Sample Description
Participants were 216 offspring from 143 families bereaved by suicide, accident, or sudden natural death who were between the ages of 7 years and 17 years and 11 months at the time of the parent’s death, and 172 nonbereaved offspring from 98 families who were also between the ages of 7 years and 17 years and 11 months (
Table 1).
The deceased parents were middle-aged, predominantly men and white, and had died from suicide (N=50), accident (N=35), or sudden natural death (N=58). The causes of sudden natural death were myocardial infarction (N=23), other cardiac conditions (N=21), pneumonia (N=3), and other conditions (N=11) (aneurysm, blood clot, cancer, complications from gastric bypass surgery, diabetes mellitus, infection, stroke). Those bereaved families recruited via medical examiners were less likely to be bereaved by sudden natural death (32.8% compared with 54.7%, χ2=6.34, df=1, p=0.01) and to be white (71.7% compared with 86.3%, χ2=4.36, df=1, p=0.04); the surviving parent was more likely to have had a history of depression (78.9% compared with 47.6%, χ2=4.18, df=1, p=0.04), and the offspring were more likely to have been physically or sexually abused prior to the death (23.1% compared with 3.4%, p=0.04, Fisher’s exact test).
Compared with their living counterparts, deceased parents had higher lifetime rates of bipolar disorder (11.2% compared with 2.0%, χ2=7.04, df=1, p=0.01), alcohol or substance use disorder (61.5% compared with 43.9%, χ2=7.31, df=1, p=0.01), and personality disorders (24.5% compared with 4.1%, χ2=17.83, df=1, p<0.001). The surviving caretaking adults were middle-aged and predominantly women (81.3%), and compared with their nonbereaved peers, had higher predeath rates of lifetime depression (48.2% compared with 31.6%, χ2=6.56, df=1, p=0.01) and anxiety disorders (32.6% compared with 15.2%, χ2=9.37, df=1, p=0.002).
The 68% of offspring who completed the 7-year assessment, compared with those not retained, were less likely to have been bereaved (60.2% compared with 76.7%, χ2=11.97, df=1, p=0.001), to be black or Hispanic (13.4% compared with 33.3%, χ2=21.34, df=1, p<0.001), and to have had a parent with a history of bipolar disorder (3.4% compared with 16.7%, χ2=20.88, df=1, p<0.001) (see Table S2 in the online data supplement), although the median duration of follow-up was similar between bereaved and nonbereaved offspring (6.6 compared with 6.4 years, χ2=3.10, df=1, p=0.08, Wilcoxon rank sum test).
Incidence
Compared with nonbereaved offspring, bereaved offspring showed an increased incidence of depression (incidence rate ratio=2.08, 95% CI=1.45, 3.03) during the first 2 years postbereavement (incidence rate ratio=3.13, 95% CI=1.89, 5.40), but not thereafter (incidence rate ratio=1.24, 95% CI=0.70, 2.20). Bereavement increased the incidence of depression, even after adjusting for predeath risk variables (hazard ratio=2.67, 95% CI=1.58, 4.51) (see Table S3a in the
online data supplement). For incident depression, there was a significant interaction between bereavement and the offspring’s age at the time of parental death (hazard ratio=0.85, 95% CI=0.75, 0.97) (see Table S3b in the
data supplement). The adjusted hazard ratio for incident depression was increased in offspring who lost a parent at age 12 or younger (hazard ratio=4.92, 95% CI=2.04, 11.87) but not in those who lost a parent during adolescence (hazard ratio=1.15, 95% CI=0.69, 1.90) (
Figure 1; see also Table S3c and S3d in the
data supplement). Relative to comparison subjects, there was a significantly increased incidence of depression in offspring whose parents died by suicide (hazard ratio=2.26, 95% CI=1.39, 3.66) and by sudden natural death (hazard ratio=2.19, 95% CI=1.26, 3.83), but not in offspring bereaved by accidental death (hazard ratio=1.59, 95% CI=0.88, 2.85).
Bereaved offspring showed an increased incidence of PTSD (incidence rate ratio=7.27, 95% CI=2.58, 28.29) (
Figure 2), which was increased in the first 2 years after the loss (incidence rate ratio=10.41, 95% CI=2.57, 91.10). The incidence of PTSD in bereaved youths compared with nonbereaved youths did not reach significance thereafter (incidence rate ratio=4.14, 95% CI=0.86, 39.34). Bereavement increased the incidence of PTSD, even after adjusting for predeath risk variables (adjusted hazard ratio=5.66, 95% CI=1.95, 16.40) (see Table S4 in the
online data supplement). Relative to comparison subjects, those bereaved by suicide (hazard ratio=6.11, 95% CI=1.94, 19.29) and by sudden natural death (hazard ratio=8.00, 95% CI=2.39, 26.83) showed elevated hazard ratios for PTSD, but offspring bereaved by accidental death did not (hazard ratio=2.93, 95% CI=0.69, 12.43).
Bereaved offspring had a higher incidence of clinically significant suicidal ideation (defined as a Suicidal Ideation Questionnaire score ≥31; incidence rate ratio=1.89, 95% CI=1.20, 3.03) (
Figure 3). Bereavement did not have a significant effect on increased suicidal ideation in the first 24 months (incidence rate ratio=1.72, 95% CI=0.96, 3.19), but it did thereafter (incidence rate ratio=2.18, 95% CI=1.04, 4.92). The effect of bereavement on suicidal ideation became nonsignificant after controlling for predeath risk variables (see Table S5 in the
data supplement).
There were no significant effects of bereavement on the incidence of anxiety (hazard ratio=1.44, 95% CI=0.86, 2.40), alcohol or drug abuse (hazard ratio=0.97, 95% CI=0.55, 1.69), bipolar disorder (hazard ratio=1.34, 95% CI=0.45, 3.99), or behavioral disorders (conduct disorder, oppositional defiant disorder) (hazard ratio=1.02, 95% CI=0.48, 2.15).
Incidence and Course of Impairment
Compared with nonbereaved offspring, bereaved offspring had an increased incidence of impairment (incidence rate ratio=2.93, 95% CI=2.10, 4.14) even after adjusting for demographic and predeath risk variables (hazard ratio=2.07, 95% CI=1.43, 2.99) (
Table 2; see also Figure S1 in the
data supplement). Impairment related to bereavement was increased over the first 2 years (incidence rate ratio=2.63, 95% CI=1.72, 4.13) and thereafter (incidence rate ratio=2.56, 95% CI=1.47, 4.61), and it was also increased in all three types of parental death: suicide (hazard ratio=1.69, 95% CI=1.05, 2.74), accident (hazard ratio=1.73, 95% CI=1.10, 2.72), and sudden natural death (hazard ratio=2.71, 95% CI=1.78, 4.14). Mixed-effects logistic regression indicated that the prevalence of impairment was consistently increased in bereaved offspring (odds ratio=6.60, 95% CI=2.66, 16.32, p<0.001), with no change in this relationship over time (nonsignificant bereavement-by-time interaction, p=0.23).
Pathways for the Relationship Between Bereavement and Impairment
Logistic regression identified the most parsimonious set of variables at baseline and the average score over the next three time points associated with impairment at 7 years (see Table S7 in the
data supplement), and they were used to fit a structural equation model (
Figure 5).
There was a significant direct effect of bereavement on impairment (standardized coefficient [β]=0.19, SE=0.09, p=0.04). The indirect effects of bereavement on impairment were mediated by self-reported depression at 9 months and the average of self-reported depression over the next three time points (β=0.04, SE=0.02, p=0.02); by negative life events at 9 months and the average over the next three time points (β=0.03, SE=0.01, p=0.02); and by self-reported depression at 9 months and the average of negative life events over the next three time points (β=0.02, SE=0.01, p=0.03). A history of predeath child psychiatric disorder was more common in bereaved offspring and showed indirect pathways to impairment via its impact on self-reported depression (β=0.11, SE=0.04, p=0.01), social support (β=0.13, SE=0.06, p=0.02), and negative life events (β=0.05, SE=0.02, p=0.02), as well as through self-reported depression at 9 months and the average of negative life events over the next three time points (β=0.04, SE=0.02, p=0.01). This model showed a good fit to the data (test of model fit: χ2=12.61, df=10, p=0.25; comparative fit index=0.994; Tucker-Lewis index=0.970; weighted root mean square residual=0.37; root mean square error of approximation=0.03, 90% CI=0.00, 0.08).