Bereavement: The Issue

Many older adults experience loss with aging—loss of social status and self-esteem, loss of physical capacities, and death of friends and loved ones. But in the face of loss, many older people have the capacity to develop new adaptive strategies, even creative expression (Cohen, 1988, 1990). Those experiencing loss may be able to move in a positive direction, either on their own, with the benefit of informal support from family and friends, or with formal support from mental health professionals.

The life and work of William Carlos Williams are illustrative. Williams was a great poet as well as a respected physician. In his 60s, he suffered a stroke that prevented him from practicing medicine. The stroke did not affect his
intellectual abilities, but he became so severely depressed that he needed psychiatric hospitalization. Nonetheless, Williams, with the help of treatment for a year, surmounted the depression and for the next 10 years wrote luminous poetry, including the Pulitzer Prize-winning Pictures From Bruegel, which was published when he was 79. In his later life, Williams wrote about “old age that adds as it takes away.” What Williams and his poetry epitomize is that age can be the catalyst for tapping into creative potential (Cohen, 1998a).

Loss of a spouse is common in late life. About 800,000 older Americans are widowed each year. Bereavement is a natural response to death of a loved one. Its features, almost universally recognized, include crying and sorrow, anxiety and agitation, insomnia, and loss of appetite (Institute of Medicine [IOM], 1984). This constellation of symptoms, while overlapping somewhat with major depression, does not by itself constitute a mental disorder. Only when symptoms persist for 2 months and longer after the loss does the DSM-IV permit a diagnosis of either adjustment disorder or major depressive disorder. Even though bereavement of less than 2 months’ duration is not considered a mental disorder, it still warrants clinical attention (DSM-IV). The justification for clinical attention is that bereavement, as a highly stressful event, increases the probability of, and may cause or exacerbate, mental and
somatic disorders.

Bereavement is an important and well-established risk factor for depression. At least 10 to 20 percent of widows and widowers develop clinically significant depression during the first year of bereavement. Without
treatment, such depressions tend to persist, become chronic, and lead to further disability and impairments in general health, including alterations in endocrine and immune function (Zisook & Shuchter, 1993; Zisook et al., 1994). Several
preventive interventions, including participation in self-help groups, have been shown to prevent depression among widows and widowers, although one study suggested that self-help groups can exacerbate depressive symptoms in certain individuals (Levy et al., 1993). These are described later in this chapter.

Bereavement-associated depression often coexists with another type of emotional distress, which has been termed traumatic grief (Prigerson et al., in press). The symptoms of traumatic grief, although not formalized as a mental disorder in DSM-IV, appear to be a mixture of symptoms of both pathological grief and post-traumatic stress disorder (Frank et al., 1997a). Such symptoms are extremely disabling, associated with functional and health impairment and with persistent suicidal thoughts, and may well respond to pharmacotherapy (Zygmont et al., 1998). Increased illness and mortality from suicide are the most serious consequences of late-life depression.

The dynamics around loss in later life need greater clarification. One pivotal question is why some, in confronting loss with aging, succumb to depression and suicide—which, as noted earlier, has its highest frequency after age 65—while others respond with new adaptive strategies. Research on health promotion also needs to identify ways to prevent adverse reactions and to promote positive responses to loss in later life. Meanwhile, despite cultural attitudes that older persons can handle bereavement by themselves or with support from family and friends, it is
imperative that those who are unable to cope be encouraged to access mental health services. Bereavement is not a mental disorder but, if unattended to, has serious mental health and other health consequences.

Retrieved From Mental Health: A Report to the Surgeon General ; March 2009.