Bereaved offspring are at increased risk for adverse outcome in part due to factors that antedate and may have contributed to their parents’ early deaths. This was particularly marked in the suicidal death group compared with the control group, with the former showing much higher rates of bipolar disorder. However, accidental deaths were also more likely to have psychiatric disorders compared with controls, specifically alcohol/substance abuse and personality disorder. We also demonstrate that the loss of a parent conveys an increased risk for new-onset depression and PTSD in their children, even after controlling for antecedent and concomitant risk factors. Finally, we demonstrate that, despite greater loading for antecedent risk factors, bereavement due to suicide does not convey an increased risk for adverse outcome 9 months after the death, compared with other types of sudden death.
Psychiatric disorder in the parent is clearly an antecedent to early parental death. The disorders most closely associated with premature parental death were bipolar disorder, alcohol and substance abuse, and personality disorder. High rates of bipolar disorder are expected in suicide victims, but the accidental and sudden natural death groups also showed a trend toward higher rates of bipolar disorder than the control group. While the association between bipolar disorder and suicide is well known, there are also reports that patients with bipolar disorder have a greater number of cardiovascular risk factors, including smoking and obesity, and an increased risk of pulmonary embolism.18,20–23
Thus, the previously reported association between parental bereavement and bipolar disorder in offspring may be explained in part by a higher rate of bipolar disorder in parents who die prematurely.4,6,8,10
In addition, psychological autopsy studies of traffic accidents show an overrepresentation of substance abuse disorders and personality styles that are termed impulsive and sensation seeking.19,24
These findings highlight the importance of reducing health risk behaviors in individuals with these complex and challenging disorders and providing integrated medical and psychiatric management for these individuals.
Moreover, offspring who lose a parent due to suicide, accident, or sudden natural death are at increased risk for adverse outcomes, not only due to higher incidence of psychiatric disorders among probands but also because of higher rates of disorder in the coparent and the offspring themselves. These findings may be explained by assortative mating, and by the familial transmission of parental disorder to offspring.
Loss of a parent due to sudden death conveys an increased risk of depression and PTSD in bereaved offspring, above and beyond increased antecedent risk. Higher caregiver functioning was protective against depression, which was similar to the results of a previous study by Sandler et al.9
Caregivers had higher rates of disorder before the death and increased risk of depression and PTSD after the death, which in turn affected offspring’s outcome. Other factors that affected outcome included the nature of the last conversation with the deceased. A recollection of a supportive conversation with the deceased was associated with a higher risk of depression, which is consistent with other studies finding that the closer the relationship to the deceased, the higher the risk of depression.60
Understanding the mechanisms through which bereavement conveys its effects is essential to identify those at highest risk who should be the target of future prevention and intervention efforts.
At the initial assessment, suicide-bereaved offspring had the greater loading for predeath risk factors. However, their outcome was similar to those of other bereaved youth. This supports a view that, in the short term, there are more similarities than differences among offspring whose parents die of suicide and those who lose a parent to accidental or sudden natural death. Further follow-up is indicated to determine whether these groups begin to diverge over time.
This study has several strengths and limitations. To our knowledge, it is the first controlled, population-based study of the effect of sudden parental death on offspring and has the largest sample of suicide-bereaved offspring. However, it is very difficult to determine whether this sample is representative or not because coroners’ records do not routinely list surviving offspring, and because natural deaths usually are not the province of the coroner. However, our sample of suicides and accidents was demographically similar to Allegheny County overall, and our response rate was 71%, which is relatively high for these types of studies. Although it is possible that there were referral biases, because disturbed families more worried about their children might have been more likely to participate, bereaved families recruited by advertisement showed lower rates of some proband disorders, which would argue against such a referral bias. Our profile of the deceased parents is similar to those obtained in previous psychological autopsy studies, which makes it more likely that our results are not simply the result of sampling bias.19,61
A second limitation is the use of an informant rather than self-report in the case of the deceased probands. However, the psychological autopsy procedure is a specific and fairly sensitive method for determining psychiatric disorder,34
and if anything, is likely to underestimate the rate of disorder, thus biasing the results more toward the null hypothesis.36
Our findings have important clinical and public health implications. The best way to attenuate the effect of parental bereavement among offspring is to prevent early death in their parents by improving the detection and treatment of bipolar illness, substance and alcohol abuse, and personality disorders, and by addressing the lifestyle correlates of these illnesses that lead to premature death. The caregiver should be monitored for depression and PTSD, because restoration of functioning is a positive prognosticator for offspring. Given the increased risk of depression and PTSD, bereaved offspring should be monitored and, if needed, referred and treated for their psychiatric disorder. Further studies are needed to examine the course and long-term effect of bereavement on offspring and their surviving caregivers, to test the mechanisms by which parental bereavement exerts these effects, and to identify the subset of bereaved families who may require treatment, which can then frame targets for intervention and prevention efforts.