Bereavement Can Set Stage for Several Mental Illnesses

Losing a loved one unexpectedly can be emotionally devastating and increase the risk for development of a mental disorder, a new study has found.

Katherine Keyes, Ph.D.

The study, published May 16 in AJP in Advance, was led by Katherine Keyes, Ph.D., an assistant professor of epidemiology at Columbia University, and Katherine Shear, M.D., a professor of psychiatry at Columbia.

The researchers used data from approximately 28,000 subjects who had been interviewed as part of the National Epidemiologic Survey on Alcohol and Related Conditions in 2004 and 2005. Their goal was to determine whether there was a relationship between experiencing the unexpected death of a loved one and developing for the first time a DSM-IV anxiety, mood, or alcohol disorder. The anxiety disorders included generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobia, and posttraumatic stress disorder (PTSD). The mood disorders included dysthymia, a major depressive episode, and a manic episode. The alcohol disorders included either alcohol abuse or dependence.

Fifty percent of the subjects reported having experienced the unexpected death of at least one loved one. The researchers then divided these subjects into five-year intervals depending on when this unexpected death occurred, investigating whether the subjects developed a first episode of one or more of the mental disorders of interest within the five-year interval in which the unexpected death occurred.

Unexpected death was associated with increased odds of each mood and alcohol use disorder examined in at least one age group, with significant associations tending to cluster in older age groups. For example, subjects who had unexpectedly lost a loved one for the first time between ages 65 and 69 were three times more likely to develop an alcohol use disorder, five times more likely to develop a manic episode, and 11 times more likely to develop a major depression in that time interval than were subjects who had not unexpectedly lost a loved one in that interval or before.

Increased odds of major depressive episodes were observed in 12 of 14 age groups, dysthymia in six age groups, manic episodes in five age groups, and alcohol use disorders in the six age groups occurring after age 45.

When anxiety disorders were assessed, the researchers found that the risks of disorder onset were heightened in all 14 age groups for PTSD, 12 age groups for panic disorder, seven age groups for generalized anxiety disorder (all after age 40), five age groups for specific phobia (all after age 40), and two age groups for social phobia.

The odds ratios of developing PTSD in the wake of an unexpected death of a loved one were especially striking, with PTSD about three to four times as likely in subjects aged 50 and older than in subjects in their teens or 20s.

“Several of the findings were unexpected,” Keyes said. “I would have predicted that experience of unexpected death at young age would have the most profound effect on mental health, but we saw that experiences all along the life course were associated with increased risk for first incidence of a psychiatric disorder, across a broad range of disorders. Our findings for manic episodes are also noteworthy. While there have been a fair share of clinical reports, dating back almost a century, of manic episodes and mania during bereavement, these effects have never been empirically demonstrated in the general population of non-treatment-seeking individuals.”

“We think the important message for psychiatrists is really a reinforcement that close personal relationships are among our most important and central experiences,” Keyes continued. “The loss of such a relationship is uniquely stressful and profoundly troubling among all stressful life experiences, given the centrality of relationships for our sense of self. The period of bereavement after the loss of a relationship is a vulnerable period for the onset of psychiatric disorders all along the life course. The experience of loss and bereavement should be included in assessments of patients and considered carefully in the etiology of illness.”

Commenting on the study, Sidney Zisook, M.D. a professor of psychiatry at the University of California, San Diego, and a bereavement expert, called it “clinically impactful and timely.”

“For too many years,” he said, “studies on loss, grief, and bereavement have been sparse, and these important clinical issues have not received due diligence in the academic or clinical communities. . . . In my experience, bereavement often is overlooked and not even explored in many diagnostic interviews.”

Zisook added that the findings underscore “the importance of recognizing that bereavement is an important stressor that may put an individual in harm’s way after the death of a loved one. Rather than automatically negating the diagnosis of major depression (or other mental disorders) in the aftermath of bereavement, as the now-defunct ‘bereavement exclusion’ did for all but the most severe episodes, it behooves clinicians to recognize the potential for a new-onset disorder or a worsening of a preexisting condition.”

Also, he noted, “This is the first empirical study I am aware of that has demonstrated stress-related manic episodes in older individuals with no histories of prior mood disorders. Very few clinicians are aware of this possibility and therefore are at risk of missing the diagnosis and/or its etiology in their practice.”

The results raise crucial questions, Zisook pointed out. For example, are people who lose loved ones following chronic medical illnesses just as vulnerable to mental illnesses as are people who lose loved ones unexpectedly? And how about individuals who experience nonbereavement-related unanticipated losses—say, losing their possessions in a house fire, or losing their bodily function in a crippling injury? It is hoped that further research will provide answers to such questions and help clinicians optimally treat patients who have experienced loss, he concluded.

The study was funded by the National Institutes of Health. ■