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SSRIs and Suicidality Cause or Cure

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					 The Relief of Grief: The
Impact of Sudden Parent
    Loss on Children
        David A. Brent, M.D.

21st Annual STAR-Center Conference
             May 3, 2007
           Pittsburgh, PA

         Supported by MH65368
  No financial relationship with industry.
Impact of Sudden Parental Death
    on Children: Personnel
 Nadine Melhem, PhD – Co-Investigator
 Monica Walker, MA – Project Coordinator
 Grace Moritz, LSW
 David Rizzo, LSW
 Bertille Donohoe, MA
 Yuan Brustoloni, MAMS

 Grant # MH65368
               Objectives
• Review what is known about impact of
  parent loss on children
• Outline gaps in the field
• Describe IMPACT Study
  – What are 1-2 year effects of bereavement?
  – Is suicide bereavement different?
  – Pathways and predictors of outcome
  – Phenomenology of grief – What is
    “pathological?”
          Extent of Problem


• 4% of children will lose one parent by
  age 18
• Subjectively, rated one of the most
  stressful life events
• No long-term prospective, controlled
  studies of parent loss
              Retrospective Studies
• Adults with mental disorders have
  higher rates of parent loss
• Kendler – 12 year impact of parent loss
  on risk for depression
• Bias of retrospective studies –
  depressed people more likely to recall
  negative events

Kendler et al., 2002
       Record Linkage Studies

• Large standard population-based data
  sets
• Breadth rather than depth
• Suicide particularly deleterious, but also
  impact from maternal loss due to any
  source
• Outcome: suicide, psychiatric
  hospitalization
               Prospective Studies

• Sandler – 244 children, 53%
  internalizing, 45% externalizing
• Weller, 1991 – increased risk of
  depression
• Risky sexual behavior (Rotheram-
  Borus)
Sandler et al., 2003; Weller et al., 1991
Longer Term Impact of Bereavement
• Rutter – 5yr. Study- worse functional
  outcomes
• Kendler – the increased rate of depression
  – 12 years later
• Reinherz (1999) – 13-fold increased risk in
  females for depression if lost parent < 9
  years of age
 Rutter et al., 1983
 Kendler et al., 2006
 Reinherz et al., 1999
    Broader Range of Outcomes

• Developmental competency
• Health - retrospective studies tie family
  adversity to range of health outcomes
• Stress response - HPA and BP reactivity
  – Mediated by family environment and “threat
    appraisal”
           Theoretical Model of Impact of Parent
                 Loss on Child Outcome

                                               Mediating
         Pre-Death
                                               Variables
         Variables
Child                                      Child Resources
                                                                                   Outcomes
 Prior Psychopathology                     Coping, Threat
                                            Assessment                           Mental Health
 Trauma History            Parental
                                           Self-Esteem                      Depression, PTSD, Int/Ext
 Age                        Death
 Gender                                    Locus of Control                   Complicated Grief (CG)
Family                                     Family Resources                      Developmental
                                                                Mediation         Competence
 Proband and Caregiver                     Caregiver Function
   Psychopathology       Circumstances                                            Health-Related
                                            and Mental Health
 SES                          and                                           Stress Response (HPA, BP)
                                           Parenting
 Proband Relationship    Type of Death                                               BP, BMI,
                                           School Connection
   to Child                                Social Support                      Health Risk Behaviors
 Stress Genes                              Life Events



                              Moderation
        Predictors of Outcome

• Not loss, what happens afterwards
• Pre-death – parent and child psychiatric
  disorder
• Mediators
  – Child – coping, self-esteem, locus of control,
    threat appraisal, open expression
  – Family – caregiver function, positive parenting,
    social support, life events
• Gender – Moderates outcome?
Effect, Cause and Manner of Death

• Sudden vs. anticipated – very little
  evidence that there is a difference
  One study showed slower recovery
• Suicide vs. other – very little data. One
  small study (N=24) found no differential
  impact
• Pfeffer – suicide vs. cancer bereavement:
  Increased depression in suicide grief
Pfeffer et al., 2000
 Impact of Parent Loss Due to Suicide
     vs. Other Causes of Death

• Cerel (1999) – compared 26 children who lost a
  parent to suicide vs. 322 parentally bereaved
  children
   – Suicide group: less acceptance, more shame,
     anger and impairment
   – But not more depression, PTSD, suicidal
     behavior
• Cerel (2000) – suicide group had more impaired
  family functioning than others before the death,
  but after the death were similar (therefore, family
  function in suicide survivors improved).
    Suicide Bereavement Could Be
          Different Because:


• Family loading for disorder and suicidal
  behavior
• Stigma
• Pre-death family adversity
• Traumatic exposure
      Complicated Grief (CG)

• Impairment associated with grief experience:
  Rumination, yearning, sense of loss of
  purpose, anger/bitterness
• Is it a separate condition?
   – Yes: Predicts functional outcome (ideation,
     health) after controlling for depression and
     PTSD. CG – specific treatment > IPT for
     depressed individuals with CG
   – No: High correlations with PTSD and
     depression
                       CG in Children
 • Brown & Goodman – “traumatic grief” – grief
   is intrusive and interferes with development of
   positive memories (but based upon children
   who lost parents in uniformed services in
   9/11)
 • Sandler – Intrusive grief, continued affective
   reactions, social detachment – related to
   functional impairment (the latter with peers)
Brown & Goodman, 2005
Sandler et al., 2003
          Gaps In The Field

• No controlled, long-term population-based
  prospective studies
• Role of suicide, other pre-death factors,
  exposure
• Complicated grief
• Mediators and moderators (pathways)
• Impact on health and development
      Impact of Sudden Death
           on Children

• Describe course of children bereaved by
  parental suicide, accident, sudden natural
  death
• Compare to non-bereaved neighborhood
  controls
• Role of cause and circumstances of death
• Predictors and pathways
• Complicated grief
                  Design (1)

•   Probands – suicide, accident, sudden
    natural death
    – Definite verdict/no ambiguous cases
    – No multiple death/injuries/no suicides in
      non suicide families
    – Death within 24 hours
    – Children 8-18, biological parent, living at
      home
              Design (2)


• Obtained for coroners records and
  advertisement
• 71% acceptance
• Appears representative of suicides and
  accidents in Allegheny County
              Design (3)

• Neighborhood controls: Random Digital
  Dialing or advertisement, no
  bereavement in last 2 years, both
  parents alive, demographically matched
  to deceased families
       Demographic Characteristics
             of Probands
                                         S            A            N        C        p
N (Probands)                             44           36           60       99
                                                 ab            a
Age                                      43           41           47       44 <.01
Sex (% male)                             77           72           82       76       ns
Race (% white)                           93           78           82       86       ns
                                             a            ab           a        b
Income (x 10,000)                        6            6            6        7       <.01
S = Suicide; A = Accident; N = Natural; C = Controls
Superscripts that are different indicate significant pairwise difference.
        Demographic Characteristics
           of Adult Caregivers
                     S                               A          N          C    p
N (Adult Caregivers) 43                             36         60         101
                        a                              a,b        b          a
Age (years)          42                             45         46         42 <.01
Sex (% female)       84                             81         92         74   ns
Race (% white)       93                             78         85         87   ns
Relation to proband
                        a                                a          a,b        b
 (% married)         56                             50         68         77       <.01

 S = Suicide; A = Accident; N = Natural; C = Controls
 Superscripts that are different indicate significant pairwise difference.
       Demographic Characteristics
              of Children
                       S       A        N        C            p
N (Children)           66     51       94       183
Age (years)            14     13       13       13            ns
Sex (% male)           52     47       56       50            ns
                          a      a,b     b        a
Race (% white)         92     82       73       85           <.05
Lived with both parents
                         a         a     b           c
  before death        35      45       65       81           <.001
Biological Parent
                          a        a        a            b
  of child (%)         88     88       85       100          <.001
Time since death
 (months)               9      9        9        -            ns
 Pre-Death Psychiatric History and
    Family Adversity: Probands
                        S        A            N            C            p
N (Probands)            44       36           60           99
                            a         ab           b               b
Any disorder (%)        98       78           65           75          <.001
Depression     (%)      56       44           37       33              ns
                             a       ab        ab          b
Bipolar disorder (%)    23       8            7        2               <.001
Anxiety (%)             26       25           19       28              ns
                            a        a             b           b
Substance/alcohol (%)   84       72           42       42              <.001
Cluster B personality
                             a           ab       bc   c
 disorders (%)          43       19           15       4               <.001
Pre-Death Psychiatric History and
     the Caregiving Adults

                       S        A          N       C         p

N (Caregivers)         43       36         60 101
Past psychiatric
                            a       a, b       b       b
 disorders (any) (%)   86       69         64      56       <.01

                            a       a, b       b        b
Past depression (%)    63       42         40      31 <.01

                            a       a          a        b
Past anxiety (%)       35       33         35      14 <.01
    Pre-death Psychiatric History
        and Family Adversity
                          S       A              N                 C     p
N (re:Children)           66      51         94            183
                           a,b     a          a,b           b
Sexual Abuse (%)          3       8          4             1           <.05
                           a,b        a,b        a,b           b
Physical Abuse (%)        5       4          0             1           <.05
Past disorder
                              a        a,b           a,b           b
Any disorder(%)           46      33         32            23 <.01
                             a      a           a           b
Behavioral disorder (%)   14      12         11            4 <.05
Mood disorder (%)         17      20         12            8   ns
Anxiety disorder (%)      12      8          6             8   ns
 Bereavement Sequelae in Children at
    9-months after Parental Death
                                                 S            A            N            C                p

N (Children)                                   66            51           94       183
                                                  a              a,b         a          b
New-onset disorder (%)                         39            32           49       24                 .001
                                                  a              a             a       b
New-onset MDD (%)                              23            20            21        6                <.001
                                                   a           a,b           a         b
New-onset PTSD (%)                              11           2            11         0                <.001
                                                   a               a           a          b
Depression*                                    .37           .21          .13      -.23               <.001
                                                    a              b           a           b
PTSD                                            7.3          3.5          5.7        1.1              <.001
                                                      a              a           a           b
SIQ (suicide ideation)                         25.2          21.9          21.3     19.8              <.02
                                                   a             a,b          a           b
CGAS (functioning)                              76           78            76        82               <.001
ICG (complicated grief                          59.2         53.6          52.8       ---                ns

S = Suicide; A = Accident; N = Natural; C = Controls Superscripts that are different indicate significant pairwise
difference. *Standardized scores.
                   Bereavement Sequelae in
                      Caregiving Adults
                                                          S            A            N             C          p

N (Caregivers)                                            43          36           60           101
New-onset depression (%)                                  28          36           35            11         <.001
New-onset PTSD (%)                                        26          31           23            1          <.001
BDI (depression)                                          12.5        13.4         11.9          4.9        <.001
BAI (anxiety)                                             10.7        10            8.5          4.2        <.001
PTSD                                                      12.4        10            8.8          1.8        <.001
SIQ (suicide ideation)                                    26.7        28.5          26.2         19.3       <.001
GAS (functioning)                                         72          75            75            82        <.001
ICG (% complicated grief)**                               32          25            31            na          ns
S = Suicide; A = Accident; N = Natural; C = Controls Superscripts that are different indicate significant
pairwise difference. ** Above clinical cutpoint of 25.
Risk of New Onset Depression in Children
        by Type of Parental Death

                         Kaplan Meier for New-Onset Depression by Type of Death
              0.50
              0.40
     1-Survival Probability
0.00 0.10 0.20 0.30




                              0                10                        20              30
                                        Time to Onset Since Death (months)

                                                     Suicide                  Accident
                                                     Natural                  Control
Predictor of MDD within First Year


Adjusted risk (IR) = 2.6 (95% CI 1.2-6.9)
 within bereaved:
Higher care giving function protective
 (OR = .93, 95% CI .88-.99)
Last conversation was confiding (OR=4.8,
 95% CI 1.4 - 17.1)
  Impact of Parental Death on Children
         Over 1st Two Years (%)

                   Bereaved Controls P       IR

New-onset depression    27    11.5   <.001   2.6
New-onset, recurrent
 ongoing (depression)   16    8.4     .04
Substance abuse         4.5    0     <.02
   Predictors of PTSD in Children
      (Within Bereaved Only)


                              OR 95%CI
Past history of psychiatric   10.7 1.2-97.7
 disorder
Family history of PTSD        12 1.9-78
Being at the scene of death   12.4 1.2-130
Confiding conversation        .08 (.006-.99)
Predictors of New-Onset Depression
           through Year 2

                                 HR     95%CI
Bereavement                      3.8    2=7.3
Child history of
  depression                     2.6    1.5-4.6
Caregiver function (higher)      .97    .95-.98
Not living with natural mother   1.9    1.5-2.4
Child negative coping             1.3   1.0-1.6
         Pathways from Parental Loss to
          Child New-Onset Depression
                                                Adult Survivor
                                             Functional Impairment




                                 .5




                                                                     -.0
                               -7




                                                                        3
                                                                                  New-Onset
                                      2.22
                                                                                  Depression

                                                 3
                                             1.00
 Previous                                                            .38
 History of    Bereavement
Depression
                             .77
                                                     Life Events


                                                                              5




                                                        .37
                                                                            .3




                                                Negative Coping
           Global Health


            Bereaved    Controls     P
Baseline    1.4(.55)    1.3(.57)    .26
Year 1      1.6 (.71)   1.4(.58)    .00
Year 2      1.6 (.63)   1.4 (.58)   <.03
                Complicated Grief (1)
• Inventory of complicated grief – Revised (ICG-
  R)  = .94
• 3 Factors:
   • Yearning/Preoccupational/Anger
   • Numbness/lack of safety and control/startle
   • Avoidance, detactment
• Similar to Sandler’s “intrusive grief,” “affective
  reaction,” and “social attachment”

Sandler et al., 2003
Melhem et al., in press
                Complicated Grief (2)

• All factors show high internal consistency
• ( =.79-.93) and correlation with total
• (r=.78-.95)
• ICG-R – Correlates with depression (r=.47),
  PTSD (r=.62), anxiety (r=.45), CGAS (r=.38)
• Relationship to impairment persisted after
  controlling for PTSD and depression

Melhem et al., in press
            Prevention Study
          (Sandler et al., 2003)

• Bereaved youth, 6-30 months after parent loss
• Groups for parents and for children (random
  assignment)
• Targeted children’s active coping, efficacy,
  threat appraisal, open expression, positive
  parenting
• Improvement in int/ext symptoms up to 3 years
  after death, mainly in girls
            Conclusions (1)

• Parent loss increases risk for depression,
  PTSD, substance abuse, behavioral
  disorders, global health
• Circumstances of death relevant for
  depression, PTSD
• Effect is above and beyond pre-death risk
  factors
            Conclusions (2)


• Mediated by caregiver function, life
  events, positive parenting, child coping,
  and threat appraisal
• CG appears to be real
• Unclear if suicide bereavement is worse
              Limitations


• Hard to prove it is a representative
  sample
• Not diverse
• Did not study homicide
           Future Plans

•   Longer-term follow-up
•   Broader assessment of outcomes
•   More definitive tests of model
•   Develop interventions based on
    findings

				
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