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Bereavement: Reactions, Consequences, and Care (1984)

Chapter: Epidemiologic Perspectives on the Health Consequences of Bereavement

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Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
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Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 14
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 15
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 16
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 17
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 18
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 19
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 20
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 21
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 22
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 23
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 24
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 25
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 26
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 27
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 28
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 29
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 30
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 31
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 32
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 33
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 34
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 35
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 36
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 37
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 38
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 39
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 40
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 41
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 42
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 43
Suggested Citation:"Epidemiologic Perspectives on the Health Consequences of Bereavement." Institute of Medicine. 1984. Bereavement: Reactions, Consequences, and Care. Washington, DC: The National Academies Press. doi: 10.17226/8.
×
Page 44

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Epidemiologic Perspectives 011 the Health Consequences of Bereavement

.;~ :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.

CHAPTER 2 Epiclemio10gic Perspectives on the Health Cor~sequences of Bereavemen t r ~ _ his chap t er rev i e w s and evaluat e s the epidemiologic evidence that adults are at greater risk for a variety of adverse health consequences following bereavement. The health conse- quences of bereavement during childhood are discussed in Chapter 5. Epidemiology is the medical science that studies the distribution of disease in populations. Epidemiologic research attempts to determine the incidence, prevalence, and timing of health-related phenomena, and to identify risk factors that alter the probability of such occurrences. The identification of risk factors, even in the absence of full understand- ing of the etiology of disease, has in the past contributed to the develop- ment of public health measures for control and prevention. The applica- tion of such methods to bereavement phenomena will, it is hoped, also lead to intervention strategies that can reduce long-term negative out- comes, as well as to research that increases understanding of the be- reavement process. It has been hypothesized that bereavement: · predisposes people to physical and mental illness; · precipitates illness and death; · aggravates existing illness; This chapter is based on material prepared by committee members Gerald L. Kler- man, M.D., and Paula Clayton, M.D. 15

16 / Bereavement: Reactions, Consequences, and Care · brings on a host of bodily complaints and physical symptoms; · leads to or exacerbates health-threatening behaviors such as smok- ing, drinking, and drug use; · causes increased use of health services. To test these hypotheses, observations of bereaved individuals must be compared with those of nonbereaved individuals matched for such relevant characteristics as age, sex, social class, and race. However, the collection of reliable information about bereavement is not easy. There is difficulty even in establishing baseline rates of bereavement for any given population in any given time period. Although mortality rates are readily available for the general population and for specific subgroups, rates of bereavement cannot be readily extrapolated from death rates be- cause 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. For example, Imboden et al.35 found in a population of 455 healthy men (employees at an Army base, average age 35) that 8.9 percent had lost a family member to death ~ , _ 1 ,_1 ~ o~ ~ ~ ~ ~ ~ _ ~ ~ ~ ~ ~ ;~-; within one year. frost and Layton reported a ~ percent oIle-yeuI ~ll~l- dence of bereavement of first-degree relatives among 109 people with an average age of 61. Pearlin and Lieberman59 report that death of a parent occurs in 5 percent of the population annually. These estimates of bereavement rates in the general population pro- vide some basis for determining whether there is a relationship between bereavement and ill health. If it is found that sick populations have higher rates of bereavement in the year preceding their illness, that would suggest a possible relationship between bereavement and the subsequent development of illness. PavLel et al. so for example, found a , , . one-year incidence rate of ~ percent in a healthy population, compared with lS percent in a population of clinically depressed people whose be- reavement occurred in the year preceding their diagnosis. Retrospective studies, which rely on extrapolations of base rates cal- culated from previous reports, are generally less accurate than prospec- tive studies which match a population at risk with a concurrent control group. For this reason, greater weight is given in this chapter to prospec- tive studies. Among such studies, three designs have been used: (1J studies of whole population groups, {2) studies of bereaved samples compared with control groups, and {3) case control studies. Prospective studies of whole populations, such as the one by Helsing and SzkTo,3i are the most powerful designs, because they enable assess- ment of individuals before they are bereaved and therefore the observa

Epidemiologic Perspectives / 17 tions made are not influenced by the state of bereavement. Very large samples are required for such studies because the rate of bereavement for an immediate family member in a general adult population is only about 5 percent per year. Because of the complexity and logistical difficulties of doing prospec- tive 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 fol- Towed in order to observe the subsequent occurrence of symptoms, par- ticular behaviors, and health changes. This design has been used most powerfully by Clayton in a series of studies on the bereavement experi- ence of widows.9 ~0 it In the third type of design case control individuals with a particu- lar condition {e.g., depression, ulcerative colitis) that is believed to be associated with bereavement are compared with an appropriate control croup. This approach is used because of the low frequency of both be ~ ~ . ~ reavement and the conditions that may be precipitated by it. Assuming that approximately 5 percent of the population is bereaved in a given year and that only a small portion of the bereaved develop a depression or other specific disorder, it would be necessary to follow an extremely large sample prospectively to determine whether bereavement is associ- ated with a greater risk of that illness. Thus several researchers have worked backwards from a disorder to ask how many people with the disorder were recently bereaved. If the proportion is higher than the rate for the same age and sex group in the general population, it suggests that the bereaved are at risk for that condition. The somewhat conflicting results found in epidemiologic studies are accounted for in large part by differences in the study designs just dis- cussed, in sample sizes and characteristics (including, for example, con- trolling for length of widowhood and remarriage], and in changes in pop- ulations over time. These differences make it hard to compare studies and to establish precise rates of bereavement or its health conse- quences. In addition, as is true of all research on humans, perfect experi- mental controls are never possible; there will always be some uncon- trolled variables. THE QUESTION OF OUTCOMES Another major problem in bereavement research is the lack of agree- ment about what constitutes normal or abnormal outcomes and the ab- sence of reliable criteria for assessing them. Among the normal out- comes that have been proposed are reduction of depression-like

18 / Bereavement: Reactions, Consequences, and Care symptoms, return to usual level of social functioning, remarriage {in the case of spousesJ, reduction in frequency of distressing memories, the capacity to form new relationships and to undertake new social roles, and other functional outcomes such as return to work. Numerous scales and indices have been used to measure reduction of symptoms and various aspects of social and emotional recovery and adjustment, but their reliability and validity often have not been ascertained. Some other outcomes, although easy to measure, are conceptually faulty, es- pecially if they are the only measure used. Kinship patterns and related social roles, for example, can never be fully reestablished because of the irreversibility of the death. Remarriage may sometimes be a useful out- come measure of conjugal bereavement; for elderly women, however, it is unrealistic to expect high rates of remarriage because there are not enough elderly men available in the population. Clinicians have described a number of processes associated with poor outcomes, including absent, delayed, prolonged, or chronic grief. The nature of these reactions is covered in detail in Chapter 3, and the thera- peutic implications are discussed in Chapter 10. It is commonly as- sumed, particularly by clinicians, that the absence of grieving phenom- ena following bereavement represents some form of personality pathology and will have later adverse consequences. But the empirical research in support of this assumption has not been undertaken. Indi- vidual variation in response to bereavement is expected, but the amount of grief that is too much or too little in terms of psychologic well-bei}:lg has not been definitively determined. Until the criteria for distinguishing normal from abnormal and too much grief from too little have been agreed on, definitive epidemologic research on the frequency of these outcomes cannot be conducted. THE CONSTELLATION OF DISTRESS AND GRIEF Human experience through the centuries has recorded the near-uni- versal occurrence of intense emotional distress following bereavement, with features similar in nature and intensity to those of clinical depres- sioIl. These features include crying and sorrow, anxiety and agitation, sleeplessness, lack of interest in things, and frequent gastrointestinal complaints, such as loss of appetite. Grieving individuals are also often seriously impaired in their social functioning. There is considerable controversy about whether it is appropriate to consider this constellation of depression-like symptoms to be an illness. This issue was raised most pointedly by Enge! in "Is Grief a Disease?"20 The current consensus is that although individuals experiencing grief

Epidemiologic Perspectives / 19 are distressed, they are not ill or diseased. A number of considerations lead to this conclusion. For one thing, society does not consider them to be sick, nor do bereaved individuals consider themselves ill; they be- lieve they are undergoing a "normal" period of distress. In this sense bereavement may be compared to pregnancy. Both are naturally occur- ring conditions for which many individuals seek medical attention. Grieving individuals may seek medical attention and may be prescribed tranquilizers, steeping pills, and sedatives, but they seldom seek psychi- atric care. Second, although there are similarities between the behavior and dis- tress of grieving individuals and those who are clinically depressed, there are also some important differences. Most grieving people do not report gross motor retardation or suicidal thoughts. A persuasive dis- tinction between grief and depression was made by Freud in his classic paper on Mouming and MeJancho~ia.22 He contended that most people in the grieving state fee] there has been a loss or emptiness in the world around them, while depressed patients feel empty within. A pervasive Toss of self-regard and self-esteem is common in depressed patients but not in most grieving individuals. Therefore the almost universal con- clusion among clinicians and theorists is that grief and clinical depres- sion, although they share some subjective and objective features, repre- sent different conditions. That grief is not generally considered an illness is also reflected in the American Psychiatric Association's Diagnostic and Statistical Manuals (DSM-III) by the category "uncomplicated bereavement. " The descrip- tion 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. Despite the general agreement that grief is not an illness, many theo- rists, particularly those of psychoanalytic background, regard the grief situation as the prototype for understanding the dynamics of clinical de- pression, particularly depression precipitated by loss-either through bereavement or through separation, disappointments, or "symbolic" losses. Moreover, in animal research, particularly in the primate studies described in Chapter 7, experimentally induced separation has been found to produce a characteristic syndrome of behaviors. Whether this represents a true animal mode! of clinical depression remains unre- solved. Until the patterns of normal bereavement reactions are understood, it is not possible to develop sound criteria for abnormal reactions. For ex

20 / Bereavement: Reactions, Consequences, and Care ample, since the bereaved suffer from and report significant depressive symptoms, how many of them have enough symptoms to be diagnosed as "depressed"? In prospective studies of older widows and wid- owers,3~3 ~4 Clayton aIld her colleagues found that 35 percent at one month, 25 percent at four months, and 17 percent at one year could be classified as depressed based on a constellation of symptoms. Forty-five percent were depressed at some point during the year and 13 percent were depressed for the entire year. When a consecutive series of younger widowed people was added to the sample, 42 percent at one month and 16 percent at one year met the criteria; 47 percent of the sample were depressed at one of the two points and ~ ~ percent were depressed for the entire year. Among a control group who had not lost a first-degree rela- tive in the preceding year, ~ percent reported a depressive syndrome at some time during the year, a one-year incidence figure that can be com- pared with 47 percent in the widowed population. It should also be noted that, of the many widowed who did not meet the criteria for the syndrome of depression, many did have individual symptoms in varying combinations, durations, and sequences. ADVERSE HEALTH CONSEQUENCES OF BEREAVEMENT Mortality Notwithstanding methodological shortcomings in both retrospective and prospective controlled studies, it is clear from the epidemiologic ev- idence that some people are at increased risk for mortality following be- reavement. The most important evidence is from studies that demon- strate an increase in overall mortality among the recently bereaved See Table ~ for a summary of the studies discussed in this section). Kraus and Lilienfeld39 reported one of the earliest systematic studies on mortality in the bereaved. They retrospectively calculated mortality rates for widows and widowers, matching data from the National Office of Vital Statistics for 1956 with data from the 1950 census. Death rates of widowed subjects were compared to the rates for married men and women matched for age, sex, and race The mortality ratios of widowed to married were strikingly higher at younger ages; as age increased the differences in mortality between the widowed and married decreased for men and women and for all races. Mortality rates for males who were widowed were consistently higher than those of female widowed. Specifically, younger widows and widowers (ages 20-24J had the highest ratio of mortality for eight causes of death: vascular lesions of the central nervous system, arteriosclerotic heart disease, non

Epidemiologic Perspectives / 21 TABLE 1 Summary of Epidemiologic Evidence for Mortality Following Bereavement Authorts) Coun- Research Number and Type and Date try Design of Subjects Mortality Risk Kraus and USA Retrospec- Bereaved spouses Elevated for widows and Lilienfeld, tive from from all deaths in widowers. Risk of mortal 195939 vital US in 1949-1951 ity 7x greater for widowed statistics vs. matched mar- under age 45 than for con ried controls trots. 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. No differences after same age. Fol- 6 months. lowed for 5 years. Cox and UK Retrospec- 60,000 widows fol- Some elevation of mortal Ford, tive from lowed for 5 years ity rate in 2nd year follow 1964~7 vital after application ing bereavement; none in statistics for widow's 1st, 3rd, 4th, or 5th year. pension. Rees and UK Cohort of 903 bereavedrela- Significantlyhighermor Lutkins, bereaved fives vs. 878 non- tality for bereaved spouses 763 relatives bereaved matched in 1st year. Insignificant controls followed differences in 2nd and 3rd for 6 years. years. In general, mortality rate for men higher than for women; rates for be reaved relatives higher than nonbereaved for all types. Clayton, USA Cohort of 109 widows and No increased risk of 19749 widows and widowers and mortality. widowers matched controls followed for 4 years. Shepherd UK Cohort of 44 spouses of sui- No difference in mortality and bereaved cides vs. nonspeci- and remarriage rates be Barraclough, spouses fled, nonsuicide tween suicide widows and 97466 widow group. Age nonsuicide widows in 1st unspecified. year. 23% mortality over 58-month period.

22 / Bereavement: Reactions, Consequences, and Care TABLE 1 Summary of Epidemiologic Evidence for Mortality Following Bereavement {Continued) Authoress Coun- Research Number and Type end sate try Design of Subjects Mortality Risk Gerber USA Cohort of 169 bereaved No deaths in either group et al., bereaved spouses and during 1st year. Slightly 7525 spouses matched married higher percentage of deaths controls followed among bereaved in 2nd for 4 years. and 3rd years. Ward, UK Cohort of 87 widowers and No increased risk of 197675 bereaved 279 widows cam- mortality spouses pared with known age- and sex specific rates. Helsing and USA Prospective 12-yearprospec- No increased mortality in Szklo, population live study of 1st 6 months. Highly sig 19813i study 92,000 people. nificant increase thereafter Matched pair anal- for widowers, especially ysis of bereaved those who did not re and married marry. No excess mortal spouses. ity for widows. Levav, UK Reanalysis 35 bereaved Highly significant dif 19824 ~of Rees and parents vs. 29 con- ference between bereaved Lutkins63 trots followed for and nonbereaved cumula cohort fo- 5 years. tive death rate over 5 years cueing on ` 34 .3 % vs . 6. 9 % ~ . parents rheumatic chronic endocarditis and other myocardial degeneration, hy- pertension with heart disease, general arteriosclerosis, tuberculosis, and influenza and pneumonia. When all these disease groups were com- bined, 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 dis- ease was 10 times higher for young widowers than for married men of the same age. Kraus and Lilienfeld concluded that as a group, the re- cently bereaved were at greater risk for mortality. Although provoca- tive, these data did not take into account either the duration of widow- hood or the fact that widows and widowers who do not remarry may have been in poorer health. Cox and Fordi7 reanalyzed government records of 60,000 widows re- ceiving pensions for the first time in 1927, and then identified from vital statistics those who died over the next five years. They compared the

Epidemiologic Perspectives / 23 actual and expected numbers of deaths for the first five years of widow- hood. Only during the second year following bereavement was there some excess in mortality, and it appeared most pronounced in women between the ages of 60 and 68. Several studies of relatively small cohorts of widows and wid- owers9 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. No differences were found after six months. Rees and Lutkins,63 in a prospective study, followed a cohort of 903 relatives of 371 residents of a village in Wales who had died during the previous year. These 903 persons were compared with a cohort of 87g nonbereaved individuals matched for age, sex, and marital status. These cohorts were followed for six years. Mortality rates were slightly higher for all types of bereaved relatives, but significant differences were only found among spouses during the first year. The mortality rate for the bereaved spouses was significantly greater than for the control spouses-12 percent of bereaved spouses died compared with ~ percent of nonbereaved spouses. The most definitive study on mortality after bereavement was con- d.ucted by Helsing and his colleagues.30-32 In a 1963 health census con- ducted in Washington County, Maryland, data were obtained on 91,909 persons-98 percent of the noninstitutionalized population. The popu- lation was followed prospectively to 1975. The widowed population in 1963 was matched to a married population of the same race, sex, year of birth, and geographic category of residence. Any member of the married population who became widowed after entry into the study was with- drawn from that category and enrolled in the widowed population as of the date of death of the spouse. Widowed men aged 55-74 exhibited a highly significant increase in mortality. Those younger, 19-54, also showed a difference in the rela- tive risk of death, but because there were so few deaths in this group the differences did not achieve statistical significance. Interestingly, wid- owers over 75 did not have a significantly increased mortality. This finding is consistent with CIayton's~ observation that older widowed men who survive their spouses may be in better health than married men of the same age. There was no evidence that men's mortality was higher in the first year than in subsequent years of the study; for women, however, the data suggest that the risk of mortality is greatest in the second year following bereavement.

24 / Bereavement: Reactions, Consequences, and Care Although there were some differences in the mortality rates by age among females, and for widows as compared with married women, when education, social class, cigarette smoking, and other potential risk factors were controlled the differences disappeared. Control of these factors did not affect the significance of the mortality rates in men.32 At least half the men who were widowed before the age of 55 remar- ried during the course of the study. As would be expected, given the de- mographic composition of the population, remarriage among women was far less common, with the remarriage rate in any age group being similar to that among males 20 years older. The differences in mortality rates between the widowed males who remarried and those who did not remarry were substantial. In fact, age-specific mortality rates among widowed males who remarried were lower than the rates among mar- ried males. The ratio of remarried/not remarried mortality rates for mates ranged from about l: ~ to I :2; the small numbers of widowed fe- males who remarried plus the already low mortality rate among the widowed females made their remarried/not remarried ratios meaning- less. Clearly, remarriage must be taken into account in any mortality study of bereavement. It should be noted, however, that it is not known whether marriage itself protects against ill health or whether good health is what permits remarriage. Helsing and his colleagues32 also found that there was a significant mortality difference for both sexes by change of address after widow- hood. This high mortality rate among subjects who moved was due largely to those who moved into nursing homes, retirement homes, and chronic care facilities Presumably indicators of poor hearth). Finally, living alone was also associated with a higher mortality than living with others. It has often been suggested that vulnerability to illness and death is increased following the suicide of someone close. Shepherd and Barra- clough66 reported that spouses of suicides have no increased mortality in the first year of bereavement. Over a longer period, 58 months, there were 10 deaths in 44 spouses {23 percent), a trend that indicates survi- vors of suicidal deaths are at greater risk of mortality than survivors of other deaths. Compared with mortality rates of the married rather than widowed, this excess mortality is even more significant. Half the spouses who subsequently died were seriously ill at the time of the sui- cide. 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 simi- lar findings about poor health and mortality in the War674775 data.

Epidemiologic Perspectives / 25 The mortality studies reviewed in this section provide examples of somewhat different results due to the methodological and population variations mentioned earlier. Unless differences are very great they will not reach statistical significance in small samples. 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. The differ- ent findings may also be traced to changes in general mortality charac- teristics {such as reduction in cardiovascular death rates) during the 20 years between these two studies, or to differences stemming from retro- spective and prospective study designs. These differences notwithstanding, the weight of the evidence indi- cates that, up to age 75, widowed men are about one-and-one-half times more likely to die prematurely than their married counterparts. Al- though especially pronounced during the first year, the mortality rate for men who do not remarry continues to be elevated for many years. For widows, there is no increase in risk the first year, but several reli- able studies find excess mortality in the second year. It should be noted that there are very few studies dealing with mortal- ity following any bereavement other than conjugal loss. The effect of the death of parents, children, or siblings has been virtually unstudied. With regard to parents, there is one highly controversial study. Levav4i reanalyzed the data from Rees and Lutkins,63 focusing specifically on bereaved parents in the original sample. The 35 bereaved parents were compared with 29 control parents. When the accumulated deaths were compared over the five-year study period it was found that 34.3 percent of bereaved parents had died compared with 6.9 percent of nonbereaved parents. Although Toss of a child is generally considered hazardous, these mortality figures seem very high, perhaps because of some un- specified characteristics of the particular population that was studied. The effects of this type of Toss are discussed in detail in Chapter 4. Death by Suicide. National statistics for the United States in the years 1949-1951 established that suicide rates were higher among the widowed than the married. Since that time numerous studies from vi- tal statistics and from survey data ie.g., Kraus and Lilienfeld,39 Bock and Webber,2 Stroebe et ai.,69 and Helsing et al.30) have confirmed this in- crease, especially among elderly men. Among women the suicide rate is not as high for widows as for the divorced or separated.

26 / Bereavement: Reactions, Consequences, and Care Several hypotheses have been tested in recent studies, including that bereavement itself and the circumstances of widowhood predispose people to suicide, that those who remain widowed {that is, do not re- marry) following the death of their spouse have preexisting characteris- tics {such as alcoholism and depression) that predispose them to sui- cide, and that the nature of the death of the spouse Especially suicide) predisposes the surviving spouse to suicide. MacMahon and Pugh43 found that the suicide rate among a widowed population was 2.5 times higher in the first six months after bereave- ment and I.5 times higher in the first, second, and third years after be- reavement 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) in Massachusetts between ~ 948 and 1952. The suicide sample was com- pared with a control group of widows and widowers matched for age, sex, and race who died from causes other than suicide. The age-stand- ardized suicide rate for widowed men was 3.5 times higher than among married men and for women the rate was twice as high. Generally, men were found to have a higher suicide rate than women. In a striking study, Bunch et al.6 reported that half of 75 people who committed suicide in West Sussex, Great Britain, had experienced ma- ternal bereavement within the last three years. This high maternal be- reavement rate in suicides was compared to a 20 percent rate among controls who were matched for age, sex, marital status, and geographi- cal location. Moreover, 22 percent of the suicides, compared with 9 per- cent of the controls, had experienced loss of their fathers within the pre- vious five years. In addition, although married suicides and controls were not significantly different with respect to loss of a mother, the sin- gle male suicides showed greater recent maternal bereavement (60 per- centJ than the single male controls {6 percents. The authors hypothesize that single men may be a high-risk group for suicide following their mother's death because of a higher proclivity of males to act out via self- destructive impulses, whereas women more easily seek out medical and psychiatric help. In a small study, Murphy and Robins49 found that among a group of alcoholics who committed suicide, 17 percent {5 out of 31) had experi- enced the death of someone close in the previous year. An additional 41 percent of the alcoholics who committed suicide had experienced an- other type of loss such as separation or divorce. Thirty-two percent of these other types of Toss occurred within six weeks of the suicide. In a later study64 it was found that in a group of people who were diagnosed

Epidemiologic Perspectives / 27 after their suicides as having had an affective disorder Chiefly depres- sion), 5 percent {3 out of 60) had experienced bereavement in the year before they killed themselves. An additional 12 percent with affective disorders had experienced other types of losses. The authors' main con- clusion was that alcoholics were a high-risk group for suicide after the Toss of an affectional relationship. Morbidity Ed Health Care Utilization There is considerable controversy over the nature and extent of mor 1 1 · . _ _ . ~ . ~ . ovary associated warn bereavement and the concomitant burdens on the health care system. General health status, specific medical and rsv- chiatric disorders, health-related behavior, and health care utilization have all been studied in an attempt to determine the impact of bereave- ment on health and the use of services. The findings from these studies, however, are frequently inconsistent and inconclusive, in part because of very small sample sizes in many studies. Psychiatric Morbidity. r ~ An increase in psychiatric morbidity in the first year of bereavement could be signaled by higher rates of emotional and mental symptoms sufficient for diagnosable mental disorder; con- sumption of pills or alcohol; and use of psychiatric services, both inpa- tient and outpatient. As described earlier in this chapter, all studies have documented that distress and depressive symptoms dominate the emotional life of the bereaved during the first year. But how often do the bereaved meet criteria for true psychiatric illness? Stein and Susser68 studied widowhood and mental illness among out- patients in Salford, England. They looked at the transition into widow- hood and first entry into psychiatric care and compared the widows with a general population control group. Significantly more widows en- tered psychiatric care in the first year after the death of a spouse than in subsequent years. Thus, widows who enter psychiatric care are more likely to do so early in widowhood than later .,,;- ;~ ,,= ....,v `,,,~,v ~ hip id the only study with controls, though not age-matched. showing a relatinn.shin hetwe~n widowhood and psychiatric care. in _ t1~ ~ ~ ~ _ c I: -aims and Drown, In a prospective study, followed for four years a group of Boston widows and widowers under the age of 45. They found higher rates of depressive symptoms among the widowed and more use of counseling by the young widowed than by controls. Other studies also mention this use of counseling, 62 but the appropriate data are sparse. Data on psychiatric hospitalization are also very limited. CIayton's prospective studies of the widowed9 i0 found that psychiatric hospital

28 / Bereavement: Reactions, Consequences, and Care ization occurred in three (2 percent) of the bereaved and one of the con- trols. Two were alcoholics and the third was previously diagnosed as depressed. Of all the psychiatric conditions, clinical depression would appear to be the one most likely to occur with greater frequency among the be- reaved. As noted earlier in this chapter, Clayton and others have found that a fairly substantial proportion of bereaved individuals estimated at approximately 17 percent still have a constellation of depressive symptoms such that they could be diagnosed as depressed at one year. Conceptually this makes sense. Loss through death would be expected to be an important life stressor precipitating clinical depressive disor- ders, particularly in those predisposed by virtue of family history, per- sonality, or previous life experience. In view of this, it is surprising how few studies have systematically attempted to test this commonly believed clinical hypothesis. 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. Sixteen of the depressives and four of the control group reported the death of an immediate family member in the six months prior to the onset of the illness or the interview. There were five patients who had experienced the death of a child, which is surpris- ingly high but is consistent with other research indicating that this type of bereavement is extremely traumatic. Hudgens et al.34 studied 40 hospitalized patients with affective disor- ders and 40 matched nonpsychiatric hospital controls for precipitating events and found no deaths of spouses in either group. In the year pre- ceding, 13 percent of the psychiatric patients and 3 percent of the con- trols had lost a first-degree relative, a difference that was not significant. When the sample was expanded to 100 psychiatric patients and 100 con- trols, 7 percent of the former and 3 percent of the latter experienced the death of first-degree relatives, though none was a spouse.48 Frost and CIayton23 evaluated 344 psychiatric inpatients for bereave- ment in the six months preceding admission. These patients were matched with nonpsychiatric hospitalized patients. In each group, 2 percent reported the death of a first-degree relative. Three psychiatric patients (less than ~ percent) had experienced the death of a spouse within six months of the current admission to the hospital; there were no deaths of spouses in the control group. Many of the bereaved subjects in all these studies reported marked increases in their consumption of pills, alcohol, and tobacco, which

Epidemiologic Perspectives / 29 ~21 nor ~ ~.. could indicate psychiatric morbidity, and some reported initial use of these substances following bereavement. Parkes53 observed that sedative Unugs were prescribed seven times more frequently for widows under the age of 65 during the first six months of bereavement than in the period preceding the death. For wid- ows agea oo ana other, there was no significant increase in the prescrip- tion of sedatives. In their later study, Parkes and Brown56 observed that 25 percent (17) of the 68 widows in Boston under the age of 45 years reported an in- crease in the consumption of tranquilizers, alcohol, and tobacco during ~ '~-~ Gallup am v~leavemenl. 1wenry-elgnt percent of be- reaved subjects reported an increase in smoking, compared with 9 per- cent of controls. Increased consumption of alcohol was reported by 28 percent of the bereaved women versus 3 percent of the controls. A first use of tranquilizers was reported by 26 percent of the widows and 4 per- cent of the controls. There was no statistically significant difference be- tween bereaved subjects and controls in the use of sleeping pills. Maddison and Viola44 reported a marked increase in both sedative {tranquilizers) and hypnotic [steeping pills) drug intake in their sample of 374 widows aged 45-60 years old, compared with controls, during the 13 months after bereavement. They also noted increased alcohol con- sumption and tobacco use among the widows versus the controls. There was a small but significant difference in the consumption of sleeping pills between the 90 widows and widowers {average age 61 years) and the matched controls in CIayton's9 study. There were no dif- ferences between the two groups, however, in consumption of tranquil- izers or other medicine taken for general health. In a study of recently widowed persons over the age of 55 and a control group of married individuals, Thompson et al.70 report both increased and new medicine use among the widowed. Fifty-four percent of the medicines used by the widowed were analgesics. sedative. glean merli cation, or antidepressants. 4~1^ ~1 ~ ~_ ~c, 1 . ~. A, Se~f-Reported Symptoms and Hearth Status. Many investigators have asked the bereaved about physical and other symptoms following bereavement. These include crying, changes in Steen cattems or a~r)e , - --I, site, difficulty in breathing, sighing, palpitations, natty to concen- trate, and a host of other signs of distress. Unfortunately there are only a few studies that assessed self-reported symptoms before and after be- reavement. Self-reports of symptoms and of perceived changes in health status are likely to be exaggerated by the general distress of bereavement . . ...

30 / Bereavement: Reactions, Consequences, and Care such that these reports are not ideal measures of actual health status. They may be better indicators of general distress, especially if repeated measures are done over time. Crisp and Priestly 6i administered a brief self-rating inventory in- tended to cover a full range of neurotic symptoms to samples of be- reaved and controls between the ages of 40 and 65 who were registered with a group practice in southwest London. Although their numbers were small, they found minimal differences between the bereaved wid- ows and the controls. They commented that the bereaved subjects on the whole withstood the stress in a "robust way." Heyman and Gianturco,33 as part of a continuing Duke Center Longi- tudinal Study for Aging, reported on the reactions to widowhood in the elderly. They found little difference in before-and-after scores of either sex on health, leisure activity, financial security, or ratings for anxiety or hypochondriasis. There was a small increase in depression in the women after bereavement, but it was felt that this depression was mild and that all the widows kept active contact with their friends despite depression. Parkes54 studied a group of London widows, average age 49 years, who had visited their doctors during the first month of bereavement. At 13 months, six widows {27 percent) reported that their health was defi- nitely worse. In the later study, in Boston, Parkes and Brown56 found that in terms of self-reported physical symptoms, widows and their con- trols were not significantly different, but widowers reported more se- vere symptoms and more anxiety than controls. No excess of psychoso- matic illness was found. There were no differences in general health or in "health worries." In a retrospective mail survey of 375 widows aged 40-60 ~132 in Bos- ton, Massachusetts, and 243 in Sydney, Australia), Maddison and Vi- ola44 found significant differences between widows and matched con- trols in reports of several symptoms and complaints. Among widows considered to be at high risk, Raphael62 found marked deterioration in health in the first year following bereavement as evidenced by numer- ous 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 symp- toms, reflecting the somatic effects of anxiety. There were no signifi- cant differences in the worsening of chronic symptoms, perceived gen- eral health, or health worries between the groups. However, Thompson et al.70 found that recently widowed elderly individuals reported wors

Epidemiologic Perspectives / 31 ening of existing illness as well as new illnesses more frequently than controls. These prospective studies document less physical distress than had been expected. 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. Specific Meccas Disorders. The hypothesis that bereavement pre- disposes to, precipitates, or exacerbates medical illness and thus in- creases morbidity has been proposed for several disorders, including acute closed-angle glaucoma, cancer, cardiovascular disorders, Cush- ing's disease, disseminated lupus erythematosus, idiopathic giossody- nia, pernicious anemia, pneumonia, rheumatoid arthritis, thyrotoxico- sis, tuberculosis, and ulcerative colitis isee Klerman and dozens for a detailed review of this literatures. The evidence linking each of these diseases to bereavement and grief is meager. Not only is much of the evidence based on clinical case re- ports of small numbers of patients, but many studies use "loss," "stress," or "depression" broadly defined as the condition preceding the disorder. Bereavement as a specific stressor and the "depression of grief" as distinct from other types of depression are often not distin- guished, thus rendering it difficult to draw definitive conclusions about the association between bereavement and specific diseases. Adequate testing of the hypothesized associations requires prospective studies with large samples. Nonetheless, an extensive literature in the psychosomatic tradition suggests that bereavement is a contributing factor to somatic disease in individuals who are already predisposed to that disease because of ge- netic susceptibility, physiologic responsiveness, or preexisting psycho- logic susceptibility. For example, studies of hyperthyroidism ithyrotoxicosis or Graves' diseased in children45 46 and in adults37 suggest that traumatic events, especially loss, may activate the disease in susceptible individuals. In the case study reports of children with hyperthyroidism, loss of a parent by divorce, separation, or death was found to be a common antecedent to depression, which in turn may activate the disease in those children who are genetically predisposed or physiologically vulnerable. In adults who are already excessively anxious or depressed, a "normal life stress," such as bereavement, can contribute to the development of hy- perthyroidism. However, as Kleinschmidt et ai.37 caution, affective

32 / Bereavement: Reactions, Consequences, and Care states and disorders are unlikely to cause the disease without some ge- netic or physiologic vulnerability as well. Parental loss has also been proposed as a precipitator of diabetes in children40 but probably only in genetically or physiologically predis- posed individuals. There is also some evidence of an association be- tween psychologic trauma and exacerbation of diabetes in some adult patients {see, for example, Grant et al.26 and Treuting7~J. In many dis- cussions of this issue, however, bereavement as a specific stressor is not separated out from other stressors, nor is it clear what makes some indi- viduals vulnerable to an altered course of their disease when they are under stress. Bereavement has been implicated as a contributor to many different kinds of cancer. As with studies of other diseases, most of the cancer studies are retrospective and often do not distinguish among various losses that precede the disease. SchmaTe and {ker65 reported an associa- tion between Toss and several cancers, especially cancer of the cervix. Several studies by Greene27-29 suggest a high incidence of leukemia and lymphoma among individuals with a recent loss {actual or psychic). Men who are separated from their mothers or mother figures appear to be particularly vulnerable. Once again, however, these findings remain inconclusive because of lack of control groups, small sample sizes, and a failure to distinguish actual bereavement from other losses.47 Although the ink between bereavement and the development of various types of cancer has not been confirmed by rigorous epidemiologic studies, there is currently great interest among researchers in exploring the immuno- logic mechanisms that could contribute to the development of cancer. These are discussed in Chapter 6. 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 sys- tem. Studies have shown that patients with congestive heart failures and with essential hypertension76 are particularly prone to exacerbation of their condition in response to threatened or actual loss of human rela . . tlOnS. Alps. In a study of 170 sudden and rapid deaths during psychologic stress, Engel2i found that 39 percent of the women and ~ ~ percent of the men died immediately following the death of someone close and another 23 percent of women and 20 percent of men died within 16 days of such a death. Although Engel did not have access to clinical data for all the people in his sample, he suggests (based on what he did have and on the literature) that most of these sudden deaths were due to cardiac arrest in

Epidemiologic Perspectives / 33 individuals with preexisting cardiovascular disease. As Parkes and WeissS7 conclude: It certainly seems unlikely that bereavement causes arteriosclerosis since that condi- tion takes many years to develop, but it seems very likely that a person who already has arteriosclerosis affecting his or her heart is at special risk after bereavement. The added burden of bereavement on that heart may be sufficient lo produce a myocardial infarction and to reduce the person's chances of surviving an infarction should one occur. Beyond case reports there are two additional sources of data regarding specific morbidity following bereavement that lend credence to the hy- pothesized association. Several of the studies discussed in the section on mortality examined specific causes of death. For example, Helsing et al.30 found that widowed women who died had a higher percentage of deaths from cirrhosis of the liver than would have been expected. In men there were increased death rates from infectious diseases, acci- dents, and suicides, but no increase from cardiovascular disease. Kraus and Lilienfeld39 found for the young widowed who had not remarried greatly increased mortality rates for several kinds of cardiovascular and infectious diseases. 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 consulta- tions 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 pre- sumably morbidity, in the recently bereaved may be mediated by behav- ioral changes that compromise health maintenance or chronic disease management. Increased alcohol consumption and cigarette smoking, common behavioral changes in the bereaved, may exacerbate or precipi- tate illness. Excess mortality, especially among bereaved men, is ex- plained in large part by deaths from suicide, cirrhosis, and cardiac ar- rest. All three conditions have clinical antecedents {depression, alcoholism, and cardiovascular disease) that could be detected before or very shortly after bereavement, thus identifying three high-risk groups for whom early intervention might be useful. Health Care Utilization. Use of health services can be an indicator of medical morbidity or a measure of the burden, including costs, of be- reavement on the health care delivery system. The second is straightfor- ward. As a proxy for actual medical disease, however, the use of health services, especially physician visits, is imperfect; it is well established in the health services research literature that a substantial proportion of

34 / Bereavement: Reactions, Consequences, and Care visits are precipitated by psychosocial concerns and nonorganic symp- toms rather than by diagnosable illness. Given that bereavement often results in significant distress, depres- sion-like symptoms, and increased use of drugs, and is sometimes asso- ciated with increased morbidity and mortality, significant increases in the use of health services would be expected. Yet most studies con- ducted in the United States show no increase in physician visits or hos- pitalization 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. study of elderly widows in a prepaid health plank do show an increase in physician visits for some people following bereavement. This discrepancy suggests that payment method may have a powerful effect on people's decisions to visit a phy- sician, with fee-for-service systems inhibiting health care utilization. Possible Consequences Beyond the First Year The form that grief takes, its outward expressions, and the length of the recovery process all are influenced by the social and cultural context within which bereavement occurs (see Chapter A. Although most stud- ies report a decrease in the reported distress and other manifestations of grieving by the end of the first year, persistent experiences of distress are frequently observed. Many people who are grieving report "it is always with you." The significance of these reactions is not clear. True delayed grief in the sense of physiologic disruptions, social withdrawal, and persistent sadness and yearning that emerge only after a period of absent grief-is so rare that little research has been conducted on it. Yet, distor- tions of personality and alterations in the quality of social functioning that are related to the distress associated with memories of the dead per- son have been observed by many clinicians, particularly for patients in psychotherapy. A number of observers have proposed that failure to cope adequately during the usual bereavement period predisposes a person to later psy- chiatric and medical problems. Although there are no systematic data available to support or refute this hypothesis, its proponents put forth two alternative explanations of the process. The first predicts that later health problems are a consequence of the duration and intensity of dis- tress the more prolonged and intense the distress, the greater the bur- den on an individual's adaptive capacity.

Epidemiologic Perspectives / 35 In contrast, many psychiatric and mental health professionals believe that the grieving process is adaptive and that "failure to grieve" or an interruption of the grieving process leaves an individual vulnerable to later illness. This hypothesis is usually attributed to Erich L~ndemann In his writings on the survivors of the Coconut Grove Disaster42 and is a view held widely in mental health circles. Mental health professionals generally encourage emotional expression during the bereavement pro- cess. 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. i9 These issues are discussed further in Chapters 3, 5, and 10. As discussed earlier in this chapter there is some evidence suggesting that mortality rates remain high for certain categories of bereft individ- uals beyond the first year-perhaps into the sixth year after their loss. There is also some indication of an increase in medical illnesses in the second and third years following bereavement, but adequate studies have not been performed to verify this hypothesis. RISK FACTORS Many factors relating to characteristics of the bereaved individual, the nature of the relationship to the deceased, the nature of the death, and the early reactions to bereavement have been hypothesized as plac- ing individuals at risk for one or more adverse outcomes or as protecting individuals from them. These variables are listed in Table 2, with an indication of the chapters in which they are discussed in detail. Because research in this area has not been systematic, few definitive conclusions can be offered. Characteristics of Bereaved] Individina~s Some studies have reported that men do more poorly than women fol- lowing conjugal bereavement.25 56 60 72 Other studies4 l2 67 have not. If premature death is the outcome studied, certainly men do worse; if re- marriage is the outcome, men do better. The physical and psychologic outcomes are unclear because most prospective studies have not had large enough samples of men to draw any conclusions about their rela- tive risk of illness. It is generally held that bereavement reactions are more intense and have more enduring consequences for younger people, particularly for children but also for adolescents and young adults. Older individuals

36 / Bereavement: Reactions, Consequences, and Care TAstE 2 Report's Discussion of Variables Associated With Health Outcomes of Bereavement Chaptera 3. 4. 5. 8. 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 ap- pearing early in the grieving process Consumption of alco- hol, 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. appear to experience fewer, less mtense consequences, perhaps because experiencing the death of someone close, family, or friends is common over the age of 60. Another possibility is that older individuals already have passed through the period of highest risk for psychiatric problems, such as alcoholism, depression, and anxiety disorders. It seems clear that poor prior physical or mental health is a risk factor. Those who are physically ill before a bereavement are more likely to be ill after it too, with more physician visits and perhaps even with greater risk of death in the first year.76 Those with a previous psychiatric disor- der or with a history of misuse of drugs will be at risk psychiatrically.

Epidemiologic Perspectives / 37 Most researchers and clinicians in this field would hypothesize that personality variables probably affect outcome; unfortunately only one study has examined this systematically. Vachon and her colleagues73 used Cattel's 16 Personality Factor Questionnaire7 to test whether spe- cific aspects of personality were related to level of distress and adjust- ment to bereavement. They found that widows with enduring high dis- tress scores were characterized as emotionally less stable, more apprehensive and worrying, and highly anxious. Widows with low dis- tress scores were more likely to be emotionally stable, mature, consci- entious, moralistic, conservative, controlled, and socially precise. These and other assessments were done both six months and two years after the bereavement. Ideally, these personality variables should be tested before the terminal illness or when a spouse first becomes ill, as distress itself could confound the personality inventories. In addition to the previously mentioned high suicide rate among alco- holics shortly after bereavement, alcoholics are more likely than nonal- coholics to be doing poorly one year following bereavement. When psy- chiatric hospitalization occurs, the diagnosis is likely to be alcohol- ism 49 64 The association between socioeconomic status and bereavement out- comes has not been adequately studied. Whether individuals with low incomes do any worse following bereavement than the more well-to-do is not known. A frequent concomitant of bereavement, however, espe- cially for widows, is financial difficulty brought on by the loss of the major wage earner and perhaps by large medical bills as well. Recent work by Vachon et al.73 has shown that poor outcome in middle-aged widows was associated with financial problems. ReJa~on ship to the Deceased Each kinship relationship has particular difficulties associated with it following bereavement isee Chapter 4~. In addition to kinship, the na- ture of the relationship with the deceased has been hypothesized to in- fluence outcomes. The literature on conjugal bereavement is replete with data indicating that individuals who had highly ambivalent rela- tionships with their spouses do worse following bereavement than peo- ple whose relationships did not have these characteristics {see Chapters 3 and 4~. There also is evidence to suggest that spouses who are unable to function independently do poorly following bereavement,S7 although there is some controversy about the meaning and predictive value of this variable.

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. Clayton et al.~5 defined it as an illness of five days or shorter duration. Parked classified survivors as having "short" preparation if they had less than two weeks' warning that a spouse's condition was likely to prove fatal, or less than three days' warning that death was imminent. Gerber et al.25 defined "acute illness death" as one occurring without warning and prior knowledge of the condition, or a death after a medical condition of less than two months' duration with the absence of multiple attacks and hospitalization. Contrary to commonly held views, most of the research literature in- dicates that sudden death, however defined, does not produce more dis- turbed survivors. In Parkes' data55 the young widowed who experienced a sudden death had a poorer outcome, as did widows in the study by Vachon et al.73 However, studies by Clayton et ads and by Fulton and Gottesman24 did not find this to be true. In a study by Gerber et al.23 of older men and women, there was a negative correlation between length of illness and outcome; that is, the longer the terminal illness, the more likely there was to be a poor outcome for the surviving spouse. The time course of the loss is a risk factor that deserves further atten- tion. Common wisdom holds that time to say goodbye and to express love will facilitate grieving by lessening later feelings of anger and guilt. However, it may be that the moment of death is always a surprise no matter how much warning there has been. Perhaps a very lengthy termi- nal illness produces its own stresses and strains that complicate be- reavement. Perhaps suddenness of death interacts with age of the de- ceased or age of the survivors in ways that have not yet been uncovered. As discussed in Chapter 10, suddenness of death may have important implications for the design of strategies to assist the bereaved. A number of studies have been undertaken of suicide's impact on family members and other survivors. Given the high rate of assortative mating {i.e., people with similar characteristics tending to marry each other; depressed people are particularly likely to marry other depressed people), the impact of death by suicide is likely to be associated with a propensity for psychiatric illness in the spouse, particularly for alcohol- ism and depression. In general, as discussed in Chapters 4 and 5, death by suicide renders survivors vulnerable to increased psychologic dis- tress and, especially in the case of children, may leave them vulnerable to suicide as well.

Epidemiologic Perspectives / 39 Risk Factors Appearing After the Death All bereavement studies report that among people already using alco- hol, drugs, or cigarettes, consumption of these substances increased af- ter a death. Some people, however, begin using these substances follow- ing bereavement. Even without a chronic dependency developing, increased use of these substances might lead to deterioration in health and well-being. Certain individual symptoms during the early bereave- ment period may also predict poor outcome. These include suicidal thoughts {particularly after the first month), psychomotor retardation, and morbid guilt. 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 sup- port 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. Different risk factors are likely to be involved in different outcomes; until these conceptual and methodological problems are resolved, risk factor studies and predictive studies will be seriously handicapped. CONCLUSIONS AND RECOMMENDATIONS Research to date has demonstrated some important effects of bereave- ment on health and has generated a number of intriguing findings that deserve further study. · Following bereavement there is a statistically significant increase in mortality for men under the age of 75. Although especially pro- nounced in the first year, the mortality rate continues to be elevated for perhaps as Tong as six years for men who do not remarry. There is no higher mortality in women in the first year; whether there is an increase in the second year is unclear. · There is an increase in suicide in the first year of bereavement, par- ticularly by older widowers and by single men who lose their mothers. There may be a slight increase in suicide by widows. · Among widowers, there is an increase in the relative risk of death from accidents, cardiovascular disease, and some infectious diseases. In widows, the relative risk of death from cirrhosis rises.

40 / Bereavement: Reactions, Consequences, and Care · All studies document increases in alcohol consumption and smok- ing and greater use of tranquilizers or hypnotic medication {or both) among the bereaved. For the most part, these increases occur in people who already are using these substances; however, some of the increase is attributable to new users. · Depressive symptoms are very common in the first months of be- reavement. Between 10 and 20 percent of men and women who lose a spouse are still depressed a year later. · Although these observations suggest several types of associations between bereavement and specific diseases including exacerbation of existing cardiovascular disease, vulnerability to certain infectious dis- eases, precipitation of depression leading to suicide, and health-damag- ing behavioral changes the epidemiologic evidence linking bereave- ment to specific diseases is sparse. Few well-controlled studies have been conducted. · Although some studies have shown an increase in self-reported physical symptoms and perceived deterioration in health status, other studies have not. It appears that it is only in prepaid health care delivery systems that utilization of services increases in the year following be- reavement. · Risk factors for poor outcome include poor previous physical and mental health, alcoholism and substance abuse, and the perceived lack of social supports. It is unclear whether sudden death or lingering illness produces more disturbing outcomes. · Perceived adequacy of social support and remarriage protect the be- reaved from adverse outcomes. Some promising areas require further investigation. Systematic re- search is needed on the consequences of bereavement following loss of parents, children, and siblings for people of all ages. To date, most epi- demiologic research has focused on conjugal bereavement. As part of a comprehensive program of bereavement research, system- atic epidemiologic studies should be conducted of the period of anticipa- tion prior to the death of someone close. Advances of medical science lead increasing numbers of individuals with chronic illnesses, particu- larly cardiovascular disease, cancer, Alzheimer's disease, and other cen- tral nervous system diseases, to experience long periods of illness and disability prior to their death. The epidemiologic hypothesis would be that anticipation of disruption of the attachment bond is a source of in- tense emotional distress that places family members and others at risk for adverse health consequences during-this period. Clinicians, clergy, and others are familiar with the emotional distress and strain that chronic illness places on family members, but the committee could find

Epidemiologic Perspectives / 41 no systematic epidemiologic study that attempted to document the fre- quency of this or the increased risk for some adverse consequences. During the intense distress following a death, further phenomenolo- gic studies are indicated to identify people who do not manifest emo- tional symptoms. Health care professionals, and increasingly the edu- cated public, commonly believe that the failure to manifest distress is "abnormal" and will have adverse consequences. The available re- search evidence does not allow support or refutation of this hypothesis, which needs to be tested before intervention strategies can be recom- mended for such individuals. More research is needed on the relationship between bereavement and disease in order to understand the extent to which bereavement is a specific or nonspecific stressor and to understand its role in precipitat- ing, predisposing to, or exacerbating disease. A fundamental research problem has to do with the definition of outcomes. There is no agree- ment on the criteria for adequate recovery. Pending development of such criteria from empirical studies, it is difficult to identify and mea- sure risk factors that should be paid attention to in preventive interven- tions. REFERENCES 1. American Psychiatric Association. Diagnostic and Statistical Manual {Third Edi- tion}. Washington, D.C.: APA, 1980. 2. Bock, E.W., and Webber, J.L. Suicide among the elderly: isolating widowhood and Gang alternatives. Journal of Marnage and the Family 34:24-31, 1972. 3. Bomstein, P.E., Clayton, P.J., Halikas, J.A., Maurice, W.L., and Robins, E. The depression of widowhood after thirteen months. British Journal of Psychiatry 122:561-566, 1973. 4. Bowling, A., and Cartright, A. Life After Death: A Study of the Elderly Widowed. London: Tavistock, 1982. 5. Broadhead, W.E., Kaplan, B.H., Tames, S.A., Wagner, E.H., Schoenback, V.~., Grimson, R., Heyden, S., Tibbl~n, G., and GehIback, S.H. The epidemiologic evi- dence for a relationship between social support and health. American Journal of Epidemiology 1 17:521-537, 1983. 6. Bunch, I., Barraclough, B., Nelson, B., and Sainsbury, P. Suicide following death of parents. Social Psychiatry 6: 193-199, 1971. 7. Cattell, R.B., Eber, H.W., end Tasuoka, M.M. Handbook for the 16PersonalityFac- tor Questionnaire. Champaign, Ill: Institute for Personality and Ability Testing, 1970. 8. Chambers, W.N., and Reiser, M.F. Emotional stress in the precipitation of conges- tive heart failure. Psychosomatic Medicine 15:38-60, 1953. 9. Clayton, Pa. Mortality and morbidity in the first year of widowhood. Archives of General Psychiatry 125: 747-750, 1974. 10. Clayton, P.~. The sequelae and nonsequelae of conjugal bereavement. American Journal of Psychiatry 136: 1530-1543, 1979.

42 / Bereavement: Reactions, Consequences, and Care 11. Clayton, P.T. Bereavement. In: Handbook of Affective Disorders {Paykel, E.S., ed.J. London: Churchill Livingstone, 1982. 12. Clayton, Pa., and Darvish, I.S. Course of depressive symptoms following the stress of bereavement. In: Stress and Mental Disorder {Barrett, I.E., ed. ~ . New York: Raven Press, 1979. 13. Clayton, P.~., Halikas, I.A., and Maurice, W.L. The depression of widowhood. Brit- ish [oumal of Psychiatry 120:71-78, 1972. 14. Clayton, P.J., Herjanic, M., Murphy, G.E., and Woodruff, R.A. Mourning and de- pression: their similarities and differences. Canadian Psychiatric Association four- nal 19:309-312, 1974. 15. Clayton, P.J., Parilla, R.H., Jr., and Bieri, M.D. Methodological problems in assess- ing the relationship between acuteness of death and the bereavement outcome. In: Psychosocial Aspects of Cardiovascular Disease: The Life-Threatened Patient, The Family, and The Staff {Reiffel, l., DeBellis, R., Mark, L., Kutscher, A., Patterson, P., and Schoenberg, B., eds.~. New York: Columbia University Press, 1980. 16. Cleveland, W.P., and Gianturco, D.T. Remarriage probability after widowhood: a retrospective method. [outlay of Gerontology 31:99-102, 1976. 17. Cox, P.R., and Ford, J.R. The mortality of widows shortly after widowhood. Lancer 1:163-164, 1964. 18. Crisp, A.H., and Priest, R.G. Psychoneurotic status during the year following be- reavement. journal of Psychosomatic Research 16:351-355, 1972. 19. Editorial. Is Grief an Illness? Lancer 2:134, 1976. 20 Engel, G. Is grief a disease? Psychosomatic Medicine 23:18-23, 1961. 21. Engel, G. Sudden and rapid death during psychological stress. Annals of Internal Medicine 74:771-782,1971. 22. Freud, S. Mouming and Melancholia {1917~. The Standard Edition of He Complete Psychological Works of Sigmund Freud, Vol. 14 (Strachey, T., ed. J. London: Hogarth Press and Institute for Psychoanalysis, 1957. 23. Frost, N.R., and Clayton, Pa. Bereavement and psychiatric hospitalization. Ar- chives of General Psychiatry 34:1172-1175, 1977. 24. Fulton, R., and Gottesman, D.J. Anticipatory grief: a psychosocial concept recon- sidered. British [oumal of Psychiatry 137:45-54, 1980. 25. Gerber, I., Rusalem, R. Hannon, N., BattiIl, D., and Arkin, A. Anticipatory grief and aged widows and widowers. [oumal of Gerontology30:225-229, 1975. 26. Grant, I., Kyle, G.C., Teichman, A., and Mendels, T. Recent life events and diabetes In adults. Psychosomatic Medicine 37: 121-128, 1974. 27. Greene, W.A. Psychological factors and reticuloendothelial disease. Psychosomatic Medicine 16:220-230, 1954. 28. Greene, W.A. Disease response to life stress. [oumal of the Amencan Medical Women 's Association 20:133-140, 1965. 29. Greene, W.A., Young, L.E., and Swisher, S.N. Psychological factors and reticuloen- dothelial disease. Psychosomatic Medicine 18:284-303, 1956. 30. Helsing, Kit., Comstock, G.W., and Szklo, M. Causes of death in a widowed popu- lation. Amencan Journal of Epidemiology 116:524-532, 1982. Helsing, K.J., and Szklo, M. Mortality after bereavement. Amencan Journal of Epi- demiology 114:41-52, 1981. 32. Helsing, K.J., Szklo, M., and Comstock, G.W. Factors associated with mortality after widowhood. Amencan [oumal of Public Health 71:802-809, 1981. 33. Heyman, D.K., and Gianturco, D.T. Long-term adaptation by the elderly to be- reavement. [ordeal of Gerontology 28:359-362, 1973.

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"The book is well organized, well detailed, and well referenced; it is an invaluable sourcebook for researchers and clinicians working in the area of bereavement. For those with limited knowledge about bereavement, this volume provides an excellent introduction to the field and should be of use to students as well as to professionals," states Contemporary Psychology. The Lancet comments that this book "makes good and compelling reading....It was mandated to address three questions: what is known about the health consequences of bereavement; what further research would be important and promising; and whether there are preventive interventions that should either be widely adopted or further tested to evaluate their efficacy. The writers have fulfilled this mandate well."

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