ReviewCardiovascular risk in early bereavement: A literature review and proposed mechanisms
Introduction
The death of a loved one is recognised as one of life's greatest stresses requiring significant psychological adjustment (Maciejewski et al., 2007, Stroebe et al., 2007, Stroebe, 2001). The response to bereavement, commonly referred to as grief, is a unique psychological stress that may last for several weeks or months and for some may lead to chronic psychological stress. Bereavement can be particularly devastating for the surviving spouse, who is often required to deal with simultaneous disruption to living arrangements, financial security and social status (Stroebe, 2001). For some, spousal bereavement has the potential to result in social isolation that may have an impact on cardiovascular health in the longer term (Bunker et al., 2003). The death of a child has been associated with even greater significant symptoms of depression, anxiety and stress (Goodenough et al., 2004, Miyabayashi and Yasuda, 2007).
A growing body of evidence suggests that emotional stress is strongly associated with CHD and acute events (Angerer et al., 2000, Bunker et al., 2003, Muller et al., 1994). An Expert Group of the National Heart Foundation of Australia published an account of systematic reviews of the evidence relating to psychosocial risk factors and their relation to development or progression of CHD, concluding that increased risk contributed by psychosocial factors (depression, social isolation and lack of quality of social support) is of similar order to conventional risk factors such as smoking, dyslipidaemia and hypertension (Bunker et al., 2003).
Frequently referred to as “death from a broken heart”, bereavement has long been associated with increased mortality risk for the surviving spouse, although sometimes considered to be incidental rather than bereavement related. The need to design preventative regimens to provide maximum protection during times of peak risk of myocardial infarction has been suggested (Tofler and Muller, 2006). However, the absence of insight into the impact of bereavement on risk factors in early bereavement results in uncertainty regarding appropriate strategies during this known risk period.
The purpose of this paper is to report in a narrative review the evidence of cardiovascular risk during the early bereavement period in order to identify potential risk factors that may provide evidence as to those who are most at risk. Additionally, we review potential mechanisms of risk and discuss a representation by which bereavement may trigger acute cardiovascular events as background to inform future research directions.
Section snippets
Search method
The electronic databases PubMed Medline, CINAHL and PsycINFO were searched using the key words bereavement, mortality, morbidity, spouses and parents, using various combinations. No limits were set on the searches in terms of date or publication type but only English language articles and studies involving humans were selected. Literature gathered in the search process were included for review if they were primary research articles reporting mortality or morbidity risk during bereavement. In
Bereavement and risk of mortality for the surviving spouse
Studies reporting excess mortality in early bereavement have predominantly reported on samples of bereaved spouses, possibly due to the ability to monitor spousal survival records from public records. In 1963, a landmark study reported a follow-up of 4486 widowers of 55 years or older comparing widowed mortality to that of married men (Young et al., 1963). The authors reported 66 excessive deaths in the bereaved group in the first six months following spousal death representing an odds ratio of
Discussion
Bereavement, a unique psychological stress where acute symptoms of depression, anxiety and anger may last for several weeks and months, has been associated with increased morbidity and mortality, most notably in surviving spouses. Coronary heart events appear to account for a substantial proportion of increased deaths during early bereavement, although the exact physiological changes contributing to increased risk remain relatively unexplored during this vulnerable time. Risk appears higher in
Future research directions
While the data are compelling for a link between bereavement and cardiovascular risk, there is a need for further work to better understand the mechanism by which risk occurs. Two major reviews of bereavement research in recent times recommend that research priorities focus on the physiological, behavioural and support mechanisms that place bereaved persons at increased risk (Genevro et al., 2004, Stroebe, 2001).
Identification of biological changes in bereavement is an important step towards
Limitations
The results of increased mortality and morbidity in bereavement presented in this review relate findings in bereaved spouses or parents and therefore may not be relevant to all bereaved individuals. The grief response in bereavement is a highly individualised experience and it is possible that risk is not confined to spouses or parents. In this review there is a possibility of publication bias because studies that found no changes in psychological and biological factors in the bereaved may not
Conclusion
While the focus at the time of bereavement is naturally directed on the deceased person, the health and welfare of bereaved survivors should be of great concern to medical, nursing and social work professionals, as well as family and friends. The insights from this review into the impact of early bereavement on health, and the recognition that bereavement is associated with increased cardiac risk, should provide an impetus for individuals to act on cardiac symptoms by seeking medical advice and
Acknowledgements
This work was supported by grants from the North Shore Heart Research Foundation and the Heart Foundation, Australia.
Conflict of interest: None declared.
References (87)
- et al.
Impact of social support, cynical hostility and anger expression on progression of coronary atherosclerosis
Journal of American College of Cardiology
(2000) - et al.
Sleep EEG, depression and gender
Sleep Medicine Reviews
(2001) - et al.
Moderate alcohol consumption lowers risk factors for cardiovascular disease in postmenopausal women fed a controlled diet
American Journal of Clinical Nutrition
(2002) - et al.
Psychiatric disorders among bereaved persons: the role of perceived circumstances of death and preparedness for death
American Journal of Geriatric Psychiatry
(2002) - et al.
Depressed lymphocyte function after bereavement
Lancet
(1977) A.E. Bennett award paper. Experimental approaches to human stress research: assessment of neurobiological mechanisms of stress in volunteers and psychiatric patients
Biological Psychiatry
(1989)- et al.
Childhood social circumstances and psychosocial and behavioural factors as determinants of plasma fibrinogen
Lancet
(1996) - et al.
The health impact of health care on families: a matched cohort study of hospice use by decedents and mortality outcomes in surviving, widowed spouses
Social Science and Medicine
(2003) Changes in eating behavior during the aging process
Eating Behaviors
(2002)- et al.
Long-term immune-endocrine effects of bereavement: relationships with anxiety levels and mood
Psychiatry Research
(2003)