Social Psychiatry Soc Psychiatry (1982) 17:37-42 �9 Springer-Verlag 1982

Parental Death During Childhood and Adult Depression: Some Additional Data

Geoffrey Nelson

Department of Psychology, Wilfrid Laurier University, Waterloo, Ontario, Canada

Summary. Based on their recent review of the litera- ture, Crook and Eliot (1980) concluded that there is no sound evidence for a relationship between early parental death and adult depression. The present review considers two additional sources of data perti- nent to their conclusion: research on severe depres- sion and attempted suicide. While there are methodological shortcomings in this research, there is evidence to suggest that the severely depressed and suicide attempters have a relatively high incidence of early parental death.

Based on a review of more than 20 controlled studies, Crook and Eliot (1980) have recently con- cluded that the evidence for a relationship between parental death during childhood and adult depression is equivocal. The authors have highlighted the numerous methodological problems in this field of research and their conclusion is soundly supported by the data. However, in their review, Crook and Eliot did not focus explicitly on two additional facets of depression that may be more strongly related to early parental death than undifferentiated concepts of depression, namely: severe depression and attempted suicide. In ignoring these sources of data, the review- ers have glossed over a potentially important rela- tionship. Thus, the purpose of this paper is to briefly review research that has examined the incidence of early parental death in cases of severe depression and attempted suicide.

Review of the Literature

Severe Depression

Table 1 presents the findings from eight studies examining the relationship between early parental death and severity of depression. In six of nine com-

parisons, psychiatric patients and "cases" diagnosed as severely depressed have a significantly higher inci- dence of early parental death than comparison groups of moderately, mildly, or non-depressed sub- jects 1. In the Munro (1966) study, the severely depressed have a marginally significant higher inci- dence of early parental death only when compared with the moderately depressed. Overall then, the majority of studies reviewed found severity of de- pression to be associated with early parental death.

While these studies suggest than there is an association between early parental death and severity of depression, these findings must be weighed against certain methodological considerations. First, as Crook and Eliot point out, in this type of correla- tional research, a relationship between two variables may be a function of some other unexamined vari- able(s) that covary with the variables in question. Thus, Crook and Eliot argued that age and socioeconomic status (SES) should be controlled in studies in this area. Researchers should add sex to this list, as epidemiological studies have shown women to have a significantly higher rate of depres- sion than men (Warheit, Holzer, Schwab 1973; Weissman and Klerman 1977). As indicated in Table 1, only one of these studies controls for all of these variables (Crook and Raskin 1975) and only one of the studies controls for SES (Crook and Raskin 1975). Since Warheit et al. (1973) have shown a strong inverse relationship between SES and severity of depression, a more definitive conclusion regarding the relationship between early parental death and severe depression awaits research that controls for SES.

A second methodological consideration is the assessment of severity of depression. All of the

1 To insure comparable statistical analysis, the author recomputed the data from all of the studies reviewed in this paper using the chi- square test of significance.

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Table 1. Studies examining the relationship between early parental death and severity of depression

Controls

Age in Study Groups childhood Age SES Sex Incidence of early parental death

Beck, Sethi, 100 severely 0-16 yes ? no SD (27.0%) >MD (15.5%) >C (12.0%) b Tuthill (1963) depressed

Birtchnell (1970 a, b)

Brown, Harris, Copeland (1977)

Brown, Harris, Copeland (1977)

Crook and Raskin (1975)

Forrest, Fraser, Priest (1965)

patients (SD) 97 moderately depressed patients (MD) 100 non- depressed patients (C)

94 severely 0-15 yes ? no depressed patients (SD) 148 moderately depressed patients (MD) 203 non- depressed patients (C1) 473 community controls (C2)

37 severely 0-17 yes ? yes depressed female patients (SD) 37 moderately depressed female patients (MD) 37 mildly depressed female patients (MLD)

46 severely 0-17 ? ? yes depressed female "cases" (SD) 31 moderately depressed female "cases" (MD) 382 non- depressed community con- trols (C)

94 severely 0-12 yes yes yes depressed patients (SD) 136 moderately depressed patients (MD) 285 community controls (C)

62 endogenously 0-15 ? ? no depressed patients (ED) 43 neurotically depressed patients (ND)

SD (28.7%) >MD (19.6%) <C~ (23.6%) >C 2 (18.0%) b

SD (67.6%) >MD (43.2%) >MLD (10.8%) b

SD (52.1%) >MD (38.7%) >C (19.6%) b

SD (10.6%) >MD (9.6%) <C (11.2%)

ED (37.1%) <ND (48.8%)

Table 1. (continued)

Controls

Age in Study Groups childhood Age SES Sex Incidence of early parental death

Kendall (1968) 25 severely 0-17 yes ? yes SD (48.0%) >MD (39.1%) >MLD depressed female (13.6%) b patients (SD) 23 moderately depressed female patients (MD)

22 mildly depressed female patients (MLD)

102 severely 0-16 ? ? no depressed patients (SD) 51 moderately depressed patients (MD) 163 general hos- pital outpatient controls (C)

45 severely 0-16 ? ? no depressed patients (SD) 28 moderately depressed patients (MD) 43 mildly depressed patients (MLD)

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Munro (1966)

Sethi(1964)

SD (25.5%) >MD (13.7%) ~ SD (25.5%) >C (20.2%)

SD (15.6%) <MD (17.9%) >MLD (16.3%)

a p <0.10 b p <0.05

studies reviewed used psychiatrists' ratings based on interview and case record data to assess the severity of depression. Only three studies determined inter- rater reliability (Beck, Sethi, Tuthill 1963; Brown, Harris, Copeland 1977; Sethi 1964). A self-report depression inventory was used in the Beck et al. and Sethi studies as the primary tool to determine sever- ity of depression. Interestingly, the differences be- tween groups in terms of parental death prior to age 16 were more pronounced when the clinical ratings, as opposed to the self-report depression inventory, were used: severely depressed (36.4%), moderately depressed (15.8%), mildly depressed (16.7%) and non-depressed (15.2%) (Beck et al. 1963). The depression inventory and clinical ratings were sig- nificantly correlated (r = 0.67).

A few investigators (Forrest, Fraser, Priest 1965; Gay and Tonge 1967) have used the "endogenous- reactive" concept to classify their depressed sample. Forrest et al. (1965), but not Gay and Tonge (1967), showed that their "endogenous" group was rated as

significantly more depressed than their "reactive" group. The trend to use measures of severity of depression, rather than the conceptually and empiri- cally confusing "endogenous-reactive" classification of depression, should be continued in this research.

A related concern is that only one of the studies (Crook and Raskin 1975) indicated that the raters were blind to the hypotheses and subjects' status regarding early parental death. The problem of rater bias is particularly accentuated by the fact that the authors of most of the studies appear to be the raters of severity of depression. Future research needs to more adequately attend to these issues of reliability, validity, and rater bias in the assessment of severity of depression.

The final point to be made regarding methodol- ogy concerns the selection of comparison or control groups. As Brown et al. (1977) have noted, depress- ed people need to be excluded from comparison groups. This selection, which can be done using either interview or self-report ratings of severity of

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Table 2. Studies examining the relationship between early parental death and attempted suicide

Controls

Age in Age SES Sex Incidence of early parental death childhood

0-19 yes ? yes S (35.6%) >NS (25.70%) a Birtchnell 101 suicidal (1970c) patients (S)

140 nonsuicidal patients (NS)

Crook and Raskin 115 suicidal 0-12 yes yes yes (1975) depressed

inpatients (S) 115 nonsuicidal depressed patients (NS) 285 normal controls (C)

Greer (1966) 81 suicidal 0-15 yes yes yes patients (S) 385 nonsuicidal patients (NS)

Greer, Gunn, 156 suicidal 0-15 yes yes yes Koller (1966) patients (S)

156 nonsuicidal patients (NS) 156 general hos- pital patients (C)

Hill (1969) 236 suicidal 0-15 ? ? ? depressed patients (S) 1228 nonsuicidal depressed patients (NS)

Levi, Fales, Stein 40 suicidal 0-17 yes yes yes Sharp (1966) attempters (SA)

40 patients with suicidal urges (SU) 40 nonsuicidal patients (NS)

Moss and Hamilton 50 seriously early yes ? ? (1955) suicidal life

patients (SS) 50 potentially suicidal patients (PS) 50 nonsuicidal patients (NS)

S (9.6%) <NS (10.4%) <C (11.2%)

S (23.5%) >NS (14.3%) b

S (24.3%) >NS (9.6) <C (11.5%) b

S (16.7%) >NS (13.3%) (father deaths only) S (7.6%) >NS (6.2%) (mother deaths only)

SA (37.5%) >SU (20.0%) >NS (15.0%) b

SS (60%) >PS (15%) >NS (15%) b

a p <0.10 h p <0.05

depression, permits compar i son of rates of early parental dea th be tween groups with empirically defined degrees of depression.

In addit ion to the studies presented in Table 1, two studies using the M M P I provide suppor t for the assert ion that severity of depression and early paren- tal death are related. Wilson, Al l top and Buffa loe

(1967) found that 28 depressed patients who lost a paren t by death pr ior to age 16 scored significantly higher than 64 unma tched non -be reaved depressed pat ients on the Schizophrenia subscale. Birtchnell (1978) found that 29 early be reaved (prior to age 10) depressed pat ients scored significantly higher than 58 non -be reaved depressed patients, ma tched for age

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and sex, on the Hypochondriasis and Paranoia sub- scales.

Attempted Suicide

Another important aspect of depression is attempted suicide (Weissman 1974). Birtchnell (1970c) has shown attempted suicide to be directly associated with severity of depression. In this study, he found that 39% of the severely depressed patients had attempted suicide, compared with 24.5% of the mod- erately depressed and 10.8% of the non-depressed. In view of this relationship and the findings discussed in the previous section, one might expect a relatively high incidence of early parental death in the suici- dally depressed.

The results of seven studies examining the inci- dence of early parental death in groups of suicide attempters and nonsuicidal subjects is presented in Table 2. In all but one of these studies suicide attempters had a higher incidence of early parental death than nonsuicidal controls. In five of eight com- parisons, these differences are statistically significant. Incidence of early parental death for suicide attemp- ters ranges from 7.6% for mother deaths only (Hill 1969) to 60% in the early study by Moss and Hamil- ton (1955). However, Moss and Hamilton studied 50 seriously suicidal patients admitted to a mental hos- pital over a 20 year period and they did not specify the age in childhood for early parental death. In his sample of suicide attempters, Birtchnell (1970c) found that 66.7% of those judged to be severely depressed had lost a parent prior to age 19 compared with 19.6% of the moderately depressed and 40% of the non-depressed. This finding strongly supports the assertion that a high rate of early parental death is associated with cases of severe depression that are accompanied by attempted suicide.

From a methodological viewpoint, the majority of the studies in Table 2 control for age and sex, while three of seven control for SES. Moreover, the rela- tionship between early parental death and attempted suicide is clearly confirmed in all but one of those studies which control for age, SES, and sex (Greer 1966; Greer, Gunn, Koller 1966; Levi, Fales, Stein, Sharp 1966). For present purposes, it is unfortunate that most of the studies in Table 2 did not assess the severity of depression in the suicidal subjects. Birtchnell (1970c) reported an association between severity of depression and attempted suicide, as was stated earlier, but Crook and Raskin (1975) failed to find such a relationship. Moreover, the suicide attempters in a few studies were not necessarily diag- nosed as depressed. Future studies in this area need

to assess the severity of depression of suicidal and nonsuicidal subjects.

Two studies not presented in Table 2 also demon- strate that attempted suicide is related to early paren- tal death. These studies used a different method than those in Table 2, comparing the incidence of at- tempted suicide in groups of early bereaved and non- bereaved adults. In a study of university students treated at a campus mental health clinic, Adam (1973) compared 35 students who had lost a parent by death prior to age 16 with a comparison group of 50 non-bereaved students matched for age. He found that significantly more of the early bereaved (48.6 %) had suicidal ideation compared with the non- bereaved (10 %). Also, significantly more of the early bereaved (17.1%) than the non-bereaved (4%) had made a suicide attempt. Similarly, Gay and Tonge (1967) found that 63.2% of 38 reactively depressed patients who had lost a parent by death prior to age 15 had made a suicide attempt compared with 19.2% of a group of 382 psychiatric patients who had not experienced early parental death.

Conclusion

Acknowledging the methodological limitations of the studies reviewed, the evidence indicates that there is a relationship between early parental death and severe depression and attempted suicide, as Heinicke (1973) concluded earlier. It is noteworthy that roughly 60-70% of the subjects in this research are women. While many writers have invoked psycholog- ical explanations of the relationship between early parental death and depression (e. g., psychoanalytic views of introjection of the lost love object and social learning views of learned helplessness), as Crook and Eliot (1980) point out, genetic factors may be involved. That is the high incidence of early death of the parents of the severely depressed and suicide attempters may be due to accidental death or suicide of the parents. Thus future research should attend to the causes of early parental death (e. g., suicide, acci- dent, equivocal deaths) and depression in parents. Furthermore, future research should heed the recom- mendations presented herein regarding methodology to more adequately determine if in fact the severely depressed and suicide attempters do have a signifi- cantly high incidence of early parental death.

Finally, it is important for the reader to bear in mind that the majority of people who experience early parental death do not become severely de- pressed or attempt suicide. While case studies have documented children's grief following the death of a parent (Bowlby 1972; McConville 1974) and con-

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trolled studies have shown that both young children and adolescents who have lost a parent by death are more shy, anxious, and withdrawn (Hetherington 1972; Felner, Stolberg, Cowen 1975; Tuckman and Regan 1966) than non-bereaved controls, little is known about the processes of children's adjustment to the death of a parent. Controlled prospective studies, which are totally absent in this area, are needed in this regard. Studies of this nature may shed light on factors which differentiate children who eventually adjust positively to a parental death from children who show sustained adjustment problems that persist into later life.

Acknowledgment. The author would like to thank Richard Walsh for his comments on this paper.

References

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Accepted 10 March 1981

Geoffrey Nelson, Ph.D. Department of Psychology Wilfrid Laurier University Waterloo, Ontario Canada N2L 3C5