Bereavement Reactions, Consequences, and Care (1984) / Chapter Skim
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Pages 13-44
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From page 13... ...
Epidemiologic Perspectives 011 the Health Consequences of Bereavement
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From page 14... ...
.;~ :a Epidemiologic studies now confirm what has Jong been suspected and can be observed in any cemetery: the death of a close family member may result in premature death for some survivors. Following the death of a spouse, young and mid~e-aged widowers are particularly vulnerable and remain at risk for a number of years.
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From page 15... ...
The identification of risk factors, even in the absence of full understanding of the etiology of disease, has in the past contributed to the development of public health measures for control and prevention. The application of such methods to bereavement phenomena will, it is hoped, also lead to intervention strategies that can reduce long-term negative outcomes, as well as to research that increases understanding of the bereavement process.
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From page 16... ...
Although mortality rates are readily available for the general population and for specific subgroups, rates of bereavement cannot be readily extrapolated from death rates because the number of surviving family members will vary depending on many different factors. Estimates of one-year incidence rates of bereavement in the general population range from 5 to 9 percent.
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From page 17... ...
Because of the complexity and logistical difficulties of doing prospective studies of whole populations, the more commonly used approach is to study samples of recently bereaved people, and to compare them to a control group matched for relevant characteristics. Such groups are folTowed in order to observe the subsequent occurrence of symptoms, particular behaviors, and health changes.
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From page 18... ...
The nature of these reactions is covered in detail in Chapter 3, and the therapeutic implications are discussed in Chapter 10. It is commonly assumed, particularly by clinicians, that the absence of grieving phenomena following bereavement represents some form of personality pathology and will have later adverse consequences.
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From page 19... ...
" The description of this "diagnosis" acknowledges a depression-like syndrome as normal for three months following bereavement. As discussed later in this chapter and elsewhere in this report, however, three months seems substantially shorter than the time needed by most people to begin to regain their psychologic equilibrium.
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From page 20... ...
ADVERSE HEALTH CONSEQUENCES OF BEREAVEMENT Mortality Notwithstanding methodological shortcomings in both retrospective and prospective controlled studies, it is clear from the epidemiologic evidence that some people are at increased risk for mortality following bereavement. The most important evidence is from studies that demonstrate an increase in overall mortality among the recently bereaved See Table ~ for a summary of the studies discussed in this section)
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From page 21... ...
Risk for men greater than for women. Young, UK Cohort of 4,486 recent wid- Significantly higher death Benjamin, widowers owers overage 55 rates for widowers in 1st and Wallis, compared with 6 months following be 196377 death rates for reavement than for mar married men of tied.
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From page 22... ...
When all these disease groups were combined, the mortality rate was at least seven times greater among the young widowed group (under age 451 than for the matched young mar r~eo control group. ~ ne mortality rate for death from cardiovascular disease was 10 times higher for young widowers than for married men of the same age.
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From page 23... ...
Several studies of relatively small cohorts of widows and widowers9 i0 25 75 found no significant increase in mortality in the first or subsequent years following bereavement. However, Young et al.77 found that among recent widowers over the age of 55, mortality rates were significantly higher for the first six months of bereavement than in married controls of the same age.
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From page 24... ...
The authors felt that in addition to contributing to their own deaths the consequences of these illnesses might have precipitated the suicide. This is an example of the complicated interactions that arise in studying mortality following bereavement, and is consistent with similar findings about poor health and mortality in the War674775 data.
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From page 25... ...
Comparisons of the retrospective study from vital statistics by Kraus and Lilienfeld39 and the prospective study by Helsing and Szklo3~ reveal somewhat different findings with regard to mortality rates and specific causes of death. These may be attributable to differences in sample characteristics Kraus and Lilienfeld studied only widowers who had not remarried, whereas Helsing and Szklo included widowers who had remarried and examined the interaction between remarriage and mortality.
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From page 26... ...
MacMahon and Pugh43 found that the suicide rate among a widowed population was 2.5 times higher in the first six months after bereavement and I.5 times higher in the first, second, and third years after bereavement than in the fourth or subsequent years, thus suggesting that bereavement itself is a powerful etiologic factor in death by suicide. These figures were based on a study of 320 widowers and widows who had committed suicide (excluding homicide-suicide combinations)
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From page 27... ...
Stein and Susser68 studied widowhood and mental illness among outpatients in Salford, England. They looked at the transition into widowhood and first entry into psychiatric care and compared the widows with a general population control group.
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From page 28... ...
Of the three studies reported, only Paykel et al.~8 found an increased risk of clinical depression following bereavement. The authors studied life events in IS5 depressed outpatients and inpatients and a group of matched community controls.
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From page 29... ...
Many investigators have asked the bereaved about physical and other symptoms following bereavement. These include crying, changes in Steen cattems or a~r)
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From page 30... ...
Among widows considered to be at high risk, Raphael62 found marked deterioration in health in the first year following bereavement as evidenced by numerous physical symptoms, diminution of work capacity, weight loss, and health-damaging behaviors. Parkes and WeissS7 report marked differences between well-matched young widowed spouses and married controls in self-reported symptoms, reflecting the somatic effects of anxiety.
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From page 31... ...
The literature suggests that the young widowed have more anxiety symptoms than their married counterparts. Except for those already ill, older men and women reported little change in their general health status following bereavement.
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From page 32... ...
The most extensive evidence of a link between disease in a specific organ system and bereavement exists for the cardiovascular system. Sudden cardiac arrhythmias, myocardial infarction, and congestive heart failure are the most frequently mentioned conditions in that system.
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From page 33... ...
And in diagnosis-specific health care use studies, Parkes52 found that increased rates of physician visits in the first six months following bereavement were due largely to increased consultations for vascular and articular conditions, especially osteoarthritis in a widowed population under 65 years of age. Aside from psychosomatic mechanisms involving physiologic changes, Jacobs and Ostfeld36 suggest that excess mortality, and presumably morbidity, in the recently bereaved may be mediated by behavioral changes that compromise health maintenance or chronic disease management.
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From page 34... ...
Yet most studies conducted in the United States show no increase in physician visits or hospitalization following bereavement.~456 On the average, Americans make almost five physician visits each year.~° Among the bereaved it appears that although some visits are related to their reactions to loss, the actual number of visits does not increase. Most of the evidence from England,s2 54 however, and one U.S.
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From page 35... ...
Mental health professionals generally encourage emotional expression during the bereavement process. Although some believe in prescribing medications to facilitate grieving, others are hesitant to recommend the use of drugs, including tranquilizers and antidepressants, lest the adaptive function of grieving be suppressed.
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From page 36... ...
10. Variables Associated Adults' Specific Particular Socio- Inter WithHealth Outcomes Reactions Losses Types cultural venti Characteristics of bereaved individuals Sex Age Prior physical health Prior mental health Personality factors Alcohol abuse Socioeconomic status Sociocultural factors Relationship to the deceased Kinship Ambivalence, dependence Nature of the death Suddenness Suicide Behaviors and attitudes appearing early in the grieving process Consumption of alcohol, drugs Smoking x Perceived social support x x Suicidal thoughts x Morbid guilt x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x aChapters 6, 7, and 9 do not discuss these variables in any detail.
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From page 37... ...
In addition to the previously mentioned high suicide rate among alcoholics shortly after bereavement, alcoholics are more likely than nonalcoholics to be doing poorly one year following bereavement. When psychiatric hospitalization occurs, the diagnosis is likely to be alcoholism 49 64 The association between socioeconomic status and bereavement outcomes has not been adequately studied.
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From page 38... ...
38 / Bereavement: Reactions, Consequences, and Care Nature of the Death Sudden death is frequently hypothesized to be more traumatic for the survivors and to lead to poorer outcomes than deaths that have been anticipated. There are marked variations in the criteria used to assess suddenness of death.
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From page 39... ...
As discussed in several later chapters, there is mounting evidence to suggest that social support has a positive effect on general health status and may serve as a protective factor to buffer or modify the impact of adversity and stressors, not only on the mental health of an individual, but also upon his or her physical health.s Perceived lack of social support is one of the most common risk factors cited in the bereavement literature. The perception by the recently bereaved that there is no one to talk to or lean on appears to be a reliable predictor of poor outcome.73 Research testing the magnitude of these hypothesized risk factors is difficult because of lack of agreement on relevant outcome measures.
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From page 40... ...
It appears that it is only in prepaid health care delivery systems that utilization of services increases in the year following bereavement. · Risk factors for poor outcome include poor previous physical and mental health, alcoholism and substance abuse, and the perceived lack of social supports.
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From page 41... ...
Emotional stress in the precipitation of congestive heart failure. Psychosomatic Medicine 15:38-60, 1953.
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From page 42... ...
Psychological factors and reticuloendothelial disease. Psychosomatic Medicine 16:220-230, 1954.
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From page 43... ...
Separation experience and health records in a group of normal adults. Psychosomatic Medicine 25:433, 1963.
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From page 44... ...
Health after bereavement: a controlled study of young Boston widows and widowers. Psychosomatic Medicine 34:449-461, 1972.
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