STUDYING FAMILY MEMBERS
USING ADMINISTRATIVE DATA
James M. Bolton, MD
Associate Professor, University of Manitoba
Departments of Psychiatry, Psychology, Community Health Sciences
Medical Director, WHRA Crisis Response Centre
Research Summer School
Department of Psychiatry
July 14, 2015
Disclosures
• Relationships with commercial interests:
• Grants/Research Support:
• Canadian Institutes of Health Research
• New Investigator Award (113589)
• Brain and Behavior Research Foundation (NARSAD)
• Young Investigator Award
• Speakers Bureau/Honoraria: Nil
• Consulting Fees: Nil
• Other: Nil
Acknowledgments
• Wendy Au BSc
• Dan Chateau PhD
• Randy Walld BSc
• William D. Leslie MSc, MD
• Jessica Enns BSc
• Patricia J. Martens PhD
• Murray Enns MD
• Laurence Y. Katz MD
• Sarvesh Logsetty MD
• Jitender Sareen MD
Strengths of Administrative Data
• Can examine a large number of family members
• Overcomes the sampling bias in many family studies
• People who respond to bereavement surveys may be healthier and
more recovered
• Integrity of diagnoses
• Physician-generated
• Not subject to recall bias
• Can examine longitudinal outcomes
• Representative of the general population
Current State of Knowledge
• Sibling bereavement is understudied
• <25 studies
• Limitations in existing literature
• Small sample sizes
• Selection bias
• Nationwide studies in Sweden
• Increased risk of all-cause mortality after sibling death
• risk of subsequent suicide of the bereaved sibling
• No population studies of non-fatal health outcomes
among bereaved siblings
Rostila M et al. Am J Epidemiol 2012
Rostila M et al. Soc Psychiatry Psychiatr Epidemiol 2014
Objective
• Examine the health outcomes of bereaved siblings in the
general population
• Focus on deaths of people 18 years of age and younger (potentially
more intense grief)
• Adjust for pre-existing health and social confounders
Methods
• Data Sources
• Manitoba Centre for Health Policy (MCHP) data repository
• Vital statistics (mortality), physician billings and hospital discharge
abstracts (disorders and treatment use), census (age, sex, region)
• Health Registry (family linkages: identification of siblings)
• Study Period
• 1984-2009
• Cohort Formation
• All people who died who were <19 years old at time of death and had
a sibling
• Bereaved Siblings (n=7243)
• Bereaved siblings were matched 1:3 with people who were siblings,
had not had a sibling or parent die
• Non-bereave controls (n=21,729)
• Matched on sex, age, age of index sibling, relation of index sibling
(brother/sister), family income level, region of residence
Results
Characteristics of Bereaved and Control Siblings
Bereaved
Siblings
Non-bereaved
Siblings
Brother
3616 (49.9%)
10,848 (49.9%)
Sister
3627 (50.1%)
10,881 (50.1%)
Mean
5.6
N/A
Median
1.4
N/A
Mean
9.6
N/A
Median
7.8
N/A
Lowest 2 quintiles
4514 (62.3%)
13,579 (62.5%)
Highest 3 quintiles
2651 (36.6%)
7957 (36.5%)
Characteristic
Relation
Age of deceased
child
Age of sibling at
time of death
Family income
Results
Mental disorder rates, bereaved siblings before and after death
2 Years Pre-Death
2 Years Post-Death
12
P<0.001
10
8
%
6
P<0.001
P<0.001
4
2
P<0.01
P<0.01
Drugs
ADHD
0
Depression
Anxiety
Alcohol
Any mental
disorder
Rates adjusted for: Number of offspring in the family, sibling relation (brother vs. sister), low income, any physical
disorder, age of child at time of death, age of sibling at time of death
Age
• Age stratified at 13
• Significant age
interactions observed
on several measures
• The effect of sibling
loss was different for
adolescents and
children
Effects on Children vs. Adolescents
Mental disorder rates in 2 years after death (relative to a rate of 1 before death)
Bereaved children <13
Bereaved adolescents 13+
8
7
***
6
5
4
P<0.001
P<0.01
3
2
***
***
***
***
***
**
1
0
Depression
Anxiety
Alcohol
Drugs
Suicide
Attempts
Any mental
disorder
Rates adjusted for: Number of offspring in the family, sibling relation (brother vs. sister), low income, any physical
disorder, age of child at time of death, age of sibling at time of death
Bereaved Adolescent Siblings (Ages 13+)
Compared to non-bereaved control siblings
Mental Disorders
2 Years Post-Death
Adjusted Relative Rate
(95% CI)
Depression
2.27 (1.94-2.65)***
Anxiety
disorder
1.35 (1.17-1.54)***
Alcohol use
disorder
2.15 (1.56-2.96)***
Drug use
disorder
1.55 (1.25-1.91)***
Suicide
Attempt
2.01 (1.29-3.12)**
Any mental
disorder
1.48 (1.35-1.63)***
Rates adjusted for: Number of offspring in the family, sibling relation (brother vs. sister), low income, any physical
disorder, age of child at time of death, age of sibling at time of death
Bereaved Adolescent Siblings (Ages 13+)
Compared to non-bereaved control siblings
2 Years Pre-Death
Adjusted Relative Rate
(95% CI)
2 Years Post-Death
Adjusted Relative Rate
(95% CI)
Depression
1.20 (0.97-1.48)
2.27 (1.94-2.65)***
Anxiety
disorder
1.16 (0.98-1.37)
1.35 (1.17-1.54)***
Alcohol use
disorder
2.17 (1.51-3.13)***
2.15 (1.56-2.96)***
Drug use
disorder
1.44 (1.13-1.84)**
1.55 (1.25-1.91)***
Suicide
Attempt
1.72 (1.06-2.80)*
2.01 (1.29-3.12)**
1.23 (1.10-1.39)***
1.48 (1.35-1.63)***
Mental Disorders
Any mental
disorder
Rates adjusted for: Number of offspring in the family, sibling relation (brother vs. sister), low income, any physical
disorder, age of child at time of death, age of sibling at time of death
Bereaved Adolescent Siblings (Ages 13+)
Compared to non-bereaved control siblings
2 Years Pre-Death
Adjusted Relative Rate
(95% CI)
Pre-post Time Period
X
Sibling Interaction
(p-value)
2 Years Post-Death
Adjusted Relative Rate
(95% CI)
Depression
1.20 (0.97-1.48)
<0.0001
2.27 (1.94-2.65)***
Anxiety
disorder
1.16 (0.98-1.37)
ns
1.35 (1.17-1.54)***
Alcohol use
disorder
2.17 (1.51-3.13)***
ns
2.15 (1.56-2.96)***
Drug use
disorder
1.44 (1.13-1.84)**
ns
1.55 (1.25-1.91)***
Suicide
Attempt
1.72 (1.06-2.80)*
ns
2.01 (1.29-3.12)**
1.23 (1.10-1.39)***
0.004
1.48 (1.35-1.63)***
Mental Disorders
Any mental
disorder
Rates adjusted for: Number of offspring in the family, sibling relation (brother vs. sister), low income, any physical
disorder, age of child at time of death, age of sibling at time of death
Summary
• Losing a sibling is associated with significant mental
illness outcomes within 2 years
• Age of sibling at time of death is important
• Children under the age of 13 have much higher rate increases in
depression
• Bereaved adolescents have a very concerning profile of
mental disorder morbidity compared to non-bereaved
age-matched counterparts
• Adolescents that experience the death of a sibling have
high rates of mental illness even prior to the loss
• Common etiologic links between low income, childhood mortality,
mental disorders?
After the Suicide
of an Offspring
• Compared to the time before the suicide death of their
offspring, in the 2 years that follow, parents have
increased rates of:
• Single marital status
• Adjusted Relative Rate=1.18 (1.13-1.23)
• Depression
• ARR=2.14 (1.88-2.43)
• Anxiety
• ARR=1.41 (1.24-1.60)
• Outpatient physician contacts for mental illness
• ARR=1.91 (1.61-2.26)
Model covariates: deceased child was an only child, parental status (mother vs. father), marital status, poverty, any mental
disorder, any physical disorder, age of child at time of death, age of parent at time of child’s death
Suicide-Bereaved Parents and Non-Bereaved Controls
Mental Disorder Consequences
Pre-Suicide
Control (Pre)
Post-Suicide
Control (Post)
50
40
p<0.001
p<0.01
30
p<0.01
20
10
p=ns
p=ns
0
Depression
Anxiety
Alcohol
Disorders
Drug
Any Mental
Disorders
Disorder
Suicide-Bereaved vs. MVC-Bereaved Parents
Mental Disorder Consequences
Pre-Suicide
Pre-MVC
Post-Suicide
Post-MVC
50
p=ns
40
30
p<0.01
p=ns
20
10
p=ns
p=ns
0
Depression
Anxiety
Alcohol
Disorders
Drug
Any Mental
Disorders
Disorder
Parents of Offspring who Die by Suicide
Pre-Death Observations
• Compared to the parents that will lose an offspring in an
MVC, parents who will lose an offspring to suicide have
higher rates of:
• Depression (ARR=1.30)
• Cardiovascular disease (ARR=1.54)
• COPD (ARR=1.68)
• Hypertension (ARR=1.37)
• Diabetes (ARR=1.45)
• Poverty (ARR=1.34)
• Single marital status (ARR=1.21)
• Hospitalization for physical disease (ARR=1.7)
Model covariates: deceased child was an only child, parental status (mother vs. father), marital status, poverty, any mental
disorder, any physical disorder, age of child at time of death, age of parent at time of child’s death
Synthesis of Findings
• The sudden death of a child has many negative
consequences on parents
• Risk of depression, anxiety, marital break-up
• Alcohol and drugs do not appear to be coping
mechanisms for grieving parents
• This study did not find differences between suicide and
MVC bereavement
• May be related to study design
• Parents of offspring who eventually die by suicide appear
to have health and social vulnerabilities even prior to their
offspring’s death
Limitations of administrative data
• Identification of certain family relations
• Type of relation and age
• Marriages are frequently not registered
• Measures in administrative data
• Capture of suicide deaths
• Certain outcomes are poorly recorded (or not at all)
• PTSD, grief, personality disorders
• Mental and physical disorders are dependent on
treatment-seeking