Journal of Gerontology: PSYCHOLOGICAL SCIENCES 1992, Vol. 47. No. 6, P357-P366

Copyright 1992 by The Geronwlogical Society (if America

Changes in Grief and Mental Health of Bereaved Spouses of Older Suicides Norman L. Farberow,1 Dorothy Gallagher-Thompson,2 Michael Gilewski,3 and Larry Thompson2 'Los Angeles Suicide Prevention Center, A Division of Family Services of Los Angeles. 2 Stanford University, Veterans Administration Medical Center. 'Physical Medicine and Rehabilitation, Cedars Sinai Medical Center.

the list of major stressors (Holmes & Rahe, AMONG - 1967), losing a spouse through death is listed as the most difficult of life's experiences. Most studies have been of survivors of natural death (NDS) (Clayton, 1979; Glick, Parkes, & Weiss, 1975; Lund, Caserta, & Dimond, 1986; Parkes, 1985; Zisook & Schuchter, 1985, 1986). When compared with nonbereaved controls (NBC) with similar demographic characteristics, survivors have reported more intense emotional symptoms, such as denial, severe depression, overwhelming grief, anger, confusion, and others, as well as increased physical health problems, increased physician visits, and hospital use (Gallagher, Breckenridge, Thompson, & Peterson, 1983; Gallagher-Thompson, Futterman, Farberow, Thompson, & Peterson, in press). Studies of survivors of suicide (SS) have reported the same kinds of reactions as have been noted in other deaths, but have frequently reported that the reactions are more extreme and of longer duration (Cain & Fast, 1966; Demi, 1978; Wallace, 1973). Generally, the differences have been attributed to the sudden, unanticipated, sometimes violent aspect of a suicide and the frequent presence of guilt feelings, as well as to the voluntary element that implies rejection and abandonment. However, these reports most often looked at spouses of young or middle-age suicides, raising the question of whether the same results would be obtained for spouses of older suicides. In addition, in light of current interest in longitudinal studies of bereavement (Lund, 1989; Zisook & Schuchter, 1985, 1986), another question was the extent to which such psychological distress would change with the passage of time. This study examined three relatively unexplored concerns of the bereavement process, (a) It focused on the bereavement following a suicide and compared it with bereavement after natural death, (b) It focused on the older person (i.e.,

the surviving spouse of a suicide who was 55 years or older at the time of death), (c) It looked at bereavement as a longterm, adaptational process that continued at length, frequently for years. Dimond (1981) and Osterweis, Solomon, and Green (1984) provide comprehensive reviews of research into the bereavement process. Stages of grief are found in all ages and have been described by many investigators (Averill, 1968;Fulconer, 1942; Glick, Parkes, & Weiss, 1975;Lindemann, 1944; Parkes, 1972). Almost all refer to an initial period filled with shock, disbelief, and numbness, followed by a period of depression, grief, anxiety, anger, pining, social and personal withdrawal and, for some, somatic symptoms. There is a gradual reduction of physical and emotional symptoms, along with resumption of personal and social functioning as adaptation occurs. Dimond (1981) questioned whether there were well-defined stages in the bereavement process and favored Parkes' (1975) concept of psychosocial transition involving gradual adaptation. Dimond criticized studies of research in bereavement, emphasizing the need for good sampling, a longitudinal design, and the importance of taking into consideration environmental context, supportive network, concurrent losses, and coping skills. Antonovsky (1979) had previously added personality characteristics as a major set of factors to be considered. Stern, Williams, and Prados (1951), in an early study of grief reactions among elderly adults, reported that conscious guilt tended to be much less than among survivors of younger ages and that the elderly were more likely to develop somatic complaints than emotional difficulties. Elderly persons were also more likely to assume blame on themselves and to show more hostility to other members of the family and friends. Heyman and Gianturco (1973), in a study of widowhood in the aging, found few differences between P357

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Comparisons are made of the impact of a suicide death on the surviving spouse (55 years and older) with that of a natural death on spouse survivors and a married nonbereaved control group over a bereavement period of2'h years after death. Regardless of mode of death, the loss of a loved one is a difficult psychological trauma, accompanied by depression, confusion, and pervasive feelings of emptiness. Few differences in the impact of the deaths in the early months of bereavement were reported, but changes appeared over the course of the 2'h-year measurement period. Compared with natural death survivors, the process of bereavement was found to be more difficult for the survivors of a suicide death, whose severe depressive feelings do not seem to lessen significantly and whose feelings of mental health do not seem to improve until after the first year. Women, in general, report greaterfeelings than men of anxiety, tension, and apprehension, especially within the first 6 months. By the end of the observation period, most of the differences between the two bereaved groups have disappeared, and both report functioning adequately despite continuing feelings of sadness and loss.

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reactions of survivors of suicide death. Previous reports from this study have presented data on the early impact (within 2 months) of bereavement on psychological status in survivors of suicide (Farberow, Gallagher, Gilewski, & Thompson, 1987), the changes in social support network (Farberow, Gallagher-Thompson, Gilewski, & Thompson, 1992), the interaction of depression and bereavement (Gilewski, Farberow, Gallagher, & Thompson, 1991), and psychopathology symptoms (e.g., bereavement effects in older widows and widowers of natural deaths) (Thompson, Gallagher, Cover, Gilewski, & Peterson, 1989). Procedure This study focused on the longitudinal changes in grief, mental health, and personality status of survivors after the suicide death of their spouse over a period of 2'/2 years. Data were collected at four times: within 2 months (Time 1), 6 months (Time 2), 12 months (Time 3 ), and 2'/2 years (Time 4) after the death. Interim analyses of the data gathered at the first three measurement times indicated some significant trends and are summarized here. At 2 months (Farberow et al., 1987), there were no significant differences between the SS spouses and a comparison group of NDS spouses on any of the variables relating to grief, mental health, or personality status. Also, as expected, the data for a group of NBC (no loss of spouse in the 5 years prior to entry in the study) showed significantly less depression, negative self-appraisal, and psychological distress than either of the bereaved groups. At 6 months, comparison of the data continued to show no significant differences between the two bereaved groups. Levels of depression, grief, psychological difficulties, and negative self-appraisal declined slightly for the SS and markedly for the NDS, albeit not enough to reach significance. Both bereaved groups continued to report significantly more emotional distress and poorer levels of selfevaluation than the NBC. At Time 3(12 months after the death), some significant differences between the two bereaved groups appeared for the first time, with the SS rating their level of mental health significantly poorer and their feelings of depression greater than the NDS. Levels of grief and general psychopathology decreased throughout the entire 12 months, but primarily in the first 6 months for the NDS, whereas the SS reported only slight improvement in their levels of grief and general psychopathology for the entire first year. Gender differences appeared, with women reporting more apprehension, greater fearfulness and obsessive-compulsive tendencies, and more anxiety about handling the details of living. Over the year, mood improved and self-confidence increased, along with a higher level of wariness in their expanded roles. This report presents the analysis of the data collected at Time 4, 2'/2 years after the death. The focus was on the changes occurring within this period in the mental health, grief, and personality status of the older widows and widowers who survived the suicide death of their spouse. The specific questions addressed were: 1. What changes occurred in kinds and levels of grief, selfrated mental health, and psychopathology in the surviving spouse?

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sexes in "before" and "after" (bereavement) scores in areas such as health, leisure activity, and financial activity, or in ratings of anxiety or hypochondriasis. Widows, however, tended to be more socially active than widowers. Long-term studies of grief are comparatively few, probably because of the difficulty in sustaining subjects through the bereavement period, which is generally filled with emotional distress and, often, with many life changes. Zisook and Schuchter's (1985) review of the literature identified the major factors contributing to long-term grief, such as psychiatric problems (Clayton & Darvish, 1979), multiple life crises (Parkes, 1975), severe initial reactions (Parkes, 1985), poor prior health (Wiener, Gerber, Battin, & Arthur, 1975), nonsupportive environment (Raphael, 1983), poverty and poor educational background in older widows (Lopata, 1973), lack of anticipatory grief (Glick et al., 1975), and conflicted or dependent relationship with the deceased (Parkes & Weiss, 1983). In two of their own long-term studies of the bereavement process in adult survivors of all ages, Zisook and Schuchter (1985, 1986) found that, whereas distress gradually diminished and overall adjustment improved over time, 25% rated life as only fair or poor at 4 years after death. The authors concluded that adjustment to bereavement was an ongoing life process rather than a crisis always mastered or resolved within a specific period of time. The authors also provided a number of suggestions for treatment of grief and spouse bereavement. Osterweis, Solomon, and Green (1984) also concluded from their review that there is no precise point in time when grieving is over and mourning ends. Rather, it is a process that involves completion of certain tasks and resumption of others; but the pain of the loss may remain for a lifetime. The long-term effects of bereavement, specifically in elderly persons, were studied over a period of 2 years in older widows and widowers, with a mean age of 67.8 years (27% men) (Lund, 1989; Lund et al., 1986). Emotional shock was found to decline in intensity over time, but was still noticeably present after 2 years. Feelings such as anger, guilt, helplessness, avoidance, and confusion were relatively low early in the bereavement period, but these feelings also decreased in intensity throughout the study. More similarities than differences were found between men and women in the bereavement process. The biggest problems were loneliness and managing the tasks of daily living. Clayton, Halikas, and Maurice (1972) reported from a study of all ages, but with an average of 62 years, that the intensity of the depression at one month was directly related to, and was a good predictor of, the level of depression at the end of the first year. The primary objective of our study was to assess the impact of the loss by suicide of an older person on the mental health and psychological status of the surviving spouse. Peterson's (1980) model of bereavement theorized that resolution and adaptation during the mourning period depended on the interaction of three factors: coping strengths, social support network, and cumulative losses and stresses. Peterson's model was derived from the study of survivors after a natural death. This study expanded the model to include the mode of death as another important factor by exploring the

BEREAVEMENT CHANGES IN SUICIDE

2. How did these changes compare with the changes in two comparison groups, widows and widowers after a natural death, and controls who did not experience the loss of a spouse within the previous 5 years? 3. What gender differences appeared between and within the two bereaved groups? METHOD

Measurement instruments. — Psychological status was evaluated by five self-report scales and by one item [selfrated mental health (MHLTH)] in the interview questionnaire asking for self-appraisal of their own mental health on a 7-point scale (from excellent, 1, to very poor, 7). The selfreport indices were: (1) Texas Inventory of Grief-Past (TIG Past), 8 items, rating feelings and actions at the time of death of the spouse (for controls, the most recent death of a significant person, which, although not ideal, allows statistical comparisons for the bereaved samples) (Faschingbauer, 1981; Faschingbauer, Devaul, & Zisook, 1977); (2) Texas Inventory of Grief-Present (TIG Present), 33 items rating feelings and actions at the time of responding; (3) Beck Depression Inventory (BDI), 21 items (Beck, Ward, Men-

delson, Mock, & Erbaugh, 1961); (4) Severity Index, Brief Symptom Inventory (BSIsev) (Derogatis & Spencer, 1982), a summary score from the average of the nine scales of the (5) Brief Symptom Inventory (BSI) (Derogatis, Lipman, & Covi, 1973) measuring nine dimensions of psychopathology (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism); and (6) 12 factors of the 16-Personality Factor Scale (16-PF) (Cattell, Eber, & Tatsuoka, 1970). Statistical analysis. — Comparisons were conducted on a maximum of 230 subjects, of which 71 were SS, 57 females and 13 males (attrition over 2'/2 years, 34% each females and males); 147 NDS, 93 females and 54 males (31% attrition, 12% females, 43% males); and 123 NBC, 61 females and 62 males (15% attrition, 6% females, 22% males). Previous examination of demographic variables (Farberow et al., 1987) had indicated some significant differences among the three groups. Briefly, SS were 88% Caucasian, 5% Black, and 7% Hispanic; NDS and NBC were all Caucasian. About 80% attended at least one year of high school, and most reported an income between $10,000 and $30,000. Major occupation of the SS and NDS were sales and clerical, and for controls managerial and professional. Mean length of marriages in all groups was between 35 and 40 years; males in both suicides and survivor spouses generally reported a higher socioeconomic status (SES: income, education, and occupation). A principal component analysis with varimax rotation was conducted on the residuals of all the sociodemographic variables after bereavement and gender effects were removed. This reduced seven of the most stable demographic indicators to four covariates, accounting for 79% of the variance: spouse SES, longevity (including both number of years married and age of respondent), respondent SES, and income. A multivariate analysis of variance (MANOVA) on the four variables indicated significant main and interaction effects for group, sex, and group by sex. Examples of the differences are less skilled occupation and younger mean age of the SS than either the NDS or NBC; no group differences for males, but females in NBC had the greatest incomes, followed by the SS group and then the NDS group. In order to control for the demographic differences, the four variables were used as covariates in the comparisons between all groups. The kinds and significance of changes in the mental health, grief, and personality status measures over 2'/2 years of time were evaluated by means of multivariate analyses of covariance (MANCOVAs), with repeated measures between the groups for the main effects of group and sex and the interaction effects of group by sex; and within subjects for the main effects of time and the interaction effects of sex by time, group by time, and sex by group by time, using Wilk's lambda. Both linear and curvilinear (quadratic and cubic) patterns were used to evaluate changes over time. Linear changes indicated consistent patterns of increases or decreases in composite mean scores from Time 1 through Time 4; quadratic changes represented changes in composite mean scores that showed a U or inverted U pattern over the four

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Population samples. — Readers are referred to earlier reports (Farberow et al, 1987; Gallagher, Breckenridge, Thompson, & Peterson, 1983; Gallagher-Thompson et al., in press) for complete details on populations and methods of enlistment. Briefly, bereaved SS (n at start of study, 88 women and 20 men, mean age of 62 years) were identified from coroners' records in Los Angeles and two other counties. NDS (n, 104 women and 95 men, mean age of 68 years) were identified from Health Department records of Los Angeles County. Survivors were invited by letter explaining the study and by follow-up telephone calls to participate in the research. Acceptance rates were 35% for the suicide survivors and 30% for the natural death survivors, rates considered typical for this kind of study where volunteers were obtained while under considerable stress. Comparison of subjects participating with those not participating indicated no differences on demographic variables of age, sex, and race. NBC (/?, 65 women and 79 men, mean age of 70 years) were married persons who had not experienced the loss of a spouse through death or divorce in the 5 years prior to the study, but had lost a family member or close friend, almost all within that period. The controls were obtained through personal contacts from senior centers, residential facilities for elders, and through the Emeriti Center of the university. The NDS and the NBC were subjects in a study conducted at the Ethel Percy Andrus Gerontology Center, University of Southern California (Larry Thompson, principal investigator). As stated above, all subjects (SS, NDS, and NBC) were interviewed at four successive times after the death: within 2 months (Time 1), at 6 months (Time 2), at 12 months (Time 3), and at 30 months (Time 4). Respondents were interviewed primarily in their homes, but some were interviewed in the university offices. They were also given self-report measures that were mailed to the investigators within 1 to 2 weeks.

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time measurements. Cubic changes represented variations in composite mean scores that indicated a wave or S pattern over the four time periods. Univariate tests for effects were conducted for categories that were significant, followed by, where indicated, Newman-Keuls tests on the composite mean scores for each group for each variable at each time, with adjustments for covariates. RESULTS

Grief and Mental Health

Table 1. Univarate F and Composite Group Means Between and Within Groups (Linear) on Grief and Mental Health Variables Between Groups Group Means

TIG Past TIG Present MHLTH

F(2,396)

SS

20.26*** 18.11*** 3.34*

62.32 124.04 9.31

NDS

NBC

57.94 126.34 8.38

43.28 96.83 7.58

Within Groups Group by Time

Time

TIG Present BDI BSIsev MHLTH

Mean Differences

F( 1,252)

Mean Differences

F(2,252)

45.23*** 10.60*** 8.09** 15.34***

-5.25 -1.48 -.06 -.29

11.07*** 4.39* 5.26** 12.48***

SS -7.38 -3.35 -.15 -.083

NDS

NBC

-7.66 -22.9 -.10 -.58

-.36 -.23 -.01 -.21

Note. SS = suicide survivors; NDS = natural death survivors; NBC = nonbereaved controls; TIG = Texas Inventor of Grief; BDI = Beck Depression Inventory; BSIsev = severity index of Brief Symptom Inventory; MHLTH = self-rated mental health. *p = .05; **p = .01; ***p = .001.

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TIG Past, TIG Present, BDI, BSIsev, and self-rated mental health. — MANCOVAs of grief and mental health variables of past and present grief, depression, general psychopathology, and self-rated mental health were conducted to determine main and interaction effects between all subjects for group and sex. Significant differences appeared between groups [F( 10,784) = 5.90, p < .000]; the effects for sex and group by sex were not significant. Univariate analyses of effects for group only indicated significant differences for TIG Past, TIG Present, and MHLTH (Table 1). Newman-Keuls tests for significant differences between the composite group means for the three groups on each of the three measures indicated, as expected, that the two bereaved groups, NDS and SS, felt significantly more grief than the NBC. The SS also rated their level of mental health at a significantly poorer level than the controls; the NDS did not. However, the difference between the two bereaved groups was not significant. Changes in the grief and mental health variables within subjects were measured by exploring three patterns of change: linear, quadratic, and cubic. MANCOVAs were conducted within subjects for linear main effects of time, sex by time, and group by sex by time. The results indicated significant effects only for time [F(5,248) = 11.64, p < .000] and interaction effects of group by time [F( 10,496) = 4.48,

p < .000]. Univariate tests for linear patterns within subjects for time yielded significant results for TIG Present, BDI, BSIsev, and MHLTH (Table 1). Mean scores for all four measures decreased from Time 1 through Time 4, indicating regular improvement over time. Univariate tests for linear effects for group by time were conducted to determine differences between the groups in the changes over time. Results were significant for the same four scales: TIG Present, BDI, BSIsev, and MHLTH (Table 1). Newman-Keuls tests were used to test for significant differences in the changes within groups on the four scales. Results showed that, as expected, the change (improvement) for each of the two bereaved groups was significantly greater than the change for the control group. However, the bereaved groups were not significantly different from each other in any of the scales or on their self-rating of their mental health (Table 1). To determine whether the changes showed fluctuations over time, MANCOVAs were computed for significant change differences within the subjects for both quadratic and cubic patterns. Results showed no significant quadratic patterns, but significant cubic patterns were found for main effects of time [F(5,216) = 4.94,/? < .000] and interaction effects for group by time [F(10,432) = 3.82, p < .000]. Interaction effects for sex by time and group by sex by time were not significant. Univariate measures for time yielded significant differences for TIG Present, BDI, and MHLTH (Table 2). Newman-Keuls for significant differences on the TIG Present scores indicated that the feelings of grief for both groups decreased regularly with the passage of time, and that the greatest decline took place during the second year and a half (from Time 3 to Time 4) (Table 2). The BDI scores also showed a decline in the level of depression over the entire period, with the greatest decline occurring within the first 6 months, no change in the second 6 months, and then a slight decline during the second year and a half (Table 2). The

BEREAVEMENT CHANGES IN SUICIDE

Table 2. Univarate F and Cubic Composite Mean Scores for Time and Group by Time for Grief and Mental Health Mean Scores Time (months)

TIG Present BD1 MHLTH

F( 1,220)

2

6

12

30

10.07** 6.43* 12.16***

37.8 8.2 2.7

36.3 6.8 2.5

34.9 6.8 2.5

33.2 6.2 2.6

Mean Scores Group by Time (months)

BSIsev SS NDS NBC MHLTH SS NDS NBC

2

6

12

30

13.29***

40.0 43.7 28.6

40.8 39.6 30.0

40.4 39.0 27.0

35.8 36.0 28.2

3.72*

.59 .58 .41

.52 .46 .41

.54 .43 .39

.43 .44 .41

5.42**

3.3 2.9 2.0

3.0 2.6 2.1

3.0 2.4 2.3

2.5 2.1 2.2

Note. SS = suicide survivors; NDS = natural death survivors; NBC = nonbereaved controls; TIG = Texas Inventory of Grief; BDI = Beck Depression Inventory; BSIsev = severity index of Brief Symptom Inventory; MHLTH = self-rated mental health. *p = .05;**p = .0l;***p = .001.

mental health self-ratings also showed that most improvement occurred within the first 6 months, and that relatively little change occurred over the rest of the time (Table 2). Univariate analysis of changes within groups over time indicated significant main effects for TIG Present, BSIsev, and MHLTH. Table 2 indicates discernible differences in the way in which the three groups experienced feelings of grief (TIG Present) over the 2'/2-year period. The pattern for the SS was a high level of grief, which stayed high throughout the first year and dropped markedly by the end of the 2'/2 years (Table 2). Their level of grief at 2'/2 years was about the same as that of the NDS, albeit still significantly higher than the level of the controls. The pattern for the NDS was much different. Although starting at a slightly higher level than the SS, there were two major declines in the feeling of grief, the first between 2 months and 6 months, after which it stayed about the same for the next 6 months and dropped again by 30 months. Although the level of grief for both bereaved groups at 30 months was still higher than that of the NBC, the difference was not significant. As expected, the level of grief for the control group showed relatively no change throughout. The level of emotional distress (BSIsev) for the two bereaved groups also showed different patterns of change over the 2'/2-year period (Table 2). For both bereaved groups, emotional distress was high in the first 2 months. For the SS, this level dropped by 6 months, rose very slightly at

12 months, and then dropped markedly by 30 months. The NDS showed a marked decline in their general psychopathology level between 2 and 6 months, a slight drop over the remainder of the year, and stayed at practically the same level until 30 months. By the end of the 30 months, the level of emotional distress for both bereaved groups had dropped to approximately the same level as that of the controls, which had shown almost no change over the entire 2'/2-year period (Table 2). Levels of mental health for the SS improved irregularly over the 2'/2 years, with the first indication they felt better about themselves appearing between 2 months and 6 months, no change at 12 months, and then further improvement at 2'/2 years (Table 2). The NDS showed consistent improvement over the 30 months; and the NBC stayed at about the same level of mental health rating throughout each of the time periods. Comparatively, the SS rated their level of mental health as poorer, albeit not significantly, than the NDS and the NBC at all measure points. In general, significant improvements for the two bereaved groups in levels of grief, depression, psychopathology, and self-perceived level of mental health appeared over the 2'/2 years. Viewed only in terms of total group changes, the two bereaved groups seemed to show no statistically significant differences from each other in the course of improvement in mental health over the 2'/2 year period. However, curvilinear analyses revealed differences in the course of improvement for each group over time. For example, the suicide spouse-survivors did not really show any improvement in their level of grief throughout the entire first year of their bereavement, whereas the NDS group improved in two stages: within the first 6 months and then again during the second year and a half. It is worth noting again that, despite the improvement, the level of grief for both groups was still substantially higher at the end of 2'/2 years than that of the controls. The level of psychopathology for the SS also showed improvement in two stages: in the first 6 months and then again in the second year and a half. In contrast, the NDS, who presented a similar high level of psychological distress during the first 2 months, improved so much that within 6 months they had reached a level that was practically the same as that of the controls. In their perceived mental health, the SS improved in the first 6 months, but reported no further improvement until after the first year. Again, in contrast, the NDS showed regular improvement in their perceived mental health at each of the four observation points until, at 30 months, they rated their mental health at approximately the same level as the controls. BS1. — Analyses of the nine scales of the BSI were conducted with procedures similar to those used previously to determine differences between groups and changes over time in various dimensions of feelings and pathological states. MANCOVAs were performed between subjects to observe differences between the groups and sex on the nine separate scales. Results indicated significant main effects for group [F(20,786) = 7.03, p < .000] and for sex F(10,393) = 3.66, p < .000]; effects for group by sex interactions were not significant. Univariate measures for effects of

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TIG Present SS NDS NBC

/r(2,220)

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Table 3. Univariate F, Composite Group and Sex Mean Scores, and Linear Mean Score Differences on Significant Brief Symptom Inventory Scales Mean Scores Group

Sex

Subscale

F(2,402)

SS

NDS

NBC

Depression Anxiety Hostility Psychoticism Obsessive-compulsive Phobic anxiety

17.79***

2.50

2.33

1.09

5.11** 4.36*

.95 1.28

.77 1.29

1.15 .84

F( 1,402)

M

F

4.68*

1.13

1.99

5.07* 4.04*

2.16 .48

2.95 1.04

Linear Mean Score Differences

Depression Anxiety Psychoticism Obsessive-compulsive

24.77*** 8.45* 4.18* 8.81*

Group Over Time F(2,272)

SS

NDS

NBC

19.81***

-.35

-.34

.07

3.96**

-.34

-.13

.02

Note. SS = suicide survivors; NDS = natural death survivors; NBC = nonbereaved controls. *p = .05;**/; = .01;***/? = .001.

group to determine which of the nine scales were significant were conducted, yielding significant differences occurring for three of the subscales: depression, hostility, and psychoticism (Table 3). Comparison of group means by Newman-Keuls measures to determine where differences were between the groups indicated that the two bereaved groups, although not significantly different from each other, were both significantly different from the NBC, with higher levels of severe depression and psychoticism (Table 3). In hostility, it was the controls who showed the highest level, significantly higher than the NDS but not higher than the SS. There was no significant difference between the two bereaved groups in hostility. Univariate analysis for main effects of sex indicated a significant difference on three of the subscales: obsessivecompulsive, anxiety, and phobic anxiety. On all three subscales, Newman-Keuls comparison of group means indicated that women rated themselves significantly more obsessivecompulsive, anxious, and fearful than men (Table 3). Curvilinear analyses were conducted to determine the course of changes over time on the BSI scales for the three groups. Multivariate analyses for linear effects within subjects were significant for the main effects of time [F( 10,263) = 4.83, p < .000] and for interaction effects of group by time [F(20,526) = 3.92, p < .000]; analyses were not significant for interaction effects of sex by time nor for group by sex by time. Univariate analyses for linear patterns for time were significant for scales: obsessive-compulsive, depression, anxiety, and psychoticism (Table 3). On all of the scales, the mean scores decreased over the 2'/2-year period, indicating a general lessening of feelings of depression, anxiety, unreality, and obsessive thoughts over the 2'/2-year post-death period. Univariate analysis for linear interaction effects for group

over time were significant on two of the scales: depression and obsessive-compulsive (Table 3). Newman-Keuls measures indicated that the SS decreased significantly more in their obsessive thinking than both the NDS and the NBC. This might be a reflection of the degree to which SS are at first haunted by the questions of why the death occurred and whether there was anything they could have done to prevent it. On the depression scale, both the SS and the NDS decreased significantly more in their depressive feelings than the NBC, but not more than each other (Table 3). MANCOVAs for quadratic patterns yielded no significant differences on any of the BSI scales. MANCOVAs for cubic patterns were significant for main effects of time [F{ 10,236) = 2.81,/? < .003] and interaction effects of group over time [F(20,472) = 1.76,/; < .023]. Interaction effects for sex by time and for group by sex by time were not significant. Univariate measures for cubic patterns for time yielded significant effects for the obsessive-compulsive scale and depression (Table 4). Comparison of the cubic mean scores over time by Newman-Keuls indicated that obsessive thinking and feelings of depression decreased markedly within the first 6 months. After that, the obsessive-compulsive feelings stayed approximately the same for the next 2 years, whereas the intensity of their depressive feelings decreased again during the last year and a half (Table 4). Univariate measures of cubic patterns for groups over time were significant only for the depression scale (Table 4). Again, the two groups differed considerably from each other in terms of the course of their feelings of depression over the 2'/2-year period. The SS remained depressed for the entire first year and did not show a significant lessening of their depression until the 30-month measure. In contrast, the NDS reported a marked lessening of their depression in the first 6 months, a slight diminution through the next 6 months, and then a further moderate decrease by the end of the next year

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Time F( 1,272)

BEREAVEMENT

Table 5. Univariate F, Composite Mean Sex Scores, and Linear Composite Mean Differences on Significant Factors of the 16-PF

Table 4. Univariate F and Cubic Composite Mean Scores of Significant Brief Symptom Inventory Scales for Time and Group Over Time Effects

Composite Mean Sex Scores

Mean Scores Time (months) Subscale Obsessive-compulsive Depression

F( 1,245)

2

6

12

30

7.05** 12.66

.89 .72

.77 .57

.79 .57

.76 .49

Mean Scores Group Over Time (months) Subscale

2

6

12

30

8.37* .88 .96 .31

.86 .68 .28

.87 .64 .32

.53 .59 .35

Note. SS = suicide survivors; NDS = natural death survivors; NBC = nonbereaved controls. *p = .05;**/; = .01.

Factors (high end) Outgoing Bright Stable Assertive Enthusiastic Suspicious Imaginative Apprehensive Tense

F( 1,402)

Males

Females

8.96** 7.43**

24.63 11.87

28.02 13.95

5.05* 8.43**

15.04 14.66

17.29 18.76

Within Subjects Linear Mean F(l,271) Differences 5.12* 9.32** 6.40* 7 44**

+ .22 + .38 -.30 + .39

6.13*

-.26

6.52*

-.41

*p = .05; **p = .01.

Table 6. Univariate F and Composite Quadratic and Cubic Mean Scores on Significant Factors of the 16-PF Composite Mean Time Scores

and a half. Both bereaved groups reported a significantly higher level of depression at all points than the NBC, including at the end of the 30-month period. The controls showed a relatively constant low level of depression through the entire period although, interestingly enough, their depression seemed to be increasing slightly but regularly over the last 18 months. Summarizing this area, both bereaved groups reported a decrease in depressive feelings over the 2'/2 years, but the SS' depressive feelings did not begin to decline until after the end of the first year. The NDS reported a major decline in the first 6 months and then another major decrease during the last 18 months. NDS showed significantly less hostility than the controls (but not less than the SS); and women, generally, were more obsessive-compulsive, anxious, and fearful than men. Personality Status 16-PF. — Multivariate analyses of 12 of the 16-PF scales were used to determine group and sex differences in personality status and changes that occurred over 30 months of the bereavement period. MANCOVAs between subjects yielded a significant main effect only for sex [F( 12,391) = 2.90, p< .001]; main effects for group and interaction effects for group by sex were both nonsignificant. Univariate measures for the effects of sex were significant on 4 of the 12 scales (high/low descriptors): outgoing/reserved; bright/dull; imaginative/practical; and apprehensive/self-assured (Table 5). Newman-Keuls tests for significant differences indicated that females were more outgoing, bright, imaginative, and apprehensive than males (Table 5). Investigation of the changes in personality traits over time by means of multivariate measures for linear patterns yielded significant main effects only for time; interaction effects for group by time, sex by time, and group by sex by time were not significant. Univariate measures for effects of time

Factors (high end)

Time (months) F(df)

2

6

12

30

Quadratic Bright Enthusiastic

F( 1,243) 7.04* 4.11*

3.76 5.76

4.12 5.91

4.12 5.91

4.11 6.18

Cubic Assertive Suspicious Imaginative

F( 1,220) 5.65* 6.54* 14.48***

4.70 4.44 4.99

4.70 4.33 4.95

4.80 4.59 5.25

4.60 4.40 4.90

*p = .05;***p = .001.

were significant for six of the scales: bright/dull, emotionally stable/unstable, assertive/humble, enthusiastic/sober, imaginative/practical, and tense/relaxed. Newman-Keuls measures over the 2'/2-year period indicated generally increasing tendencies toward brightness, emotional stability, enthusiasm, humility, practicality, and relaxed state (Table 5). Multivariate measures for quadratic changes indicated significant effects again only for main effects of time [/^ 12,232) = 1.83, p < .044]; interaction effects for group by time, sex by time, and group by sex by time were not significant. Univariate measures for effects over time yielded significant differences for two of the scales: bright/dull and enthusiastic/sober (Table 6). Newman-Keuls measures indicated that the change in brightness was mostly a significant improvement in the first 6 months, after which it stayed at relatively the same level through the rest of the observation period. A significant rise in enthusiasm appeared twice, however, in the first 6 months and in the last year and a half of the observation period (Table 6). Cubic effects evaluated by MANCOVAs were again significant only for main effects of time [F( 12,232) = 3.3O,/?< .000]; interaction effects for group by time, sex by time, and

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Depression SS NDS NBC

F(2,245)

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group by sex by time were not significant. Univariate measures were significant on three of the scales: assertive/ humble, suspicious/trusting, and imaginative/practical (Table 6). Newman-Keuls indicated a slight increase in the level of assertiveness in the second 6 months of the first year, then a drop during the second year and a half. Levels of suspicion went down and up throughout the 30-month period, with a decrease in the first 6 months followed by an increase in suspicion by 12 months, and then a decrease to approximately the original level of suspicion by the end of the second year and a half. Imaginativeness, which stayed at relatively the same level throughout the first 6 months, rose noticeably by the end of the first year, but then declined to its earlier level by the end of the second year and a half (Table 6). The results indicate clearly that the major mental health feelings experienced in bereavement by elderly survivors do not differ so much in kind as in their course during the first 2'/2 years following a death and that these feelings will also vary in the survivor depending on the mode of death, the time since death, and (sometimes) the sex of the bereaved. From our data, it was difficult to determine any orderly progression through stages, as described by Glick et al. (1975), Parkes (1972), Zisook and Schuchter (1986), and others. It is apparent there were a number of transitions, some gradual, others more abrupt. In accord with the previously cited researchers, both SS and NDS report high feelings of grief, depression, and generalized psychological distress immediately following a death. In the ensuing period of 2'/2 years, all three feelings subside but not all to the same level nor in the same way. Grief, for example, abates for both bereaved groups over the full period, but even after 2'/2 years, continues to be experienced to a considerable degree, as indicated by the differences in the levels reported between the bereaved groups and the NBC. Osterweis et al. (1984), Zisook and Schuchter (1986), and Lund (1989) also emphasized that bereavement was a long-term experience that does not end at any specified time. That death itself, regardless of mode, makes a significant emotional impact is reflected in the scores on the psychoticism scale of the BSI. Psychoticism, expressing such extreme feelings as need for expiation and punishment for sins, starts out high for both bereaved groups and then declines consistently over the 2'/2-year period. Despite this decline, there is, nevertheless, even after 30 months, a residue of feelings of alienation, unreality and anxiety, along with the remaining grief and depressive feelings. This residue is present regardless of whether the loss is from natural causes or by suicide. Apparently, to the survivor it is the fact of a loss through death that makes the most impact, not the way the death occurred. An important finding is that the course of change for the various feelings is different for the two elderly survivor groups. Grief, for example, declines in at least two discrete steps for the NDS, the first drop occurring within the first 6 months and the second during the last 18 months. The finding of only two steps may, of course, be more a factor of the study design that collected data at 6, 12, and 30 months. Shorter time intervals between the collection of the data

The curvilinear analyses revealed the differences in the

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DISCUSSION

might have revealed more. Grief in the SS, however, remains high for the first year and does not drop until the next year and a half. The longer period taken by the SS for their grief to subside is also reflected in their ratings of their own mental health and their feelings of general distress that do not improve significantly until after the first year. Although these results are derived from elderly survivors, it probably accounts in part for the differences reported in levels of grief and psychological distress for the two bereaved groups of all ages by other researchers. Measured immediately after the death, there are practically no differences between them. Even after 12 months, the SS report experiencing painful levels of both grief and emotional distress, whereas the NDS report some recovery, albeit not to a point significantly different from the SS. Studies of bereavements of SS that have taken place within the first year(Rudestam, 1977; Wallace, 1973) have reported a much more difficult time for the SS than for the NDS. Perhaps, if their studies had been extended to 30 months, the SS group would have also improved enough so that a comparison at that point would have shown practically no differences: The way the two bereaved groups perceive their own mental health status follows the same pattern. Whereas at no time over the 2'/2 years does a measurement show a significant difference between their levels of perceived mental health, the course for the NDS indicates a consistent improvement at each point, whereas the SS improve only slightly in the first 12 months and then improve mostly in the last year and a half. But even after 2 V2 years, when the NDS no longer rate their mental health significantly different from the NBC, the SS still do. Apparently, the negative effect of a suicide death on the survivors' appraisal of their own emotional functioning takes longer to subside than the impact of a natural death. The two depression schedules, the BDI and the depression subscale of the BSI, seem to measure different aspects of depression. A review of the items on the BDI indicates it taps the more generalized feelings of depression covering mild mood states to moderately severe reactions. The BSI items refer to more extreme feelings, such as feeling suicidal, feeling worthless, loss of interest in everything, etc. Although both bereaved groups were significantly more depressed than the controls at the end of one year in both general and extreme aspects, by the end of the 2 V2 years, the differences on the general depressive aspects had disappeared, whereas the differences on the more extreme depressive aspects continued. These results are similar to those found in our more detailed study of the interaction of depression and bereavement, which indicated that those SS who were most depressed initially on the BDI (mean score of 29.00) continued to show significantly more hostility, phobic anxiety, and paranoid ideation after 30 months than those initially scoring low (Gilewski, Farberow, Gallagher, & Thompson, 1991). Clayton et al. (1972) also found severe depression early in bereavement a good predictor of depression at the end of the first year. Our data show that a high level of severe depression on the BSI, as well as a high initial level of general depression on the BDI, indicate a more difficult recovery in bereavement for SS.

BEREAVEMENT CHANGES IN SUICIDE

were many more similarities than differences in the bereavement processes of females and males. In sum, the death of a loved one, whether by suicide or by natural death, is a severe psychological blow, causing grief, depression, tension, anxiety, confusion, and a severe sense of loss in their spouse-survivors. Over time, most of these feelings subside, although with different courses and with varying remaining levels by the end of 30 months of bereavement. The results also show that despite the emotional distress resulting from the loss, both groups of bereaved SS and NDS seem to manage their new roles, statuses, obligations, and responsibilities. Whereas the process seems a more difficult one for the SS, especially during the first year, they seem after 2 V2 years to be pretty much in the same place as the NDS, still feeling the loss, still carrying some grief, but generally functioning adequately. The picture reported here is, of course, an incomplete one, lacking important information about the coping strategies used, the fluctuations in their use, and the changing sources of stress during this 2'/2-year period of bereavement. Analysis of these data, currently under way, should increase our understanding of the course of long-term bereavement among the elderly still further. ACKNOWLEDGMENTS

This research was supported by grants from the National Institute of Mental Health (R0I-MH3684) and the National Institute on Aging (R0IAGO1959). Address correspondence to Dr. Norman L. Farberow, 1068 Casiano Road, Los Angeles, CA 90049. REFERENCES

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course of recovery for the two bereaved groups. For example, the general depression feelings (BDI) dissipated in the same way for both bereaved groups; that is, by a significant lifting in the first 6 months and again in the second year and a half. On the more extreme aspects of depression (BSI), however, NDS reported improvement in the first 6 months and again in the last 18 months, whereas the SS did not begin to lose their extreme feelings of depression until after the first year had passed. Murrell and Himmelfarb (1989) reported a similar course for depressive feelings in their sample of older adults, as measured on the Center for Epidemiological Studies-Depression Scale (Radloff, 1977); that is, a high initial reaction that almost dissipated in one year. The persistence of the severe feelings of depression for the SS points to a more complicated bereavement adaptation process for the SS in the first year. It is also worth noting that the SS continued to be significantly more anxious than both the NDS and the NBC 2'/2 years after the death of their spouses. As a measure of personality traits, the scores on the 16-PF should have been stable over time. McRae and Costa (1984), summarizing the 16-PF studies and their NEO-PI studies (Costa and McRae, 1988) obtaining longitudinal data across many years of the adult and older adult life spans, have argued for general stability. However, depression or other situational distress can effect short-term changes on this otherwise stable measure. The changes observed in this study probably reflect the acute effects of bereavement rather than any significant changes in enduring personality traits. But because of the underlying stability of the instrument, the stringent requirements put on univariate alpha levels in the multivariate approach, and the significant covariate effects, possible true sources of change were attenuated. For instance, inspection of the mean scores for the 16-PF factor of emotional stability with respect to linear change demonstrates this fact: the SS group changed from 6.3 at Time 1 to 7.7 at Time 4, the NDS group changed from 6.9 at Time 1 to 7.5 at Time 4, and the NBC group had the same score at both times. Although in the analyses there was a significant main effect for time and not for time by group, the source of the change was still caused by the change in the bereaved groups. As is also evident in these numbers, changes in the bereaved groups appear to bring them up to levels close to that of the controls. The changes in the specific personality traits that occur over the 2'/2-year period are found in shifts away from tension and frustration toward a more relaxed and composed outlook, with greater enthusiasm, evidence of increased interest, and imaginativeness and a willingness to be more accommodating. Again, the changes were not consistent for all of these traits. As one might also have expected, there were sex differences in the personality traits. Many women who, while their spouse was alive, did not have to solve legal problems or worry about household and car repairs, transportation, and other practical matters, were now forced to confront and resolve these problems. However, as Lund et al. (1986) have reported, many of the women discovered a previously untapped reservoir of psychological strength within themselves in dealing with their new roles. In addition, our research indicated, similar to Lund et al., that there

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