Title: Psychological interventions for depression in adults bereaved through life-limiting conditions
Funder: Health and Social Care Research and Development Division (HSC R&D) of Public Health Agency, Northern Ireland

Abstract: The focus of the proposed review will be to determine if behaviour therapy is more effective than other psychological interventions at alleviating depression in adults bereaved through life-limiting conditions. It was developed following: discussions with my supervisor and team and scoping the published literature. The topic was highlighted as a research priority by Marie Curie in 2015; and is appropriate to this proposed fellowship with my background as a social work/researcher in specialist palliative care and bereavement for almost 20 years. Grief is normally regarded as an intense emotional and physical reaction experienced by an individual following the death of a loved one. Normal grief, which is experienced by 80-90% of the population, resolves over time (Parkes, 2009). Whereas around 10% of the general population (Lathan and Prigerson, 2004) find that their grief persists and does not improve over time, leading to complicated, traumatic or prolonged grief, which is a very debilitating condition (Papa et al, 2013). However, the prevalence of prolonged grief can be 20% in bereaved dementia caregivers (Schulz et al., 2006) and over 50% in HIV+ caregivers (Bonanno et al, 2005). The latest American Psychiatric Association’s Diagnostic and Statistical Manual, Volume V (DSM V), which is used to diagnose patients, recognised the need for a new diagnostic category: Prolonged (Complicated) Grief Disorder. This is applied to bereaved individuals who experience significant impairment and distress that persists over an extended period of time after the death of a loved one and can be diagnosed through a clinical assessment as early as six months into bereavement. Bereaved individuals are more at risk of serious mental health problems and have an increased risk of suicide (Prigerson & Jacobs, 2001; Stroebe, Schut, & Stroebe, 2007), with major depression being a ‘potentially lethal disorder, with an overall suicide rate of about four percent’ (Pies, 2014: 20). According to Florence et al (2015), bereavement-related depression was found in 64.3% (using DSM-V diagnostic criteria) of their French study population. The main experimental intervention for the review will be behaviour therapy and the proposed comparators will include any other active interventions (i.e. Psychodynamic interventions; Humanistic interventions; group therapies; systemic family therapy; complementary therapies; information support; standard treatment). Behaviour therapy is a talking therapy commonly used to treat mood disorders, such as post-traumatic stress, depression or anxiety and can be modified for use with bereaved people (Kavanagh, 1990). This intervention is most commonly cited in the literature and a behaviour therapy model provides a framework for practitioners to understand the experiences of bereaved people, to identify barriers they may face and to help them develop strategies to increase their sense of control (Morris, 2008). It focuses on their thoughts and behaviours about the death and about living without the deceased. This form of therapy is reported to benefit individuals experiencing normal grief reactions (i.e. offering psycho-educational interventions or guidance) and for those with prolonged or complicated grief (i.e. offering a more structured, long-term intervention to facilitate adapting to life without the deceased) (Morris, 2008). A clinical trial comparing no treatment with behaviour activation therapy for pathological grief (Papa et al., 2013) reported large reductions in prolonged, complicated or traumatic grief and depression for the intervention group. Existential behaviour therapy has been reported to show medium effects on depression and quality of life at 12 month follow-up, when compared with results for a treatment as usual group (Fegg et al., 2013). This review will determine if behaviour therapy is more effective than other psychological interventions, at alleviating depression in adults through a range of life-limiting conditions. The proposed eligibility criteria for the review will be: Inclusion: Individuals aged over 18 who have been bereaved following the death of a spouse, parent, sibling or adult child. Deaths in the community, hospital, hospice and nursing homes caused by life limiting conditions as defined by ICD10 codes (i.e. cancer, Motor Neurone’s Disease, Parkinson’s Disease, Heart Failure, Multiple Sclerosis, Alzheimer’s Disease). Interventions will include: behaviour therapy, psychodynamic interventions; humanistic interventions; group therapies; systemic family therapy; complementary therapies; information support; standard treatment; or any other intervention offered to adults bereaved following a life-limiting illness). Outcomes will include depression and prolonged grief disorder. All studies will be trials. Exclusion: Bereaved individuals aged under 18 and individuals bereaved following the death of a child under 18. Bereavement following sudden death (i.e. homicide, suicide, road traffic accidents, terrorism, natural disasters) or perinatal/foetal deaths. These criteria are proposed because of the different reactions following a sudden death, particularly if caused by another person’s negligence, an act of terrorism or a natural disaster, or if the individual feels guilty, angry or rejected following a relative’s suicide. Whereas when an individual dies from a life-limiting condition, the surviving relative is more likely to have anticipated their impending loss, time to attend to unfinished business and an opportunity to communicate with their relative (Parkes, 2009). Including close family relatives is in keeping with findings from other research about the impact of kinship of bereavement outcomes (Parkes, 2009). Including a range of community settings acknowledges the range of places where adults with life-limiting illness die (Office for National Statistics: VOICES survey, 2012). Parkes (2009) highlights the different determinants of grief as: kinship, gender, age, mode of death, personal vulnerability and cultural/social influences. Based on this, subgroup analyses will include: gender of bereaved individual, age of bereaved individual, relationship to the deceased, time since bereavement, cause of death, length of illness, place of death and cultural differences based on country. Despite having access to hospice bereavement services, over 50% of bereaved caregivers had clinically significant depression one year following their loss, which highlighted the need to use risk assessments to screen for depression and to target services (Allen et al., 2013). Given the emphasis on evidence-based practice, and the knowledge that offering universal support to bereaved individuals irrespective of need is not effective (Auon et al., 2012), systematically reviewing the published literature will inform service delivery and inform practitioners on which therapy works best for the identified needs of their service users.


Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH