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Hajek A, König HH, Sutin AR, Terracciano A, Luchetti M, Stephan Y, Gyasi RM. Prevalence and factors associated with probable depression among the oldest old during the Covid-19 pandemic: evidence from the large, nationally representative 'Old Age in Germany (D80+)' study. Psychogeriatrics 2024; 24:838-846. [PMID: 38699978 DOI: 10.1111/psyg.13129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/09/2024] [Accepted: 04/21/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND To date, most studies examining the prevalence and determinants of depression among individuals aged 80 and over have used geographically limited samples that are not generalisable to the wider population. Thus, our aim was to identify the prevalence and the factors associated with probable depression among the oldest old in Germany based on nationally representative data. METHODS Data were taken from the nationally representative 'Old Age in Germany (D80+)' study (n = 8386; November 2020 to April 2021) covering both community-dwelling and institutionalised individuals aged 80 and over. The Short Form of the Depression in Old Age Scale was used to quantify probable depression. RESULTS Probable depression was found in 40.7% (95% CI: 39.5% to 42.0%) of the sample; 31.3% were men (95% CI: 29.7% to 32.9%) and 46.6% women (95% CI: 44.9% to 48.3%). The odds of probable depression were positively associated with being female (odds ratio (OR): 1.55, 95% CI: 1.30 to 1.84), being divorced (compared to being married, OR: 1.33, 95% CI: 1.01 to 1.76), being widowed (OR: 1.14, 95% CI: 1.00 to 1.30), having a low education (e.g., medium education compared to low education, OR: 0.86, 95% CI: 0.74 to 0.99), living in an institutionalised setting (OR: 2.36, 95% CI: 1.84 to 3.02), living in East Germany (OR: 1.21, 95% CI, 1.05 to 1.39), not having German citizenship (German citizenship compared to other citizenship, OR: 0.55, 95% CI: 0.31 to 0.95), poor self-rated health (OR: 0.31, 95% CI: 0.28 to 0.34), and the number of chronic conditions (OR: 1.12, 95% CI: 1.09 to 1.14). CONCLUSION About four out of 10 individuals aged 80 and over in Germany had probable depression, underlining the importance of this challenge. Knowledge of specific risk factors for this age group may assist in addressing older adults at risk of probable depression.
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Affiliation(s)
- André Hajek
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Hamburg, Germany
| | - Angelina R Sutin
- College of Medicine, Florida State University, Tallahassee, Florida, USA
| | | | - Martina Luchetti
- College of Medicine, Florida State University, Tallahassee, Florida, USA
| | | | - Razak M Gyasi
- African Population and Health Research Center, Nairobi, Kenya
- National Centre for Naturopathic Medicine, Faculty of Health, Southern Cross University, Lismore, New South Wales, Australia
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Cherblanc J, Gaboury S, Maître J, Côté I, Cadell S, Bergeron-Leclerc C. Predicting levels of prolonged grief disorder symptoms during the COVID-19 pandemic: An integrated approach of classical data exploration, predictive machine learning, and explainable AI. J Affect Disord 2024; 351:746-754. [PMID: 38290589 DOI: 10.1016/j.jad.2024.01.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 01/11/2024] [Accepted: 01/26/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Prior studies on Prolonged Grief Disorder (PGD) primarily employed classical approaches to link bereaved individuals' characteristics with PGD symptom levels. This study utilized machine learning to identify key factors influencing PGD symptoms during the COVID-19 pandemic. METHODS We analyzed data from 479 participants through an online survey, employing classical data exploration, predictive machine learning, and SHapley Additive exPlanations (SHAP) to determine key factors influencing PGD symptoms measured with the Traumatic Grief Inventory - Self Report (TGI-SR) from 19 variables, comparing five predictive models. RESULTS The classical approach identified eight variables associated with a possible PGD (TGI-SR score ≥ 59): unexpected causes of death, living alone, seeking professional support, taking anxiety and/or depression medications, using more grief services (telephone or online supports) and more confrontation-oriented coping strategies, and higher levels of depression and anxiety. Using machine learning techniques, the CatBoost algorithm provided the best predictive model of the TGI-SR score (r2 = 0.6479). The three variables influencing the most the level of PGD symptoms were anxiety, and levels of avoidance and confrontation coping strategies used. CONCLUSIONS This pioneering approach within the field of grief research enabled us to leverage the extensive dataset collected during the pandemic, facilitating a deeper comprehension of the predominant factors influencing the grieving process for individuals who experienced loss during this period. LIMITATIONS This study acknowledges self-selection bias, limited sample diversity, and suggests further research is needed to fully understand the predictors of PGD symptoms.
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Duran S, Altun A. Prolonged grief, reconstruction of meaning, and posttraumatic growth in nursing home residents who have lost loved ones. Geriatr Gerontol Int 2024; 24:364-370. [PMID: 38406968 DOI: 10.1111/ggi.14843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/17/2024] [Accepted: 02/07/2024] [Indexed: 02/27/2024]
Abstract
AIM This study was conducted to determine the relationship between sociodemographic characteristics, prolonged grief, meaning reconstruction, and posttraumatic growth of elderly individuals who have lost loved ones. METHODS A total of 122 elderly individuals who had lost loved ones were included in the research conducted in a nursing home. RESULTS The levels of Prolonged Grief Inventory (PG-13), Grief and Meaning Reconstruction Inventory (GMRI), and Posttraumatic Growth (PTG) scale were found to be high among the individuals in the study. While the PG-13 scores of single individuals who have lost their spouses are statistically significantly higher compared to married individuals, the scores for GMRI are higher for elderly individuals with chronic illness and expected death compared to those who have experienced sudden loss. A significant negative correlation was also determined between PG-13, GMRI, and PTG scores. CONCLUSION Counseling to reconstruct grief and meaning is recommended for at-risk groups. Geriatr Gerontol Int 2024; 24: 364-370.
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Affiliation(s)
- Songül Duran
- .Department of Elderly Care, Health Services Vocational College, Izmir Demokrasi University, Izmir, Türkiye
| | - Aydın Altun
- Institute of Health Sciences, Master Student of Elderly Health Program, Izmir Democracy University, Izmir, Türkiye
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Reime MA, Connor MO, Hystad SW, Dyregrov K. Drug-Death Related Bereavement and Social Support. OMEGA-JOURNAL OF DEATH AND DYING 2024:302228241238907. [PMID: 38477736 DOI: 10.1177/00302228241238907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
The loss of a close one to drug-related death (DRD) has been characterized as a form of stigmatized bereavement, and research has shown that there is a high risk of bereavement complications. Social support can be a buffer against bereavement complications, but because of stigma, DRD bereaved persons access to social support can be challenged. Based on data from a Norwegian sample of DRD bereaved persons (N = 252) the present study examines (1) bereaved persons' perceived access to different aspects of social support, and (2) the association between bereaved persons' experiences of societal stigma, own withdrawal, self-blame, and their perceptions of social support. Results show (1) that bereaved persons' access to contact with persons in the same situation is particularly low compared to other support aspects, and (2) that perceived stigma (4%) and own withdrawal (5%) predict variations in drug-related death bereaved persons' perception of social support.
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Affiliation(s)
- Monika Alvestad Reime
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Maja O' Connor
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | | | - Kari Dyregrov
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
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Boerner K, Stokes J, Jansen T. Widowhood and bereavement in late life. Curr Opin Psychol 2024; 55:101748. [PMID: 38071788 DOI: 10.1016/j.copsyc.2023.101748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/25/2023] [Accepted: 11/13/2023] [Indexed: 01/28/2024]
Abstract
Bereavement is a common and often challenging experience in late life. Evidence shows that while many older adults manage to adjust well and demonstrate resilience in response to the death of a close person, bereavement puts a substantial minority at risk of adverse mental and physical health impacts including mortality. Current research further indicates that 1) this is the case across different countries and cultures across the globe; 2) that the COVID-19 pandemic posed unprecedented challenges for coping with late-life bereavement; 3) that loneliness and social isolation among bereaved older adults tend to be prevalent and harmful, particularly under pandemic but also in nonpandemic circumstances; and, recently, 4) that bereavement may be a risk factor for cognitive decline in this population.
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Affiliation(s)
- Kathrin Boerner
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstraße 140, 26129 Oldenburg, Germany; Department of Gerontology, University of Massachusetts Boston, 100 Morrissey Blvd., Boston, MA 02125, USA.
| | - Jeffrey Stokes
- Department of Gerontology, University of Massachusetts Boston, 100 Morrissey Blvd., Boston, MA 02125, USA
| | - Taylor Jansen
- Department of Gerontology, University of Massachusetts Boston, 100 Morrissey Blvd., Boston, MA 02125, USA
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Thiemann P, Street AN, Heath SE, Quince T, Kuhn I, Barclay S. Prolonged grief disorder prevalence in adults 65 years and over: a systematic review. BMJ Support Palliat Care 2023; 13:e30-e42. [PMID: 33707297 DOI: 10.1136/bmjspcare-2020-002845] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/03/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Prolonged grief disorder (PGD) is a recently recognised mental health disorder with an estimated prevalence of 10% in the bereaved adult population. This review aims to appraise and summarise evidence relating to PGD in older adults (≥65 years), a growing population group, most likely to experience bereavement and often assumed to cope well. METHOD Literature from Medline, PsycINFO, CINAHL, Cochrane Library and Web of Science was searched. Epidemiological and non-epidemiological studies including data on frequency of PGD in older adults bereaved by mainly natural causes were included and a descriptive analysis undertaken. RESULTS From 2059 records, three epidemiological and six non-epidemiological studies were included. Most studies had good internal but not external validity. Conditional prevalence for PGD ranged between 3.2% and 48.8%. Heterogeneity in sample characteristics and study methodology contributed to this variability resulting in a descriptive analysis. The prevalence rate of 9.1% by Kersting et al was the best available estimate for PGD in older adults for western countries. The small number of epidemiological studies and the use of varying PGD-constructs which did not match International Classification of Diseases 11th Revision and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria were the main limiting factors. CONCLUSION This first review on PGD prevalence in older adults suggests that, despite studies' methodological short comings, a similar proportion of older adults experience PGD as the general bereaved adult population (1:10). With older adults forming the largest subgroup among the bereaved, health and social care systems need to adapt their provision of care to address the specific needs of older adults.
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Affiliation(s)
- Pia Thiemann
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Anna Naomi Street
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Eleanor Heath
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Thelma Quince
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Isla Kuhn
- Medical Library, University of Cambridge, Cambridge, UK
| | - Stephen Barclay
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Gori A, Topino E, Imperatore P, Musetti A, Sim J, Machin L. Measuring Vulnerability in Grief: The Psychometric Properties of the Italian Adult Attitude to Grief Scale. Eur J Investig Health Psychol Educ 2023; 13:975-985. [PMID: 37366778 DOI: 10.3390/ejihpe13060074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/19/2023] [Accepted: 05/29/2023] [Indexed: 06/28/2023] Open
Abstract
Although experiences of loss and the consequent grief are natural in human life, some individuals may have difficulty managing these events, to the point of developing significant impairment in their functioning in important life areas. Given this, the present research aimed to explore the psychometric properties of the Italian version of the Adult Attitude to Grief scale (AAG) to facilitate research on adult vulnerability to grief among Italian-speaking populations. A sample of 367 participants (Mage = 30.44, SD = 11.21; 78% females) participated in this research. A back-translation procedure was implemented to develop the Italian AAG. Then, participants completed the Italian AAG alongside a battery of other self-report psychometric scales in order to assess aspects of the construct validity of the AAG: the Forty-Item Defense Style Questionnaire, the Impact of Event Scale-Revised, and the Beck Depression Inventory-II. A bifactor structure was found to have the best fit to the data, supporting the possibility of using both the general factor (i.e., vulnerability) and three dimensions (i.e., overwhelmed, controlled, and resilient). Unlike the original version, the control dimension emerged as a "protective" factor in the Italian population, together with the resilient factor. Furthermore, results provided satisfactory indications of internal consistency and construct validity. In conclusion, the Italian AAG was shown to be a valid, reliable, quick, and easy-to-use scale that can be used both for research and clinical practice in the Italian context.
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Affiliation(s)
- Alessio Gori
- Department of Health Sciences, University of Florence, Via di San Salvi 12, Pad. 26, 50135 Florence, Italy
- Integrated Psychodynamic Psychotherapy Institute (IPPI), Via Ricasoli 32, 50122 Florence, Italy
| | - Eleonora Topino
- Department of Human Sciences, LUMSA University of Rome, Via della Traspontina 21, 00193 Rome, Italy
| | - Pierluigi Imperatore
- Integrated Psychodynamic Psychotherapy Institute (IPPI), Via Ricasoli 32, 50122 Florence, Italy
| | - Alessandro Musetti
- Department of Humanities, Social Sciences and Cultural Industries, University of Parma, 43121 Parma, Italy
| | - Julius Sim
- School of Medicine, Keele University, Staffordshire ST5 5BG, UK
| | - Linda Machin
- School of Medicine, Keele University, Staffordshire ST5 5BG, UK
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Yuan MD, Wang ZQ, Fei L, Zhong BL. Prevalence of prolonged grief disorder and its symptoms in Chinese parents who lost their only child: A systematic review and meta-analysis. Front Public Health 2022; 10:1016160. [PMID: 36238241 PMCID: PMC9550932 DOI: 10.3389/fpubh.2022.1016160] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/12/2022] [Indexed: 01/28/2023] Open
Abstract
Background Parents who lost their only child and cannot have a second child ("Shidu") have been a large population in China. Prolonged grief disorder (PGD) in Shidu parents is of clinical and public health concern but the reported PGD prevalence varies widely. To facilitate the planning of grief counseling services, this meta-analysis estimated prevalence of PGD and its symptoms and identified subgroups at elevated risk for PGD. Methods We searched English and Chinese literature databases to identify cross-sectional surveys reporting prevalence of PGD or PGD symptoms in Chinese Shidu parents. The Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data ("JBI") was used to assess risk of bias of included studies. Results Seven studies with a total of 2,794 Shidu parents were included and their JBI scores ranged from five to eight. The pooled prevalence of PGD and PGD symptoms was 20.9% and 75.0%, respectively. Greater risk of PGD was observed in mothers [vs. fathers, OR (odds ratio) = 1.89, P = 0.001] and in parents with religious beliefs (vs. without religious beliefs, OR = 1.65, P = 0.040). More severe PGD symptoms were presented in parents whose only child died from accidents [vs. illness, MD (mean difference) = 3.99, P < 0.001]. Deceased children of PGD parents were older than those of non-PGD parents (MD = 1.64, P = 0.035) and PGD parents had a shorter duration since the loss than non-PGD parents (MD = -3.26, P = 0.013). Conclusions PGD is prevalent among Shidu parents. Grief counseling services for Shidu parents would be more effective if they target those who are mothers and have religious beliefs and those whose children died from accidents, lost children are older, and loss occurs more recently.
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Affiliation(s)
- Meng-Di Yuan
- Research Center for Psychological and Health Sciences, China University of Geosciences (Wuhan), Wuhan, China
| | - Zong-Qin Wang
- Department of Psychiatry, Wuhan Mental Health Center, Wuhan, China
- Department of Clinical Psychology, Wuhan Hospital for Psychotherapy, Wuhan, China
| | - Lei Fei
- Department of Ultrasound, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Bao-Liang Zhong
- Research Center for Psychological and Health Sciences, China University of Geosciences (Wuhan), Wuhan, China
- Department of Psychiatry, Wuhan Mental Health Center, Wuhan, China
- Department of Clinical Psychology, Wuhan Hospital for Psychotherapy, Wuhan, China
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9
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Treml J, Brähler E, Kersting A. Prevalence, Factor Structure and Correlates of DSM-5-TR Criteria for Prolonged Grief Disorder. Front Psychiatry 2022; 13:880380. [PMID: 35664467 PMCID: PMC9159802 DOI: 10.3389/fpsyt.2022.880380] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/28/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Prolonged Grief Disorder (PGD) is now included in Section II of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR). To understand the health burden and then allocate economic and professional resources, it is necessary to provide epidemiological data for this new disorder. This is especially relevant since the new diagnostic criteria differ from its predecessors, which may affect the generalizability of previous findings. More information on the characteristics of people suffering from PGD is also beneficial to better identify individuals at risk. This study, therefore, aimed to estimate the prevalence of the new PGD criteria in a representative population-based sample, evaluate the factor structure, sociodemographic, and loss-related correlates of PGD caseness and explore possible predictors. METHODS Out of a representative sample of the German general population (N = 2,531), n = 1,371 (54.2%) reported to have experienced a significant loss throughout lifetime. Participants provided sociodemographic data and loss-related characteristics. PGD symptoms were measured using items from the German versions of the Prolonged Grief Scale (PG-13) and the Inventory of Complicated Grief (ICG), which could be matched to the DSM-5-TR criteria for PGD. RESULTS The conditional prevalence of PGD was 3.4% (n = 47). The most frequently reported symptoms were intense emotional pain and intense yearning or longing for the deceased. The confirmatory factor analysis confirmed a unidimensional model of PGD. Regression analysis demonstrated that time since the death, the relationship to the deceased, and unpreparedness for the death were significant predictors of PGD. CONCLUSION Although the prevalence of 3.4% using the new diagnostic criteria is lower than the prevalence previously suggested by a meta-analysis, PGD remains a substantial disorder in the general population. In particular, the loss of a partner or child increases the risk for PGD, as does unpreparedness for the death of a loved one. Clinicians should pay particular attention to these high-risk groups. Further clinical implications are discussed.
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Affiliation(s)
- Julia Treml
- Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Elmar Brähler
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Department of Psychiatry and Psychotherapy, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Anette Kersting
- Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty, University of Leipzig, Leipzig, Germany
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Schladitz K, Löbner M, Stein J, Weyerer S, Werle J, Wagner M, Heser K, Scherer M, Stark A, Kaduszkiewicz H, Wiese B, Oey A, König HH, Hajek A, Riedel-Heller SG. Grief and loss in old age: Exploration of the association between grief and depression. J Affect Disord 2021; 283:285-292. [PMID: 33578340 DOI: 10.1016/j.jad.2021.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/13/2021] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The proportion of older adults is increasing due to demographic changes. Depression belongs to the most common mental disorders in late life. The loss of an emotionally significant person is a risk factor for the development of depression. The aim of this study is to analyze the association between depression and grief burden resulting from loss. Based on prior evidence, we examined loneliness as a possible mediator and social support as possible moderator of this association. METHODS The cross-sectional analyses are based on a sample (N = 863) of study participants aged 75+ (M = 81.4 years, SD = 4.4, 62.2% female) with loss experience deriving from the multicenter prospective German cohort study AgeMooDe. Regression analyses (moderated mediation) were performed. RESULTS With increasing age (β = 0.10, p = .005) and grief burden (β = 0.33, p <. 001) depression severity increased. There was an indirect mediating effect of loneliness on the correlation of grief burden and depression (b = 0.04, CI [0.03, 0.05]), but no moderating effect of social support on the correlation of grief burden and loneliness. People living alone had a significantly higher risk of depression, increased loneliness and lack of social support. LIMITATIONS Assessments were based on self-reporting and recorded dimensionally. The cross-sectional design limits conclusions about directions and causality of associations. Sampling bias cannot be completely excluded. CONCLUSION The study provides empirical evidence and a better understanding of the association between grief and depression among the very old and the mediating role of loneliness.
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Affiliation(s)
- K Schladitz
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig 04103, Germany.
| | - M Löbner
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig 04103, Germany
| | - J Stein
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig 04103, Germany
| | - S Weyerer
- Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - J Werle
- Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - M Wagner
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn, Bonn, Germany; German Center for Neurodegenerative Diseases within the Helmholtz Association, DZNE, Bonn, Germany
| | - K Heser
- Department of Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn, Bonn, Germany
| | - M Scherer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Stark
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Kaduszkiewicz
- Institute of General Practice, Medical Faculty, University of Kiel, Kiel, Germany
| | - B Wiese
- Institute for General Practice, Working Group Medical Statistics and IT-Infrastructure, Hannover Medical School, Hannover, Germany
| | - A Oey
- Institute for General Practice, Working Group Medical Statistics and IT-Infrastructure, Hannover Medical School, Hannover, Germany
| | - H-H König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, University of Hamburg, Hamburg, Germany
| | - A Hajek
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, University of Hamburg, Hamburg, Germany
| | - S G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Str. 55, Leipzig 04103, Germany
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