Association Between Hospice Use and Depressive Symptoms in Surviving Spouses

Abstract

IMPORTANCE Family caregivers of individuals with serious illness are at risk for depressive symptoms and depression. Hospice includes the provision of support services for family caregivers, yet evidence is limited regarding the effect of hospice use on depressive symptoms among surviving caregivers.OBJECTIVE To determine the association between hospice use and depressive symptoms in surviving spouses. DESIGN, SETTING, AND PARTICIPANTSWe linked data from the Health and Retirement Study, a nationally representative longitudinal survey of community-dwelling US adults 50 years or older, to Medicare claims. Participants included a propensity score-matched sample of 1016 Health and Retirement Study decedents with at least 1 serious illness and their surviving spouses interviewed between August 2002 and May 2011. We compared the spouses of individuals enrolled in hospice with the spouses of individuals who did not use hospice, performing our analysis between January 30, 2014, and January 16, 2015.EXPOSURES Hospice enrollment for at least 3 days in the year before death. MAIN OUTCOMES AND MEASURESSpousal depressive symptom scores measured 0 to 2 years after death with the Center for Epidemiologic Studies Depression Scale, which is scored from 0 (no symptoms) to 8 (severe symptoms). RESULTSOf the 1016 decedents in the matched sample, 305 patients (30.0%) used hospice services for 3 or more days in the year before death. Of the 1016 spouses, 51.9% had more depressive symptoms over time (mean [SD] change, 2.56 [1.65]), with no significant difference related to hospice use. A minority (28.2%) of spouses of hospice users had improved Center for Epidemiologic Studies Depression Scale scores compared with 21.7% of spouses of decedents who did not use hospice, although the difference was not statistically significant (P = .06). Among the 662 spouses who were the primary caregivers, 27.3% of spouses of hospice users had improved Center for Epidemiologic Studies Depression Scale scores compared with 20.7% of spouses of decedents who did not use hospice; the difference was not statistically significant (P = .10). In multivariate analysis, the odds ratio for the association of hospice enrollment with improved depressive symptoms after the spouse's death was 1.63 (95% CI, 1.00-2.65). CONCLUSIONS AND RELEVANCEAfter bereavement, depression symptoms increased overall for surviving spouses regardless of hospice use. A modest reduction in depressive symptoms was more likely among spouses of hospice users than among spouses of nonhospice users.

Spousal Characteristics and Older Adults' Hospice Use: Understanding Disparities in End-of-Life Care

“…6 Hospice also has beneficial effects for families and caregivers by improving family functioning, 7 bereavement adjustment 7-9 satisfaction with care, 8,[10][11][12] and mental health. 3,[13][14][15] Despite the potential benefits of hospice enrollment for individuals and families, the majority of patients with serious illness still do not use hospice. 1 Furthermore, most individuals who use hospice are admitted very close to the end of life.…”

The Antidepressant Effect of Hospice

“…Results from the study by Ornstein et al 4 in this issue of JAMA Internal Medicine suggest that hospice care has a modest antidepressant effect among surviving spouses. Why would hospice services reduce the severity of depressive symptoms that were shown to increase, on average, as spouses transitioned from caregiver to widowed survivor?…”

“…3 In these ways, hospice may have an indirect, if some-what diluted, positive effect on surviving spouses’ bereavement adjustment. Given the observed increase in depressive symptoms in the spouses, regardless of hospice enrollment, the results of the Ornstein et al report 4 point to a need for hospices to increase the potency of their treatment of bereavement-related depression.…”

“…In addition, hospice care focuses on comfort and is associated with higher rates of completion of advanced directives that would limit the caregiver’s exposure to potentially harrowing inpatient life-prolonging procedures. 3,4 Hospices may also promote the spouse’s preparation for the patient’s impending death and may combat feelings of isolation and helplessness by providing social interaction and professional support. Because hospices recognize the family as the unit of care, they may offer counseling services for caregivers and are required to provide a bereavement follow-up service.…”

“…4 As with prolonged grief disorder, major depressive disorder following the death of a spouse is likely to be rooted, perhaps deeply, in the surviving spouse’s relationship to the decedent and in the intricacies and configuration of their life together. Hospice services may touch on the meaning of the death to surviving family members, but the resolution of depressive symptoms may require a more profound and targeted approach.…”