Family Practice Vol. 18, No. 6, 614-618
© Oxford University Press 2001
Original Paper |
Spousal bereavement—implications for health
Centre for Primary Health Care Studies, University of Warwick, Warwick,
a Biomolecular Sciences Department, UMIST, Manchester,
b Birmingham University, Birmingham and
c Merseyside, UK.
Dr Rodger Charlton, Centre for Primary Health Care Studies, Warwick University, Coventry CV4 4AL, UK.
Charlton R, Sheahan K, Smith G and Campbell I. Spousal bereavement—implications for health. Family Practice 2001; 18: 614–618.
Received 2 October 2001; Revised 1 May 2001; Accepted 9 July 2001.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionConclusionReferences |
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Background. Bereavement is a potential medical problem as it has implications for health through possible associations with morbidity and mortality.
Objective. The aim of the present study was to ascertain if spousal bereavement is associated with physical and psychological parameters of illness.
Methods. A spousal bereavement register was created at a village general practice in the West Midlands of 122 spouses (4.9% of the practice population). After exclusion of 22, a sample of 100 had their medical records analysed for the periods of 12 months before and after bereavement.
Results. Between these two periods, the average number of consultations increased from 5.99 to 7.60 (P = 0.01), where the vast majority were for physical illness. Mean number of prescriptions increased from 8.54 to 9.15 per patient (P = 0.8) for physical illness and from 0.76 to 1.34 (P = 0.09) for psychological illness.
Conclusion. Bereavement can be viewed as a medical problem, but this is not borne out in prescribing and so care should be taken not to over-medicalize grief.
Keywords. Bereavement, grief, health, morbidity, mortality, spouse.
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Introduction |
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Bereavement is a potential medical problem in the strict scientific sense as it has implications for the health of an individual through possible associations with morbidity and mortality.1
Reactions to death are variable, do not necessarily follow a set pattern and cannot always be resolved. There are, however, certain identifiable stages and points of time when events happen more frequently than others, and these stages of bereavement have been well described by many psychiatrists including Murray-Parkes2 and Kubler Ross.3 Most people progress through some of these stages, but not necessarily all of them or in any particular order,4–6 and a health care professional involved may be able to facilitate this process. If normal stages of bereavement were to be isolated, they might be distress and shock, denial, anger, feeling ‘low in spirits’, resolution and acceptance.
The life cycle is such that with increasing age, adaptation to a new situation becomes more difficult. There are several major life events. One study recorded 43 of these events and was repeated in 1965, 1977 and 1995; the findings demonstrated that the death of a spouse was the most significant life event.7
With increasing age comes a succession of losses, which may be gradual or sudden. In addition to the death of a spouse, close friends and family, these may include sensory loss (vision, hearing), loss of memory, employment through retirement, physical fitness and mobility and, worst of all, the loss of one's independence. There is also a loss of life expectancy, and this replaces the perception that many have through life of immortality. This gives rise to the shocking awareness of inevitable death, which rapidly replaces the feeling of denial that it is a long time off; rather it is imminent.8
There may also be anhedonia, the loss of enjoyment in activities that normally bring pleasure, which is one of the biological symptoms of depression. Furthermore, depression with increasing age is often undiagnosed and untreated. An editorial in the British Medical Journal in 19889 stated that severe depression may affect ~3%, but no mention of bereavement is made. However, it is stated that older people often minimize feelings of sadness and may become physically preoccupied. Depressive illness in late life often follows a major adverse life event, such as bereavement or an acute life-threatening illness.
Several studies in the literature have sought associations between bereavement and impairment of health, both psychological and physical. A Scottish study10 surveyed the psychiatric morbidity patterns experienced by three groups of women 6 months before and 4 months after various life events: (i) bereavement from loss of their spouse; (ii) spouse suffering a myocardial infarction; and (iii) entering a women's refuge. The results shown in Table 1
were obtained using the Research Diagnostic Criteria of Spitzer et al.11 and show that the measured effect of bereavement is striking.
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A similar study in the USA,12 involving 350 widows and widowers in comparison with a matched control group of 126 demographically similar men and women, specifically looked at the spectrum of depressive phenomena after spousal bereavement. The study demonstrated that depressive phenomena are more prevalent, persistent and disabling in the first 2 years following bereavement.
An association of bereavement with increased mortality has been known for a long time. In 1967, a paper was published in which a 7-fold increase in mortality among bereaved spouses was demonstrated within the first year of their bereavement when compared with a control group.13
It can be argued whether or not bereavement, which is a natural process and part of the life cycle, is a ‘medical’ problem. The following study in relation to spousal bereavement seeks to answer the question, "Is spousal bereavement associated with illness as a result of associated physical and psychological problems?" The literature would lend support to a hypothesis that bereavement is a medical problem and so is a neglected cause of illness.
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Methods |
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A semi-rural commuter village general practice in the West Midlands, UK, with a list size of 2300 was the setting for the study, where the majority of the residents were registered at the practice.
Death register
A death register had been kept from mid-1995 and was extended to preceding years using the computer records available and the memories of a practice receptionist.
Creation of a spousal bereavement register
The death register was used to create a spousal bereavement register. Using the computer registration details of marital status, it was possible to identify bereaved spouses. However, it was suspected that several bereaved spouses had not been identified. A monthly ‘Village Chronicle’ which contains details of funerals of village residents, together with a church burial register which contains entries for both burials and cremations from 1880, was used to identify ~50% of bereaved spouses in the newly created spousal bereavement register which dates from 1940 and the general medical services of four successive GPs.
Recording of health events in relation to spousal bereavement
All health events (consultations and prescriptions), 1 year prior to the death of a spouse and 1 year later from the written records, were used to update the practice computer records. These health parameters were transferred on to a PC database (Excel) and the data analysed initially in the following distinct categories to address the research question, "Is spousal bereavement associated with illness as a result of associated physical and psychological problems?":
- consultations for physical illness;
- consultations for psychological illness;
- miscellaneous consultations;
- prescriptions for physical illness; and
- prescriptions for psychological illness.
A coding system was utilized to distinguish between the location of consultation; telephone advice, surgery or home visit. Physical ailments were divided into minor, major, acute, chronic, screening and organized review. Those that could not be coded using this scheme, for example where record keeping was illegible, were placed in the category of miscellaneous as were those where the distinction between physical and psychological was not clear or the consultation was for an organized review or the issuing of a medical certificate. The task was easier for prescriptions as the majority of these records were computerized and the indication for most drugs fell within the two distinct categories of physical and psychological.
For the purposes of comparison, the analysis of data is presented in two categories where variables could be identified; total consultations and prescriptions (for physical and psychological illness). The numbers of consultations and prescriptions before and after bereavement were compared by paired t-tests (two-sided). The data were not analysed using the further subdivisions created by the coding system, as the numbers were too small to permit statistical analysis.
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Results |
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A total of 122 bereaved spouses were identified. Using the practice list size of 2300 patients (which equates with the size of the village), this reveals that 4.9% of the practice population have experienced spousal bereavement. In reality, this figure may be higher as it is possible that some bereaved spouses may not have been identified.
There were some spouses for whom it was not possible to obtain a bereavement date or where their medical records were incomplete (22 spouses). These were excluded, leaving a sample of 100 subjects, of whom 78% were female and 22% male. This is the same gender distribution as those within the excluded group. The mean age of the patients in this sample was 65.9 years, and Table 2 illustrates the distribution of their ages at the date of their bereavement.
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The year of bereavement ranged from 1940 to 1999, and Table 3
illustrates their distribution in numbers over this period.
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Table 4
shows the mean consultation rate per person per year from 1980 to 1999 as detailed in the patient records of this sample, and shows a 2-fold increase over this period.
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Table 5
details the number of consultations and prescriptions for physical and psychological illness, 12 months before and 12 months after spousal bereavement. There is a mean increase in consultations for physical illness from 4.35 per person per year before the bereavement to 4.99 per person per year the year after bereavement. Similarly, there is an increase in consultations for psychological illness from 0.21 per person per year to 0.45 per person per year. For a large proportion of consultations, it was not possible to allocate the category of physical or psychological illness to a consultation. Reasons included: difficulty reading the doctor's writing, requesting a certificate or coming in at the request of the practice for a health check, e.g. an over 75 screening check. The findings are illustrated in Figure 1.
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However, all prescriptions can be allocated to a category of physical or psychological. Again there is an increase in the total number of prescriptions per person per year in the year after bereavement in comparison with the year preceding the bereavement. The increase would appear to be more dramatic for the psychological illnesses, with nearly a 2-fold increase in prescribing. The findings are illustrated graphically in Figure 2
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The data were then subjected to statistical analysis. As can be seen from the results, three main variables could be identified:
- total number of consultations;
- prescriptions for physical illness; and
- prescriptions for psychological illness.
The t-tests used paired samples of each variable before and after bereavement, and t-values and two-tailed P-values have been calculated and are displayed in Table 6. For total consultations, the increase in mean consultations from 5.99 to 7.60 was statistically significant by the paired t-test (P = 0.010), and the 95% confidence interval (CI) for the increase was 0.398–2.822. This 95% CI can be expressed as an increase of 7–47%.
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The results were also analysed for age and gender where there is no obvious relationship.
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Discussion |
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The identified bereaved spouses illustrate that spousal bereavement is predominantly a female phenomenon (approximate ratio of 4.5:1). This would be in keeping with the fact that females live longer than males.
Following initial observation, the results would tend to support the hypothesis that bereavement is a medical problem. However, these observations are not borne out as one might expect following statistical analysis. Anecdotally, one might have expected an increase in psychological illness as evidenced by specific cases, an increase in prescribing in this area and a review of the literature. The greatest increase in health utilization is, however, for physical rather than psychological ailments.
A small number of individuals within the group of 100 would appear to utilize GP services for psychological reasons and may be associated with the non-statistically significant increase in prescribing for psychological illness following bereavement. In addition, the phenomenon of ‘pathological grief’ is well described in the literature. For the majority of the group, psychological illness is not a problem that is being reported to the GP in this practice. From the literature surveyed at the beginning of the paper, this finding can be demonstrated to be statistically significant using a larger sample size.
It might also be possible to support this view using a qualitative analysis following interviews of selected bereaved spouses who appear to be suffering psychological sequelae. This may reveal more information than the quantitative analysis of their records that has been employed in this study. However, such an intervention is difficult to justify ethically as it may have potential to cause an adverse effect on them emotionally and psychologically and may intrude on their personal and private grief. In addition, the data obtained may be influenced by the ‘Hawthorne effect’ and so the presence of the researcher or research assistant in such a small practice population.
There are a list of factors which may have affected the severity of the bereavement experienced, and thus the outcome of the study. For example, bereavement may not have resulted in the often associated sadness. Situations such as a protracted painful terminal illness might fulfil this category, or a married couple may no longer have been in a happy relationship. In such circumstances, bereavement may be a relief. It is not possible to know this information or the proportion of the sample, but it may have a significant impact on the results.
In this particular population, it may be that the good bereavement services provided in the village prevented physical and psychological problems. Bereavement services are provided by the primary health care team, vicar and associated pastoral visitors. In addition, the bereavement services available from the local town, which is 3 miles away, may also have had an impact.
Another factor that is of importance is the span of time over which the information was collected. In a few cases, bereavement occurred several years previously (see Table 3
). Medical records may not have been used or may be sparse compared with the extensive records that presently are compiled. Thus, data concerning consultations and prescriptions may not be accurate and so may not have been adequate for the purposes of this study. However, the time span of the study diminishes a possible effect of the medical practice of a single doctor, but permits the impact of four GPs providing general medical services for the village practice.
The survey does not use a control group and it could be argued that this may affect the interpretation of the results. It was felt that it would be very difficult to match accurately the 100 individuals who were bereaved and it was decided that the best match would be with themselves, before and after bereavement. However, in order to justify this decision, it is necessary to estimate the effect of age on the study subjects as they will be 12 months older in the year after bereavement when the comparison is being made. Nevertheless, the increase observed in the total number of consultations expressed as an increase of 7–47% at the 95% CI can only be explained by the factors of bereavement. One would only expect an increase of 2% from the effect of advancing age and a further 2% from the increasing use of and demand for the health service.
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Conclusion |
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This study has been used to establish a spousal bereavement register, which would appear to be unique in the literature, although death registers are being used more commonly. Many practices have disease registers for conditions such as diabetes, epilepsy and asthma, but not for an event such as bereavement. As to whether the care of the bereaved is a neglected area of health promotion, this is another issue.
With regards to the hypothesis, the study confirms that consultation rate increases and that in a small percentage of individuals there is an increase in prescribing of psychotropic drugs such as antidepressants. It could therefore be concluded that for most people, spousal bereavement is a natural part of the life cycle and the only health sequelae are of a physical nature. A study using a larger sample may show a significant association with depression in a small proportion of people.
Finally, the findings of this study might lend some support to a possible null hypothesis that bereavement has little or no effect on health. There are few papers to support this finding in the literature, but then it should be stated that this is a negative finding and negative findings are notoriously difficult to publish in peer-reviewed journals and thus establish. One review of the literature suggests that evidence associating mortality and morbidity with bereavement is conflicting,14 and an important conclusion that may be drawn is that care should be taken not to over-medicalize grief in the majority of people.15
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Acknowledgments |
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The authors thank the Claire Wand Fund of the British Medical Association for funding this project.
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References |
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