Source: Li J, Laursen TM, Precht DH, et al. Hospitalization for mental illness among parents after the death of a child. N Engl J Med. 2005;352:1190–1196.The authors from the Danish Epidemiology Science Center, University of Aarhus, and Bispebjerg Hospital, Denmark used national registries to identify 1.2 million citizens in Denmark born between 1952 and 1999 who had at least 1 child <18 years of age before 1999 to determine whether death of a child was associated with risk of hospital treatment of a mental disorder for the bereaved parent. Patients with a prior diagnosis of mental illness before the death of a child were excluded.The primary outcome was hospital admission for first-time treatment of a mental illness. Diagnoses of particular interest included affective disorders, substance abuse, and schizophrenia and related disorders. The authors collected information on the year of hospitalization, parent age at the time of the child’s death, parental age when their first child was born, and the number of children in the family. Data on 19,124 parents who died, left the country, or were lost during the study period were censored.The bereaved cohort consisted of 17,033 parents with 11,551,710 person-years of follow-up, during which there were 20,567 first psychiatric admissions. The authors reported that the relative risk for hospitalization for any psychiatric condition among those who lost a child was 1.67 (95% CI, 1.53 to 1.83) compared to parents who had not lost a child. Bereaved mothers had greater risk than fathers (RR 1.78 compared to RR 1.38). Mothers who had lost 2 or more children were more than 3 times as likely to have hospitalized care compared to non-bereaved mothers (RR 3.35; 95% CI 2.26 to 4.97), while fathers were over 2 times as likely to have hospitalized care (RR 2.49; 95% CI, 1.14 to 5.03) compared to non-bereaved fathers.The authors evaluated time after the child’s death and found that the risk of hospital care for affective disorders and schizophrenia was greatest in the year following the child’s death and decreased over time; risk for treatment of substance abuse did not decline for women during the first 4 years after a child’s death. Mothers over 30 years of age at the time of their child’s death tended to have a greater risk for hospitalized psychiatric care than younger mothers; however, a similar pattern was not seen in fathers. The number of surviving children was inversely related to the risk of hospitalized care for a bereaved parent. If an only child died, the relative risk of the mother requiring hospitalized care for an affective disorder was almost 4; however, if the mother had 2 or more surviving children the relative risk was 1.3 compared to women who had not lost a child.Dr. Bratton has disclosed no financial relationships relevant to this commentary.The authors report an important study following a large population for 30 years. As might logically be expected,1 they showed that bereaved parents are at increased risk for inpatient treatment of affective disorders, and the greatest risk is in the first year after the child’s death; however, an increased risk persisted for ≥5 years. The authors also found that inpatient treatment of other illness such as schizophrenia and substance abuse was also greater, and again showed a trend for highest risk in the first year. Mothers generally had higher rates than did fathers, and older women and families with a single child who died also had an increased risk.The authors acknowledge several study limitations such as lack of information regarding social capital, economic status, or family history of mental illness. In addition, the authors evaluated hospitalized care, which underestimates the entire spectrum of mental illness.This study does not allow one to conclude “causation.” For example, children of schizophrenic parents have been shown to have an increased risk of death.2 However, this study clearly points to the need for support services to families who have lost a child to death. Additional studies are needed to determine if the circumstances of the child’s death, such as unexpected acute traumatic death compared to a longer course due to a chronic condition, affect parental stress and mental health differently.3The findings of this study should remind all of us that our role as healthcare providers does not end when a child dies. By continuing to offer support and follow-up to families of our patients who die, we may be the one trusting tie that binds or convinces a family to agree to seek help from counseling services, help they otherwise might not feel they need, but often do.