The grief field is in need of research designs and conceptual frameworks that clarify potentially differential relations between specific characteristics of bereavement (e.g., circumstances of the death ), age-related reactions to the loss (e.g., coping , grief reactions ), and developmental trajectories across the lifespan (10, 16, 17), including risks for proximal and distal adverse outcomes (e.g., substance abuse, depression) (5). The Keyes et al. study contributes to such theory-building work by using a large population-based sample and focusing on a range of psychiatric outcomes across the life course. In discussing the study’s methodological limitations, the authors note the absence of data regarding death-related contextual factors (anticipation of death, relationship to the deceased) that may influence the etiology of pathology (18). As evidenced by studies of bereaved youth, different death-related circumstances may significantly differ in their potencies, work through different pathways of influence, and produce different sequelae (16, 17). For example, recent evidence suggests that, in children, the “anticipated” death of a caregiver (e.g., through cancer) may be more pathogenic (associated with higher levels of posttraumatic stress and maladaptive grief) than sudden death (e.g., from an accident or heart attack) (13). Similarly, the psychiatric sequelae of suicide-related deaths may differ from those following other forms of sudden death (19). The effects of bereavement may also vary as a function of one’s relationship to the person who died (5) and (as highlighted in the current study) the timing of the death (20).
Keyes et al. propose other potentially important mediators, including loss of social support and neurobiological stress responses (21, 22), while noting that the study design did not include a measure of grief—an intervening construct that may help explain the wide range of psychiatric outcomes reported. Multidimensional grief theory postulates that specific dimensions of maladaptive grief (including those described by Keyes et al., such as separation distress and disruptions in self-concept ) may differentially confer risk for various psychiatric disorders (6, 18). Future research that incorporates multidimensional measures of grief (23) and bereavement-related contextual factors (24) carries promise for explicating diverse ways in which bereavement, grief, and circumstances of the death may intersect and differentially contribute to psychiatric risk or resilience across the lifespan (8, 10, 17, 18). Our ability to develop effective interventions for bereaved children and adults in need of treatment rests largely on the success with which we unpack the essential features and roles of grief and the socioenvionmental factors that form the context of bereavement (3, 16–18).