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Articles   |    
The Burden of Loss: Unexpected Death of a Loved One and Psychiatric Disorders Across the Life Course in a National Study
Katherine M. Keyes, Ph.D.; Charissa Pratt, M.P.H.; Sandro Galea, M.D., Dr.P.H.; Katie A. McLaughlin, Ph.D.; Karestan C. Koenen, Ph.D.; M. Katherine Shear, M.D.
Am J Psychiatry 2014;171:864-871. doi:10.1176/appi.ajp.2014.13081132
View Author and Article Information

Dr. Shear received a contract from Guilford Press to write a complicated grief treatment manual. The other authors report no financial relationships with commercial interests.

This study was supported by NIMH grants MH-092526 to Dr. McLaughlin, MH-093612 and MH-078928 to Dr. Koenen, and MH-60783 and MH-70741 to Dr. Shear and by grant AA-021511 to Dr. Keyes from the National Institute on Alcohol Abuse and Alcoholism.

From the Department of Epidemiology and the School of Social Work, Columbia University, New York; and the Division of General Pediatrics, Department of Psychiatry, Boston Children’s Hospital, Harvard Medical School, Boston.

Address correspondence to Dr. Keyes (kmk2104@columbia.edu).

Copyright © 2014 by the American Psychiatric Association

Received August 25, 2013; Revised December 10, 2013; February 13, 2014; Accepted February 27, 2014.

Abstract

Objective  Unexpected death of a loved one is common and associated with subsequent elevations in symptoms of multiple forms of psychopathology. Determining whether this experience predicts novel onset of psychiatric disorders and whether these associations vary across the life course has important clinical implications. The authors examined associations of a loved one’s unexpected death with first onset of common anxiety, mood, and substance use disorders in a population-based sample.

Method  The relation between unexpected death of a loved one and first onset of lifetime DSM-IV disorders was estimated by using a structured interview of adults in the U.S. general population (analytic sample size=27,534). Models controlled for prior occurrence of any disorder, other traumatic experiences, and demographic variables.

Results  Unexpected death of a loved one was the most common traumatic experience and most likely to be rated as the respondent’s worst, regardless of other traumatic experiences. Increased incidence after unexpected death was observed at nearly every point across the life course for major depressive episode, panic disorder, and posttraumatic stress disorder. Increased incidence was clustered in later adult age groups for manic episode, phobias, alcohol use disorders, and generalized anxiety disorder.

Conclusions  The bereavement period is associated with elevated risk for the onset of multiple psychiatric disorders, consistently across the life course and coincident with the experience of the loved one’s death. Novel associations between unexpected death and onset of several disorders, including mania, confirm multiple case reports and results of small studies and suggest an important emerging area for clinical research and practice.

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TABLE 1.Proportion of a U.S. Population Sample Reporting the Unexpected Death of a Loved One as the Worst Lifetime Potentially Traumatic Experience
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TABLE 2.Association Between Age at First Unexpected Death of a Loved One and Onset of Mood or Alcohol Use Disorder in a U.S. Population Sample (N=27,534)a
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a There were 294 missing responses for age at first unexpected death.

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b Each regression model included a different denominator, as each model assessed the association between age at unexpected death and onset of the focal psychiatric disorder among respondents with no onset at a prior age.

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c Models were controlled for sex, age, race/ethnicity, income, education, marital status, number of lifetime potentially traumatic experiences, and onset of a psychiatric disorder prior to the focal disorder.

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d Group size was not sufficient to estimate a robust association.

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TABLE 3.Association Between Age at First Unexpected Death of a Loved One and Onset of Anxiety Disorders in a U.S. Population Sample (N=27,534)a
Table Footer Note

a There were 294 missing responses for age at first unexpected death.

Table Footer Note

b Each regression model included a different denominator, as each model assessed the association between age at unexpected death and onset of the focal psychiatric disorder among respondents with no onset at a prior age.

Table Footer Note

c Models were controlled for sex, age, race/ethnicity, income, education, marital status, number of lifetime potentially traumatic experiences, and onset of a psychiatric disorder prior to the focal disorder.

Table Footer Note

d Group size was not sufficient to estimate a robust association.

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TABLE 4.Association Between Number of Unexpected Deaths of Loved Ones and Number of Episodes of Psychiatric Disorders in a U.S. Population Sample (N=27,534)a
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a There were 119 missing responses for number of unexpected deaths.

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b There were 13,680 individuals who experienced no unexpected deaths and formed the reference group.

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c From Poisson regression. Models controlled for age, sex, race/ethnicity, marital status, income, education, number of lifetime potentially traumatic experiences, and each psychiatric disorder that was not the focal psychiatric disorder of the model.

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1.
Approximately what proportion of individuals in the U.S. experience unexpected death of a loved one during the course of their lifetime?
2.
Out of the 14 age groups examined, how many experience an increased risk for PTSD following the unexpected death of a loved one?
3.
What is the approximate increase in the incidence of psychiatric disorder episodes among those who experience four or more unexpected deaths of loved ones compared with those who do not experience an unexpected death?
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