Unresolved grief in a national sample of bereaved parents: impaired mental and physical health 4 to 9 years later
Open accessAbstract
Purpose: To assess unresolved parental grief, the associated long-term impact on mental and physical health, and health service use. Patients and Methods: This anonymous, mail-in questionnaire study was performed as a population-based investigation in Sweden between August 2001 and October 2001. Four hundred forty-nine parents who lost a child as a result of cancer 4 to 9 years earlier completed the survey (response rate, 80%). One hundred ninety-one (43%) of the bereaved parents were fathers, and 251 (56%) were mothers. Bereaved parents were asked whether or not, and to what extent, they had worked through their grief. They were also asked about their physical and psychological well-being. For outcomes of interest, we report relative risk (RR) with 95% CIs as well as unadjusted odds ratios and adjusted odds ratios. Results: Parents with unresolved grief reported significantly worsening psychological health (fathers: RR, 3.6; 95% CI, 2.0 to 6.4; mothers: RR, 2.9; 95% CI, 1.9 to 4.4) and physical health (fathers: RR, 2.8; 95% CI, 1.8 to 4.4; mothers: RR, 2.3; 95% CI, 1.6 to 3.3) compared with those who had worked through their grief. Fathers with unresolved grief also displayed a significantly higher risk of sleep difficulties (RR, 6.7; 95% CI, 2.5 to 17.8). Mothers, however, reported increased visits with physicians during the previous 5 years (RR, 1.7; 95% CI, 1.1 to 2.6) as well as a greater likelihood of taking sick leave when they had not worked through their grief (RR, 2.1; 95% CI, 1.2 to 3.5). Conclusion: Parents who have not worked through their grief are at increased risk of long-term mental and physical morbidity, increased health service use, and increased sick leave.
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A majority (73.5%) of parents who had lost a child to cancer had sleep difficulties 4-9 years later.
“One previous study (Lannen et al., 2008) has reported that a majority (73.5%) of parents who had lost a child to cancer had sleep difficulties 4–9 years later.”
From Feasibility and preliminary efficacy of guided internet-delivered cognitive behavioral therapy for insomnia after the loss of a child to cancer: Randomized controlled trial (2021) · cites this paper as Lannen et al., 2008
The paper studied parents 4–9 years after losing a child to cancer, but its outcome tables (Tables 3 and 4, indexed under Discussion; page unavailable) report regular difficulty falling asleep in 10%–27% of the father and mother subgroups, not 73.5% of parents overall. The Discussion highlights persistent sleep disturbance particularly among fathers with unresolved grief; it does not report that a majority of all bereaved parents had sleep difficulties. (LLM, conf=0.89)
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“For a substantial minority of parents, their grief may be sustained and clinically significant (Lannen et al. 2008, McCarthy et al. 2010).”
BackgroundCurrie, E. R., Christian, B. J., Hinds, P. S., Perna, S. J., Robinson, C. B., Day, S. W., Bakitas, M. A., & Meneses, K. (2018) · Death Studies · doi:10.1080/07481187.2018.1474285 · Cited by 48 · see citing works
Morris, S. E., Dole, O. R., Joselow, M., Duncan, J., Renaud, K., & Branowicki, P. A. (2016) · Journal of Pediatric Health Care · doi:10.1016/j.pedhc.2016.04.013 · Cited by 45 · see citing works
“…needs to be made for hospital-based pediatric bereavement programs, targeting both expected and sudden death, given the elevated risk of poor bereavement outcomes for bereaved parents (Lannen et al., 2008; Ljungman et al., 2015; Rogers et al., 2008) and the limited community resources available.”
BackgroundExperiences of African American Parents Following Perinatal or Pediatric Death: A Literature Review
Boyden, J. Y., Kavanaugh, K., Issel, L. M., Eldeirawi, K., & Meert, K. L. (2014) · Death Studies · doi:10.1080/07481187.2013.766656 · Cited by 43 · see citing works
“, 2010; Rogers, Floyd, Seltzer, Greenberg, & Hong, 2008), increased health service use, increased sick leave (Lannen et al., 2008), poorer overall well-being (Rogers et al.”
BackgroundEvaluating a bereavement follow‐up intervention for grieving mothers after the death of a child
Raitio, K., Kaunonen, M., & Aho, A. L. (2015) · Scandinavian Journal of Caring Sciences · doi:10.1111/scs.12183 · Cited by 43 · see citing works
McSpedden, M., Mullan, B., Sharpe, L., Breen, L. J., & Lobb, E. A. (2017) · Death Studies · doi:10.1080/07481187.2016.1210696 · Cited by 44 · see citing works
“Although some mothers may find the presence of living children assists them in managing their grief (Toedter, Lasker, & Alhadeff, 1988), having to support the siblings after the death may contribute to emotional distress in others (Lannen et al., 2008).”
Defining a “Good Death” in the Pediatric Intensive Care Unit
Broden, E. G., Deatrick, J. A., Ulrich, C. M., & Curley, M. A. Q. (2020) · American Journal of Critical Care · doi:10.4037/ajcc2020466 · Cited by 44 · see citing works
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“Given this condition’s impact on health and functioning (Lannen et al., 2008; Buckley et al., 2012) and its response to grief-specific interventions (Bryant et al.”
Snaman, J. M., Morris, S. E., Rosenberg, A. R., Holder, R. L., Baker, J. N., & Wolfe, J. (2019) · Supportive Care in Cancer · doi:10.1007/s00520-019-05249-3 · Cited by 44 · see citing works
Self-citationBylund‐Grenklo, T., Fürst, C. J., Nyberg, T., Steineck, G., & Kreicbergs, U. C. (2016) · Supportive Care in Cancer · doi:10.1007/s00520-016-3118-1 · Cited by 41 · see citing works
“Here, unresolved grief has been reported by 26 % of parents (aged 26–69) that 4 to 9 years earlier had lost a child [27]; by 16% of men (mean age 65) that had been widowed 4 to 5 years earlier [29]; and by 52% of young people, 2 to 9 years after the loss of a sibling at ages 12–25 [25].”
BackgroundMethodSelf-citationRoberts, K. E., Holland, J. C., Prigerson, H. G., Sweeney, C., Corner, G. W., BREITBART, W. S., & Lichtenthal, W. G. (2016) · Palliative & Supportive Care · doi:10.1017/s1478951516000626 · Cited by 44 · see citing works
“While the intensity of psychological symptoms tends to decrease over time in bereavement (Bonanno & Kaltman, 2001), a relatively small but important subset of bereaved family members (Lannen et al., 2008) go on to develop more severe and persistent bereavement-related mental health challenges (Kersting et al.”
BackgroundSelf-citationLevi‐Belz, Y., & Ari, L. L. (2019) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph16193740 · Cited by 41 · see citing works
“Individuals with high levels of CG often have substantial deficiencies in their daily, occupational, and social functioning [9].”
BackgroundGang, J., Kocsis, J. H., Avery, J., Maciejewski, P. K., & Prigerson, H. G. (2021) · Trials · doi:10.1186/s13063-021-05044-8 · Cited by 40 · see citing works
Self-citationMeasuring Maladaptive Cognitions in Complicated Grief: Introducing the Typical Beliefs Questionnaire
Skritskaya, N. A., Mauro, C., Olonoff, M., Qiu, X., Duncan, S., Wang, Y., Duan, N., Lebowitz, B. D., Reynolds, C. F., Simon, N. M., et al. (2016) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2016.09.003 · Cited by 40 · see citing works
Bereaved Parents’ Health Status During the First 6 Months After Their Child’s Death
Dias, N., Brandon, D., Haase, J. E., & Tanabe, P. J. (2017) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/1049909117744188 · Cited by 38 · see citing works
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“The loss of a child is also associated with worse physical health problems in the long term (Lannen et al., 2008).”
BackgroundParental bereavement increases mortality in older persons.
Cohen‐Mansfield, J., Shmotkin, D., Malkinson, R., Bar-Tur, L., & Hazan, H. (2012) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/a0029011 · Cited by 36 · see citing works
Bereavement Needs of Adults, Children, and Families After Cancer
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“greater levels of depression and anxiety and lower levels of physical health than thosewho couldwork through their grief.(13)Motherswith unresolved grief had more frequent sick leave and physician visits, and fathers with unresolved grief had greater difficulty with sleep.”
BackgroundThe COVID-19 pandemic has changed dying and grief: Will there be a surge of complicated grief?
Jordan, T. R., Wotring, A. J., McAfee, C. A., Polavarapu, M., Cegelka, D., Wagner-Greene, V. R., & Hamdan, Z. (2021) · Death Studies · doi:10.1080/07481187.2021.1929571 · Cited by 34 · see citing works
“A tertiary prevention approach would focus on helping those who are suffering from complicated grief and providing mental health counseling and treatment to them to prevent their complicated grief from becoming even more maladaptive (Lannen et al., 2008; Prigerson et al., 1995).”
BackgroundComplicated Grief Reactions in Children and Adolescents
Nader, K., & Salloum, A. (2011) · Journal of Child & Adolescent Trauma · doi:10.1080/19361521.2011.599358 · Cited by 35 · see citing works
“Compared to those who do not meet criteria for PGD, adults with PGD have been shown to be at increased risk for major depressive disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder, functional disability, diminished quality of life, health problems, and suicidal ideation months to years after…”
BackgroundParent Grief 1–13 Months After Death in Neonatal and Pediatric Intensive Care Units
Youngblut, J. M., Brooten, D. A., Glaze, J., Promise, T., & Yoo, C. (2016) · Journal of Loss and Trauma · doi:10.1080/15325024.2016.1187049 · Cited by 33 · see citing works
“Lannen et al. (2008), in a Swedish national sample of 449 parents 4 to 9 years after a child’s cancer death, also found that mothers were no more likely than fathers to have worked through their grief.”
Pohlkamp, L., Kreicbergs, U. C., & Sveen, J. (2019) · Journal of Clinical Oncology · doi:10.1200/jco.19.01493 · Cited by 33 · see citing works
Self-citationMedical comorbidity in complicated grief: Results from the HEAL collaborative trial
Robbins-Welty, G. A., Stahl, S. T., Zhang, J., Anderson, S., Schenker, Y., Shear, M. K., Simon, N. M., Zisook, S., Skritskaya, N. A., Mauro, C., et al. (2017) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2017.09.017 · Cited by 31 · see citing works
“…of appetite, weight loss, poor treatment adherence, sleep issues including restlessness, insomnia, and low sleep quality, and a 10-fold greater risk for hypertension and heart disease (Lannen et al., 2008; H. G. Prigerson et al., 1995a,b; Prigerson et al., 1997; Shear, 2015; Stroebe et al., 2011).”
Thienprayoon, R., Mark, M. S. J., & Grossoehme, D. H. (2017) · Journal of Palliative Medicine · doi:10.1089/jpm.2017.0333 · Cited by 31 · see citing works
Understanding Bereavement: What Every Oncology Practitioner Should Know
Kacel, E. L., Gao, X., & Prigerson, H. G. (2011) · The Journal of Supportive Oncology · doi:10.1016/j.suponc.2011.04.007 · Cited by 31 · see citing works
“Parents with unresolved grief experience increased physical and psychological morbidity, including disturbances in sleep, increased sick leave, and increased healthcare utilization (49).”
BackgroundSelf-citationSveen, J., Jernelöv, S., Pohlkamp, L., Kreicbergs, U., & Kaldo, V. (2021) · Internet Interventions · doi:10.1016/j.invent.2021.100409 · Cited by 30 · see citing works
“One previous study (Lannen et al., 2008) has reported that a majority (73.5”
BackgroundInfluentialSelf-citationHelen Pearson, H., Bryan, G., Kayum, C., Gibson, F., & Darlington, A. (2022) · BMC Pediatrics · doi:10.1186/s12887-022-03635-1 · Cited by 24 · see citing works
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“A significant risk factor and independent indicator of psychosocial morbidity (depression, anxiety, and poor quality of life) are the self-perceived status of working through your grief.(3) We found that at this early time point, only 20% reported that they had worked through their grief a lot or completely.”
BackgroundSelf-citationGrief and bereavement in people with intellectual disabilities
Dodd, P. C., & Guérin, S. (2009) · Current Opinion in Psychiatry · doi:10.1097/yco.0b013e32832e2a08 · Cited by 27 · see citing works
Impact of sleep on complicated grief severity and outcomes
Szuhany, K. L., Young, A., Mauro, C., de la Garza, Á. G., Spandorfer, J., Lubin, R. E., Skritskaya, N. A., Hoeppner, S. S., Li, M., Pace-Schott, E. F., et al. (2020) · Depression and Anxiety · doi:10.1002/da.22929 · Cited by 27 · see citing works
Professional Bereavement Photography in the Setting of Perinatal Loss: A Qualitative Analysis
Ramirez, F. D., Bogetz, J. F., Kufeld, M., & Yee, L. M. (2019) · Global Pediatric Health · doi:10.1177/2333794x19854941 · Cited by 25 · see citing works
“Perinatal loss, which encompasses fetal, neonatal, and infant death, is a devastating and traumatic experience for parents, resulting in increased risk for long-term adverse physical and psychosocial outcomes.(1-5) The death of a fetus or infant is a loss unlike any other,(6) and its social, emotional, and spiritual b…”
BackgroundThe Unique Impact of Late-Life Bereavement and Prolonged Grief on Diurnal Cortisol
Holland, J. M., Rozalski, V., Thompson, K. L., Tiongson, R. J., Schatzberg, A. F., O'Hara, R. M., & Gallagher-Thompson, D. E. (2013) · The Journals of Gerontology Series B · doi:10.1093/geronb/gbt051 · Cited by 26 · see citing works
The potential impact of bereavement grief on workers, work, careers, and the workplace
Wilson, D. M., Rodríguez‐Prat, A., & Low, G. (2020) · Social Work in Health Care · doi:10.1080/00981389.2020.1769247 · Cited by 30 · see citing works
“Parents, young and old, can also be expected to have significant impactful grief over the death of a child (Abboud & Liamputtong, 2003; Carriatore, 2010; Dahdah et al., 2018; Gibson et al., 2010; Gilmer et al., 2012; Lannen et al., 2008; Li et al., 2005; Mahan & Calica, 1997; Rappaport, 1981; Wilcox et al., 2015).”
BackgroundThienprayoon, R., Alessandrini, E. A., Frimpong-Manso, M., & Grossoehme, D. H. (2018) · Journal of Palliative Medicine · doi:10.1089/jpm.2018.0056 · Cited by 22 · see citing works
Kučukalić, S., & Kučukalić, A. (2017) · PubMed · Cited by 22 · see citing works
Bereavement Challenges and Their Relationship to Physical and Psychological Adjustment to Loss
Trevino, K. M., Litz, B. T., Papa, A., Maciejewski, P. K., Lichtenthal, W. G., Healy, C., & Prigerson, H. G. (2017) · Journal of Palliative Medicine · doi:10.1089/jpm.2017.0386 · Cited by 24 · see citing works
Self-citationDodd, A., Guérin, S., Delaney, S., & Dodd, P. C. (2020) · Death Studies · doi:10.1080/07481187.2020.1741048 · Cited by 22 · see citing works
Acute and long-term grief reactions and experiences in parentally cancer-bereaved teenagers
Bylund‐Grenklo, T., Birgisdóttir, D., Beernaert, K., Nyberg, T., Skokic, V., Kristensson, J., Steineck, G., Fürst, C. J., & Kreicbergs, U. C. (2021) · BMC Palliative Care · doi:10.1186/s12904-021-00758-7 · Cited by 24 · see citing works
Self-citationParents’ views on what facilitated or complicated their grief after losing a child to cancer
Pohlkamp, L., Sveen, J., Kreicbergs, U. C., & Lövgren, M. (2020) · Palliative & Supportive Care · doi:10.1017/s1478951520001212 · Cited by 21 · see citing works
“Parents with unresolved grief were more likely to report psychological ill health and sleep disturbances than parents with resolved grief (Lannen et al., 2008).”
BackgroundSelf-citationRasouli, O., Moksnes, U. K., Reinfjell, T., Hjemdal, O., & Eilertsen, M. B. (2022) · BMC Palliative Care · doi:10.1186/s12904-022-00978-5 · Cited by 20 · see citing works
“” This simple question has been used to measure grief in cancer-bereaved siblings and parents [11, 18, 29].”
BackgroundPatel, S. R., Cole, A., Little, V., Skritskaya, N. A., Lever, E., Dixon, L. B., & Shear, M. K. (2018) · Family Practice · doi:10.1093/fampra/cmy050 · Cited by 20 · see citing works
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“The fundamental sense of depletion and loss, as well as recovery from grief is not directly related to the time elapsed since the child’s death [7,9,10].”
Ásgeirsdóttir, H. G., Valdimarsdóttir, U. A., Fürst, C. J., Steineck, G., & Hauksdóttir, A. (2013) · Psycho-Oncology · doi:10.1002/pon.3345 · Cited by 19 · see citing works
Integrative therapies for children with hematological malignancies
Kelly, K. M. (2009) · Hematology · doi:10.1182/asheducation-2009.1.307 · Cited by 19 · see citing works
“Palliative care should include interventions offered to parents and siblings, who often suffer both psychological and physical distress during the child’s end of life and consequent phase of bereavement.(30) A recent survey investigating the current practices and resources surrounding palliative and end-of-life care a…”
BackgroundRasouli, O., Bø, M. A., Reinfjell, T., Moksnes, U. K., & Eilertsen, M. B. (2021) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2021.101929 · Cited by 19 · see citing works
The Impact of Pediatric Cancer on the Family
Gerhardt, C. A., Salley, C. G., & Lehmann, V. (2015) · Springer eBooks · doi:10.1007/978-3-319-21374-3_9 · Cited by 19 · see citing works
Yang, L., Weng, X., & Subramanian, S. V. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.03.136 · Cited by 17 · see citing works
Zhao, S., Ren, L., Wang, Q., Long, M., Wu, H. L., & Wang, Y. (2021) · Asia-Pacific Psychiatry · doi:10.1111/appy.12489 · Cited by 19 · see citing works
Harrison, O., Windmann, S., Rosner, R., & Steil, R. (2021) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2697 · Cited by 17 · see citing works
Impaired mental health among the bereaved spouses of cancer patients
Asai, M., Akizuki, N., Fujimori, M., Shimizu, K., Ogawa, A., Matsui, Y., Akechi, T., Itoh, K., Ikeda, M., Hayashi, R., et al. (2012) · Psycho-Oncology · doi:10.1002/pon.3090 · Cited by 17 · see citing works
“On the other hand, cross-sectional studies reported that negative effects such as anger, sadness, self-blame, and guilt did not decrease among those who had been bereaved for more than 4 years [12,13] and 25% of the bereaved parents had not worked through their grief even 4–9 years after the loss [14].”
BackgroundParent-Reported Experience Measures of Care for Children With Serious Illnesses: A Scoping Review
Ang, F. J. L., Finkelstein, E. A., & Gandhi, M. (2022) · Pediatric Critical Care Medicine · doi:10.1097/pcc.0000000000002996 · Cited by 16 · see citing works
“The death of a child is severely traumatic for parents (45, 46), and some bereaved parents suffer long-term mental and physical health impairment, and increased health service use (47).”
BackgroundOlder adults and companion animal death: A survey of bereavement and disenfranchised grief
Brown, C. A., Wilson, D. M., Carr, E., Gross, D. P., Miciak, M., & Wallace, J. E. (2023) · Human-Animal Interactions · doi:10.1079/hai.2023.0017 · Cited by 16 · see citing works
Helton, G., Morris, S. E., Dole, O. R., Wolfe, J., & Snaman, J. M. (2020) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2020.11.012 · Cited by 16 · see citing works
Self-citationPrognostic indicators for children and young people at the end of life: A Delphi study
Shaw, K. L., Brook, L. A., Cuddeford, L., Fitzmaurice, N., Thomas, C., Thompson, A. M., & Wallis, M. (2014) · Palliative Medicine · doi:10.1177/0269216314521852 · Cited by 16 · see citing works
A Portrait of Self-Reported Health and Distress in Parents Whose Child Died of Cancer
Dumont, É., Bourque, C., Duval, M., Payot, A., & Sultan, S. (2020) · Omega · doi:10.1177/0030222820959943 · Cited by 16 · see citing works
“In fact, a national study conducted in Sweden suggested that 26% of parents had not worked through their grief up to 9 years after their child’s death (Lannen et al., 2008).”
BackgroundResultDead-infant carrying by chimpanzee mothers in the Budongo Forest
Soldati, A., Fedurek, P., Crockford, C., Adue, S., Akankwasa, W., Asiimwe, C., Asua, J., Atayo, G., Chandia, B., Freymann, E., et al. (2022) · Primates · doi:10.1007/s10329-022-00999-x · Cited by 14 · see citing works
“Humans experiencing the loss of socially close individuals undergo significant psychological trauma with long-term physiological effects, including symptoms of post-traumatic stress disorder, anxiety and depression (Figley et al. 1997; Parkes et al. 1997; Lannen et al. 2008).”
Coping strategies in families who lost a child to cancer: A scoping review
Pedraza, E. C., Michel, G., Altherr, A., Hendriks, M. J., & De Clercq, E. (2023) · EJC Paediatric Oncology · doi:10.1016/j.ejcped.2023.100011 · Cited by 14 · see citing works
- Authors
- Lannen, P. K., Wolfe, J., Prigerson, H. G., Onelov, E., & Kreicbergs, U. C.
- Affiliations
- From the Phyllis F. Cantor Center; the Department of Psychooncology and Palliative Care Research; and the Department of Pediatric Oncology and the Center for Outcomes and Policy Research, Dana-Farber Cancer Institute; and the Department of Medicine, Children's Hospital, Boston, MA; the Department of Psychology, Universität Bern, Bern, Switzerland; the Division of Clinical Cancer Epidemiology; and the Department of Women and Child's Health, Karolinska Institutet, Stockholm, Sweden
- University of Bern (CH)
- Venue
- Journal of Clinical Oncology
- Published
- 2008-12-20
- Volume
- 26
- Issue
- 36
- Pages
- 5870-5876
- ISSN
- 0732-183X (ISSN-L)
- 1527-7755
- PMC
- PMC2645112
- OpenAlex
- W2129225171
- Cited by
- 246
- References
- 34
- Citations by year
- 2026: 12 · 2025: 14 · 2024: 13 · 2023: 12 · 2022: 13 · 2021: 24 · 2020: 19 · 2019: 15 · 2018: 19 · 2017: 18 · 2016: 17 · 2015: 14 · 2014: 8 · 2013: 13 · 2012: 13
- FWCI
- 7.81
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Clinical Oncology (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Bern Open Repository and Information System (University of Bern) (submittedVersion)
- Funders
- Charles H. Hood Foundation
- Svenska Sällskapet för Medicinsk Forskning
- National Cancer Institute (K07CA096746)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
- Social Sciences › Anthropology › Death, Funerary Practices, and Mourning
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Keywords
- unresolved grief, parental bereavement, child cancer, bereaved parents, mental health, physical health, sleep disorders, health care utilization, sick leave, grief processing, parents
- MeSH terms
- Adaptation, Psychological, Adolescent, Adult, Bereavement, Fathers, Female, Grief, Health Services, Health Status, Humans, Male, Mental Health, Mothers, Neoplasms, Parents, Surveys and Questionnaires, Sweden, Time Factors
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