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The depressive feelings of a 59-yr-old widow are examined to determine symptoms of traumatic grief due to bereavement. The widow underwent a period of depression after her husband's death and after some of her prized possessions were stolen. Using the Structured Clinical Interview for DSM-III-R-Non-Patient Edition as a diagnostic tool, it was found that the widow's worries regarding companionship and finances were caused by several important life experiences.

Objective: This study was conducted to identify which elderly patients with remitted recurrent major depression remain well with maintenance interpersonal psychotherapy after discontinuation of active antidepressant medication (nortriptyline). Method: The authors examined outcomes of maintenance therapy over I year for 47 elderly patients who were randomly assigned to monthly maintenance interpersonal psychotherapy with placebo (N=19) or to placebo and a supportive medication clinic without interpersonal psychotherapy (N=28). A Kaplan-Meier survival analysis was performed on the basis of treatment assignment and subjective sleep quality assessed by the Pittsburgh Sleep Quality Index, on which good subjective sleep quality is indicated by a score of 5 or lower. Results: Nine (90%) of 10 patients reporting good subjective sleep quality (by 1 month into continuation treatment) remained well for at least i year when treated with monthly maintenance interpersonal psychotherapy, versus five (31%) of 16 patients with good sleep quality assigned to a medication clinic, three (33%) of nine patients with impaired sleep quality treated with maintenance interpersonal psychotherapy, and two (17%) of 12 patients with impaired sleep quality assigned to a medication clinic. Conclusions: Recovery of good subjective sleep quality by early continuation treatment is useful in identifying which remitted elderly depressed patients will remain well with monthly maintenance interpersonal psychotherapy, following discontinuation of antidepressant medication, and which patients may be more vulnerable to recurrence of major depressive episodes in the absence of antidepressant medication.

Objective: The authors documented outcomes of elderly depressed patients requiring adjunctive medication during acute-phase pharmacotherapy because of slow or partial response to nortriptyline. Twenty-eight patients (17.7%) received inpatient care at some point during acute-phase treatment. Method: Rates of response, relapse, and sustained remission were examined in 158 elderly patients with recurrent major depression, grouped by whether they received brief treatment with adjunctive medication (lithium, perphenazine, or paroxetine) (N=39) or did not (N=119). Results: The group receiving adjunctive medication had a lower rate of response to acute therapy (64.1% versus 83.2%), a higher relapse rate during continuation therapy (52.0% versus 6.1%), and a lower rate of sustained remission (recovery) (48.7% versus 76.5%) than did the group without augmentation. Conclusions: Elderly depressed patients requiring augmented pharmacotherapy to achieve remission may need continuation of adjunctive medication to remain well and to avoid early relapse. Alternatively, factors that lead to augmentation in the first place (e.g., heightened anxiety) may also increase the risk of relapse.

Objective: This study sought to determine whether a set of symptoms interpreted as complicated grief could be identified and distinguished from bereavement-related depression and whether the presence of complicated grief would predict enduring functional impairments. Method: Data were derived from a study group of 82 recently widowed elderly individuals recruited for an investigation of physiological changes in bereaved persons. Baseline data were collected 3-6 months after the deaths of the subjects' spouses, and follow-up data were collected from 56 of the subjects 18 months after the baseline assessments. Candidate items for assessing complicated grief came from a variety of scales used to evaluate emotional functioning (e.g., the Hamilton Depression Rating Scale, the Brief Symptom Inventory). The outcome variables measured were global functioning, medical illness burden, sleep, mood, self-esteem, and anxiety. Results: A principal-components analysis conducted on intake data (N=82) revealed a complicated grief factor and a bereavement-depression factor. Seven symptoms constituted complicated grief: searching, yearning, preoccupation with thoughts of the deceased, crying, disbelief regarding the death, feeling stunned by the death, and lack of acceptance of the death. Baseline complicated grief scores were significantly associated with impairments in global functioning, mood, sleep, and self-esteem in the 56 subjects available for follow-up. Conclusions: The symptoms of complicated grief may be distinct from depressive symptoms and appear to be associated with enduring functional impairments. The symptoms of complicated grief, therefore, appear to define a unique disorder deserving of specialized treatment.

Objective: Differentiation of stable, trait-like characteristics from more episodic or state-dependent disturbances will be helpful in gaining a better understanding of the pathophysiology of depression. However, research in this area has been complicated by artifactual and clinical problems associated with pharmacologic treatment. In this investigation the authors used EEG sleep studies to assess medication-free depressed male patients before and after cognitive behavioral therapy. Method: Forty-five male patients with the diagnosis of major depression according to the DSM-III-R criteria and the Research Diagnostic Criteria underwent EEG sleep studies before and after 16 weeks of cognitive behavioral therapy, during which they were free of medication. In addition to the documentation of changes within these patients, the findings were compared with those for 47 healthy subjects, including 15 who were restudied 12-24 months after their baseline assessments. Results: The EEG sleep profiles of the depressed patients showed a significant reduction in REM sleep density after treatment, suggesting 'normalization' of an abnormal state-dependent process. By contrast, slow wave sleep and tonic REM measures, including reduced REM latency, were unchanged after treatment. Conclusions: These findings suggest that early in remission there is disaggregation of irreversible, trait-like correlates of depression (e.g., diminished slow wave sleep and reduced REM latency) from more reversible disturbances (e.g., increased REM density).

Objective: A great majority of the evidence pertaining to the effectiveness of the time-limited psychotherapies as treatments of major depression are derived from studies of either predominantly or entirely female subject groups. Depressed men and women differ in a number of important respects that may alter the course of affective disorder, and as a result, they may also differ in their responses to psychotherapy. In this study the outcomes of 40 men and 44 women treated with cognitive behavior therapy were compared. Method: The patients were interviewed with the Schedule for Affective Disorders and Schizophrenia and diagnosed according to the Research Diagnostic Criteria and DSM-III-R criteria. Subsequently, they were assessed every other week (with the Hamilton Depression Rating Scale, Beck Depression Inventory, and Global Assessment Scale) during a standardized, time-limited cognitive behavior therapy protocol. The outcomes of the men and women were compared by means of a series of analyses of variance and covariance and survival analyses. Results: There were several significant pretreatment differences, and the men attended significantly fewer therapy sessions than the women. Although the men and women generally had comparable responses, patients with higher pretreatment levels of depressive symptoms, particularly women, had poorer outcomes. Conclusions: This study provides further evidence of gender-specific differences in depressed patients' symptoms and treatment utilization. Cognitive behavior therapy appears to be a comparably useful outpatient treatment for men and women. However, either more intensive cognitive behavior therapy or alternative methods of treatment may be warranted for patients with more severe syndromes.

Objective: This study sought to confirm in an independent, nonclinical study group previous work which demonstrated that the symptoms of complicated grief were distinct from the symptoms of bereavement-related depression and anxiety. Method: Data used in the analyses were derived from a group of 150 widowed individuals who were interviewed 6 months after their deceased spouses' hospital admission (study entry). Complicated grief was measured with a modified version of the Grief Measurement Scale. Principal axis factoring was used to determine the distinctiveness of complicated grief, depression, and anxiety. Results: The principal axis factoring showed that the symptoms of complicated grief loaded quite highly on the first (complicated grief) factor and loaded very poorly on the anxiety and depression factors. Conclusions: The results confirmed the authors' previous findings demonstrating the distinction between symptoms of complicated grief and symptoms of bereavement-related depression and anxiety.