general factor of “negative affectivity” which obscures distinctions be- tween anxiety and depression. To our knowledge, ex- tant research has not examined the extent to which symptoms of anxiety and depression may form distinct symptom profiles among recently widowed elders, a group at heightened risk for experiencing both symp- toms of anxiety and depression (Bruce et al., 1990; Clayton et al., 1972; Jacobs et al., 1990; Parkes and Weiss, 1983; Zisook and Shuchter, 1993).
In addition to the question of whether the symp- toms of anxiety and depression can be separated among the bereaved, the question of whether anxiety, depression and grief form distinguishable symptom clusters also has not been addressed. Many investiga- tors have likened the symptoms of anxiety to those of grief. For example, Bowlby (1980), and later Parkes (1 972), considered the “pangs of pining and yearning” as manifestations of separation anxiety. Belitsky and Jacobs (1986) asserted that anger is a hallmark of mourning and closely tied to yearning and protest. However, in a recent study in which we sought to de- termine whether the symptoms of grief were distinct from those of depression (Prigerson et al., 1995a), we found that the symptoms of anxiety and anger had aligned themselves with the symptoms of depression (e.g., depressed mood, suicidal ideation, apathy), while the symptoms of yearning, searching, preoccupation with thoughts of the deceased, disbelief and being stunned by the loss could all be clearly classified as symptoms of grief. The inconsistencies among these reports suggest a need for further clarification of what bereavement-related symptoms are best classified as components of anxiety, depression and grief, respectively.
Because we were primarily interested in examining the distinctions between grief and depression in our original analysis (Prigerson et al., 1995a), we had not fully explored the relations among the symptoms of depression, grief and anxiety. As a result, we did not include other prominent manifestations of anxiety (e.g., somatization symptoms such as faintness, chest- pains, nausea, hodcold spells, shortness of breath, tin-
gling, weakness), and had constrained the analysis to the two primary factors which had emerged (i.e., depression and grief). Consequently, we had only ex- amined the extent to whch a few anxiety-related symp- toms Ioaded on either the depression or grief factors.
The purpose of the present study was to test the hy- pothesis that the symptoms of anxiety, depression and grief among recently spousaily bereaved elders form distinct symptom profiles. We included a broader ar- ray of anxiety-related symptoms in the present com- pared with the earlier analyses, and examined the possibility of anxiety emerging as a third, distinguish- able factor, thereby extending the previous work that distinguished depression from grief. Through the use of longitudinal data, we were also able to explore rela- tions between baseline and follow-up assessments of anxiety, depression and grief-related symptom clusters. Confirmatory factor analyses and path analytic tech- niques were used to determine: (I) whether the symp- toms of anxiety, grief and depression formed separate factors and ( 2 ) the linkages between baseline and fol- low-up severity of the emergent factors.
METHOD SUBJECTS
Data were obtained from a study population of spousally bereaved elders originally recruited to par- ticipate in a study of sleep physiological changes in be- reavement (Reynolds e t al., 1992). Individuals with medical problems that were well-controlled (using medications not having known psychotropic effects) and appeared to be stable were accepted into the study. All subjects had an interview with the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L) at study entry. Subjects found to have a personal history of prior psychiatric disorder other than minor depression or anxiety were excluded. Subjects were not permitted to be receiving psychiatric treatment outside of that administered as part of the protocol.
Approximately 45% of the screened volunteers en- tered the protocol. In 72% of the excluded cases, rea- sons for exclusion were either a current psychiatric disorder other than depression or anxiety, presence of dementia, or not being age 60 or above, while in 28% of the cases, non-participation resulted from a reluc- tance to accept the time commitment involved. Writ- ten consent was obtained from all participants.
Fifty-six subjects had entered the study by six months post-loss (baseline) and were later assessed at the 12- and l8-month post-loss follow-ups. Because some subjects had entered the study after six months post-loss, the sample size continued to grow beyond the 56 subjects who had entered the study by six months post-loss. Seventy-six subjects had entered by 12 months post-loss and 82 subjects were available at the 18 month post-loss assessment.
The demographic characteristics of the study popu- lation are displayed in Table 1. For the confirmatory
Tab
le 1
. Des
crip
tive
stat
isti
cs o
f sam
ple
at b
asel
inea
(< 6
mon
ths p
ost-
loss
) and
follo
w-u
pb (1
8 m
onth
s pos
t-lo
ss)
Bas
elin
e Fo
llow
-up
Diff
eren
ce
Paire
d V
aria
ble
Mea
n (S
TD
) N
M
ean
(ST
D)
N
Mea
n (S
TD
) r
t P
Age
rang
e (6
0-85
) 68
.57
(5.8
2)
56
Mal
e/Fe
mal
e 18
/3 8
Bla
cMW
hite
4/
5 2
Educ
atio
n (y
rs)
13.1
6 (2
.79)
56
M
onth
s fr
om lo
ss
2.68
(1
.35)
56
18
.06
(0.4
5)
54
Com
plic
ated
Grie
f Fac
tor
15.7
5 (4
.75)
51
11
.09
(3.9
9)
54
4.7
8
(4.2
4)
0.55
-7
.85
0.00
01
Ber
eave
men
t-Dep
ress
ion
Fact
or
7.45
(4
.04)
56
2.
46
(1.8
2)
54
-5.0
2 (4
. 15)
0.
40
-6.3
4 0.
0001
B
erea
vem
ent-A
nxie
ty F
acto
r 1.
19
(1.4
2)
48
0.60
(0
.77)
52
-0
.65
(1.1
6)
0.72
-3
.78
0.00
05
TR
IG'
rese
nt
45.6
2 (1
1.24
) 50
37
.69
(11.
57)
54
-8.3
3 (8
.82)
0.
72
-6.5
5 0.
0001
12
.13
(7.4
0)
56
4.43
(3
.83)
54
-7
.78
(7.7
0)
0.18
-7
.42
0.00
01
Dep
ress
ed m
ood
(HR
SD)
2.11
(0
.91)
56
0.
83
(0.8
2)
54
-1.2
6 (1
.10)
0.
20
-8.4
0 0.
0001
G
uilt
(HR
SD)
0.82
(0
.92)
56
0.
15
(0.3
6)
54
-0.6
7 (0
.97)
0.
08
-5.0
4 0.
0001
In
som
nia
(HR
SD)
3.27
(2
.17)
56
1.
02
(1.0
7)
54
-2.3
0 (2
.07)
0.
33
-8.1
5 0.
0001
A
path
y (H
RSD
) 1.
25
(0.9
4)
56
0.46
(0
.75
54
-0.8
0 (1
.26)
-0
.12
-4.6
3 0.
0001
D
isbe
lief (
GM
S)'
0.75
(0
.91)
51
0.
40
(0.6
3)
53
-0.3
8 (0
.89)
0.
39
-2.9
2 0.
005
Preo
ccup
atio
n w
ldec
ease
d (G
MS)
1.
53
(0.9
9)
51
0.62
(0
.69)
53
-0
.90
(1.0
8)
0.23
-5
.76
0.00
01
Cry
ing
(GM
S)
1.47
(1
.12)
51
0.
47
(0.7
0)
53
-1.0
8 (1
.11)
0.
33
-6.7
8 0.
0001
Sear
chin
g fo
r dec
ease
d (G
MS)
1.
16
(1.0
5)
51
0.43
(0
.60)
53
-0
.77
(0.9
3)
0.46
-5
.75
0.00
01
Yea
rnin
g fo
r dec
ease
d (G
MS)
2.
25
(1.0
0)
51
1.28
(0
.99)
53
-1
.00
(1.0
7)
0.42
-6
.46
0.00
01
Anx
iety
(BSI
)~
0.56
(0
.64)
48
0.
25
(0.3
6)
52
-0.3
6 (0
.55)
0.
54
-4.3
5 0.
0001
H
ostil
ity (B
SI)
0.27
(0
.41)
48
0.
13
(0.2
8)
52
-0.1
3 (0
.34)
0.
60
-2.6
6 0.
02
B H
RSD
Acc
epta
nce
of th
e de
ath
(TR
IG)
1.32
(1
.33)
50
0.
87
(1.1
5)
54
-0.4
4 (0
.97)
0.
71
-3.1
4 0.
003
Stun
ned
(GM
S)
0.3 1
(0
.76)
51
0.
19
(0.4
8)
53
-0.1
5 (0
.71)
0.
44
-1.4
1 0.
16
Som
atiz
atio
n (B
SI)
0.36
(0
.56)
48
0.
22
(0.2
9)
52
-0.1
7 (0
.49)
0.
51
-2.2
8 0.
028
"Bas
elin
e = 4
mon
ths a
fter
the s
pous
e's d
eath
.. 'F
ollo
w-up
= I8
mon
ths a
fter
the s
pous
e's d
eath
; If-
mon
th fo
llow-
up d
ata
are
not p
rese
nted
for
the s
ake
of sim
plic
ity, b
ut a
re a
vaila
ble
upon
requ
est.
'TR
IG =
Tex
as R
evise
d In
vent
ory
of G
rief
(Fas
chin
gbau
er et
al.,
198
7); p
rese
nt =
cur
rent
sym
ptom
s of
grie
f dH
RSD
= H
amilt
on R
atin
g Sc
ale f
or D
epre
ssio
n (H
amilt
on, 1
960)
. 'G
MS
= G
rief
Mea
mre
men
t Sca
le ga
cobs
et a
l., 1
986)
. fB
SI =
Bri
ef S
ympt
om In
vent
ory
(Der
ogat
is an
d M
elisa
rato
s, 19
83).
4 Prigerson et al.
factor analyses, in which we sought to determine the distinctiveness of each factor at every assessment, all available data at each time point were used (e.g., n = 76 and n = 82 for the 12- and 18-month post-loss as- sessments, respectively). Because only 56 subjects (38 females; 18 males) had data available at both the baseline and follow-up assessments, we used this re- duced study group to calculate the descriptive statistics and in the path analyses which predicted the 12- and 18-month post-loss outcomes.
Given the disproportionate number of females, we examined the extent to which widows and widowers differed on the analyzed measures. No significant gen- der differences emerged for the variables of primary interest (i.e., the anxiety, depression and grief factor scores). The comparison between widows and widow- ers on measures not included in the analyses, however, revealed that widowers had marginally higher scores of medical burden (Cumulative Illness Rating Scale score = 10.1 versus 7.9, p = .07, for men and women, respectively), greater suicidal ideation (Hamilton item #3 = .94 versus .40, p = .02, for men and women, re- spectively), and greater preoccupation with thoughts of the deceased (Grief Measurement Scale item #32 = 1.9 versus 1.3, p = .OS, for men and women, respec- tively) than did widows.
None of the subjects who entered the study depressed were being treated for depression. Following initial as- sessment, however, subjects who met SADS-L/RDC for current major depression and scored 17 or higher on the monthly Hamilton Rating Scale for Depression (HRSD: Hamilton, 1960) were diag- nosed as depressed. Fourteen of the 56 subjects who were diagnosed as syndromally depressed were openly treated with nortriptyline (mean dose = 49.2; st.dev. = 13.5; mg/day; mean steady-state level = 68.1 ng/ml; st.dev. = 19.4). The projected nortrip- tyline dose needed to maintain a steady-state plasma concentration of 50-150 ng/ml was determined by using a 25-mg single challenge dose and measuring the 48-hour plasma nortriptyline level. Patients be- ginning treatment were seen weekly a t the Benedum Geriatric Center by a study psychiatrist and the psy- chiatric research nurse for nortriptyline dosage ad- justment and measurement of blood levels, clinical assessment (including assessment of depression us- ing the HRSD), social support, and psychoeduca- tion. Nine of the 14 subjects who had received nortriptyline also concurrently received Interper- sonal Psychotherapy (TPT), which was administered by a trained clinician. The median duration of treat- ment for both nortriptyline and IPT was 32 weeks. The criteria for response was an HRSD score of less than seven for at least three consecutive weeks after a therapeutic level of nortriptyline was achieved. Subjects continued treatment for 16 weeks after re- sponse to minimize the risk of relapse. Non-re- sponders continued to receive nortriptyline for a t least 12 weeks.
MEASURES This study represents an extension of our recent
work conducted to explore whether the symptoms of complicated grief and depression formed distinct symptom clusters. Consequently, the depressive and complicated grief items included in the present confir- matory factor analyses were derived from exploratory principal components analyses from the previous study (Prigerson et al., 199Sa). In that study, we chose symp- toms of depression from the HRSD and the Brief Symptom Inventory (BSI: Derogatis and Melisaratos, 1983), and symptoms of complicated grief from the Grief Measurement Scale (GMS: Jacobs et a]., 1987) and the Texas Revised Inventory of Grief (TRIG “present”: Faschingbauer et al., 1987). The TRIG “present” asks respondents how they currently feel about the death, whereas, the TRIG “past” asks re- spondents how they felt a t the time of the death.
In the earlier report (Prigerson et al., 1995a), we la- belled the symptoms of yearning and searching for the deceased, intrusive recollections of the deceased, and disbelief over the death as symptoms of “complicated” grief because they were shown to predict long-term dysfunction (e.g., impairments in global functioning, self-esteem, sleep), after controlling for baseline levels of depressive symptomatology. However, more re- cently, we developed the Inventory of Complicated Grief (ICG: Prigerson et al., 1995b) to more thor- oughly and reliably assess symptoms of complicated grief (e.g., including symptoms of avoidance of reminders of the deceased, survivor guilt, bitterness over the death). These measures were not available at the time of data collection for the present study. Consequently, only a subset of complicated grief symptoms from the ICG were available for selection to load on the grief factor.
Although diagnostic assessments of anxiety disor- ders had not been conducted a t any of the follow-up assessments, post hoc examination of the measures used revealed several symptoms for inclusion in an anxiety subfactor. The BSI anxiety subscale included measures of nervousness, feeling suddenly scared for no reason, fearfulness, tenseness, panic, and restless- ness. The BSI hostility subscale included measures of irritation, uncontrollable temper outbursts, urges to harm someone and break things, and argumenta- tiveness. The BSI somatization subscale included mea- sures of sympathetic nervous system arousal typically associated with anxiety (e.g., including measures of faintness, chest pains, nausea, hodcold spells, short- ness of breath, tingling, weakness), but not the veg- etative symptoms associated with depression (e.g., anorexia, loss of libido). The numbness item (Q2) from the Grief Measurement Scale measures was also hypothesized to load on the anxiety factor. Although we might have added other BSI subscales to load on the anxiety factor, we decided to limit inclusion to only those that could be interpreted as part of the fi hdflight (anxiety) reaction and its associated physi- o lp ogic arousal symptoms.
Research Article: Anxiety Among Widowed Elders 5
RESULTS SYMPTOM RESOLUTION BETWEEN BASELINE AND FOLLOW-UP
Paired t-tests (Table 1) were utilized to analyze change from baseline to follow-up. Nearly all of the symptoms of anxiety, grief and depression included in the analyses declined significantly between the base- line (56 months post-loss) assessment and the 18-month post-loss assessment. The only symptom measure which did not decline significantly from baseline to the 18-month post-loss assessment was that of feeling stunned (t = -1 .41;~ = .16; n = 51).
ITEM SELECTION AND CONFIRMATORY FACTOR ANALYSES
The selection of items to be factor analyzed was guided by the results of the prior principal compo- nents analyses and our theoretical model which was derived from clinical experience with these distinct pa- tient populations. Our theoretical model specified the anxiety, somatization, hostility and numbness mea- sures to load on the anxiety factor, the symptoms of depressed mood, apathy, guilt, insomnia, psychomotor retardation, suicidal ideation, hypochondriasis, loneli- ness and self-esteem to load on the depression factor, and the symptoms of yearning, preoccupation, search- ing, disbelief, acceptance of the death, crylng and be- ing stunned by the loss to load on the grief factor.
Diagnostic statistical tests (e.g., the Wilk-Shapiro test for non-normality) and examination of the fre- quency distributions were used to determine items un- acceptable for inclusion in the analyses. Numbness was omitted because its distribution was highly skewed (90% reported no numbness). The psychomotor re- tardation, suicidal ideation and hypochondriasis, loneliness and self-esteem items were also removed because the internal consistency (Cronbach’s alpha) of the revised set of items constituting the depres- sion factor was shown to increase when they were deleted. Square-root transformations were per- formed on the hostility, guilt, anxiety, somatization and insomnia variables to correct for skewness. In ad- dition, the error terms for: (a) being stunned by the death and disbelief over the death, and for (b) preoc- cupation and thoughts of the deceased with yearning for the deceased, were allowed to correlate. We al- lowed these two pairs of error terms to be correlated because we considered being stunned by the death and disbelief over the death as two aspects of shock, while preoccupation with thoughts of the deceased would be expected to influence directly the amount of the survivor’s yearning for the deceased.
LISREL VII (Joreskog and Sorbom, 1989), with a maximum likelihood estimation method, was used to conduct the confirmatory factor analyses and the full structural model analysis. Confirmatory factor analysis allowed us to test and compare the goodness-of-fit of the hypothesized models. Our first aim was to deter-
mine whether a model in which the specified anxiety items loaded on the anxiety factor, the grief items loaded on the grief factor and the depression items loaded on the depression factor, adequately described the relations within the data. If the hypothesized model provided a good fit to the data (i.e., the ex- pected and observed relationships did not differ sig- nificantly from one another), the chi-square would merge as non-significant.
Following the recommendation of other authors (Bollen, 1989; Tanaka, 1993), we also provide the Tucker-Lewis Index (TLI; Tucker and Lewis, 1973) and the Incremental Fit Index, Delta 2 (IFI; Bollen 1989) statistics because, unlike the chi-square statistic, they are uninfluenced by the number of subjects. Val- ues greater than .9 are typically considered to indicate good model fit. The hypothesized model was tested across the three time points (i.e., 16-, 12- and 18- month post-loss assessments) to determine whether the specified factor structure could be replicated at each of these assessments.
The confirmatory factor analyses revealed that a model in which the symptoms of anxiety formed a dis- tinct cluster apart from the symptoms of grief and de- pression provided a good fit to the data at all three time points (see Table 2). At baseline, the chi-square statistic was 87.93 @ = .lo; df = 72) with a Tucker- Lewis Index score of .911 and an Incremental Fit In- dex score of .935. It should be noted that because no subject had received nortriptyline, or other antide- pressant medication at the baseline assessment, the baseline test was unbiased by the effects of antidepres- sant medication. At the 12-month post-loss assess- ment, the chi-square statistic was 79.84 @ = .25; df = 72) with a TLI of .965 and a IF1 of .974. At 18-month post-loss the chi-square statistic was 79.02 @ = .27; df = 72) with a TLI of .964 and an IF1 of .973. Given that the chi-square statistic was repeatedly non-significant and that the fit indices were all above .9, it appeared that our three-factor scale consistently provided a good fit to the data at each assessment period.
Table 3 displays factor loadings for the depression, grief and anxiety factors at each time point. All factor loadings were significant at p < .05. To simplify pre- sentation, we here describe only those factor loadings obtained at baseline. The BSI hostility, anxiety, and somatization subscale measures loaded highly on the
TABLE 2. Fit of 3-factor confirmatory models
Assessment (months) X2 (do b TLI” IFI* N‘
c6 87.93 (72) .10 ,911 ,935 48 12 79.84 (72) .246 ,965 ,974 73 18 79.02 (72) .267 .964 .973 81
“TLI = Tucker-Lewis index (Tucker and Lewir, 1972) bIFI = Incremental Fit Index (A2, Bollen, 1989). ‘N = sample size.
6 Prigerson et al.
TABLE 3. Standardized confirmatory factor loadings and interfactor correlations'
Assessment (months) Factor Item <6 12 18
Depression Apathy B O O .819 Guilt ,623 .477 Mood .780 .672 Insomnia ,724 ,453
Grief Yearning 543 .599 Preoccupation ,433 .657 Searching ,487 .325 Disbelief ,599 .719 Acceptance .750 ,620 C v n g ,590 .752 Stunned .461 ,548
Hostility ,780 .780 Anxiety .858 ,763 Somatization ,739 ,594
Depression with grief ,724 .540 Depression with anxiety ,547 .486 Grief with anxiety ,603 ,666
"All loadings and correlations are significant a t p < .OY or less.
Anxiety
Interfactor correlations
.SO3
.460 ,688 .477
,524 .679 ,498 .733 .698 ,552 ,438
,641 .732 ,612
,674 ,572 ,560
anxiety factor (.780, .858, .739, respectively). The symptoms of yearning and searching for the deceased, preoccupation with thoughts of the deceased, disbelief about the death, acceptance of the death, crying and being stunned by the death all had factor loadings on the grief factor between .433 and .750. The symptoms of depressed mood, apathy, guilt, and insomnia had factor loadings between .623 and .80 on the depres- sion factor.
The interfactor correlations are also presented in Table 3. All the interfactor correlations are significant at the p < .05 level. The anxiety and grief factors had an interfactor correlation (a) ranging from .560 to .666 across the three time points. The anxiety and de- pression factors had a w = .486-.572 across the three time points, and the depression and the grief factors had a w = 540-.724. It should be noted that although the bereavement-depression factor contained only four of the 17 HRSD items, the depression factor and the HRSD total score remained closely associated with one another (baseline: r = .90; p < .0001; n = 56).
COMPARISON AND MODEL FIT When we compared the fit of the three-factor
model with that of the one-factor model, we found that this model fit the data significantly better than did the one-factor model (baseline: x' difference = 45.07; df = 2 ; p = .OOl), in which all the 14 symptoms of emo- tional distress were expected to load on a single factor. The three-factor model also fit the data significantly
better than the two-factor model at each of the three assessments (e.g., baseline: x difference = 3 1.42; df = 1; p < .OOl). (It should be noted that in the two-factor model we had placed anxiety and hostility with depres- sion because this was the position advanced by re- searchers such as Angst and Dobler-Mikola [1985] and Watson et al. [1988] who stated that anxiety and de- pression were merely different aspects of the same un- derlying construct. Moreover, the results of an earlier principal components analysis revealed that anxiety and hostility loaded more highly on the depression factor than they did on the grief factor. Given that somatization was subsequently found to cluster with the other symptoms of anxiety, we also specified that it should load on the depression factor in the two-factor model.) Thus, consistent with data documenting the distinctiveness of anxiety and depression, the three- factor model, in which anxiety was a specified third factor, had a significantly better fit to the data than did the one- or the two-factor models which had clustered the symptoms of anxiety with those of depression.
PATH ANALYSIS Path models were specified using LISREL VII. The
path models were used to estimate the effects of the mean scores of each factor at baseline on the measures of those same mean scores of each factor at follow-up (both at 12 and 18 months post-loss), after correcting for measurement error using alphas in the estimate of unreliability (Bollen, 1989). We tested similar models for anxiety, depression and grief, but to streamline presentation we report only the significant results.
The results of path analyses conducted on all sub- jects (n = 56) revealed that grief and anxiety had sig- nificant lagged effects a t the 18-month post-loss assessment (e.g., standardized path coefficients: grief + grief, controlling for baseline depression = .599; p < .0001, see Fig. la; anxiety + anxiety, controlling for baseline depression = .650; p < .OOl). However, initial or baseline depression was not significantly associated with depression at either the 12-month or 18-month post-loss follow-ups (at 18 months, standardized path coefficient: depression + depression, controlling for baseline grief = .050: ns, see Fig. la).
In terms of cross-lagged effects conducted on the full study group, we found that grief significantly pre- dicted depression at the 18-month post-loss follow-up (standardized path coefficient: grief + depression, controlling for baseline depression = .420; p < .OS). Moreover, the fit of the model in which grief pre- dicted depression (x' = 1.17, df = 1; p = .279: see Fig. la) was significantly better than the fit of the model in which depression predicted grief (x' = 4.65, df = 1; p = .03: see Fig. lb).
A similar result appeared for the baseline anxiety prediction of depression at the 12-month post-loss fol- low-up. The model in which baseline anxiety pre- dicted 12-month post-loss depression, controlling for baseline depression, fit the data well (x' = 0.64, df = 1;
Research Article: Anxiety Among Widowed Elders 7
2 a. Model with grief predicting depression ( x (1) = 1.17, p = .279).
< 6 months
.050 depression P
grief .599* * *
18 months
depression
grief
.312*
2 b. Model with depression predicting grief ( x (1) = 4.65, p = .031) .
< 6 months 18 months
.27 1 - demession w detxession /
f .620** [
grief
Figure 1. Path analyses showing the relation between grief and depression over time. The values of the double-headed arrows between the independent variables (at left) are correla- tion coefficients. The values of the double-headed arrows be-
p = .40) and better than the model in which baseline depression predicted 12-month post-loss anxiety, con- trolling for baseline anxiety (x’ = 3.58, df = 1; p = .06). The path from baseline anxiety to 12-month post-loss depression was marginally significant (standardized path coefficient = .308; p < .lo). PATHS AMONG UNTREATED SUBJECTS (N = 42)
Because we suspected that treatment may have been blunting the above-described effects of anxiety on de- pression, we conducted subanalyses which removed the treated subjects. Among the untreated subjects, we found that baseline anxiety significantly predicted de- pression a t both the 12- and the 18-month post-lost assessments (standardized path coefficients = .418; p < .OS and .486; p < .OS, respectively: see Fig. 2a and b).
r
.610** grief
tween the dependent variables (at right) are correlation coeffi- cients between the error terms of the dependent variables. *p c .05; **p c .01; ***p c .001.
Baseline grief among the untreated subjects also sig- nificantly predicted depression at the 12-month post- loss assessment (standardized path coefficient = 598; p < .OS: see Fig. 2c), but only marginally at the 18- month post-loss assessment (standardized path coeffi- cients = .401; p < .lo). Interestingly, even when treated subjects were excluded from the analysis, baseline de- pressive levels were not found to be significantly asso- ciated with follow-up severity of depression at either the 12- or the 18-month post-loss assessments.
REPEATED MEASURES ANOVA OF ANXIETY, GRIEF AND DEPRESSION FACTORS OVER TIME AND BY TREATMENT
Separate repeated measures ANOVAs were used to determine the effects of time and treatment on each of
8 Prigerson et al.
2 a. Model with anxiety predicting depression at 1 2 months (X(1) = 1.03, p = .310)
< 6 months 12 months
depression ~ . I 89 c depression J].og6
anxiety b anxiety
.582**
J .790* * *
2 b. Model with anxiety predicting depression at 18 months ( X (1) = .94, p = .332)
< 6 months 1 8 months
depression ~ .136 * depression 43
.548**
J anxiety - - anxiety .624***
2 c. Model with grief predicting depression at 1 2 months ( X (1 = .19,
< 6 months 12 months
.054 c depression r depression
.662** i
p = .664)
7 0 1 4
J J / c grief .643**”
grief
Figure 2. Path analyses (untreated subjects only) showing the relation between anxiety and depression and the relation between grief and depression over time. The values of the double-headed arrows between the independent variables (at
left) are correlation coefficients. The values of the double- headed arrows between the dependent variables (at right) are correlation coefficients between the error terms of the depen- dent variables. *p < .05; **p < .01; ***p < .001.
the mean scale scores for anxiety, depression and grief. The repeated measures ANOVA (see Table 4) revealed that the depression, grief and anxiety factors all de- clined significantly over time (time main effect: F = 81.04; df = 1,52; p < .0001; F = 54.45; df = 1,47; p < .0001; F = 26.85; df = 1,43; p e .0001, respectively).
Not surprisingly, when the subjects treated with nortriptyline were compared with those who were not, the nortriptyline-treated subjects declined more dramatically over time in terms of both depression (group-by time interaction: F = 4.85; df = 1 . 5 2 ; ~ < .OS) and anxiety (F = 9.78; df = 1.43; p < .OOS) than did
Research Article: Anxiety Among Widowed Elders 9
TABLE 4. Repeated measures ANOVA of anxiety, depression, and grief factors from baseline (c 6 months at study entrv) to follow-ut, (18 months Dost-loss)
Treated vs. nontreated subjects” Group Time Group x Time
F P F P F P Bereavement depression factor 10.22 0.003 8 1 . 0 4 1 , ~ ~ ~ 0.0001 4.851~2 0.05 Complicated grief factor 0.71 N.S.’ 54.451,47 0.0001 0.547~47 N.S. Bereavement anxiety factor 4.72 0.05 26.85 1,43 0.0001 9.781,43 0.005
“Treatment = Received nortripyline if diagnosed as depressed (see Method section fir details). bSubscripts denote degrees offi-eedom. ‘N.S. = Not significant.
subjects who did not receive nortriptyline. Interest- ingly, however, the nortriptyline-treated and untreated subjects did not differ significantly over time in the resolution of grief-related symptomatology (group-by- time interaction: F = 0.54; df = 1,47; ns). Consistent with earlier reports from our group (Pasternak et al., 1993), it appears that nortriptyline significantly reduced the symp- toms of depression and anxiety although it did not sig- nificantly reduce the symptoms of grief.
We also found that the nine subjects who received both nortriptyline and IPT declined significantly on the depression, grief and anxiety factors (i.e., mean change score between I 6 and 18 months post-loss = -7.22 [st.dev. = 4.941; p = .002; -6.56 [st.dev. = 5.831; p = .01; -2.00 [st.dev. = 1.731;~ = .O1, n = 9, respectively).
DISCUSSION Our study population appeared to report levels of
grief, depression and anxiety similar to those found in other bereavement samples reported in the literature. When we examined mean scores on the TRIG scale we found that our study population had levels of “gen- eral” grief comparable to those found in other be- reavement studies (see Table 1). At 18 months from loss, our study population had a mean TRIG score of 37.69 (st.dev. = 11.57; n = 54), which was comparable to the Faschingbauer et al. (1987) study that reported a mean TRIG score at the end of the first year of be- reavement of 34.2 (st.dev. = 1.5; n = 53).
In terms of depression, our population also seemed to be consistent with rates of depression reported else- where in the literature. About one-fourth of our sub- jects (28%) had an HRSD > 17 and 26% met RDC criteria for major depression at the baseline (2.68 months post-loss on average) assessment. This was comparable to the 24% who met DSM-111-R criteria for major depression at two months post-loss in the Zisook and Shuchter (1993) community sample.
With respect to the BSI anxiety, hostility and soma- tization subscales, Thompson et al. (1989) reported very similar mean scores among their community sample of bereaved elders to those reported in our study. At approximately two months post-loss, the
Thompson et al. (1989) mean (averaging the male and female scores) for their 2 11 subjects was .64 (st.dev. = .67) for BSI anxiety, 5 1 (st.dev. = .63) for somatization and .28 (st.dev. = .40) for hostility, while our study group means at the less than six month post-loss as- sessment were .56 (st.dev. = .64; n = 48: before square- root transformation), .36 (st.dev. = 56; n = 36: before square-root transformations), and .27 (st.dev. = .41; n = 52: before square-root transformations), respectively.
Although an argument could be made for the exclu- sion of the treated subjects from this report, we chose to conduct one set of analyses including the treated subjects and one set of analyses excluding them. This strategy was chosen for three reasons. First, removing the treated subjects would have removed the most de- pressed subjects, a group of primary clinical interest. Second, excluding the treated subjects would have substantially reduced our sample size in the combined study group and, thereby, would have significantly com- promised our statistical power in one set of analyses.
Third, a comparison of treated and untreated sub- jects enabled us to observe the differences in the ef- fects of treatment on symptoms of anxiety, depression and grief over time (although in an uncontrolled man- ner). We believed that conducting analyses both with and without treated subjects allowed for greater gener- alizability of results from the combined (heteroge- neous) sample, while allowing for unbiased results from the “untreated” (homogenous) sample.
When individual symptoms of anxiety, depression and grief were analyzed among both treated and un- treated subjects over time, we found that all but the “stunned by the death” measure declined significantly from baseline (I 6 months post-loss) to 18-months post-loss. Thus, contrary to stage theories of grief (e.g., Bowlby [1963]; Clayton et al. [1968]; Parkes et al. [1972]) which posit feelings of being stunned or shocked by the death to be the initial grief reaction which subsequently declines, feeling stunned appeared to be the symptom least amenable to amelioration with time. It may be that persistent shock resulting from the death of one’s spouse is a major impediment to successful adaptation to the loss. A heightened sense of feeling stunned by the death reported in the
10 Prigerson et al.
first six months of bereavement may, therefore, prove to be of particular importance in the diagnosis of compli- cated grief and as a prodromal event.
As one would expect given the significant resolution of the individual symptoms over time, the average anxiety, depression and grief factor scores also de- clined significantly from baseline to the 18-month fol- low-up. It should be noted that when we examined the resolution of depression, grief and anxiety factors over time, we found that even among the subjects who were not treated for their depression, the effect of time re- mained significant.
The analytic methods used for this study were cho- sen because they were well-suited to address the ques- tions posed by this study. In contrast with exploratory factor models, such as principal components analysis, the confirmatory factor model has the advantage of testing the fit of specific factor structures. We there- fore could test the fit of a model which specified that the symptoms of anxiety would load on a third factor, distinct from the depression and grief factors. Further- more, we could compare the fit of the three-factor model which included anxiety with the fit of the one- and two-factor models which did not specify a distin- guishable anxiety factor, to see which fit the data best.
We were particularly well-positioned to examine the paths between each of the factors because: (1) we had longitudinal data on 56 subjects; (2) we could take ini- tial levels into account; and (3) we could compare the fit of models using cross-lagged effects (e.g., compare the fit of a model in which grief was caused by depres- sion versus a model in which depression was caused by gnef) to see which model better described relations in the data. Longitudinal data for the path analyses greatly improved our ability to make causal inferences in con- trast with data obtained from cross-sectional designs.
We found that a model which included anxiety as a third distinct factor provided the best fit to the data at baseline, 12- and 18-month post-loss assessments. While the anxiety, depression and grief factors were found to be significantly associated with one another, the interfactor correlations were not so high as to sug- gest that they were essentially measuring the same thing. Moreover, it should be noted that because the reported correlations were based on associations be- tween factors once measurement error was taken into account, they were higher than correlations that would have been found between the scale means. Conse- quently, our results did not support Angst and Dobler- Mikola’s (1985), Vanvalkenburg et al.’s (1983) or Watson et a1.k (1984, 1988) contention that depression and anxiety constitute different aspects of a single, unifylng latent construct. To the contrary, our results suggest that anxiety may be best classified as a unique component of emotional distress among the late-life spousally bereaved.
We believe that it is important to note that we do not mean to imply that these various symptom clusters could not co-occur. A bereaved person with major de-
pression could, and probably would, have clinically significant levels of anxiety and grief. We simply wish to suggest that each of these symptom profiles repre- sents a distinguishable form of emotional dysfunction.
As a further indication that these symptom clusters are distinct, the results of the path analysis revealed that the anxiety, depression and grief factors predicted different outcomes. The finding that baseline assess- ments of grief and anxiety predicted follow-up assess- ments of these measures was expected because of the tendency of individuals to maintain prior levels of symptoms which have not been targeted for treatment. When one considers that subjects who were diagnosed as depressed were subsequently treated with the anti- depressant nortriptyline and/or IPT, and that depres- sion declined significantly over time from loss among the treated and untreated subjects alike, it is not sur- prising that baseline levels of depression did not pre- dict follow-up depression levels.
The finding that baseline levels of grief significantly predicted depression at the l8-month post-loss fol- low-up among the combined treated and untreated sample and at 12 months post-loss among the un- treated subjects, however, was not anticipated. Thus, counter to any beneficial cathartic effect, those who had high levels of grief relative to the mean at baseline not only continued to have high levels of grief, but they also were found to have high levels of depression relative to the mean in the long-term. This indicates that not only do the symptoms of grief persist, but in the absence of a grief-focused treatment, those high on grief in the first few months post-loss are also likely to be depressed in the long-term.
Consistent with recent research by Angst et al. (1990) which found that baseline anxiety was predic- tive of comorbid anxiety and depression at follow-up, and a study by Kessler et al. (1995) which suggest tha t anxiety is predictive of depression rather than vice versa, we found that baseline anxiety significantly pre- dicted both 12- and 18-month post-loss assessments of depression among the untreated subjects. There was also a trend of baseline anxiety predicting depression at 12 months post-loss among the combined study group. It may be that while all those diagnosed as de- pressed were treated for their depression, the indi- viduals who had initially high levels of anxiety but not depression were not treated and, not only did their anxiety persist, but they also had high levels of depres- sion at follow-up relative to the mean.
Lastly, comparisons between subjects who re- ceived nortriptyline and those who did not reveal that anxiety and depression decline more dramati- cally among the nortriptyline treated subjects. In- terestingly, the average grief factor scores did not decline more rapidly among the nortriptyline treated subjects than they did among the untreated subjects, a result which was also found by Pasternak et al. (1993). This suggests that nortriptyline, while effective at reducing anxiety and depression over
Research Article: Anxiety Among Widowed Elders 11
time, does not appear to effectively reduce the symptoms of grief.
Furthermore, the finding that grief significantly predicted both grief and depression at follow-up sug- gest that there is a need for the development and test- ing of a treatment specifically designed to ameliorate the symptoms of grief. In previous research (Prigerson et al., 199Sa), we found that the symptoms of grief sig- nificantly predicted long-term functional impairments such as sleep, self-esteem and global functioning after controlling for depression and despite the receipt of nortriptyline by the syndromally depressed. Thus, this call for a grief-specific treatment serves to echo and amplify a conclusion which we have previously drawn.
CLINICAL IMPLICATIONS The results of this study have direct bearing on the
Freudian (191 7) assumption that “grief work” is neces- sary for healthy adaptation to the loss of a significant other. Some researchers and clinicians believe that failure to do “grief work” (i.e., experience the grief- related symptoms involved in “decathecting from the love object”-Freud [19 171) will result in overall malad- justment and psychiatric difficulties (Lindemann, 1944; Parkes, 1965). Other researchers have shown that early bereavement-related distress predicts subse- quent distress and that those who do not experience early depression are less likely to be depressed at later points in time (Parkes and Weiss, 1983; Wortman and Silver, 1989; Zisook and Shuchter, 1991). Similarly, the Stroebe’s (1991), in southern Germany, found that widows who avoided confronting their loss did not differ in their depression scores from widows who worked through their grief. The Stroebes conclude from their findings that “grief work” does not neces- sarily work. Our results appear to support the latter view, i.e., early “grief work,” when manifested as symptoms of complicated grief (e.g., feeling stunned, preoccupation with thoughts of the deceased) or anxiety, is predictive of long-term psychological maladaptation.
The absence of a treatment effect of nortriptyline alone and the significant effect of combined nortrip- tyline and IPT for symptoms of grief suggests that psychotherapy may have been the effective component of the combination therapy for the treatment of symp- toms of complicated grief. The early identification of symptoms of complicated grief and anxiety, and the application of psychosocial interventions such as IPT, possibly conjointly with antidepressants such as nortrip- tyline, appear to hold promise for treating these persis- tent and pernicious complications of bereavement.
Finally, given that this study of widowers had higher levels of medical burden, suicidal ideation, and more frequent preoccupation with thoughts of the deceased, in addition to other reports by our re- search group which indicate that symptoms of compli- cated grief, and bitterness over the loss in particular, may actually increase beyond three years post-loss
(Bierhals et al., 199S), we believe that treatments for bereavement-related complications need to be made gender-specific.
CONCLUSION The findings that symptoms of anxiety, depression
and grief are, indeed, distinct, are differentially af- fected by treatment and are shown to differentially predict subsequent symptomatology, has important implications for assessment and treatment of bereaved individuals. We found that nortriptyline did not ame- liorate symptoms of grief, and that left untreated, symptoms of grief persist and predict depression at Llie year post-spousal loss. Furthermore, if the symp- toms of anxiety are believed to be normal manifesta- tions of grief or are not considered to be elements of a disorder in their own right (e.g., considered aspects of depression), then they may not receive the profes- sional attention from which they have been shown to benefit. Our results indicate that if left untreated, anxiety in the first few months post-loss may also per- sist and predict depression and anxiety not only one year post-lost, but also at 18 months post-loss.
In the present study, we did not have data which could be used to determine whether subjects met cri- teria for syndromal levels of anxiety and complicated grief. Research which uses established diagnostic crite- ria for anxiety and developed criteria for complicated grief is underway. This will enable us to examine fac- tors which predict and are predictive of syndromal lev- els of anxiety, depression and grief. Future research could also help to determine whether bereavement in younger subjects and those whose grief stemmed from non-spousal losses show a similar pattern of relations among symptoms. Finally, the relations among anxi- ety, depression and grief at times further removed (i.e., beyond 18 months) from the spouse’s date of death would be another recommended topic for further in- vestigation.
Acknowledgments. This research was supported in part by MHOllOO, MH37869, MH43832, MH00295, MH30915, and MH52247.
REFERENCES Angst J, Dobler-Mikola A (1985) The Zurich study VI. A con-
tinuum from depression to anxiety disorders. Eur Arch Psychia- try Neurological Sci 235:179-186.
Angst J, Vollrath M, Merikanges KR, Erenst C (1990) Comorbidity of anxiety and depressions in the Zurich cohort study of young adults. In Maser JD, Cloninger CR (eds): Comorbidity of Mood and Anxiety Disorders. Washington, D.C: American Psychiatric Press, pp 123-127.
Barrett J (1 98 1) Psychiatric diagnosis (research diagnostic criteria) in symptomatic volunteers. Arch Gen Psychiatry 38:153-157.
Belitsky R, Jacobs S (1986) Bereavement, attachment theory, and mental disorders. Psychiatric Ann 16:276-280.
Bierhals AJ, Prigerson HG, Reynolds CF, Frank E, Miller MD, Fasiczka A (1995) Gender differences in complicated grief
12 Pyigerson et al.
among the elderly. Omega: Journal of Death and Dying (in press).
Blazer D, Hughes D, George LK (1987) Stressful like events and the onset of a generalized anxiety syndrome. Am J Psychiatry
Bollen K (1989) Structural Equation with Latent Variables. New York: Wiley.
Bornstein PE, Clayton PJ, Halikas JA, Maurice W, Robins E (1973) The depression of widowhood after 13 months. Brit J Psychiatry
Bowlby J (1963) Pathologic mourning and childhood mourning. J Am Psychoanalytic Assoc 11:500-541.
Bowlby J (1980) Attachment and loss, Vol. 3: Loss. New York: Basic Books Inc.
Breier A, Charney DS, Heninger GP (1986) Agoraphobia and panic disorder: Development, diagnostic stability, and course of illness. Arch General Psychiatry 44:1029-1036.
Bruce ML, Kim K, Leaf JP, Jacobs S (1990) Depressive episodes and dysphoria resulting from conjugal bereavement in a prospec- tive community sample. Am J Psychiatry 147:608-611.
Clayton P, Desmarais L, Winokur G (1968) A study of normal be- reavement. Am J Psychiatry 125:168-178.
Clayton P, Halikas JA, Maurice W (1972) The depression of wid- owhood. Brit J Psychiauy 120:71-78.
Coryell W, Noyes R, Clancy J (1983) Panic disorder and primary unipolar depression. J Affective Disord 5:3 11-3 17.
Crowe RR, Noyes R, Pads DL, Slymen D (1983) A family study of panic disorder. Arch Gen Psychiatry 40: 1065-1069.
Derogatis LR, Melisaratos N (1983) The brief symptom inventory: An introductory report. Psychol Med 13595-605.
Faschingbauer TR, Zisook S, DeVaul R (1987) The Texas revised inventory of grief. In Zisook S (ed): Biophychosocial Aspects of Bereavement. Washington, D.C: American Psychiatric Press, Inc. pp 109-124.
Finlay-Jones R, Brown G W (1981) Types of stressful life event and the onset of anxiety and depressive disorders. Psychol Med 115303-815.
Freud S (19 17) Mourning and Melancholia. Internationale Zeitsch- rift fur arzliche Psychoanalyse 4:288-301.
Hamilton M (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry 23:56-62.
Harris EL, Noyes R, Crowe RR, Chaudhry DR (1983) Family study of agoraphobia. Report of a pilot study. Arch Gen Psychia-
Jacobs S, Kasl SV, Ostfeld AM, Berkman L, Kosten TR, Char- pentier P (1987) The measurement of grief: Bereaved versus non-bereaved. Hospice J 2:2 1-36.
Jacobs S, Hansen F, Kasl S, Ostfeld A, Berkman L, Kim K (1990) Anxiety disorders during acute bereavement: Risk and risk fac- tors. J Clin Psychiatry 5 1:269-274.
Jacobs SC, Kosten TR, Kasl SV, Ostfeld AM, Berkman L, Char- pertier P (1988) Attachment Theory and multiple dimensions of grief. Omega: Journal of Death and Dying 18:41-42.
Joreskog KG, Sorbom D (1989) LISREL 7: A Guide to the Pro- gram and Applications. 2nd edn. Chicago: SPSS Inc.
Kessler RC, Nelson CB, McGonagle KA, Lui J, Swartz M, Blazer DG (1995) Cormorbidity of DSM-111-R major depressive disor- der in the general population: Results for the U.S. National Co- morbidity Survey. Brit J Psychiatry (in press).
Klein DF (1964) Delination of two drug responsive anxiety symp- toms. Psychopharmacologia 5:397408.
Lindemann E (1944) Symptomatology and management of acute grief. Am J Psychiatry 101:141-148.
Mountjoy CQ, Roth M (1982a) Studies in the relationship between depressive disorders and anxiety states. Part I. Rating scales. J Affective Disord 4:127-147.
Mountjoy CQ, Roth M (1982b) Studies in the relationship between
144: 1 178-1 183.
122:561-566.
try 40:1061-1064.
depressive disorders and anxiety states. Part 11. Clinical items. J Affective Disord 4:149-161.
Parkes C (1972) Bereavement: Studies of Grief in Adult Life. New York: International Universities Press, Inc.
Parkes C (1964) The effects of bereavement of physical and mental health. Brit Med J 2:274-279.
Parkes CM (1965) Bereavement and mental illness. Brit Med J
Parkes CM (1970) The first year of bereavement: A longitudinal study of the reaction of London widows to the death of their husbands. Psychiatry 33:444.
Parkes CM, Weiss RS (1983) Recovery for Bereavement. New York: Basic Books.
Pasternak RE, Reynolds CF, Frank E, Miller M, Houck PR, Schlernitzauer M, Prigerson HG, Kupfer DJ (1993) The tempo- ral course of depressive symptoms and grief intensity in late-life spousal bereavement. Depression 1 :45-49.
Prigerson HG, Frank E, Kasl SV, Reynolds CF, Anderson B, Zubenko GS, Houck PR, George CJ, Kupfer DJ (1995a) Com- plicated grief and bereavement-related depression as distinct dis- orders: Preliminary empirical validation among in elderly bereaved spouses. Am J Psychiatry 152:22-30.
Prigerson HG, Maciejewski PK, Reynolds CF, Bierhals AJ, New- som JT, Frank E, Miller M, Doman J, Fasiczka A (199513) The inventory of complicated grief: A scale to measure certain mal- adaptive symptoms of loss. Psychiatry Res (in press).
Prusoff B, Herman GL (1974) Differentiating depressive from anx- ious outpatients. Use of discriminant function analysis for sepa- ration of neurotic affective states. Arch Gen Psychiatry 30:
Raskin M, Peeke W S , Dickman W (1982) Panic and generalized anxiety disorders. Arch Gen Psychiatry 39:687-689.
Reynolds CF, Hoch C, Buysse DJ, Houck PR, Schlernitzauer M, Frank E, Mazumdar S, Kupfer DJ (1992) Electroencephalo- graphic sleep in spousal bereavement and bereavement-related depression in late life. Biological Psychiatry 3 1:69-82.
Stroebe M, Stroebe W (1991) Does "Grief Work" work? J Consul Clin Psychology 59:479-482.
Surtees PG, Miller P (1994) Partners in adversity: 111. Mood status after the event. Europ Arch Psychiatry Clin Neurosci 243:
Tanaka JS (1993) Multifacited conceptions of fit in structural equa- tion models. In Bollen KA, Long JS (eds): Testing Structural Equation Models. Newbury Park, CA: Sage, pp 10-39.
Thompson LW, Gallagher D, Cover H, Gilewski M, Peterson J (1989) Effects of Bereavement on symptoms of psychopathology in older men and women. In Lund DA (ed): Older Bereaved Spouses: Research with Practical Applications. New York: Hemi- sphere, pp 17-24.
Tucker L, Lewis C (1973) A reliability coefficient for maximum likelihood factor analysis. Psychometrika 38: 1-10.
Uhlenhuth EH, Paykel ES (1973) Symptom configuration and life events. Arch Gen Psychiatry 28:744-748.
Vanvalkenburg C, Wnokur G, Lowery M, Behar D, Vanvalken- burg D (1983) Depression occuring in chronically anxious per- sons. Comp Psychiatry 24:285-289.
Watson D, Clark LA (1984) Negative affectivity: The disposition to experience aversive emotional states. Psychological Bull 96: 465-490.
Watson D, Clark LA, Carey G (1988) Positive and negative affectivity and their relation to anxiety and depressive disorders. J Abnorm Psychol 97:346-353.
Wortman C, Silver R (1989) The myths of coping with loss. J Con- sul Clin Psychol 57:349-357.
Zisook S, Shuchter S (1993) Uncomplicated Bereavement. J Clin Psychiatry 54:3 65-3 72.
3 8: 13-26.
302-309.
3 11-3 18.