Bereavement Associated With Early Mortality Risk

Bereavement Associated With Early Mortality Risk

Pauline Anderson



December 21, 2007 — A new review of the literature shows that bereavement is associated with an increase in mortality risk, particularly in the first weeks or months following a loss.A “broken heart,” or the psychological stress following the loss of a loved one, along with related losses such as changes to living arrangements and economics, may increase the risk for death in the person who is mourning, the authors, led by Margaret Stroebe, MD, from the Research Institute for Psychology and Health at Utrecht University, in the Netherlands, conclude.

Further, people who have been bereaved are more likely to have physical health problems, with higher rates of disability, medication use, and hospitalization, compared with nonbereaved people, they note. However, in most cases, professional counseling does not improve outcomes for people who are grieving the loss of a loved one, but rather, most cases of uncomplicated grief will resolve without intervention, the authors conclude.

Their report is published in the December 8 issue of the Lancet.

Absolute Risk is Low

For the review, the investigators analyzed reports on bereavement published after 1997, mostly from the United States, Europe, and Australia.

Bereavement, the situation of having lost someone significant through death, according to Dr. Stroebe, is a normal life event, and most people recover emotionally and physically over the long term. “For most people, the experience, though difficult, is tolerable and abates with time. For some, however, the suffering is intense and prolonged,” the authors write.

Several studies in Europe and North America have examined excess mortality in relation to bereavement, they note. One, for example, found a 3.3-fold increase in risk for suicide in men over 60 years of age who lost their wife, but no such increase in women of the same age who lost their husband.

Another report in 2006 showed that widowers had a 21% increased risk for all-cause mortality and widows a 17% increased risk. Risks were further increased in the first 30 days after bereavement. For parents losing children, a Danish study published in 2003 showed fathers and mothers have an increased risk for suicide after the death of a child, a risk that is higher with younger children and particularly high in the first 30 days after bereavement.

“The patterns are quite consistent, enabling the conclusion that the mortality of bereavement is attributable in large part to a so-called broken heart,” the authors write. However, they note, “Although mortality is a drastic outcome of losing a loved one, it must be assessed in terms of the absolute number of bereaved people who die. Baseline rates are low, with, for instance, about 5% of widowers vs 3% of married men in the 55-years-and-older category dying in the first 6 months of bereavement.”

Grief Distinct From Depression

The study noted that grief, defined by Dr. Stroebe as the primarily emotional reaction to the loss of a loved one through death, is a normal but complex reaction to loss, incorporating diverse psychological and physical manifestations. For most people, family, friends, religious and community groups, and various societal resources provide the necessary support. “Professional psychological intervention is generally neither justified nor effective for uncomplicated forms of grief,” the authors wrote.

The authors made a distinction between grief and depression. “Growing evidence suggests that depression and grief might represent distinct, though related, clusters of reactions to bereavement,” they write.

But many studies report an increase in psychiatric symptoms among the bereaved. For a few people, depression reaches clinical importance; findings of some studies suggest that 25% to 45% have mild levels of depressive symptoms and 10% to 20% show clinical levels. Bereaved people can also develop posttraumatic stress disorder (PTSD), especially following a particularly horrific death. One study found that among bereaved parents 5 years after the death of their child, 27.7% of mothers and 12.5% of fathers met diagnostic criteria for PTSD.

Complicated grief — grief that might be considered pathological due to its high intensity, long duration, or dominant symptoms, according to Dr. Stroebe, is not classified as a category of mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV).

Whether it should be included is an important issue facing bereavement researchers today, she said in an email comment to Medscape Psychiatry. She noted that there are good arguments for inclusion; for example, it would enable those who most need professional help to get it. But there are also arguments against inclusion, a main one being the fear that grief will become unnecessarily “medicalized.”

Links to Increased Physical Illness

The study authors also cite research showing that bereavement is linked to impaired memory, nutritional problems, work and relationship difficulties, concentration problems, and decreases in social participation. It is also associated with increased risks for physical illness. “For example, research has been done looking at how bereavement affects the immune system; leads to changes in the endocrine, autonomic nervous, and cardiovascular systems; and helps to account for increased vulnerability to external agents,” the authors write.

However, many potential risk factors have been underresearched, they said. Research is only now beginning to look at the importance of certain personality traits, such as resilience. “Findings of available studies support the view that robust individuals adjust to bereavement better than people who are fragile,” the authors write, adding that further research is needed on other predisposing vulnerabilities such as previous mental-health disorders and substance abuse.

Working Through Grief May Not Help

The researchers also looked at the role of support groups but raise questions about whether “grief work” is necessary. In recent decades, they write, “researchers have been critical of the generally accepted notion that so-called grief work (confronting the reality of loss and relinquishing the bond to the deceased individual) is essential for overcoming bereavement. Empirical research has shown that people who do not work through their grief frequently recover as well as, if not better than, those who do so.”

They note that to their knowledge very little research exists on the effectiveness of pharmacological and medical interventions for bereaved people.

Dr. Stroebe is currently at work on a new handbook of bereavement research. One of the areas she will touch on in her new book, she said, are remarkable developments in the examination of brain systems, including the use of functional magnetic resonance imaging of the brain, to investigate the neural circuits associated with emotion-motivation systems. Emerging research looks at neural mechanisms underlying the state of romantic rejection to see whether there are possible implications for the psychobiology of bereavement.

Lancet. 2007;370:1960-1973. Abstract




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