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)
Plasma cortisol and natural killer cell activity during bereavement
Biological Psychiatry
Heart disease mortality following widowhood: some results from the OPCS Longitudinal Study. Office of Population Censuses and Surveys
Journal of Psychosomatic Research
Natural and unnatural triggers of myocardial infarction
Progress in Cardiovascular Diseases
Cortisol and vital exhaustion in relation to significant coronary artery stenosis in middle-aged women with acute coronary syndrome
Psychoneuroendocrinology
Mechanism by which quinapril improves vascular function in coronary artery disease
American Journal of Cardiology
Mortality after spousal loss: are there socio-demographic differences?
Social Science and Medicine
Triggers, acute risk factors and vulnerable plaques: the lexicon of a new frontier
Journal of the American College of Cardiology
Childhood parental loss and cortisol levels in adult men
Psychoneuroendocrinology
Autonomic and emotion regulation in bereavement and depression
Journal of Psychosomatic Research
Sleep and depression—results from psychobiological studies: an overview
Biological Psychology
Triggers of acute coronary syndromes
Progress in Cardiovascular Disease
Acute depressed mood as a trigger of acute coronary syndromes
Biological Psychiatry
Health outcomes of bereavement
Lancet
Measures of endothelial dysfunction in plasma of patients with posttraumatic stress disorder
Psychiatry Research
Neuroendocrine and behavioral mechanisms mediating the relationship between anger expression and cardiovascular risk: assessment considerations and improvements
Journal of Behavioral Medicine
Influence of anxiety on the course of heart disease after acute myocardial infarction—risk factor or protective function?
Psychotherapy and Psychosomatics
Power law behavior of RR-interval variability in healthy middle-aged persons, patients with recent acute myocardial infarction, and patients with heart transplants
Circulation
A prospective study of early bereavement on psychological and behavioural cardiac risk factors
Internal Journal Medicine
“Stress” and coronary heart disease: psychosocial risk factors
Medical Journal of Australia
Depression, heart rate variability, and acute myocardial infarction
Circulation
Spousal bereavement—implications for health
Family Practice
Clinical insights into normal grief
Rhode Island Medical Journal
Environmental events preceding sudden death in women
Psychosomatic Medicine
Self-reported psychological states and physiological responses to different types of motivational general imagery
Journal of Sport and Exercise Psychology
Thrombosis and acute coronary–artery lesions in sudden cardiac ischemic death
New England Journal of Medicine
Effects of mental stress on cardiovascular and endocrine response in Air Force Academy cadets
Neuroendocrinology Letters
Stressful life events and fibrinogen level in middle-aged teachers
Psychopathology
Cortisol effects on body mass, blood pressure, and cholesterol in the general population
Hypertension
Hostility predicts magnitude and duration of blood pressure response to anger
Journal of Behavioral Medicine
Short sleep duration as a risk factor for hypertension: analyses of the first National Health and Nutrition Examination Survey
Hypertension
Report on bereavement and grief research
Death Studies
Bereavement outcomes for parents who lose a child to cancer: are place of death and sex of parent associated with differences in psychological functioning?
Psychooncology
Bereavement is associated with time-dependent decrements in cellular immune function in asymptomatic human immunodeficiency virus type 1-seropositive homosexual men
Clinical and Diagnostic Laboratory Immunology
Cited by (76)
The association between adverse events in later life and mortality in older individuals
2023, Comprehensive PsychoneuroendocrinologyMental Health, Ill-Defined Conditions, and Health Care Utilization Following Bereavement: A Prospective Case-Control Study
2022, Journal of the Academy of Consultation-Liaison PsychiatryHealth in widowhood: The roles of social capital and economic resources
2020, Social Science and MedicineCitation Excerpt :A large body of literature has documented the negative associations between widowhood and health. Strong evidence exists for excess mortality among widowed individuals (Moon et al., 2011; Shor et al., 2012), along with increased incidences of cardiovascular disease, diabetes (Buckley et al., 2010; van den Berg et al., 2011), depression, anxiety, suicidal ideation (Lindeboom et al., 2002; Siflinger, 2017; M. S. Stroebe et al., 2005a; Tseng et al., 2017), and ultimately suicide (Ajdacic-Gross et al., 2008). Given these findings, along with rising costs of healthcare for the elderly (Harper, 2014), it is important that researchers, policy-makers, and healthcare providers better understand factors that promote or hinder good health in widowhood.
Spouses’ Health: What Happens Beyond the Widowhood Effect?
2024, Journal of Family Issues