Elsevier

The Lancet

Volume 370, Issue 9603, 8–14 December 2007, Pages 1960-1973
The Lancet

Review
Health outcomes of bereavement

https://doi.org/10.1016/S0140-6736(07)61816-9Get rights and content

Summary

In this Review, we look at the relation between bereavement and physical and mental health. Although grief is not a disease and most people adjust without professional psychological intervention, bereavement is associated with excess risk of mortality, particularly in the early weeks and months after loss. It is related to decrements in physical health, indicated by presence of symptoms and illnesses, and use of medical services. Furthermore, bereaved individuals report diverse psychological reactions. For a few people, mental disorders or complications in the grieving process ensue. We summarise research on risk factors that increase vulnerability of some bereaved individuals. Diverse factors (circumstances of death, intrapersonal and interpersonal variables, ways of coping) are likely to co-determine excesses in ill-health. We also assess the effectiveness of psychological intervention programmes. Intervention should be targeted at high-risk people and those with complicated grief or bereavement-related depression and stress disorders.

Introduction

Research on stressful life-events has progressed during the past three decades, from study of the cumulative effect of life-events (measured with scales such as the social readjustment rating scale [SRRS])8 to a focus on specific life-events, such as bereavement. Death of a spouse ranks as the life-event needing the most intense readjustment on the SRRS, confirming the status of bereavement as a highly stressful event. Much research has been undertaken on bereavement, defined as the situation of having recently lost a significant person through death.3 Although comparatively rare in childhood, bereavement is a life-event that, sooner or later, becomes part of nearly everyone's experience. Of children younger than 18 years, 3·4% have experienced the death of a parent,9 whereas in elderly populations, spousal bereavement is most frequent, with about 45% of women and 15% of men older than 65 years becoming widowed.10 As such, bereavement can be viewed as a normal, natural human experience, one which most people manage to come to terms with over the course of time. Nevertheless, it is associated with a period of intense suffering for most individuals, with an increased risk of developing mental and physical health problems. Adjustment can take months or even years and is subject to substantial variation between individuals and across cultures. For a few people, mental and physical ill-health is extreme and persistent. For this reason, bereavement is a concern not only for preventive care but also for clinical practice.

Grief is defined as the mainly emotional reaction to bereavement, incorporating diverse psychological and physical reactions.3 Over the past few decades, scientific study of the symptoms, mental and physical health outcomes, and ways of coping with grief has expanded rapidly.3, 11 This research seeks to develop ways to identify and provide preventive care for individuals at risk for bereavement-related health problems. The current state of knowledge with respect to the consequences of bereavement and care of bereaved people is the focus of this Review. We review scientific published work on the mental and physical health outcomes of bereavement. We address two basic questions. What psychological and physical effects does loss of a loved person have on survivors? Is the risk of succumbing to health disorders greater in bereaved than non-bereaved counterparts? We try to establish prevalence of health outcomes, identifying subgroups that are especially vulnerable. Furthermore, we review studies on the effectiveness of psychological intervention programmes in reducing the risk of negative health issues in bereaved individuals, asking a third question: Can counsellors and therapists help to reduce the health problems of bereaved people?

Section snippets

Overall patterns

For several decades, researchers have examined whether the death of a loved one increases the mortality risk of the bereaved person—understood popularly as dying of a broken heart. The most valid and reliable information is provided in longitudinal investigations comparing bereaved with non-bereaved counterparts, controlling for several confounders12 such as socioeconomic and lifestyle factors the bereaved spouse would have shared with their deceased partner, which could affect the bereaved

General patterns

Some investigators have reported a greater occurrence of physical health complaints in bereaved people (compared with matched controls), ranging from physical symptoms (eg, headaches, dizziness, indigestion, and chest pain) to high rates of disability and illness, greater use of medical services (in some studies), and drug use.1, 35 Many surveys have been undertaken cross-sectionally, thus researchers have not identified recently bereaved people. Most studies have been done with bereaved

Psychological symptoms

Bereavement is also associated with various psychological symptoms and illnesses;1, 35 panel 1 provides an overview of common reactions.1, 7 Neimeyer and Hogan have reviewed grief assessment methods.43 Psychological reactions are, generally speaking, most intense in early bereavement.35, 44 Studies of individual psychological reactions to bereavement, such as those listed in panel 1, have been undertaken by many researchers, including investigation of suicidal ideation,34, 44, 45, 46, 47, 48

Additional medical implications

Bereavement can have an even broader range of consequences than those already discussed. Bereavement has been shown to be associated with impaired memory performance,103 nutritional problems,104 work and relationship difficulties and difficulties concentrating; and decreases in social participation.105, 106 And health-care costs for bereaved individuals have been shown to be higher.11 These health effects are likely to be associated with changes in different underlying physiological mechanisms.

Risk factors

Much research effort has been directed at identification of risk factors to understand why people are affected by bereavement in different ways; why some people have extreme or lasting outcomes and others do not.110 Bereavement researchers use the term risk factor to signify the situational and intrapersonal and interpersonal characteristics associated with increased vulnerability to the range of bereavement outcomes.110, 111 Some researchers have integrated into their analyses protective

Intervention efficacy

Since bereavement increases the risk of negative health outcomes for some individuals, research needs to establish whether intervention is to be recommended and whether intervention is actually effective. The focus here is on psychological and not medical or pharmacological intervention: we restrict the discussion to effectiveness studies of psychosocial and psychological counselling and therapy programmes (to our knowledge, very little research exists on the effectiveness of pharmacological

Final comments

We have recorded negative health issues across various mental and physical outcomes and for some different types of bereavement, finding quite consistent patterns in research from various (mostly the USA, Europe, and Australia) countries. At the same time, we have noted that grief is a normal natural process after bereavement. Most reactions are not complicated and for most bereaved people, family and friends, religious and community groups, and various societal resources will provide the

Search strategy and selection criteria

We searched PubMed, Medline, and PsycINFO with the terms “bereavement” and “grief” for reports published after 1997. When selecting reports for inclusion, we gave priority to: recent studies; those meeting quality criteria (sample size, response rate, use of standardised measurements, analytical techniques, etc); those that included a control group of non-bereaved individuals (where appropriate); prospective studies (before or after a death); and longitudinal studies. We also referred to

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