Trajectories of depression following spousal and child bereavement: A comparison of the heterogeneity in outcomes
Introduction
In recent years there has been a transformation in our understanding of how people respond to the loss of close loved ones. Emerging longitudinal studies have highlighted the significant heterogeneity in bereavement outcomes: Some people experience ongoing, disabling levels of distress, some people experience symptoms that gradually decline, and others experience little or no disruption in functioning (e.g., Bonanno et al., 2004, Bonanno et al., 2002, Galatzer-Levy and Bonanno, 2012, Mancini et al., 2011, Thomas et al., 2013). Latent growth mixture modelling (LGMM) has emerged as a particularly strong methodology to explore such population heterogeneity. LGMM tests whether the population under investigation is best represented by a single response trajectory or is composed of several discrete populations each characterized by a different growth curve (Curran and Hussong, 2003). LGMM has been used to investigate heterogeneity in a wide variety of potentially stressful life events, including injury, cancer, combat, and bereavement (Bonanno et al., 2012, Bryant et al., 2015, Burton et al., 2014, Galatzer-Levy and Bonanno, 2012, Karstoft et al., 2013, Pietrzak et al., 2014).
In the context of bereavement, Bonanno and colleagues (Boerner et al., 2005, Bonanno et al., 2004, Bonanno et al., 2002) identified trajectories of depression following spousal loss in a prospective sample of participants drawn from the changing Lives of Older Couples (CLOC) study, who were followed up to 48 months post-bereavement. LGMM analysis identified a robust model solution characterized by four distinct trajectories (Galatzer-Levy and Bonanno, 2012): Participants who reported little or no depression at any time point (Resilience; 66.3%); participants who reported a high level of depression at all points (Pre-existing Chronic; 14.5%); participants who reported high levels of depression at the pre-bereavement assessment followed by lower levels of post-bereavement depression (Improved; 10.1%); and participants who reported low pre-bereavement levels of depression followed by high post-bereavement levels (Chronic grief; 9.1%; see also Lotterman et al., 2014). Underscoring the utility of identifying distinct trajectories, financial stress was associated with elevated depression for all classes, whereas poor health was associated with higher depression in the resilient and remitting classes only. That is, financial stress appeared to be a general stressor, whereas, health impacted depression only in populations that were otherwise doing well. Age did not predict response trajectories for any class.
To date, our understanding of the distinct trajectories of bereavement comes largely from studies examining spousal bereavement (e.g., Galatzer-Levy and Bonanno, 2012, Holland et al., 2014, Utz et al., 2012). The extent to which these trajectories are present following other bereavements has yet to be investigated. It is possible that the number, shape, and predictors of response trajectories may vary across loss type, indicating that bereavement response differs by loss type. This may be the case as studies have suggested that individuals who experience the death of a child are more likely to show chronically high levels of distress (Dyregrov et al., 2003, Meert et al., 2011). However this research has relied on samples of individuals who have self-selected for participation in bereavement studies and most involve the loss of young children (e.g., Arnold et al., 2005, Bonanno et al., 2005, Dyregrov et al., 2003, Meert et al., 2011). The extent to which such findings are representative of the population of individuals who have experienced the death of a child is unknown (Levav et al., 1988). Moreover, existing studies have typically relied on retrospective self-report or longitudinal assessments lacking pre-loss assessments, which may also introduce bias associated with self-report of past emotional functioning (Watkins, 2002). True prospective studies are important, however, not only for overcoming memory biases, but also for identifying the full set of population trajectories. In the CLOC study, more than half of participants with high levels of post-bereavement depression were in fact depressed prior to their spouse's death. However, not all individuals who were depressed prior to the death remained depressed (Galatzer-Levy and Bonanno, 2012). Thus, while existing investigations of the impact of child loss have been helpful in highlighting potential differences between child and spousal loss, there is a critical need for the issue to be examined using a prospective design in a sample of individuals not self-selected for bereavement.
We addressed this issue in the current study using data from the Health and Retirement Study, a large nationally representative longitudinal survey that collects data from individuals on an array of family, health, and economic variables every 2 years. Of particular value for addressing questions relating to bereavement, loss information has been recorded but individuals have not been included on the basis of their losses, thus minimizing the possible impact of selection biases. The database also allows for ongoing assessment of pre- and post-loss functioning. It has previously been used to map the heterogeneity of responses to such events as cancer and chronic pain (Burton et al., 2014, Zhu et al., 2014). Accordingly, in the current study, we applied LGMM to the HRS to identify prospective trajectories of depression following spousal and child bereavement. We expected that the trajectories associated with spousal bereavement would be similar to those identified in Galatzer-Levy and Bonanno (2012; see also Bonanno et al., 2004). We hypothesized that we would observe a large class of resilient individuals and three smaller classes comprising pre-existing chronic depression, chronic grief, and improved depression. In the case of child bereavement, we expected that similar trajectories would be identified; however, based on existing literature we anticipated that the proportion of individuals classified into the chronic grief trajectory would be greater (Dyregrov et al., 2003, Meert et al., 2011). As the HRS comprises mainly older respondents, and the majority of the children in the sample were adults at the time of their death, we included age of the deceased among the potential predictors of trajectory membership.
Section snippets
Data
Data were taken from the Health and Retirement Study (HRS), a nationally representative longitudinal study designed to explore numerous aspects of aging in American adults. The study commenced in 1992 and collected data every 2 years. Data for the current analysis were drawn from 9 waves (1994–2010) from the RAND HRS vM and RAND family database. Data from Wave 1 (1992) were excluded as that wave used an alternate measure of depression. (For details of the survey and sampling methods see Sonnega
Unconditional model
Table 2 presents the information indices and likelihood tests for the one to five class models. These indices showed improved fit as the number of classes increased, with the exception of a negligible reduction in entropy and a non-significant result for Lo-Mendell test for the five-class model. This indicated that the five-class model failed to fit the data better than the four-class model. Overall consideration of the indices suggested that the four-class model provided a better fit than
Discussion
In this study we used a large population-based sample and a prospective design to examine trajectories of depression following spousal and child bereavement in later life. While a number of population-based studies have examined depression trajectories in the context of spousal loss (Galatzer-Levy and Bonanno, 2012) this is the first study to use a population-based prospective design to explore trajectories following spousal and child loss. In doing so, this study enables direct comparison of
Role of the funding source
Funding bodies had no involvement in any aspect of this study.
Author contributions
F. Maccallum, I. R. Galatzer-Levy and G. A. Bonanno designed the study and wrote the manuscript. F Maccallum analyzed the data. All authors have approved the final manuscript.
Declaration of conflicting interests
Conflicts of interest: none.
Acknowledgments
Fiona Maccallum is supported by a National Health and Medical Research Council Early Career Research Fellowship (NHMRC GNT1053997). I R Galatzer-Levy is supported by an NIMH grant K01MH102415. G. A. Bonanno is the recipient of an NIMH grant R01MH091034.
References (46)
- et al.
Exploring parental grief: combining quantitative and qualitative measures
Arch. Psychiatr. Nurs.
(2005) - et al.
Human grief: is its intensity related to the reproductive value of the deceased?
Ethnol. Sociobiol.
(1989) - et al.
Adaptive and maladaptive dependency in bereavement: distinguishing prolonged and resolved grief trajectories
Personal. Individ. Differ.
(2011) - et al.
Beyond normality in the study of bereavement: heterogeneity in depression outcomes following loss in older adults
Soc. Sci. Med.
(2012) - et al.
Trauma and bereavement: examining the impact of sudden and violent deaths
J. Anxiety Disord.
(2003) - et al.
The heterogeneity of long-term grief reactions
J. Affect. Disord.
(2014) - et al.
Health outcomes of bereavement
Lancet
(2007) - et al.
Heterogeneous depression responses to chronic pain onset among middle-aged adults: a prospective study
Psychiatry Res.
(2014) - et al.
A cognitive-behavioral conceptualization of complicated grief
Clin. Psychol. Sci. Pract.
(2006) - et al.
Resilient or at risk? A 4-Year study of older adults who initially showed high or low distress following conjugal loss
J. Gerontol. Ser. B Psychol. Sci. Soc. Sci.
(2005)
Trajectories of resilience, depression, and anxiety following spinal cord injury
Rehabil. Psychol.
Prospective patterns of resilience and maladjustment during widowhood
Psychol. Aging
Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events?
Am. Psychol.
Toward an integrative perspective on bereavement
Psychol. Bull.
Resilience to loss in bereaved spouses, bereaved parents, and bereaved gay men
J. Personal. Soc. Psychol.
Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss
J. Personal. Soc. Psychol.
Trajectory of post-traumatic stress following traumatic injury: 6-year follow-up
Br. J. Psychiatry
Treatment type and demographic characteristics as predictors for cancer adjustment: prospective trajectories of depressive symptoms in a population sample
Health Psychol.
Family check up effects on adolescent arrest trajectories: variation by developmental subtype
J. Res. Adolesc.
The use of latent trajectory models in psychopathology
J. Abnorm. Psychol.
Predictors of psychosocial distress after suicide, SIDS and accidents
Death Stud.
The impact of nonnormality on full information maximum likelihood estimation for structural equation models with missing data
Psychol. Methods
Optimism and death: predicting the course and consequences of depression trajectories in response to heart attack
Psychol. Sci.
Cited by (65)
Trajectories of insomnia following bereavement
2024, Sleep MedicineThe death of an adult child and trajectories of parental depressive symptoms: A gender-based longitudinal analysis
2024, Social Science and MedicinePredictors of prolonged grief in an internet-based grief therapy for people bereaved by suicide
2022, Journal of Psychiatric ResearchCitation Excerpt :Furthermore, analyses did not differ between different kinships to the deceased, which might be due to the low number of participants. As trajectories of depression between child and spousal bereavement have been compared in previous studies (Maccallum et al., 2015), further research on grief trajectories for different kinships is needed. Moreover, variables were investigated in an exploratory manner.
Machine yearning: How advances in computational methods lead to new insights about reactions to loss
2022, Current Opinion in PsychologyDepressive-Symptom Trajectories From End-of-Life Caregiving Through the First 2 Bereavement Years for Family Caregivers of Advanced Cancer Patients
2021, Journal of Pain and Symptom ManagementCitation Excerpt :However, we identified two uncommon trajectories, and the commonly identified trajectories’ prevalences were not totally consistent with the literature in our caregiving-to-bereavement longitudinal study. These two uncommon trajectories (i.e., preloss-grief only and delayed symptomatic) were not observed in studies of bereaved caregivers25,26 or prospective cohort studies of bereavement30−32 with preloss data. The preloss-grief-only trajectory was characterized by slight-to-moderate depressive symptoms only during EOL caregiving, subsiding quickly to near threshold 1-month postloss.