2. Relationship analysis between bereavement and addiction

Several authors have noted the possible relationship between the loss of a significant person, complications in grief, and substance abuse [11, 13]. This section showed the results of the review of quantitative scientific literature about the relationship between the diagnosis of an SUD (especially alcohol, cocaine, or heroin) and bereavement.

Table 1 described the quantitative studies, which have analyzed the relation between bereavement and SUD. The columns specify: the authors and the date of publication, the type (where "B" means bereavement and "SLE" stressful life events where bereavement was included as a specific SLE), the objective of the study, the sample characteristics or participants, the instruments used, and the main results indicating if there is an evidence of the relationship between bereavement and addiction.

The aspects and variables contemplated and analyzed in different investigations are numerous. As can be seen from the table, the main variables studied were:

Authors

Type\*

 Purpose of study

Sample

characteristics

Method

Results (Is there any evidence of a

relationship

addiction?)

 between loss and

(Date)

Country

Birtchnell

B

 Examine the prevalence

death

 of parental

N = 6795 patients aged 20 or over

The psychiatric

interviewed

answered a post survey

 and the control group

 sample was

Yes, relationship parental death and alcoholism

found only in female patients. The

diagnosis most

associated with early

was among the depressives

alcoholics

Yes, loss can affect the pattern of

alcohol alcoholism

reflect a precipitant

unmasks the stable phase of the individual

concerned

Yes, the older women with no

family history or the women with

an alcoholic spouse have a higher

risk factor

Yes, relationship and addiction was shown.

Unexpected

early in life and inadequate

mourning as factors in

progressively

risk-taking.

26.4% experienced sudden deaths of adult family members before age 15. Significant

relationship

 between those who

Bereavement and Substance Use Disorder http://dx.doi.org/10.5772/intechopen.73125

under-mourned

abused as children. The earlier

deaths the higher was their sex trading.

Those with incomplete

 mourning 33

respondents

experienced,

 and being sexually

 one or more

 higher adult HIV

 deaths experienced

 between death

 factor which

predisposition

 in a

 after loss could perhaps

consumption.

 The onset of

significantly

bereavement

 and the

 between early

 was

N = 3425 of control group

[24] UK.

Blankfield

SLE&B Assess the different ways in which

N = 50 alcoholic patients (aged

MAST

> from 19 to 61 years)

"Loss"

or divorce and unexpected

 losses

included: death, separation,

loss effected patterns of alcohol

consumption

[26].

Australia

Blankfield

B

 Examine the patterns of

establishment

dependence

 in widows

 of alcohol

N = 37 widows who had not

MAST

remarried.

N = 85 nonwidows

[20].

Australia

Bowser et al.

B

 Ascertain the relationship

intravenous

high levels of HIV risk-taking both a) death of significant others

experienced

unresolved

 mourning

 before age 15 and b)

 and

(71.4% male) (Aged from 19 to 67)

Primary losses = before 15 years

 drug users between

 among

N = 592 participants

treatment intravenous

 (out-of-

CFBQ/CIDUS

> drug users)

[29]. USA


physical complications as well as medical complications, and high psychiatric comorbidity [8, 9]. Therefore, the SUD population is highly vulnerable than the general population and often pre-

Bereavement is a life-event that everybody experiences during their lives, but for some individuals, it is often associated with a period of intense suffering with an increased risk of developing mental and physical health problems [10]. Hence, when it happens to vulnerable people with psychiatric comorbidity, the result may be complications in the grief process. In this regard, different studies have reported a link between losing a significant person and drug

Both conditions (having an SUD diagnosis and having experienced a loss of a significant person) have implications in known brain mechanisms. Scientific evidence has suggested that not only does the use of substances cause changes in brain structure and functioning but it is also relevant to understand the influence of bereavement on a biological level. According to Luecken [14], parental death is a powerful early life experience with the potential to alter the development of biochemical, hormonal, emotional, or behavioral responses to the environment and later life stressors. Following the paragraph from Luecken [14]: "Maternally separated rodents and primates show neurobiological alterations that indicate permanently altered sensitivity to drugs of abuse and consume significantly more alcohol than motherreared animals both before and after stress exposure" [15, 16], suggesting that disrupted care during development may form a neurobiological basis for vulnerability to substance abuse later in life. Cortisol dysregulations are also associated with the increased risk of substance abuse, externalizing and internalizing disorders, and behavioral precursors to

In this chapter, a review of the main quantitative studies related to these two complex topics, the diagnosis of SUD (especially alcohol, cocaine or heroin) and bereavement, has been carried out.

Several authors have noted the possible relationship between the loss of a significant person, complications in grief, and substance abuse [11, 13]. This section showed the results of the review of quantitative scientific literature about the relationship between the diagnosis of an

Table 1 described the quantitative studies, which have analyzed the relation between bereavement and SUD. The columns specify: the authors and the date of publication, the type (where "B" means bereavement and "SLE" stressful life events where bereavement was included as a specific SLE), the objective of the study, the sample characteristics or participants, the instruments used, and the main results indicating if there is an evidence of the relationship between

The aspects and variables contemplated and analyzed in different investigations are numer-

2. Relationship analysis between bereavement and addiction

SUD (especially alcohol, cocaine, or heroin) and bereavement.

ous. As can be seen from the table, the main variables studied were:

sents life stories marked by suffering and loss.

consumption among substance users [11–13].

illness [17, 18].

32 Drug Addiction

bereavement and addiction.


Authors

Type\*

 Purpose of study

Sample

characteristics

Method

Results (Is there any evidence of a

relationship

addiction?)

substance use was not statistically

significant.

youth had an increased incidence

at an earlier time to onset of SUD

relative to Bereaved youth were at a greater

risk of SUD than their

counterparts

Yes, results established

relationships

in childhood and the of mental illness in adult life.

Statistically

in the incidence of death of both

parents between young male

alcoholics (aged 20–29) and the

controls but no significant difference in the rate of death of either father or mother between older alcoholics and the controls

Yes, a greater proportion bereaved youth showed drug problems after the loss. SLE may lead to substance abuse through individuals' poor coping skills and

vulnerability

 to depression

 of

 significant difference

 between parental loss

development

 certain

nonbereaved

nonbereaved

 controls.

 However, bereaved

 between loss and

(Date)

Country

youth and, if so, what might

N = 178 nonbereaved

 youth

demographically

 similar

psychopathology,

social support and ways of coping

 self-esteem,

> explain this increased incidence

> > Hilgard and

B

 Determine the prevalence parental loss by death in childhood

among

patients compared with a

nonpatient

Kaplow et al.

B

 Examine the potential differences

N = 172

N = 815 youth who experienced death of another relative; N = 235

nonbereaved

21 years

 youth, aged 11–

parent-bereaved

 youth;

C-GAS/CAPA

> the

in the presence of psychiatric

symptoms between parentally bereaved children, children who

experienced

relative and

Kendler

B&SLE Examine the impact of parental loss due to death and separation on

risk for major depression (MD) and

alcohol dependence

 (AD).

et al. [21].

USA.

nonbereaved

 children N = 5070 twins participants

same-sex and 2118 participants

from ascertained

based registry

 from a population-

opposite-sex

 twin pairs

 from

Cox

Proportional

Nonproportional

 Hazard models

 Hazard and

Yes, relationship loss and alcoholism

demonstrated.

differences

parental loss were seen for Alcohol

Dependence

Depression.

was associated with a increased risk for Alcohol

substantially

35

 Parental separation

 but not Major

 in the association

 with

 Consistent sex

 between parental

 was

Bereavement and Substance Use Disorder http://dx.doi.org/10.5772/intechopen.73125

> the death of another

[19]. USA.

 community

 sample

schizophrenic

 and alcoholic

 of

N = 1561

(631 males and 930 females) and

N = 929 patients (678 males and

251 females); N = 1096 (478 males

and 618 females) for control group

All participants

and 40 years

 aged between 20

schizophrenic

 patients

Control survey Alcoholics admission records

Newman

[22]. USA.


Authors

Type\*

 Purpose of study

Sample

characteristics

Method

Results (Is there any evidence of a

relationship

addiction?)

had the highest level of heroin and

cocaine injection

Yes, significant incidence of

parental death and addictions were

found. There was a significant incidence of death of mother under

15, but no significant loss at a

particular age was seen. Male

alcoholics also showed an excess of

loss of father between the ages of

10–15. Among the drug addicted,

there was significant excess of loss

of both parents of female drug user

before the age of five

Yes, loss was an issue that may

appear during any phase of

addiction counseling

are prudent and avoid establishing

causal relationship

 but authors

Furr et al.

B&SLE Examine the

experienced

individuals

treatment for SUDs

 currently receiving

 throughout

 life in

self-reported

 losses

N = 68 addicted patients divided

Experience

Inventory

 of loss in Addictions

> into: adult residential program

(n = 14); substance abuse

comprehensive

substance abuse intensive

outpatients

(n = 14)

Furukawa

B

 Examine the relationship early parental loss and subsequent

development

dependence

 among Japanese men

 of alcohol

 between

N = 75 men with alcohol

PISA

No relationship parental loss and alcohol

dependence

stratified for sex and age, there was

no statistically difference between the patients

and the controls in the rates of

maternal or paternal death or

separation before the age of

16 years

 significant

 was found. When

 between childhood

dependence

N = 52 healthy controls without

any lifetime psychiatric

 disorder

 in treatment

et al. [36].

Japan.

Hamdan

B

 Examine whether the incidence of

N = 235 youth participants

parents died of suicide, accident or

sudden natural death

 whose

Longitudinal

study. Validated scales covering

population-based

No, the relationship

parental pathological

 youth alcohol and

bereavement

 and

 between

> alcohol and substance abuse is

higher in parentally bereaved

et al. [34].

USA.

 (n = 34) and aftercare

 outpatient (n = 6);

[28]. USA

 between loss and

34 Drug Addiction

(Date)

Country

Dennehy

B

 Determine the incidence of

N = 1020 patients from 3

Interview

psychiatric

587 women) diagnosed as

depressive,

alcoholic and drug addicted and

other

schizophrenic,

 hospitals (433 men and

bereavement,

parent by death, in a psychiatric

population

 that is, loss of a

[23]. UK


Authors

Type\*

 Purpose of study

Sample

characteristics

Method

Results (Is there any evidence of a

relationship

addiction?)

Drug abuse may be an indication

of dysfunction

system.

Yes, SLE and addiction was linked.

Loss events and potentially

traumatic events were present, and

tend to increase, in passing from

the before- to the after- DAO

period. During the

period, "the death of a close friend

or relative," "divorce" and "being

neglected or

rated by patients as the most

important events. Exposure to SLE

seems to strongly increase the risk

of becoming No, few indications

a significant increase in mental

disorders in adulthood after the

death of a parent during

childhood.

found in the lifetime prevalence

substance abuse for parentally bereaved compared to no parental

bereavement.

before the age of 16 was not

associated with a younger age of

onset of mental health problems.

 Parental death

 of

 A small decrease was

 that there was

Stikkelbroek

B

 Examine association parental death during childhood

and adult

psychopathology

 between

N = 7076 participants

18 to 64 years)

 (aged from

CIDI/ MOS-SF-36

Cross-sectional

study

 and prospective

[37].

Netherlands

Tennant &

B&SLE Examine if both narcotic users and

N = 70 heroin dependent patients

MiniMental

Zung Depression

Inventory/PBI

 State

Examination/

Yes, there was a relationship

Bereavement and Substance Use Disorder http://dx.doi.org/10.5772/intechopen.73125

> between loss and alcoholism,

although it was not significant.

More alcoholics and addicts reported maternal loss than

controls (no statistical difference).

Separations

 from both parents 37

and N = 40 alcohol dependent in

treatment

N = 123 controls (patients and

accompanying

 relatives)

alcoholics are more likely to have

experienced

or prolonged separation from one

or both parents in childhood than a

control group of nonaddicts

 the death of a parent

Bernardi

[35].

Australia

drug-addicted.

abandoned" were

before-DAO

 within the family

 between loss and

(Date)

Country

Rugani et al.

B&SLE Assess the life events (loss and

N = 82 in treatment (aged from 17 to

61 years)

heroin-dependent

 patients

DAH-RS/TALS-SR

traumatic) before and after the

dependence

and their responses to these events

 age of onset (DAO)

[31]. Italy


Authors

Type\*

 Purpose of study

Sample

characteristics

Method

Results (Is there any evidence of a

relationship

addiction?)

Dependence

males. The loss in childhood of a parenting figure due to death does

not appear to be pathogenic

Alcohol

Dependence.

 for

 in females but not in

 between loss and

36 Drug Addiction

(Date)

Country

Masferrer

B

 Explore the loss of a significant

N = 196 SUD patients

Self-constructed

questionnaire

 Yes, 83.2% patients stated that after

suffering the loss, they increased

drug Yes, the presence of CG symptoms

was 34.2% among SUD patients in

comparison

group

Yes, loss as a predictor of suicide

among alcoholics. 26% of

alcoholics had experienced

close within 6 weeks of their death and

50% for the entire year

Yes, a link between

and alcohol problems was found.

Among bereaved men, the risk of

alcohol related problems tends to

be higher (than nonalcohol)

Yes, there was a relation between

SLE and drug abuse. 80% of drug

users were reported to have

experienced

(parents' divorce or the death of a

parent) during their childhood).

The Mean age at death was

24.6 years. Those who experienced

a traumatic event during their

childhood started to smoke earlier.

 a traumatic event

bereavement

interpersonal

 relationship

 a loss of

 to 5% in the control

consumption.

person

et al. [27] Masferrer

B

 Determine the presence of CG

N = 196 SUD patients

ICG

> N = 100 control patients

> symptoms among an SUD sample

et al. [42]

Murphy

B

 Analyze if loss has a role in those

N = 50 participants

description

 postmortem

Interview the nearest available relative (the spouse of the victim

mainly) in 2 phases.

alcohol dependent people who

died by suicide

et al. [33].

USA

Pilling et al.

B

 Analyze the relationship

bereavement

consumption

and gender differences

national

> Risser et al.

B&SLE Describe family

drug-related

 deaths

[25]. Austria

representative

 sample characteristics

 of

N = 51 (have experienced

one drug overdose and 53% of

them had contact with therapeutic

institutions)

 at least

Interviews

deceased drug users

 with relatives of

 accounting

 for time

 on a

 and alcohol

 between

N = 466 participants 75 years) who had lost a close

relative in the past 3 years

 (aged 18–

Slightly modified Hungarian

version of AUDIT

[30].

Hungary


Bonding Instrument. \*Typeofarticle:B=bereavement; SLE =stressfullifeevents.

a. The family relationship or proximity to the deceased person. Most studies identified the loss of significant people, such as the father, the mother, or the husband. One example of these studies is a longitudinal epidemiological study, which examined differences in psychiatric symptoms between young parents (N = 172), youth who experienced the death of another relative (N = 815), and non-mature youth (N = 235). A large proportion of bereaved youth showed drug problems after the loss. According to the results, the impact of parental death on children must be considered in the context of pre-existing risk factors [19]. Some years later, Blankfield [20] conducted further research comparing similar age-grouped widows (n = 37) and nonwidows (n = 85) who were in treatment in a unit of alcohol dependence. The results suggested that the widows of alcoholics who had unresolved marital conflicts or who become socially isolated are more vulnerable to abnormal grief responses. She pointed out the premorbid personality style (more solitary lifestyle) as a risk factor for complications afterwards. On the other hand, the death of an alcoholic spouse could be a more powerful factor than family history in triggering the same depen-

Bereavement and Substance Use Disorder http://dx.doi.org/10.5772/intechopen.73125 39

b. The gender of people who have suffered loss is also a variable that has been very important in many studies and has contributed different results, as Kendler points out [21]. Consistent sex differences in the association with parental loss were seen for alcohol dependence. For example, Hilgard and Newman [22] compared the incidence of death of a parent among 929 alcoholic patients from a state hospital and 1096 controls from a community nearby. They found a statistically significant difference in the incidence of both father and mother death between young male alcoholics and controls. Dennehy [23], comparing the data for 1020 psychiatric patients (depressive, schizophrenic, alcoholic, drug addicted, other) with the expected incidence of loss of parents calculated from the data census, found that there was a significant incidence of death of mother for those who were under 15 at the time. Male alcoholics also showed an excess of loss of father between the ages of

–15. Among the drug addicted, there was significant excess of loss of both parents of

c. The age at the time of loss of the person has been a very frequently studied factor. In this sense, losses at early ages seem to have a very important impact on the evolution of people in relation to addiction problems and other disorders. This is the point obtained from the research carried out by Birtchnell [24], involving patients with various psychiatric diagnoses (depressive, neurotic, psychotic, alcoholic and personality disorders) and a control group drawn from the general population. The author found that early morning affected only female patients. The diagnoses most significantly associated with early bereavement

were depressive and alcoholism. The most crucial period for parenting was age 0

event during their childhood began to smoke at a significantly lower age.

old. Risser et al. [25] stated that 80% of addicted patients had experienced at least one traumatic event during their childhood (mean age at the event was 7.8 years), such as the

d. Impact on substance consumption patterns. In some studies, such as Blankfield [26], the different ways in which grief-affected patterns of alcohol consumption was analyzed.

' separation. Also, those patients who experienced a traumatic

–9 years

dence for their widows or social isolation for others.

female drug users before the age of 5.

loss of a parent or parents

10

Table 1. Quantitative studies about the relationship between bereavement and addiction.


Authors

Type\*

 Purpose of study

Sample

characteristics

Method

Results (Is there any evidence of a

relationship

addiction?)

were both alcoholics and addicts than in controls. However, parental deaths

were not associated with addiction

Yes, parental deaths were linked

with addiction. Offspring of

suicide decedents had an especially

high risk of

suicide attempt. Child survivors of

parental suicide were at

particularly

hospitalization

and psychosis

 for drug disorders

 high risk of

hospitalization

 for

significantly

 more common in

 between loss and

38 Drug Addiction

(Date)

Country

Wilcox et al.

B

 Examine the risk of suicide,

psychiatric

violent criminal convictions offspring of parents who died from

suicide, accidents, and other causes

MAST = Michigan Alcoholism

naire; PISA = psychiatric

ICG = Inventory of

Spectrum-Self

Bonding Instrument.

\* Type of article: B =

Table 1.

Quantitative

 studies about the relationship

 between

bereavement

 and addiction.

bereavement;

 SLE = stressful life events.

 Report Instrument

 Screening Test; CIDUS =

 initial screening for affective disorders; C-GAS = Children's

Complicated

 Grief; AUDIT = Alcohol Use Disorders

Questionnaire;

 CIDI = Composite

International

 Diagnostic

 Interview;

 MOS-SF-36

 = Medical Outcomes Study Form-36; PBI = Paternal

Collaborative

 Intravenous

 Drug Users Study

 Global Assessment

Identification

 Test; DAH-RS = Drug Addiction History Rating Scale; TALS-SR = Trauma And Loss

questionnaire;

 Scale; CAPA = Child and Adolescent

 CFBQ = The Coleman Family Background

 Question-

> Psychiatric

Assessment;

hospitalization,

 and

decedents, N = 41,467 offspring of

accident decedents, N = 417,365 offspring of parents who died by

other causes, and N = 3,807,867

offspring of alive parents

N = 44,397 offspring of suicide

Population-based

multiple Swedish national registers

were linked from 1969 to 2004.

 data from

> among

[32]. USA

After assessing 50 inpatients of an alcohol and drug treatment center, it concluded that the loss can influence the pattern of alcohol consumption in different ways as the intake can be started, remain unaltered, increase, or even decrease. She also described that the onset of alcoholism after loss could perhaps reflect a precipitating factor that unmasks the predisposition in a stable phase of the individual concerned. Moreover, 83.2% of SUD patients (alcohol, cocaine, and heroin dependence) stated that after suffering a loss of a significant person, they increased drug consumption [27]. On the other hand, Furr et al. [28] differentiated between different types of losses: losses prior to addiction, losses while abusing substances, and losses associated with entering treatment. They interviewed 68 addicted patients using a self-report instrument. They concluded that the loss was an issue that may appear during any phase of addiction counseling but authors are prudent and avoid establishing causal relationship.

disorders and psychosis. From another aspect, the loss could be a predictor of suicide among alcoholics, as noted in the study by Murphy et al. [33], in which 26% of alcohol dependent patients who died by suicide had lost a close interpersonal relationship within the previous

Bereavement and Substance Use Disorder http://dx.doi.org/10.5772/intechopen.73125 41

Previous studies described relationships between loss and mourning, in different analyzed variables, but the data was controversial because it is also important to indicate studies that did not find this association, or found that it was very weak [21, 34]. For example, Tennant and Bernardi [35] studied 40 alcoholic patients who were admitted to a specialized in-patient facility and 123 controls attending general medical practitioners and found that childhood parental loss through separation but not through death, was significantly more common among alcoholics than in controls. Some authors have also reported nonsignificant associations between parental death and alcoholism [21, 36]. In a Japanese study, Furukawa et al. [36] examined the relationship between early parental loss and subsequent development of alcohol dependence among Japanese men. They did not find a statistically significant difference between patients and controls in the rates of maternal or paternal death or separation before the age of 16. Along the same lines are the results of the Hamdan study [34], in which the relationship between parental bereavement and pathological youth alcohol and substance use was not statistically significant. However, unemployed youth had an increased incidence and an increased risk of SUD than their

More recently, Stikkelbroek et al. [37] found few indications that there was a significant increase in mental disorders in adulthood after the death of a relative during childhood. A small decrease was found in the prevalence of alcohol abuse for the parentally bereaved compared to no parental bereavement. Parental death before the age of 16 was not associated

It is highly important to bear this information in mind because, as different retrospective studies [19, 32, 36] point out, the circumstances surrounding parental loss, including economic privation, conflict, parental hostility, neglect, distress, and disruption are more important in the prediction of psychopathology than parental bereavement per se. When looking for risk factors, a multidimensional perspective must be taken, examining both individual and family variables [38]. For example, there is evidence that the lack of adequate parental care following the death is a more powerful predictor of later adult impairment than the simple fact that a parent has died [39]. Further investigation will be needed to establish consistent patterns of parental deprivation and that such patterns per se may not indicate exact modes of causation, but may well be of considerable etiological significance when taken in conjunction with other

When arriving to this point, it is clear that the subject we are dealing with has great theoretical and methodological complexity. For example, the different terminology used relative to

bereavement, such as grief or abnormal grief responses, as Blankfield [20] pointed out.

6 weeks and 50% during the whole previous year.

with a younger age of onset of mental health problems.

3. Limitations of the quantitative studies

nonbereaved counterparts.

objective factual data [40].

Moreover, some results also emphasized the fact that substance use was a strategy used as a coping mechanism in certain traumatic vital circumstances. According to Bowser et al. [29], drug abusers may be people with a variety of background traumas and these accumulated traumas, and respondents and their families' inability to deal with or process emotions, were what motivates their self-medication and extremes in life-threatening and risk-taking behavior. In this regard, they reported that 26.4% of 592 participants experienced one or more sudden deaths of adult family members before the age 15. The same research showed that those drug dependent people with incomplete mourning had the highest level of heroin use and injection of cocaine. According to the study, almost half of the respondents (48%) used heroin as an adaptive attempt to regulate and control high anxiety at the same time as a way of managing stressful life events. Related to stressful life events, the authors claimed a significant relationship between those who under-mourned and being sexually abused as children. Moreover, the earlier the death that respondents experienced, the higher was the likelihood that they would become involved in the sex trade.


disorders and psychosis. From another aspect, the loss could be a predictor of suicide among alcoholics, as noted in the study by Murphy et al. [33], in which 26% of alcohol dependent patients who died by suicide had lost a close interpersonal relationship within the previous 6 weeks and 50% during the whole previous year.

Previous studies described relationships between loss and mourning, in different analyzed variables, but the data was controversial because it is also important to indicate studies that did not find this association, or found that it was very weak [21, 34]. For example, Tennant and Bernardi [35] studied 40 alcoholic patients who were admitted to a specialized in-patient facility and 123 controls attending general medical practitioners and found that childhood parental loss through separation but not through death, was significantly more common among alcoholics than in controls. Some authors have also reported nonsignificant associations between parental death and alcoholism [21, 36]. In a Japanese study, Furukawa et al. [36] examined the relationship between early parental loss and subsequent development of alcohol dependence among Japanese men. They did not find a statistically significant difference between patients and controls in the rates of maternal or paternal death or separation before the age of 16. Along the same lines are the results of the Hamdan study [34], in which the relationship between parental bereavement and pathological youth alcohol and substance use was not statistically significant. However, unemployed youth had an increased incidence and an increased risk of SUD than their nonbereaved counterparts.

More recently, Stikkelbroek et al. [37] found few indications that there was a significant increase in mental disorders in adulthood after the death of a relative during childhood. A small decrease was found in the prevalence of alcohol abuse for the parentally bereaved compared to no parental bereavement. Parental death before the age of 16 was not associated with a younger age of onset of mental health problems.

It is highly important to bear this information in mind because, as different retrospective studies [19, 32, 36] point out, the circumstances surrounding parental loss, including economic privation, conflict, parental hostility, neglect, distress, and disruption are more important in the prediction of psychopathology than parental bereavement per se. When looking for risk factors, a multidimensional perspective must be taken, examining both individual and family variables [38]. For example, there is evidence that the lack of adequate parental care following the death is a more powerful predictor of later adult impairment than the simple fact that a parent has died [39]. Further investigation will be needed to establish consistent patterns of parental deprivation and that such patterns per se may not indicate exact modes of causation, but may well be of considerable etiological significance when taken in conjunction with other objective factual data [40].
