We find that the widowhood effect is not monolithic. The extent to which widowhood increases the mortality of a surviving spouse depends on the cause of death of their pre-decedent spouse. Moreover, surviving partners are at risk of some causes of death more than of others after the death of their spouse. This variation in the widowhood effect according to causes of death of both spouses provides some analytic leverage to better understand the nature and mechanism of the widowhood effect. Since over 13 million Americans are widowed,(34
) and since the excess risk of mortality imposed by widowhood is non-trivial, this phenomenon is of substantial public health significance.
Our work advances prior work in this area in a number of ways. Existing research often considers only a small number of causes of death, such as the broad categories of cancer or violent deaths,(15
) uses samples with relatively small numbers of cases for each individual cause of death, uses samples that are not nationally representative,(4
) uses a cross sectional methodology,(12
) or lacks statistical controls for confounding beyond age, sex, and race.(12
) By contrast, this study considers 17 causes of death separately for both spouses in a longitudinal and nationally representative sample of 373,189 married couples experiencing a total of 317,300 deaths while adjusting for a wide range of covariates, including baseline health, that are measured for both members of the couple.
Our results suggest several observations regarding the effect of widowhood on partners’ cause-specific mortality. First, in contrast to several,(4
) but not all,(12
) previous studies, we find a statistically significant effect of widowhood on cancer mortality for elderly men and women. The effect is particularly large for deaths from colon and lung cancer. It is much smaller (and statistically insignificant for female partners) for certain rarer cancers that typically and predictably lead to death quickly (cancer of the head and neck, upper gastrointestinal tract, liver, central nervous system, pancreas, or melanoma, lymphoma, or leukemia), and it is small but still significant for all other cancers. Second, in agreement with most,(12
) though not all,(4
) previous studies, we find a clear, positive, and statistically significant association between widowhood and partners’ mortality from vascular diseases for men and women. The effect is moderately strong, and it is approximately the same (no statistically significant difference) for all four categories of cardiovascular disease (ischemic heart disease, congestive heart failure, CVA/stroke, and other heart/vascular disease). Third, the broad effect of widowhood on the different types of cardiovascular disease, cancer, and other causes of death suggests that widowhood triggers a broad set of biopsychosocial mechanisms that affect mortality, and that the effect is not limited to one aspect of human biology. Widowhood appears to have particularly strong effects on death from causes that are either acute health events (infections/sepsis, accidents) or chronic diseases that require careful patient management to treat or prevent (diabetes, COPD, colon cancer). This points to the role of the loss of social support and social integration in widowhood as a possible origin for the widowhood effect.(40
Many of the same observations also apply to the differences in surviving partners’ all-cause mortality as a function of the specific cause of death of the pre-decedent spouse. The lack of increased all-cause mortality following spouses’ death from Alzheimer’s/Parkinson’s disease confirms a similar finding from a British study which attributed the lack of a widowhood effect to anticipatory grief, i.e. the ability of caregivers to prepare adequately for the predictable death of their spouse.(36
) The theory of anticipatory grief is also consistent with our finding of similarly small (albeit statistically significant) widowhood effects in the wake of spouse’s death from cancers that typically lead to death quickly. This suggests that it may be the predictability of the death per se
, rather than the duration of spouse’s terminal illness, that may shield the survivor from some of the adverse consequences of bereavement. The lack of a widowhood effect following spouse’s death from Alzheimer’s or Parkinson’s disease, however, is also consistent with an alternative explanation that patients suffering from these diseases may simply cease to contribute to their partner’s health long before they die, or that the health consequences of caring for a person with Alzheimer’s has already been absorbed by the end of the sick spouse’s life, such that there is no measurable discontinuity in the survivor’s mortality at the actual time of spousal death.(41
) Lastly, we note that the differences in male partners’ all-cause mortality across their pre-decedent wives’ illnesses or causes of death appear to be somewhat larger, in relative terms, than the differences observed for female partners. This may indicate that for women it mostly matters that their husband has died, whereas for men it additionally matters what their wife has died of.
Our analysis has several limitations. Despite adjusting for a more extensive set of potentially confounding variables than most prior research, including baseline health, there may be some residual confounding in the data that may explain certain features of the reported findings. Specifically, we note that the large effects of widowhood on mortality from COPD and lung cancer in male and female partners may be owed in part to shared behaviors, such as smoking,(1
) and the large effect on death by accidents/fractures may be owed to incidents involving both spouses.(6
) On the other hand, the analysis treats same-day deaths as non-widowed deaths, and if confounding were driving all cause-specific results, we would expect that contagious diseases more generally would be associated with large effects, which is the case for infections/sepsis but not for influenza/pneumonia. Second, causes of death are derived from decedents’ diagnostic history rather than official death certificates. This leads to an unavoidable underascertainment of causes that lead to death suddenly or without prior detection.
The results of this longitudinal study of 373,189 elderly American couples show that the effect of widowhood on mortality varies substantially by the causes of death of both spouses. These results were found for male and female partners, even after adjusting for a wide range of potentially confounding factors, including the baseline health of both spouses. Widowhood increases survivors’ risk of dying from almost all causes, including cancer, but it increases the risk for some causes more than for others. The converse also holds: widowhood increases survivors’ all-cause mortality due to almost all causes of death of the pre-decedent spouse, but the actual cause of death of the pre-decent spouse makes a difference. The death of a spouse, for whatever reason, is a significant threat to health and poses a substantial risk of death by whatever cause.