1. 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

2. 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

3. 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

4. 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

7. 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. Soc Psychiatry Psychiatr Epidemiol 2014 Rostila M et al. Am J Epidemiol 2012

8. 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

9. 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

10. Results Characteristics of Bereaved and Control Siblings Characteristic Bereaved Siblings Non-bereaved Siblings Relation Brother3616 (49.9%)10,848 (49.9%) Sister3627 (50.1%)10,881 (50.1%) Age of deceased child Mean5.6N/A Median1.4N/A Age of sibling at time of death Mean9.6N/A Median7.8N/A Family income Lowest 2 quintiles4514 (62.3%)13,579 (62.5%) Highest 3 quintiles2651 (36.6%)7957 (36.5%)

11. Results Mental disorder rates, bereaved siblings before and after death P<0.001 P<0.01 % 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

12. Age Age stratified at 13 Significant age interactions observed on several measures The effect of sibling loss was different for adolescents and children

13. Effects on Children vs. Adolescents Mental disorder rates in 2 years after death (relative to a rate of 1 before death) P<0.001 P<0.01 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 *** **

14. Bereaved Adolescent Siblings (Ages 13+) Compared to non-bereaved control siblings Mental Disorders 2 Years Post-Death Adjusted Relative Rate (95% CI) Depression2.27 (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

15. Bereaved Adolescent Siblings (Ages 13+) Compared to non-bereaved control siblings Mental Disorders 2 Years Pre-Death Adjusted Relative Rate (95% CI) 2 Years Post-Death Adjusted Relative Rate (95% CI) Depression1.20 (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)** Any mental disorder 1.23 (1.10-1.39)***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

16. Bereaved Adolescent Siblings (Ages 13+) Compared to non-bereaved control siblings Mental Disorders 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) Depression1.20 (0.97-1.48)<0.00012.27 (1.94-2.65)*** Anxiety disorder 1.16 (0.98-1.37)ns1.35 (1.17-1.54)*** Alcohol use disorder 2.17 (1.51-3.13)***ns2.15 (1.56-2.96)*** Drug use disorder 1.44 (1.13-1.84)**ns1.55 (1.25-1.91)*** Suicide Attempt 1.72 (1.06-2.80)*ns2.01 (1.29-3.12)** Any mental disorder 1.23 (1.10-1.39)***0.0041.48 (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

17. 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?

19. 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

20. Suicide-Bereaved Parents and Non-Bereaved Controls Mental Disorder Consequences

21. Suicide-Bereaved vs. MVC-Bereaved Parents Mental Disorder Consequences p=ns p<0.01

22. 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

23. 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

24. 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