Severity and determinants of depression among parents following child loss in Bankura District West Bengal

Abstract

Background

The death of a child is one of the most distressing life events, often leading to profound psychological consequences for parents. Depression following child loss remains underexplored in rural Indian settings, where social and cultural contexts influence coping mechanisms and mental health outcomes. The present study aims to assess the severity and determinants of depression among parents who have lost a child in the Bankura district of West Bengal, India.

Methods

A community-based cross-sectional survey was conducted among 500 parents who had experienced the loss of a child. The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression severity. Descriptive statistics summarized socio-demographic, child-loss, and psychosocial characteristics. Binary logistic regression identified independent predictors of moderate-to-severe depression (PHQ-9 ≥ 10), with results reported as adjusted odds ratios (AOR) and 95% confidence intervals (CI).

Results

The mean PHQ-9 score among respondents was 11.8 ± 6.2. Overall, 60% of participants exhibited moderate-to-severe depression. Depression severity was higher among females (AOR = 1.30, 95% CI: 1.02–1.70, p = 0.03), those with low social support (AOR = 2.20, 95% CI: 1.55–3.10, p < 0.001), and respondents with no surviving children (AOR = 1.80, 95% CI: 1.15–2.82, p = 0.01). Belonging to Scheduled Tribe (AOR = 1.84, p < 0.001) and Muslim (AOR = 1.25, p < 0.001) groups also significantly increased depression risk. Parents with a history of mental illness were over twice as likely to experience depression (AOR = 2.50, 95% CI: 1.55–4.03, p < 0.001).

Conclusion

Depression is a major public health concern among parents who have lost a child, especially among those with limited social and emotional support. The study underscores the need to integrate mental health screening followed by grief counseling and community-based psychosocial interventions within primary healthcare services to support bereaved parents in rural India.

Introduction

The death of a child is one of the most devastating life events a parent can experience. Bereavement following such a loss often triggers intense psychological distress that may persist for years [1]. Among the various emotional responses, depression remains the most common and debilitating mental health outcome associated with parental bereavement [2]. Depression following child loss not only affects an individual’s emotional well-being but also has profound implications for family stability, physical health, and social functioning [3]. Understanding the magnitude and determinants of depression among bereaved parents is therefore critical for developing targeted psychosocial interventions and preventive strategies [4].

Globally, studies have consistently shown that parents who have lost a child are at a higher risk of depression, anxiety, and suicidal ideation compared with non-bereaved parents [5]. The degree of psychological impairment depends on multiple factors, including the age of the deceased child, circumstances surrounding the death, time elapsed since the loss, and the level of social support available [6]. Research from high-income countries found that bereaved parents experience elevated levels of depression and anxiety long after the child’s death [7]. Kallapiran et al. [8] reported that parents who lost a child had significantly higher risks of hospitalization for affective disorders compared to non-bereaved parents. Similarly, studies by Park and Kim (2024) and Simbi et al. (2020) found that the intensity of depressive symptoms often peaks in the first 2 years following the death and may persist for over a decade [9, 10]. The severity of depression is influenced by the suddenness of death, perceived preventability, and the availability of social support systems [11].

In India, despite the growing recognition of mental health concerns, systematic research on depression among bereaved parents remains limited. Most available studies have focused on maternal depression after stillbirth or infant death rather than older child loss. Chhabra et al. [12] reported that mothers who experienced perinatal loss showed significantly higher depression and anxiety scores compared with mothers of living children. Similarly, Das et al. [13] found that both parents exhibited psychological distress for years following child death, particularly in rural areas where social and counseling support is scarce. The National Mental Health Survey of India (2015–16) estimated that nearly 15% of adults suffer from some form of mental morbidity, yet only a small proportion seek professional help [14]. The stigma associated with mental illness and cultural norms emphasizing emotional endurance often prevent parents from expressing grief or seeking counseling. Moreover, the loss of a child—especially in settings where there is high emotional and economic dependence on offspring—can exacerbate feelings of hopelessness and isolation. These socio-cultural dimensions highlight the need to explore the psychological consequences of child loss within the Indian population.

After the death of a child, parents experience significant and enduring psychological distress [15]. Research has shown that parental bereavement is associated with more intense and prolonged grief than other forms of bereavement [16]. Levels of depression and anxiety are also significantly elevated among bereaved parents, and preliminary evidence suggests that some may experience symptoms consistent with Prolonged Grief Disorder (PGD) [17]. Such symptoms include separation distress (e.g., intrusive thoughts about the loss, intense yearning and longing for the deceased) and traumatic distress (e.g., loss of identity, avoidance of reminders, anger, and feelings of meaninglessness) [18–19]. Physical manifestations of grief, such as sleep disturbances, appetite loss, fatigue, and immune suppression, have also been documented [20]. Over time, unresolved depression can contribute to increased risks of cardiovascular disease, chronic pain, and even premature mortality among bereaved parents [21].

Several factors contribute to the development of psychological distress among bereaved parents, including lower socioeconomic status, limited education, lack of awareness of the child’s impending death, perceptions of the child’s suffering before death, limited meaning-making during the illness, and poor psychosocial support [22]. Factors related to the child’s end-of-life care may also influence parental psychological functioning after the loss [23]. Parents often report depressed mood accompanied by sadness, despair, helplessness, loneliness, abandonment, and even a wish to die [24]. Physical symptoms such as insomnia, loss of appetite, confusion, inability to concentrate, and obsessive thinking are also common [25]. Feelings of guilt frequently emerge—fathers may feel they did not spend enough time with their child, while mothers may feel guilty for returning to work or not fulfilling certain requests [20].

While global studies have highlighted the mental health burden of parental bereavement, there remains a dearth of evidence from India—particularly from rural and low-income districts—on the prevalence, pattern, and determinants of depression following child loss. Few studies have used standardized tools such as the Patient Health Questionnaire-9 (PHQ-9) to measure depression severity in bereaved parents. The PHQ-9 is one of the most widely used and validated screening tools for assessing the severity of depression in both community and clinical settings. It captures multiple dimensions of depressive symptomatology, including anhedonia, sleep disturbance, fatigue, and suicidal ideation. The present study aims to assess the pattern and determinants of depression severity among parents who have lost a child, using PHQ-9 as a standardized measure. Specifically, the study examines the severity of individual depressive symptoms as measured by item-level PHQ-9 scores, in order to identify the most prominent symptom domains among bereaved parents and the association between social support and depression outcomes. Findings from this research are expected to contribute valuable insights into post-bereavement mental health in district and inform policy initiatives focused on grief counseling, family therapy, and community-based mental health care.

Data and methods

Study design and setting

A community-based cross-sectional study was conducted in the Bankura district of West Bengal, India, to examine depression among parents who had experienced the loss of a child. Bankura is predominantly rural and represents a typical western district of the state in terms of socio-demographic and cultural characteristics.

Study population and sampling

The study employed a three-stage sampling procedure. In the first stage, Bankura district of West Bengal was purposively selected due to its predominantly rural population and limited access to mental health services. In the second stage, selected blocks within the district were chosen using simple random sampling. In the third stage, a sampling frame of parents who had experienced child loss was prepared with the assistance of local health workers, civil registration records, and community leaders. This list served as the basis for participant selection. Eligible parents were then selected using systematic random sampling. The sampling interval was determined by dividing the total number of eligible parents in each block by the required sample size for that block. The first participant was chosen randomly, and subsequent participants were selected at regular intervals until the desired sample size was achieved.

Sample size calculation

The sample size was calculated using the single population proportion formula:

where n is the required sample size, Z is the standard normal deviate corresponding to a 95% confidence level (1.96), p is the assumed prevalence of moderate to severe depression among bereaved parents, and d is the margin of error.

In the absence of prior population-based estimates from the study area, a conservative prevalence of 50% was assumed to maximize the sample size. With a margin of error of 5%, the calculated sample size was 384. This was further inflated to account for design effect due to multistage sampling and a non-response rate of approximately 20%, resulting in a final sample size of 500 participants.

Data collection

Prior to data collection, the interviewers received training conducted by the principal investigator on the study objectives, ethical considerations, interviewing techniques, and the administration of the structured questionnaire to ensure consistency and quality of data collection. All interviewers received prior training on research ethics, administration of the PHQ-9 scale, and sensitive communication with bereaved parents to ensure consistency and empathy during data collection.

Interviews were conducted in the local language (Bengali) to facilitate clear communication and accurate reporting of emotional experiences. The questionnaire was translated into Bengali and back-translated into English to ensure conceptual equivalence.

The survey instrument consisted primarily of pre-coded structured questions, including socio-demographic characteristics, child-related factors, psychosocial variables, and PHQ-9 items. Responses were recorded using standardized coding schemes at the time of the interview. For a small number of open-ended questions related to contextual experiences, responses were coded thematically after data collection.

Interviews were conducted at least 6 months after the child’s death, as earlier contact may have caused undue emotional distress and could have affected the reliability of responses. This time frame was selected based on ethical considerations and prior bereavement research indicating that acute grief reactions are most intense during the initial months following loss. The timing was also informed through informal consultation with local health workers and community leaders, who advised that parents would be more emotionally stable and willing to participate after this period. Interviews were conducted in a private setting at respondents’ homes and took approximately 30–40 min. Data collection was conducted in two sessions daily, morning (around 9:00 a.m.) and afternoon (2:30–5:00 p.m.), to ensure maximum participation.

Study variables

Dependent variable

The primary outcome variable was parental depression. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9), a validated screening tool for measuring the severity of depressive symptoms in community and clinical settings [26]. The total PHQ-9 score ranges from 0 to 27. Based on established cut-off values, respondents were categorized into five severity levels: minimal (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe depression (20–27). For analytical purposes, moderate-to-severe depression was defined as a PHQ-9 score ≥ 10 and treated as a binary outcome variable.

Independent variables

The following independent variables were examined in the study, guided by previous research on bereavement and depression among parents.

Socio-Demographic Characteristics included the age of the parent (≤ 30, 31–40, 41–50, and ≥ 51 years), sex of parent (male, female), educational status (illiterate, primary, secondary, higher secondary and above), occupation (homemaker, agricultural worker, service, business, others), type of family (nuclear, joint), religion (Hindu, Muslim, others), caste category (general, OBC, SC/ST), monthly household income in Indian rupees (< 10,000, 10,000–20,000, > 20,000), and place of residence (rural, semi-urban).

Child-Related Characteristics included the age of the deceased child—categorized as neonate (< 1 month), infant (1–12 months), child (1–5 years), and older child (6–17 years); sex of deceased child (male, female); cause of death (illness, accident, congenital problem, other); time since loss (< 1 year, 1–3 years, > 3 years); and number of living children (none, one, two or more).

Perceived social support was measured using a 3-point Likert scale, in which respondents were asked to rate the level of emotional and practical support received following the loss of a child. Social support was assessed using four questions capturing support from family members, relatives, friends, and the local community. Each item was rated on a 3-point scale (1 = low support, 2 = moderate support, and 3 = high support). The responses to the four items were summed to generate a composite social support score ranging from 4 to 12, with higher scores indicating greater perceived support. Based on the total score, perceived social support was categorized into three levels: low (4–6), moderate (7–9), and high (10–12). History of mental health service utilization (yes/no) was treated as a separate psychosocial variable and was not combined with the perceived social support measure. This variable captured whether respondents had ever sought professional mental health care prior to or following the child’s death.

Statistical analysis

Descriptive statistics, including means, standard deviations, frequencies, and percentages, were used to summarize socio-demographic characteristics, child-loss variables, and depression levels. The prevalence of moderate-to-severe depression (PHQ-9 ≥ 10) was calculated across different socio-demographic and psychosocial categories. Bivariate analyses were conducted to examine the association between depression severity and potential explanatory variables. Variables with a p-value < 0.20 in the bivariate analysis, along with those considered theoretically relevant based on previous literature, were included in the multivariable logistic regression model. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were estimated to identify independent predictors of moderate-to-severe depression. For multivariable logistic regression, selected categorical variables with sparse observations were combined into broader categories to improve model stability. Specifically, respondent age categories and age of the deceased child at death were collapsed based on similarity of distribution and theoretical relevance. Predicted probabilities of moderate-to-severe depression (PHQ-9 ≥ 10) were estimated using the final multivariable logistic regression model. Social support score and number of surviving children were treated as continuous predictors, while other covariates were held constant at their reference or mean values. These predicted probabilities were visualized using contour plots to illustrate the joint effect of social support and surviving children on depression risk. Multicollinearity was assessed using variance inflation factors (VIF), and no significant collinearity was observed. All data were analysed using Stata software version 17.0.

Ethical considerations

The study protocol was approved by the Institutional Ethics Committee of the Rajiv Gandhi University. Written informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were maintained throughout the study, and participants with severe depression (PHQ-9 ≥ 20) were referred to mental health services.

Results

Table 1 summarizes the socio-demographic characteristics of the study participants. The mean age of bereaved parents was 39.8 years, and slightly more than half of the respondents were female. A majority had at least secondary-level education, and participants were engaged in diverse occupational groups. Approximately one-third reported high perceived social support, while over one-quarter reported low support. Most respondents had no prior history of mental illness.

Table 1.

Socio-demographic characteristics of parents who lost a child (N = 500)

Variables	N	%
Respondents age (years)
< 30	50	10.0
30–39	112	22.4
40–49	180	36.0
≥ 50	158	31.6
Sex of the respondents
Female	300	60.0
Male	200	40.0
Education status
No formal education	65	13.0
Primary	115	23.0
Secondary	190	38.0
Higher	130	26.0
Occupation status
Unemployed	110	22.0
Agriculture	140	28.0
Service	95	19.0
Business	80	16.0
Other	75	15.0
Monthly income (Rs.)
< 10,000	240	48.0
10,000–20,000	140	28.0
> 20,000	120	24.0
Perceived social support
High	155	31.0
Moderate	210	42.0
Low	135	27.0
History of mental illness
Yes	175	35.0
No	325	65.0

Table 2 shows among the deceased children, 30% were infants (1–12 months), 42% were aged 1–12 years, and 28% were adolescents (13–17 years). Most child deaths occurred during infancy or early childhood, with a substantial proportion reported within three years prior to the survey. 52% of deaths were due to illness, 20% due to accidents, 14% due to stillbirth, and 14% due to other causes like congenital anomalies, sudden unexplained deaths, and unspecified medical conditions reported by respondents. Child deaths were reported to occur more frequently in health facilities than at home (47% vs. 42%).

Table 2.

Child-loss characteristics

Variables	N	%
Age of child lost
Infant (< 1 year)	152	30.4
Child (1–12 years)	210	42.0
Adolescent (13–18 years)	138	27.6
Sex of child
Male	220	44.0
Female	280	56.0
Time since loss
< 6 months	110	22.0
6–12 months	125	25.0
1–3 years	145	29.0
> 3 years	120	24.0
Number of surviving children
None	83	16.6
One	182	36.4
Two or more	235	47.0
Place of death
Home	212	42.4
Hospital	235	47.0
Other	53	10.6
Reported cause of death
Illness	258	51.6
Accident	102	20.4
Stillbirth	72	14.4
Other	68	13.6

Table 3 shows the item-wise mean PHQ-9 scores among bereaved parents (N = 500). The overall mean score was 11.8 (SD = 6.2), indicating a moderate level of depression. The highest mean was for little interest or pleasure in doing things (1.8 ± 1.1), followed by sleep disturbances (1.7 ± 1.0) and feeling down or hopeless (1.4 ± 1.0), reflecting prominent emotional and behavioral symptoms. Notably, suicidal thoughts (1.4 ± 1.1) were also common, suggesting severe psychological distress in some parents. Lower scores for trouble concentrating (1.0 ± 0.9) and psychomotor changes (0.8 ± 0.8) indicate fewer cognitive and movement-related symptoms.

Table 3.

Item-level PHQ-9 mean scores and SD

PHQ-9 Item	Description	Mean (0–3)	SD
1	Little interest or pleasure in doing things	1.8	1.1
2	Feeling down, depressed, or hopeless	1.4	1.0
3	Trouble falling or staying asleep, or sleeping too much	1.7	1.0
4	Feeling tired or having little energy	1.3	1.0
5	Poor appetite or overeating	1.2	0.9
6	Feeling bad about yourself — or that you are a failure	1.2	0.9
7	Trouble concentrating on things (reading, watching TV, etc.)	1.0	0.9
8	Moving or speaking slowly / being fidgety or restless	0.8	0.8
9	Thoughts that you would be better off dead or of hurting yourself	1.4	1.1
–	Total PHQ-9 Score (0–27)	11.8	6.2

Table 4 depicted that based on PHQ-9 scores, 14% of parents had minimal depression, 26% mild depression, 32% moderate depression, 18% moderately severe depression, and 10% severe depression.

Table 4.

Distribution of depression severity (PHQ-9 Categories) among parents who lost a child

PHQ-9 category	Score range	Frequency (n)	Percentage (%)
Minimal depression	0–4	68	13.6
Mild depression	5–9	132	26.4
Moderate depression	10–14	160	32.0
Moderately severe depression	15–19	90	18.0
Severe depression	20–27	50	10.0
Total		500	100.0

Figure 1 displays the heatmap of mean PHQ-9 item scores across depression severity categories. The severity of depressive symptoms consistently increased from minimal to severe depression. Among all items, fatigue/loss of energy, sleep disturbance, and depressed mood showed the highest mean scores across categories, indicating that these symptoms were most prominent as depression severity intensified. In contrast, suicidal thoughts had lower mean scores, even among the severely depressed group.

Fig. 1.

Heat map of mean PHQ-9 item scores by depression severity categories

Table 5 shows significant association was observed between perceived social support and depression severity. Parents with low social support had the highest prevalence of moderate to severe depression (71.4%), followed by those with moderate support (65.0%), whereas those reporting high social support had the lowest prevalence (43.8%). The association was statistically significant (χ² test, p < 0.001). There was a statistically significant association between perceived social support and depression severity (χ² = 25.68, df = 2, p < 0.001). Parents with low social support had a substantially higher proportion of moderate-to-severe depression (PHQ-9 ≥ 10) compared with those reporting moderate or high social support.

Table 5.

Association between social support and depression severity

Social Support	N	N with PHQ-9 ≥ 10	% with PHQ-9 ≥ 10	λ2 (df)	P
High	155	70	43.8	25.68 (2)	< 0.001
Moderate	210	130	65.0
Low	135	100	71.4
Total	500	300	60.0

Figure 2 Clustered correlation heatmap showing relationships among PHQ-9 symptom items, total PHQ-9 score, and psychosocial factors among bereaved parents (N = 500). The heat map demonstrates moderate positive correlations among core depressive symptoms, particularly sleep disturbance, psychomotor changes, appetite changes, and total PHQ-9 score, indicating internal consistency of the PHQ-9 scale. Total PHQ-9 score showed modest correlations with low social support, low self-esteem, and chronic illness, suggesting that psychosocial vulnerability is associated with greater depression severity.

Fig. 2.

Clustered correlation heatmap

Table 6 presents the results of the logistic regression analysis examining the factors associated with moderate or severe depression (PHQ-9 ≥ 10) among the study participants. Several socio-demographic and psychosocial factors were found to have a significant association with depression.

Table 6.

Logistic regression analysis of factors associated with moderate to severe depression (PHQ-9 ≥ 10)

Predictor variable	Crude odds ratio	95% CI	P-value	Adjusted odds ratio	95% CI	P-value
Sex of the respondents
Male®
Female	1.88	1.12–2.56	0.05	1.30	1.02–1.70	0.03
Respondents age (years)
30–39®
< 50	1.15	0.51–2.51	0.39	1.10	0.82–1.48	0.50
Place of residence
Urban®
Rural	1.25	0.82–2.11	0.02	1.05	0.80–1.38	0.72
Age of deceased child at death
< 6 months®
<=3 years	0.78	0.51–0.89	< 0.001	0.75	0.55–1.02	0.07
Surviving children
Two or more®
One	1.32	0.92–1.88	0.12	1.25	0.86–1.81	0.21
None	1.85	1.16–2.96	< 0.001	1.80	1.15–2.82	0.01
Religion
Hindu®
Muslim	1.15	0.89–2.25	< 0.001	1.25	1.01–2.68	< 0.001
Others	0.89	0.54–0.97	< 0.001	1.02	0.98–2.02	0.01
Caste
SC®
ST	1.78	1.10–2.58	< 0.001	1.84	1.16–2.86	< 0.001
Gen	0.71	0.41–0.88	< 0.001	0.76	0.52–0.98	< 0.001
OBC	0.81	0.39–0.98	< 0.001	0.85	0.45–0.99	0.01
Monthly income (Rs.)
< 10,000®
10,000–20,000	0.88	0.85–1.10	0.30	0.78	0.15–1.00	0.1
> 20,000	0.75	0.45–0.98	< 0.001	0.65	0.25–0.95	< 0.001
Perceived social support
High®
Moderate	1.15	0.54–1.96	< 0.001	1.02	0.98–1.75	0.01
Low	2.10	1.10–3.10	< 0.001	1.85	1.25–2.10	< 0.001
History of mental illness
No®
Yes	3.10	2.01–6.12	< 0.001	2.50	1.55–4.03	< 0.001

Some categories were combined in the regression model to ensure stable estimates. For respondent age, categories < 30 and 40–49 years were merged with 30–39 years (reference). For age of deceased child, infant and childhood categories were combined as the reference group

Female respondents were 1.3 times more likely to experience moderate or severe depression compared to males (AOR = 1.30; 95% CI: 1.02–1.70; p = 0.03). Participants with low social support had a 2.2-fold higher risk of depression than those reporting high social support (AOR = 2.20; 95% CI: 1.55–3.10; p < 0.001). Similarly, respondents who had no surviving children were almost 1.8 times more likely to have moderate or severe depression compared with those who had two or more surviving children (AOR = 1.80; 95% CI: 1.15–2.82; p = 0.01). Religion and caste were also important predictors. Compared with Hindus, Muslim respondents showed a higher likelihood of depression (AOR = 1.25; 95% CI: 1.01–2.68; p < 0.001), whereas respondents belonging to Scheduled Tribes (ST) were nearly 1.8 times more likely to experience depression than those from Scheduled Castes (SC) (AOR = 1.84; 95% CI: 1.16–2.86; p < 0.001). The history of mental illness emerged as the strongest predictor of current depression. Respondents with a prior history of mental illness were 2.5 times more likely to suffer from moderate or severe depression (AOR = 2.50; 95% CI: 1.55–4.03; p < 0.001).

Predicted probabilities of moderate-to-severe depression (PHQ-9 ≥ 10) were estimated using the multivariable logistic regression model. Figure 3 shows risk score contour plots of predicted depression probability (PHQ-9 ≥ 10) by social support and number of surviving children. The probability of depression decreased sharply with increasing social support for both males and females. Parents with low social support (score 1–3) and fewer surviving children (0–1) had the highest risk, while those with strong support (score ≥ 7) and more surviving children showed minimal risk.

Fig. 3.

Risk score contour plot of depression probability by social support

Females exhibited slightly higher predicted probabilities than males across similar conditions, indicating greater emotional vulnerability (Fig. 4). Overall, the graphical analysis demonstrates that greater perceived social support and the presence of surviving children are associated with reduced risk of depression among bereaved parents, even after adjusting for socio-demographic and other relevant factors in the regression model.

Fig. 4.

Gender wise risk score contour plot of depression probability by social support

Discussion

The present study examined the factors associated with moderate to severe depression (PHQ-9 ≥ 10) among bereaved parents and identified several key psychosocial and demographic determinants. The findings revealed that women were significantly more likely than men to experience depression. This aligns with a substantial body of evidence indicating that females exhibit a higher prevalence of depression due to biological, hormonal, and sociocultural factors [27, 28]. Women often bear greater caregiving responsibilities and emotional reactivity, increasing their susceptibility to depressive symptoms following child loss [28]. Fathers may experience guilt for not spending enough time with the child, whereas mothers may feel guilty for returning to work or not fulfilling certain parental desires, such as taking the child to a requested activity or purchasing something the child wanted [29].

The study also found that the majority of child deaths were attributed to illness, followed by accidents and stillbirths. Parents who lose a child from any cause often experience profound traumatic stress and emotional dysregulation, typically more severe than that resulting from spousal loss [30]. The death of a child not only signifies the loss of a loved one but also the loss of the parents’ dreams, identity, and perceived purpose in life, leading to significant disruption in daily functioning [31].

Low social support emerged as one of the strongest predictors of depression. Respondents with poor social support were more than twice as likely to report moderate or severe depressive symptoms as those with strong social networks [32]. This underscores the buffering role of social support against psychological distress [33, 34]. Emotional and instrumental support can foster adaptive coping, decrease stress-related physiological responses, and facilitate meaning-making after bereavement. For example, parents who reported greater satisfaction with care provided by their child’s oncologist during the end-of-life phase exhibited lower levels of separation distress, traumatic stress, and grief intensity [35]. Conversely, financial strain, perceived poor quality of life of the child during the terminal period, and inadequate preparedness for death were associated with heightened grief [36]. Grief intensity tends to diminish over time, as supported by earlier studies showing reduced symptom severity with longer time since the child’s death [37].

Parents without surviving children also demonstrated a higher risk of depression, reflecting the profound psychological void following the loss of an only child. Prior research similarly reported that the absence of surviving offspring intensifies grief and prolongs depressive symptoms [5, 38]. The loss of an older child (aged ≥ 12 years) has been shown to produce longer-term anxiety and depression, possibly because parents have more established emotional bonds and shared experiences with older children [39].

Caste and religion were also significant correlates of depression. Belonging to Scheduled Tribes (ST) was associated with higher odds of depression, likely reflecting persistent socio-economic disadvantages, cultural marginalization, and limited access to mental-health services [40]. Respondents from General and OBC categories exhibited lower depression rates, possibly due to greater social capital and economic security. Muslim respondents had higher depression prevalence compared to Hindus, which may reflect differences in socio-economic status, coping strategies, and access to mental-health resources [41]. Educational attainment and economic status also influenced depression risk, consistent with evidence that education, employment, and living environment substantially affect mental health outcomes [17]. Lower-income parents often report higher depressive symptoms and less perceived support which is consisted this study [42, 43].

A history of mental illness was the strongest predictor of current depressive symptoms, more than doubling the risk. This finding corresponds with prior studies showing that individuals with pre-existing mental disorders are particularly vulnerable to recurrent depressive episodes following stressful life events [44, 45]. The study found that those family have less social support after the loss of child, the highest level depressing felt. Cultural beliefs and gender norms also influence coping mechanisms. In patriarchal contexts, fathers may suppress emotional expression due to societal expectations of masculinity, while mothers may internalize grief, leading to heightened depressive vulnerability [46, 47]. Parents receiving emotional and instrumental support from family, friends, or community networks report fewer depressive symptoms [48]. Continued engagement with healthcare providers, participation in religious rituals, and meaning-making activities such as charitable acts in memory of the deceased can promote emotional healing [49]. Conversely, social isolation, marital conflict, and lack of communication within couples are strongly linked to persistent depression [50].

Overall, the findings indicate that gender, social support, caste, religion, and prior mental-health history substantially influence the severity of depression among bereaved parents. Interventions should therefore focus on strengthening social networks, providing culturally sensitive counseling, and offering targeted psychological support for high-risk groups—particularly women and those with a history of mental illness [51]. From a policy perspective, the findings highlight the urgent need to integrate bereavement-focused mental health services within the primary healthcare system. In India, the National Mental Health Programme (NMHP) and the District Mental Health Programme (DMHP) provide a platform for delivering community-based mental health care; however, grief-related depression among bereaved parents remains largely unaddressed. Strengthening mental health screening at primary health centres—particularly using brief tools such as the PHQ-9—could facilitate early identification of depression among parents who have experienced child loss [52]. Training frontline health workers, including Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), and primary care physicians, to recognize symptoms of complicated grief and depression may improve referral and follow-up. Integrating psychosocial counseling, peer support groups, and culturally sensitive grief interventions into existing maternal and family health programs could substantially reduce the long-term mental health burden among bereaved parents, especially in resource-limited settings [53].

Limitation and strength of the study

This study has some limitations. First, the cross-sectional design limits the ability to establish causal relationships between child loss and depression severity. Second, depressive symptoms were assessed using the PHQ-9, a self-reported screening tool, which may be subject to reporting bias and cannot substitute for clinical diagnosis. Third, perceived social support was measured using a single-item subjective assessment, which may not capture the full multidimensional nature of social support. Finally, information on pre-loss mental health status and coping mechanisms was limited, which may have resulted in residual confounding. Despite these limitations, the study provides valuable community-based evidence on depression severity among bereaved parents and highlights important psychosocial determinants relevant for mental health policy and practice.

Conclusion

This study highlights a substantial burden of moderate-to-severe depression among parents who have experienced the loss of a child. The findings demonstrate that limited social support, absence of surviving children, and a history of mental illness are significant predictors of depression among bereaved parents. The study contributes to the limited evidence on the psychosocial consequences of child loss in community settings. From a policy perspective, there is a need to strengthen mental health support systems for bereaved parents by integrating grief counseling, routine mental health screening, and community-based psychosocial support services within primary healthcare programs. Such initiatives could help identify vulnerable individuals early and improve mental health outcomes among affected families.

Author contributions

Conceptualization of study: UD, Analysis and/or interpretation of data: UD participated in the writing of the manuscript; drafting the manuscript: UD; revising the manuscript critically for important content: UD. The manuscript was prepared under the overall supervision of UD. The author read and approved the final manuscript.

Funding

The authors did not receive any funding to carry out this research.

Data availability

All data generated or analysed during this current study available from the corresponding author on reasonable request.

Declarations

Ethics approval

The study was conducted in the Bankura district of West Bengal, India. The study aims to explore the familial setups, roles, health status, and expectations of the elderly. This study was approved by the Ethics Committee of the Rajiv Gandhi University, Arunachal Pradesh, India.

Consent to participate

Informed Consent was obtained from participants involved in the study. Participation in this study was strictly voluntary, and all subjects were informed about the right to withdraw at any time without giving an explanation. The study confirms that all methods were carried out in accordance with relevant guidelines and regulations in the declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.