Risk Factors for Complicated Grief and Other Negative Bereavement Outcomes
One study  of 248 caregivers of terminally ill cancer patients investigated the presence of predeath complicated grief and its correlates. Results revealed the following variables associated with higher levels of predeath complicated grief:
- Age younger than 60 years.
- Lack of perceived available social support.
- History of depression and current depression.
- Lower income.
- Pessimistic thinking.
- Severity of stressful life events.
Of these correlates, pessimistic thinking and severity of stressful life events were independent predictors of predeath complicated grief.
Other research has focused on predictors of outcomes such as symptoms of depression and overall negative health consequences. Three categories of variables have been investigated:
- Situational (e.g., circumstances of the death).
- Personal (e.g., personality characteristics, gender).
- Interpersonal context (e.g., social support, kinship).
Most research has focused on spousal/partner loss and is not uniquely focused on death via cancer.
Situational: Expected or Unexpected Death
Although theory suggests that a sudden, unexpected loss should lead to more difficult grief, empirical findings have been mixed. The impact of an unexpected loss seems to be moderated by self-esteem and perceived control: Bereaved persons with low self-esteem and/or a sense that life is uncontrollable seem to suffer more depression and somatic complaints after an unexpected death than do bereaved persons with higher self-esteem and/or a sense of control.
Personal: Personality Characteristics
Attachment theory  has suggested that the nature of one’s earliest attachments (typically with parents) predicts how one would react to loss. Bereaved persons with secure attachment styles would be least likely to experience complicated grief, while those with either insecure styles or anxious-ambivalent styles would be most likely to experience negative outcomes.
In a study of 59 caregivers of terminally ill spouses, the nature of their attachment styles and marital quality were evaluated. Results showed that caregivers with insecure attachment styles or in marriages that were "security-increasing" were more likely to experience symptoms of complicated grief. Persons with a tendency toward "ruminative coping," a pattern of excessively focusing on one’s symptoms of distress, have also been shown to experience extended depression after a loss.
Personal: Religious Beliefs
Theory has proposed that strong religious beliefs and participation in religious activities could provide a buffer to the distress of loss, via two different mechanisms:
- A belief system that helps one cope with death.
- A network of social support that comes with religious participation.
However, empirical results about the benefits of religion in coping with death tend to be mixed, some showing positive benefit and others showing no benefit or even greater distress among the religious. Studies that show a positive benefit of religion tend to measure religious participation as regular church attendance and find that the benefit of participation tends to be associated with an increased level of social support. Thus it appears that religious participation via regular church attendance and the resulting increase in social support may be the mechanisms by which religion is associated with positive grief outcomes.
In general, men experience more negative consequences than women do after losing a spouse. Mortality rates of bereaved men and women are higher for both men and women compared to nonbereaved people; however, the relative increase in mortality is higher for men than for women. Men also tend to experience greater degrees of depression and greater degrees of overall negative health consequences than do women after a spouse’s death. Some researchers have suggested that the mechanism for this difference is the lower level of social support provided to bereaved men than that provided to bereaved women.
In general, younger bereaved persons experience more difficulties after a loss than do older bereaved persons. These difficulties include more severe health consequences, grief symptoms, and psychological and physical symptoms. The reason for this age-related difference may be the fact that younger bereaved persons are more likely to have experienced unexpected and sudden loss. However, it is also thought that younger bereaved persons may experience more difficulties during the initial period after the loss but may recover more quickly because they have more access to various types of resources (e.g., social support) than do older bereaved persons.
Interpersonal Context: Social Support
Social support is a highly complex construct, consisting of a variety of components (perceived availability, social networks, supportive climate/environment, support seeking) and measured in a variety of ways. However, as mentioned above, lack of social support is a risk factor for negative bereavement outcomes: It is both a general risk factor for negative health outcomes and a bereavement-specific risk factor for negative outcomes after loss. For example, after the death of a close family member (e.g., spouse), many persons report a number of related losses (often unanticipated) such as the loss of income, lifestyle, and daily routine—all important aspects of social support.
- Tomarken A, Holland J, Schachter S, et al.: Factors of complicated grief pre-death in caregivers of cancer patients. Psychooncology 17 (2): 105-11, 2008. [PUBMED Abstract]
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