In this longitudinal study, there were enduring effects of parental bereavement on the offspring, with higher rates of depression and alcohol or substance abuse, greater functional impairment, and higher self-reported anxiety nearly 2 years after the loss. Bereavement by accident and by suicide were associated with higher risks of depression than seen in nonbereaved comparison subjects; suicide-related bereavement was also associated with alcohol or substance abuse, and accident-related bereavement was also related to higher symptom levels. The direct effect of bereavement on incident depression and PTSD was limited to the first 9 months after the loss, except in the offspring of parents who died by suicide, who continued to have a higher incidence of depression than offspring whose parents had sudden natural deaths. During the second year of follow-up, the effect of bereavement on depression was mediated by the occurrence of new-onset depression during the first 9 months postbereavement. Within the bereaved group, depression at 21-month follow-up was predicted by parental suicide, loss of a mother, postbereavement depression, complicated grief, negative coping, low self-esteem, and blaming others for the death.
These results should be considered within the context of the strengths and limitations of this study. This is one of the largest population-based longitudinal studies of the impact of parental bereavement on children, and it is one of the few to examine the specific effects on offspring of parental death by suicide. Despite the study’s relative size, contrasts among the different causes of death can detect only relatively large effects. Also, the study group is mostly Caucasian and does not include parental homicide, thereby limiting the generalizability of these findings.
Nearly 2 years after the death, bereaved youth showed higher rates of depression and alcohol or substance abuse than comparison subjects, higher self-rated anxiety, and greater functional impairment. The main effect of bereavement on both incident depression and PTSD occurred shortly after the death, as has been reported in other studies of adolescent bereavement (12
). However, bereavement had an indirect effect on depression during the second year of follow-up, by increasing the risk of incident depression within 9 months of the loss, which increased the likelihood of depression during the next year. This pathway is attributable in part to the persistence and recurrence of these incident episodes of depression occurring shortly after the loss in the bereaved group.
Prior history of depression was related to depressive outcome at 21-month follow-up through two pathways. First, a history of depression was associated with an increased risk of negative life events, which then increased the risk of subsequent depression. Second, a history of depression was related to anxiety at 9 months, which was associated with incident depression during the first 9 months; depression in the first 9 months increased the risk of incident depression between 9 and 21 months. While a prior history of depression predicted depression at 21 months among the bereaved, it was an even stronger predictor of subsequent depression in the nonbereaved comparison subjects, which contrasts with findings in some other studies of adolescent bereavement (12
As hypothesized, offspring of parents who died by suicide showed higher rates of current and incident depression from 9 to 21 months after the death, in relation to the comparison subjects and the offspring of parents who died by sudden natural death, respectively. Offspring of the suicide group also showed a higher rate of alcohol or substance abuse. However, all deleterious effects of bereavement were not attributable to suicide. Offspring of parents who died through accidents also showed higher rates of depression than comparison subjects at 21 months, had the highest scores on self-reported anxiety and complicated grief, and were more functionally impaired. Other studies have shown either no difference between youth whose parents died by suicide and those whose parents died of other causes (35
) or more behavioral or anxiety symptoms, but not depression (36
The pathways and predictors of depression in this study group suggest that there may be a window of opportunity shortly after a parent’s death in which to prevent or attenuate further depressive episodes in bereaved youth. This is because the effect of bereavement on depression 21 months after the death is mediated by the occurrence of depression in the 9 months after the death. Previous intervention studies have not found a critical period during which the intervention is more effective, but these studies did not have data about prior course for participants enrolled longer after the death (37
). However, our previous (4
) and current findings are convergent with the prevention studies of Sandler and colleagues, who have identified the critical roles of coping, self-esteem, negative life events, family cohesion, and social support in mediating long-term outcome for parentally bereaved youth (37
Within the bereaved group, we found that the loss of a mother was more deleterious than the loss of a father. Although this finding did not survive multivariate analyses, it is consistent with other reports (38
). Bereaved youth who had high levels of complicated grief and those who blamed others for the death were at particularly high risk for depression at the 21-month follow-up. This finding is consistent with studies in adults showing prolonged time to recovery from depression in those with complicated grief, and it provides additional support for the existence of complicated grief in children and adolescents (14
). Interventions that target complicated grief and the placement of blame for the death on others may be useful in managing symptomatic and impaired parentally bereaved youth.
In conclusion, we have shown that there are enduring effects of parental bereavement, especially with regard to the occurrence of depression during the second year of follow-up. The offspring of parents who died by suicide showed the highest risk for subsequent depression. Since the effects of bereavement on depression in the second year were mediated by the increased risk of depression occurring shortly after the death, the best time to intervene to prevent further depression episodes may be shortly after the loss. Further follow-up of this cohort should help to address the validity and impact of complicated grief and whether individuals with a parent who dies by suicide do indeed suffer more long-term sequelae, compared to other bereaved youth.