- 2015 - Pilot Grant
The overall aim of this project is to adapt, pilot, and refine a mind-body group program targeting psychiatric, medical, biological and physiological manifestations of the stress of spousal bereavement in older age.
Specific Aim 1: To create an innovative mind-body intervention for widowed older men and women with bereavement-related psychiatric and/or medical symptoms, by adapting an existing relaxation-response program (based on focus group feedback), and piloting it;
Specific Aim 2: To collect pilot feasibility, and acceptability data, as well as assess psychiatric and medical symptoms, and stress reactivity data pre- and post-program in a pilot group of 10 adults aged 55 or more who lost their spouse in the prior year;
Specific Aim 3: To develop and use an innovative paradigm to measure bereavement-related biological and physiological stress reactivity.
1.1 Bereavement Is a Common, Distressing, and Impairing Major Life Stressor in Older Age
Over the past decades, the number of older people has been on the rise in Westernized countries. The growing number of older people has also brought an increase in the rates of widowhoods. Among the 40 million Americans older than 65, 40% of women and 13% of men are widowed (NCHS 2012).
The loss of a loved one is often one of the most painful and disruptive events survivors will experience, and many develop distressing and impairing symptoms grief (Shear et al. 2011), but also traumatic stress (Mutabaruka et al. 2012), anxiety (Bui et al. 2015), and depression (Prigerson et al. 1995). For example, in a representative cohort of older adults, 19% reported currently experiencing grief, with 25% of those meeting criteria for complicated grief, a severe and persistent form of grief (Newson et al. 2011). Further, in this sample, complicated grief was associated with increased depression and anxiety.
In parallel, widowhood has also been found to be associated in both sexes with a range of physical complaints and problems including limitations in daily activities, general health, pain, fainting and falling out, stiffness, and leg weakness (Wilcox et al. 2003, Williams et al. 2005). Unsurprisingly, older bereaved individuals utilize a high level of health care services, with results from a longitudinal study of medicare claims among n=1,138 older women (mean age = 75.1) indicating that recent widows exhibited a 40% higher risk for hospitalization compared to women who were not recently widowed (Laditka and Laditka 2003).
1.2 Bereavement Triggers a Range of Maladaptive Beliefs
The stress of widowhood has been associated with a number of bereavement-related maladaptive beliefs. A recent longitudinal study thus reported that almost one in four widowed older adults exhibited high levels of bereavement-related regrets that were stable (or increasing) over 48 months post-loss, and were associated with poorer outcomes (Holland et al. 2014). In a recent spousal bereavement study, guilt was also a powerful determinant of grief-specific difficulties following the loss of a loved one (Stroebe et al. 2014). Similarly, self-blame was found significantly associated to the severity of symptoms of grief, but also depression, and anxiety, even when controlling for background and loss-related variables (Boelen et al. 2003). Taken together, these data suggest that bereavement-related maladaptive beliefs including guilt, regrets, and self-blame are frequent after the loss of a loved one and may contribute to poorer psychiatric and functional outcomes.
1.3 Bereavement Triggers a General Physiological Stress Response
Separation from an attachment figure is a threat to homeostasis, and triggers a range of protest and search behaviors to facilitate reunion (Bowlby 1980). These initial manifestations can be understood in the context of an alarm reaction, or general adaptation syndrome (Selye 1956), and are thought to be associated with activation of both sympathetic adrenal medullary and hypothalamo-pituitary adrenal systems. In order to mobilize resources to face the stress of separation, the sympathetic system activates an epinephrine and norepinephrine-mediated “fight or flight” physiological response (including increase in heart rate and blood pressure), and the hypothalamo-pituitary adrenal axis triggers a glucocorticoid and inflammatory response (Sbarra and Hazan 2008). The loss of a loved one in the context of bereavement has thus been found to trigger a general physiological stress response involving the cardiovascular system, hypothalamic-pituitary-adrenal axis, and immune system (for review see: O’Connor 2012). In addition, a recent study reported that bereavement was associated with specific alterations of the immune and stress systems (e.g., reduced neutrophil phagocytosis and reactive oxygen species production, and increased stress hormone levels) only in the elderly (Vitlic et al. 2014), suggesting that this population may be more vulnerable to the biological effects of bereavement than younger adults.
1.4 Bereavement Increases Morbidity and Mortality
In line with bereavement-triggered stress, endocrine, and immune responses, widowed individuals are at high risk for accelerated aging through increased physical morbidity and mortality. A recent study reported that within 30 days of spousal loss, adults aged 60 to 89 (n=114,000) were exposed to a two-fold increased risk for myocardial infarction or stroke (incidence Ratio Risk = 2.2 [95% CI, 1.52-3.15]) (Carey et al. 2014).Two recent meta-analyses also highlighted the effects of widowhood on mortality in the six month following spousal death. Pooling data from 15 studies (n=2,263,888), Moon et al. (2011) reported a 1.41 [95%CI, 1.26-1.57] overall relative risk for mortality, while using mortality risk estimates from 124 publications reporting over 500 million individuals, Shor et al. (2012) found an adjusted hazard ratio of 1.58 [95%CI, 1.32-1.88].
1.5 There Is a Need for an Integrative Treatment Approach Targeting Bereavement-Related Psychiatric and Medical Symptoms in Older Age
Spousal bereavement, therefore, is common in older age, may trigger a general bereavement-related distress syndrome that includes psychiatric and somatic symptoms (see 1.1), maladaptive bereavement-related self-blaming and guilty beliefs (see 1.2), increased sympathetic and inflammatory responses to the loss (see 1.3), and that may accelerate aging through increased morbidity and mortality (see 1.4). This suggests that an integrative (i.e., mind-body) program targeting grief and other psychiatric symptoms, maladaptive self-blaming beliefs, somatic symptoms and complaints, increased sympathetic and inflammatory responses, may promote healthy aging in this underserved population of widowed older adults.
However, the treatment strategies available to date have mainly targeted the psychiatric manifestations of the stress of bereavement, including depression (Reynolds et al. 1999) or complicated grief (Shear et al. 2005). To our knowledge, only one study has examined the potential efficacy of a mind-body intervention for bereaved individuals with promising results. The authors reported that 17 Korean widowed women receiving self-help associated with Dan-jeon, a practice involving concentrating the mind and taking slow deep lower abdominal breaths exhibited significant pre-post changes in grief and depressive symptoms, and life-satisfaction (Yoo and Kang 2006, Kang and Yoo 2007). However, this small study was limited by possible cultural factors that may be specific to this population, the lack of assessment of somatic symptoms, or maladaptive cognitions, and was not specifically adapted to bereaved individuals. There is therefore a critical need for an integrative treatment approach targeting both bereavement-related psychiatric and medical symptoms that may also reduce grief-related self-blame beliefs and the adrenergic and inflammatory responses triggered by bereavement.
1.6 A Mind-Body Intervention Based on the Relaxation-Response and Self-Compassion May Be Efficacious to Support Older Adults Cope with the Stress of Bereavement
The relaxation response (RR) is a state, elicited by mind-body techniques such as meditation and yoga, which is conceptually opposite to the stress (or fight-or-flight) response (Benson et al. 1975). We have previously reported some preliminary efficacy data for an RR-based group intervention on a wide range of psychiatric symptoms, including anxiety, stress, and depression among n=124 treatment seeking individuals attending community health centers (Jacquart et al. 2014). Another similar RR-based symptom reduction group program showed promising significant pre-post program drops in somatic symptoms frequency (d=0.79) including gastrointestinal symptoms, palpitations and chest pain, fatigue, and muscle pain, as well as in psychological distress including depressive (d=0.953), anxiety (d=0.83), and somatization (d=0.96) (Samuelson et al. 2010). In addition, we recently reported in a transcriptome analysis that RR practice reduced expression of genes linked to inflammatory response and stress-related pathways including those connected with the pro-inflammatory transcription factors NF-kB and RELA, and TNFR2, IL7 and TCR signaling (Bhasin et al. 2013).
Self-compassion is defined by the extension of compassion to one’s self in instances of perceived inadequacy, failure, or general suffering. Self-compassion is composed of self-kindness, common humanity, and mindfulness, has been found associated negatively with shame and self-criticism (Gilbert and Procter 2006). Self-compassion training has shown promising results in decreasing trauma-related guilt (pre-post change d=0.82) (Held and Owens 2015), and has thus been proposed as a potential intervention for grievers (Wada and Park 2009).
Taken together, a program based on RR and self-compassion may be efficacious on psychiatric, medical, and biological manifestations of the stress of bereavement in older age. In addition, recent data (Ghesquiere et al. 2013) suggest that the group format may be best adapted to grievers. The Benson-Henry Institute for Mind Body Medicine has developed a range of programs aimed at increasing resiliency including the Relaxation Response Resiliency Program (3RP), a multimodal mind-body intervention that combines RR elicitation strategies (e.g., meditation, imagery) with stress reappraisal skills, and components from positive psychology including self compassion (Park et al. 2013). In the present proposal, we aim to adapt, pilot, and refine the 3RP to meet the specific needs of older adults who lost their spouse and present with psychiatric and medical manifestations of the stress of bereavement. In line with the Osher Center for Integrative Medicine’s strategic themes, our proposal aims to develop a mind-body program to promote healthy aging.
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