THE MOURNING AFTER: An analysis of the effect of bereavement on mental health McCann M, Maguire A , Moriarty J Institute of Child Care Research, Queen’s University Belfast Institute of Child Care Research
INTRODUCTION • Bereavement is a significant life event which most people will be exposed to in their lifetime • Involves major life transition and can have negative implications for health and well-being • The Grief Study aims to investigate how factors such as age, gender, family environment, employment and religion affect how people cope after bereavement. • The study will also look at how people become bereaved - for example, after illness, sudden death or after suicide - to see if how people react and the factors that help people cope differ depending on how they lost their loved ones. • This presentation focuses on some preliminary findings
RESEARCH QUESTIONS 1. Does bereavement lead to an increased risk of poor mental health – as measured by use of hypnotic, anxiolytic and antidepressant medication? 2. Does the likelihood of poor mental health following bereavement vary according to the cause of death? 3. To what extent do individual, household, and area characteristics mitigate or compound the risk of poor mental health following bereavement? 4. Does the ‘risk profile’, in terms of the magnitude of risk conferred by individual, household and area characteristics, differ between those bereaved following an expected death, sudden death, violent death or suicide. 5. To what extent does bereavement confer an increased risk of mortality, particularly when accompanied by poor mental health?
METHOD Figure 1: Description of Datasets used in linkage to create Grief Study Dataset Data merged to create dataset of NILS members characteristics and that of their other Northern Ireland house members from 2001 Census NISRA and BSO NISRA Data Longitudinal Study (NILS) returns data Merged on • Census data for NILS HCN and all Census data and vital events data for personal members and members of c.28% NI pop. identifiers their household Contains: Census ID, Household ID, HCN removed Grief Study • Deaths of NILS members Grief Study and members of their Dataset Dataset Northern Ireland Mortality household • 2001 Census data for • 2001 Census data for • HCN number of NILS Study (NIMS) Deaths of NILS NILS members and NILS members and members only* members and Census data for 100% NI pop. linked to members of their members of their their household mortality data household household members • Info on relationship of Contains: Census ID, Household ID • Info on relationship of captured NILS member to others NILS member to others in their household in their household • Deaths 2001-2011 of • Deaths 2001-2009 of NILS members and NILS members and Enhanced Prescribing members of their members of their BSO Data household household Database (EPD) Prescription Drug data for • Psychotropic drug • Psychotropic drug Prescription Drug data for 100% NI pop. 100% NI pop. and HCN* Information on all uptake NILS members uptake NILS members Contains: HCN antidepressant, 2009-2011 2009-2013 anxiolytic and hypnotic medication prescribed in NI from 2009-2013
ANALYTICAL STRATEGY 1. Characteristics of study cohort and descriptive analysis of the bereaved 2. Construct Cox Regression models to determine risk of death post bereavement 3. Construct Cox Regression models to determine risk of poor mental health (as measured by antidepressant drug uptake) post bereavement 4. Investigate long-term effects of bereavement by constructing logistic regression looking at risk of poor mental health in January 2009 given bereavement experiences from 2001-2008
RESULTS Table 1: Descriptive Characteristics of the Cohort of 346,850 NI residents Category % n Gender Male 48.8 169,269 Female 51.2 177,581 Age 16-24 years 18.5 64,138 25-64 years 62.1 215,342 (in 2009) 65 years+ 19.4 67,370 Marital Status Never Married 38.7 134,050 Married 51.1 177,191 Co-habiting 3.8 13,262 Separated/Divorced 3.9 13,380 Widowed 2.6 8,967 Religion Protestant 53.9 187,069 Catholic 43.8 151,955 Other 2.3 7,826 General Health Good 71.7 245,064 Fair 19.3 66,893 Not good 10.0 34,893 Limiting Long Term Illness LLTI 19.0 65,821 Area of residence Rural 28.4 98,352 Intermediate 33.2 155,049 Urban 38.5 133,449 Bereavement Status Not Bereaved 92.2 319,936 Bereaved 7.8 26,914 Not Bereaved 92.2 319,936 Bereavement Type Bereaved by illness 7.3 25,248 Bereaved sudden 0.3 972 Bereaved by suicide 0.2 694
RESULTS Table 2: Breakdown of Bereavement Type by Age Group, % of population Age Group 16-24 years 25-64 years 65 years+ (n=64,138) (n=215,342) (n=67,370) Bereavement Status Bereaved 4.2 6.0 16.7 Bereaved of whom Spouse Died 0.0 19.4 79.1 Parent Died 57.1 52.6 3.9 Child Died 0.0 4.5 3.1 Other bereavement 42.9 23.5 13.9 Bereavement Type Not Bereaved 95.5 93.9 80.1 Bereaved by illness 3.6 5.7 19.6 Bereaved sudden 0.4 0.3 0.3 Bereaved by suicide 0.3 0.2 0.1
RESULTS Table 3: Cox Proportional Hazards model calculating risk of death following a bereavement by bereavement type. RR (95% CI) Model 1 Model 2 Model 3 Model 4 Bereaved Illness 1.00 1.00 1.00 1.00 Bereaved sudden 1.23 (0.94,1.62) 1.22 (0.92,1.60) 1.22 (0.93,1.61) 1.34 (1.02,1.76) Bereaved Suicide 1.64 (1.15,2.34) 1.63 (1.14,2.33) 1.61 (1.13,2.31) 1.70 (1.19,2.43) Model 1: unadjusted Model 2: further adjusted for age and sex Model 3: further adjusted for marital status Model 4: further adjusted for Antidepressant Medication
RESULTS Table 4: Logistic Regression calculating likelihood of antidepressant treatment given bereavement status. OR (95% CI) Bereaved 2001-2008 Model 1 Model 2 Model 3 Model 4 Non-bereaved 1.00 1.00 1.00 1.00 Bereaved illness 1.34 (1.27,1.41) 1.22 (1.15,1.29) 1.28 (1.21,1.35) 1.24 (1.18,1.32) Bereaved Sudden 1.67 (1.32,2.12) 1.71 (1.35,2.17) 1.69 (1.31, 2.13) 1.67 (1.30,2.14) Bereaved Suicide 2.02 (1.55,2.62) 2.15 (1.65,2.81) 1.97 (1.50,2.58) 1.89 (1.43,2.50) Model 5 Model 6 Model 7 Age 16-24yrs Age 25-64yrs Age 65yrs+ Non-bereaved 1.00 1.00 1.00 Bereaved illness 1.49 (1.01,2.21) 1.16 (1.07,1.26) 1.30 (1.19,1.42) Bereaved Sudden 2.27 (0.91,5.45) 1.52 (1.14,2.03) 1.72 (1.00,2.97) Bereaved Suicide 2.08 (0.76,5.65) 1.73 (1.27,2.37) 1.64 (0.78,3.47) Model 1: unadjusted Model 2: further adjusted for age and sex Model 3: further adjusted for marital status and economic activity Model 4: further adjusted for level of deprivation Model 5: based on DAG adjusted for illness, living arrangement and deprivation Model 6: based on DAG adjusted for age, gender, illness, living arrangement, religion, education, carer status and deprivation Model 7: based on DAG adjusted for age, gender, illness, living arrangement, religion, carer status and deprivation
RESULTS Figure 2: Graph showing risk of Antidepressant Rx after a bereavement by bereavement type OR(95% CI) - Unadjusted 4 3.5 Likelihood of receiving AD Rx in Jan 2009 3 2.5 2 1.5 1 REF CAT 0.5 0 Spouse ill Spouse Spouse Parent ill Parent Parent Child ill Child Child Other ill Other Other Sudden Suicide Sudden Suicide Sudden Suicide Sudden Suicide Who died how
RESULTS Figure 3: Graph showing risk of Antidepressant Rx after a bereavement by bereavement type OR(95% CI) – Fully Adjusted 3 2.5 Likelihood of receiving AD Rx in Jan 2009 2 1.5 1 REF CAT 0.5 0 Spouse ill Spouse Spouse Parent ill Parent Parent Child ill Child Child Other ill Other Other Sudden Suicide Sudden Suicide Sudden Suicide Sudden Suicide Who died how
CONCLUSIONS • Being bereaved increases your risk of dying, especially if bereaved by suicide • Ever having been bereaved increases risk of poor mental health, especially if bereaved by suicide • Effect seems most significant in 25-64years • Relationship to bereaved affects risk of poor mental health with worst outcomes observed in those bereaved of a child by suicide
THE GRIEF STUDY • Preliminary analysis shows that reactions to grief are complicated and vary depending on type of bereavement and relationship to bereaved • The Grief Study will continue to tease apart these associations • Main future questions relating to which other factors best predict mental health outcome post bereavement • Also focus on prescription uptake post bereavement and time to prescriptions in relation to the bereavement exclusion criteria and the notion of medicalising sadness It is important to identify the people who are in greatest need after bereavement, so that professionals, family and friends can make sure to offer the care and support that they need.
Questions?
Acknowledgements “ The help provided by the staff of the Northern Ireland Longitudinal Study/Northern Ireland Mortality Study (NILS/NIMS)and the NILS Research Support Unit is acknowledged. The NILS/NIMS is funded by the Health and Social Care Research and Development Division of the Public Health Agency (HSC R&D Division) and NISRA. The NILS-RSU is funded by the ESRC and the Northern Ireland Government. The authors alone are responsible for the interpretation of the data and any views or opinions presented are solely those of the author and do not necessarily represent those of NISRA/NILS .”
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