Cortisol response to stress as a predictor for suicidal ideation in youth.

OBJECTIVE: To examine the association between cortisol response to stress and suicidal ideation (SI) cross-sectionally and longitudinally in our sample of bereaved and non-bereaved youth. METHODS: The sample included 114 youth bereaved by sudden parental death and 109 non-bereaved controls, mean age of 12.3 (SD = 3.6), evaluated at four time-points over an average follow-up period of 7 years. The Trier Social Stress Test (TSST) was conducted on average 6 years after bereavement. We used latent class analyses to examine the trajectories of SI over follow-up and up to the time of the TSST and compare them on cortisol measures. We examined whether cortisol measures predicted future SI at 18.5 months on average after the TSST. RESULTS: Bereavement was associated with higher cortisol reactivity after controlling for covariates [ß = 0.96, 95% CI (0.28, 1.65), p < 0.01, d = 0.41]. Cortisol reactivity to stress was higher in those belonging to the high SI trajectory [ß = 1.23, 95% CI (0.41, 2.06), p = 0.004, d = 0.23] compared to the low SI trajectory. Higher baseline cortisol showed small to medium effect size in predicting future SI [ß = 2.34, 95% CI (0.17, 4.51), p = 0.03, d = 0.38]. CONCLUSION: The persistence of SI is associated with higher cortisol reactivity to stress, and higher baseline cortisol may predict future SI. These results emphasize the importance of HPA-axis activity in youth exposed to major stressors, and those with SI. More research is needed to further clarify biological mechanisms linking SI and behavior, bereavement, and HPA axis response to stress, to better identify at-risk subjects for targeted prevention and intervention efforts.

The Burden of Bereavement: Early-Onset Depression and Impairment in Youths Bereaved by Sudden Parental Death in a 7-Year Prospective Study.

OBJECTIVE: The authors sought to determine the long-term impact of sudden parental death on youths and pathways between youth bereavement and impairment. METHODS: Youths (N=216) who lost a parent to suicide, accident, or sudden natural death and nonbereaved youths (N=172) were followed periodically for up to 7 years. The incidence and prevalence of disorder and of functional impairment, as well as pathways to impairment, were assessed using Cox and mixed-effects logistic regression and structural equation modeling. RESULTS: Prior to parental death, bereaved youths had higher rates of psychiatric disorder, parental psychiatric disorder, and maltreatment. Even after adjustment for predeath risk factors, bereavement was associated with an increased incidence of depression, posttraumatic stress disorder, and functional impairment. The peak incidence of depression was in the first 2 years postbereavement, with incident depression occurring mainly in those who lost a parent at age 12 or younger. Youths bereaved by all three causes of death showed higher rates of impairment at all time points. Structural equation modeling found that bereavement had a direct effect on impairment and was also linked to impairment via its effects on early and later depression and through negative life events. Child psychiatric disorder prior to parental loss also contributed to functional impairment. CONCLUSIONS: Parental death increased the incidence of depression in offspring early in the course of bereavement. Early identification and treatment of depression in bereaved youths and augmentation of family resilience may protect against later sequelae of functional impairment.

Identifying prolonged grief reactions in children: dimensional and diagnostic approaches.

OBJECTIVE: Children with prolonged grief reactions (PGR) have been found to be at increased risk for depression and functional impairment. Identifying and diagnosing PGR in children is challenging, as there are no available dimensional measures with established thresholds and no diagnostic criteria in the DSM-IV. We examine thresholds for the Inventory for Complicated Grief-Revised for Children (ICG-RC) and compare this dimensional approach to the proposed DSM-5 criteria for Persistent Complex Bereavement-Related Disorder. We also identify a screening tool for PGR. METHOD: Parentally bereaved children and adolescents, 8 through 17 years of age, were assessed at 9, 21, and 33 months after parental death. Receiver operating characteristics were used to establish the "best threshold" that would identify youth with PGR and evaluate the proposed DSM-5 criteria cross-sectionally and longitudinally. RESULTS: A score of 68 or higher on the ICG-RC was found to have high sensitivity (0.942) and specificity (0.965) in differentiating cases of PGR from noncases at 9 months. We also identified a 6-item screening tool that consists of longing and yearning for the deceased, inability to accept the death, shock, disbelief, loneliness, and a changed world view. The proposed DSM-5 criteria correctly identified only 20% to 41.7% of cases with PGR at different time points. CONCLUSIONS: For the identification of youth at risk for PGR, the dimensional approach outperformed the proposed categorical diagnostic criteria. We propose a brief screening scale that, if validated, can help clinicians to identify bereaved children and adolescents at risk for PGR, and guide the development of prevention and intervention strategies.

Cortisol response to social stress in parentally bereaved youth.

BACKGROUND: Parental bereavement is associated with increased risk for psychiatric illness and functional impairment in youth. Dysregulated hypothalamic-pituitary-adrenal (HPA) axis functioning may be one pathway through which bereaved children experience increased risk for poor outcomes. However, few studies have prospectively examined the association between parental bereavement and cortisol response while accounting for psychiatric disorders in both youth and their caregivers. METHODS: One-hundred and eighty-one bereaved and nonbereaved offspring and their caregivers were assessed at multiple time points over a 5-year period after parental death. Offspring participated in an adaptation of the Trier Social Stress Task (TSST), and salivary cortisol samples were collected before and after exposure to social stressors. Mixed models for repeated measures were used to analyze the effects of bereavement status, psychiatric disorder in both offspring and caregiver, and demographic indices on trajectories of cortisol response. RESULTS: After controlling for demographic variables and offspring depression, bereaved offspring demonstrated significantly different trajectories of cortisol response compared with nonbereaved offspring, characterized by higher total cortisol output and an absence of cortisol reactivity to acute social stress. Within the bereaved group, offspring of parents who died by sudden natural death demonstrated significant cortisol reactivity to social stress compared with offspring whose parents died by suicide, who demonstrated more blunted trajectory of cortisol response. CONCLUSIONS: Parentally bereaved youth demonstrate higher cortisol output than nonbereaved youth but are less able to mount an acute response in the face of social stressors.

The phenomenology and course of depression in parentally bereaved and non-bereaved youth.

OBJECTIVE: To compare the phenomenology and course of bereavement-related depression to depression that occurred later in the course of bereavement and to depression in non-bereaved youth. METHOD: This sample is drawn from a cohort of parentally bereaved youth and non-bereaved controls followed for approximately 5 years. Three groups of depressed youth were compared with respect to symptoms, severity, duration, risk for recurrence, and correlates and risk factors: (1) a group with bereavement-related depression (BRD, n = 42), with the onset of a depressive episode within the first 2 months after parental loss; a group with later bereavement depression (LBD, n = 30), with onset at least 12 months after parental loss; and a non-bereaved control group with depression (CD, n = 30). RESULTS: BRD episodes were similar to LBD and CD with respect to number of symptoms, severity, functional impairment, duration, risk for recurrence, and most risk factors and correlates. BRD, compared with both CD and LBD, were younger, exposed to fewer life events, and less likely to have experienced feelings of worthlessness. Also, caregivers of BRD showed higher rates of depression and post-traumatic stress disorder at the time of the depression compared with each of the other two groups. CONCLUSION: BRD is similar to both LBD and CD in phenomenology, course, and risk factors, supporting a diagnostic and therapeutic approach to BRD similar to that for non-bereavement-related depressions. In the bereaved child who presents with depression shortly after parental death, the clinician should also be alert to caregiver depression and post-traumatic stress disorder.

Grief in children and adolescents bereaved by sudden parental death.

CONTEXT: Major advances have been made in our understanding of the phenomenology and course of grief in adults. However, little is known about the course of grief in children and adolescents. OBJECTIVE: We report on the course of children's and adolescents' grief reactions after sudden parental death and the effect of those reactions on subsequent psychiatric and functional status. DESIGN: Longitudinal study (July 1, 2002, through January 16, 2007) of bereaved children, adolescents, and families, with yearly comprehensive assessments as long as 3 years after parental death. SETTING: Bereaved children and adolescents and their surviving parents recruited through coroners' records and a newspaper advertisement. PARTICIPANTS: A total of 182 parentally bereaved children and adolescents aged 7 through 18 years whose parent died due to suicide, unintentional injury, or sudden natural causes. MAIN OUTCOME MEASURES: Grief, functional impairment, and incident depression. RESULTS: Three distinct trajectories of grief reactions were observed in the study participants. In 1 group, which consisted of 10.4% of the sample, grief reactions showed no change 33 months after death. Children and adolescents with prolonged grief reactions had higher rates of previous personal history of depression. Prolonged grief made unique contributions to increased levels of functional impairment, even after controlling for the clinical characteristics before and after the death. Conversely, prolonged grief in children, adolescents, and the surviving caregiver predisposed children and adolescents to an increased hazard of incident depression. Another group (30.8%) showed increased grief reactions 9 months after the death, which gradually decreased over time. Despite this finding, grief reactions in this group also were associated with functional impairment and increased risk of incident depression. CONCLUSIONS: Grief reactions abate over time for most children and adolescents bereaved by sudden parental death; however, a subset shows increased or prolonged grief reactions, which in turn increases the risk of functional impairment and depression. Research regarding interventions designed to relieve the burden of grief in bereaved children and adolescents are needed. Such efforts also should assess and address grief reactions in the surviving parent.