Bereavement after sibling death: a population‐based longitudinal case‐control study

Abstract

The objective of this study was to examine mental disorders and treatment use among bereaved siblings in the general population. Siblings (N=7243) of all deceased children in the population of Manitoba, Canada who died between 1984 and 2009 were matched 1:3 to control siblings (N=21,729) who did not have a sibling die in the study period. Generalized estimating equations were used to compare the two sibling groups in the two years before and after the index child's death on physician‐diagnosed mental disorders and treatment utilization, with adjustment for confounding factors including pre‐existing mental illness. Analyses were stratified by age of the bereaved (<13 vs. 13+). Results revealed that, in the two years after the death of the child, bereaved siblings had significantly higher rates of mental disorders than control siblings, even after adjusting for pre‐existing mental illness. When comparing the effect of a child's death on younger versus older siblings, the rise in depression rates from pre‐death to post‐death was significantly higher for siblings aged under 13 (p<0.0001), increasing more than 7‐fold (adjusted relative rate, ARR=7.25, 95% CI: 3.65‐14.43). Bereaved siblings aged 13+ had substantial morbidity in the two years after the death: 25% were diagnosed with a mental disorder (vs. 17% of controls), and they had higher rates of almost all mental disorder outcomes compared to controls, including twice the rate of suicide attempts (ARR=2.01, 95% CI: 1.29‐3.12). Siblings in the bereaved cohort had higher rates of alcohol and drug use disorders already before the death of their sibling. In conclusion, the death of a child is associated with considerable mental disorder burden among surviving siblings. Pre‐existing health problems and social disadvantage do not fully account for the increase in mental disorder rates.

Most children have a sibling1. While fertility rates are lower in Western nations and family sizes have diminished in recent decades, the majority of households with children in the U.S. in 2010 had two or more children2. Each year more than 40,000 children and adolescents die in the U.S., leaving a substantial number of bereaved siblings3.

Sibling bereavement is an experience with a very sparse literature and thus the consequences of losing a sibling are unclear. A series of Swedish national cohort studies revealed increased mortality of bereaved siblings when compared to non‐bereaved controls4, 5, 6, 7, 8. These analyses, however, were restricted to adult sibling populations and did not examine outcomes other than death.

Other smaller studies have examined bereavement experiences related to specific causes of sibling death, namely cancer and suicide, with mixed findings9, 10, 11, 12. One study of cancer‐related bereavement showed no differences in anxiety and depression between bereaved and non‐bereaved siblings13, while other descriptive case series found anxiety, substance misuse, depression, and social difficulties among bereaved siblings14, 15, 16.

Taken together, the extant literature suggests that sibling bereavement is an emotionally damaging experience and may result in premature death. However, the vast majority of studies are limited by sampling bias and small numbers of subjects, and many lack a control group. As such, the true impact of losing a sibling remains unknown.

The current study sought to extend the understanding of this experience by examining, for the first time, the mental health outcomes of bereaved siblings in the general population. Furthermore, by focusing on siblings of decedents who were under age 18 and examining relatively short time frames (two years before and after the death), it was designed to capture emotional consequences in the period of acute grief among siblings who were likely still living in the same dwelling as the deceased child.

Through the use of validated physician‐generated diagnoses, non‐bereaved matched controls, longitudinal follow‐up, and a representative dataset of a population with universal access to free medical care, this study was able to overcome many of the limitations of prior research. We hypothesized that bereaved individuals would have elevated rates of depression and anxiety within two years following the death of their sibling when compared to controls and to pre‐death rates.

METHODS

Data sources

The data in this study were drawn from the Population Health Research Data Repository at the Manitoba Centre for Health Policy at the University of Manitoba in Canada. The repository contains health, Census, Vital Statistics, and other social databases for the 1.2 million residents in the province of Manitoba. Individual‐level data are linked through these datasets by a personal health information number that is scrambled to ensure anonymity. Linkage accuracy in the databases is excellent17.

The following data sources were included in this study: physician claims (providing diagnoses for mental and physical disorders from virtually all physician contacts), hospital discharge abstracts (inpatient admission contacts and disorders), population registry (age, sex, region of residence, specification of family structure), Statistics Canada Census data (income quintile), and Vital Statistics (mortality data).

Manitoba provides universal free medical care to all residents, and thus virtually all persons in the population are included in the datasets; exceptions include active military personnel and incarcerated persons. The study period was 1984‐2009, based on completeness of the available data for that period, and was approved by the University of Manitoba research ethics board.

Cohort formation

Figure 1 presents a flowchart that describes how the cohort of bereaved siblings was composed. All children under the age of 18 who died in Manitoba during the study period were identified from the Vital Statistics dataset. If several children in a family died, only the first was included in the study and considered the index death. Using the shared family registration number, only decedents with a sibling at time of death were included in the study.

Figure 1.

Development of bereaved sibling cohort

Seven thousand four hundred bereaved siblings were identified. Siblings who died during the same index event (e.g., a house fire) or within 90 days of the index death were excluded (N=104), along with siblings who suffered the death of a parent during or within 90 days of the index event (N=53). This resulted in a bereaved cohort of 7,243 siblings. Of this group, 59 had lost multiple siblings in the same index event. In families where there was more than one surviving sibling, all were included in the bereaved sibling cohort.

These bereaved siblings were matched 1:3 to non‐bereaved siblings based on sex and age at date of death (date of death=index date), relation (brother, sister), age (±3 years), family income quintile, and region of residence at the index date. Control siblings were excluded if they had suffered the loss of a sibling or parent at any point between 1984 and two years after the index date, or if they died within 90 days of the index date. There were 21,729 non‐bereaved siblings included in analyses.

Outcomes of interest

Mental disorders

The conditions of interest included depression (unipolar and bipolar), anxiety disorders, alcohol use disorders, drug use disorders, attention deficit hyperactivity disorder (ADHD), and suicide attempts. “Any mental disorder” included all people who met criteria for any of the above disorders. These disorders were defined using ICD‐9 Clinical Modification (ICD‐9‐CM) and ICD‐10 Canada (ICD‐10‐CA) codes derived from inpatient hospital discharge abstracts and outpatient physician billing records, and were coded using previously validated disorder definitions18.

Based on previous work, the time periods for calculating the rates of these disorders were the two years prior to index date and the two years after index date19.

Health service utilization

There were four types of health service use examined. These included two measures of outpatient services (outpatient physician visits for mental health or for any reason) and two measures of inpatient admissions (hospitalization for mental health or for any reason).

Rates of each type of service use were based on the total sum of contacts within each sibling group during each time period of interest. Hospitalization was based on spending more than one day in hospital and did not include hospitalization for birth.

Covariates

The following variables were included as covariates: whether the bereaved sibling was the only remaining offspring in the family (vs. 2+ remaining offspring), sibling sex (brother, sister), sibling marital status (married, single), low income, age of index child at time of death (0‐4, 5‐17), age of sibling at time of index child's death (0‐4, 5+), presence of any previously diagnosed mental disorder (yes, no), and presence of any previously diagnosed physical disorder (yes, no).

Physical conditions examined in this study included cardiovascular disease, cancer, asthma, and diabetes. Validated definitions from previous studies were used to establish physical disease presence20.

Family income level was calculated by aggregating household income based on dissemination areas in Census data, and then grouping them into five income quintiles (1 being poorest and 5 being wealthiest)21. Each quintile contains approximately 20% of the population. Individuals who could not be assigned an income quintile from Census data were assigned to the unknown group (e.g., people in prison). Low income was defined as quintiles 1 and unknown (vs. the remaining four quintiles combined as the reference group).

Statistical analysis

Analyses were conducted using SAS version 9.3. Chi‐square tests were used to compare characteristics of bereaved and non‐bereaved sibling controls across demographic and social measures. Outcomes of interest were compared using adjusted relative rates (ARR) obtained from a generalized estimating equation model using negative binomial or Poisson distributions.

The initial set of analyses examined only bereaved siblings, comparing rates of outcomes in the two years after the death of the index child to rates in the two years before the death. Based on disorder rate differences in children and adolescents, an interaction term for age (13+ vs. <13) by time period (post‐ vs. pre‐death) was introduced in the model. Significance of the interaction term guided the need for age‐stratified analyses.

The second set of analyses compared bereaved and non‐bereaved siblings on outcome rates across time periods (post‐index date vs. pre‐index date). These analyses were likewise stratified by age. An interaction term of sibling group (bereaved vs. non‐bereaved) by time period (pre‐index date vs. post‐index date) was included in the models as a method to account for rates in the pre‐index date period. The interaction between sibling groups across the time periods effectively compares the rate changes between the two groups across time, therefore controlling for conditions present prior to the death/index date.

Relative rates in all analyses were adjusted for the above‐listed covariates, conditionally entered into models based on the outcome of interest and model fit.

RESULTS

The characteristics of the children decedents and siblings are provided in Table 1. Of the 7,243 siblings of interest, there was an almost equal split of bereaved brothers and sisters. The majority of bereaved siblings (and hence income‐matched controls) were from financially disadvantaged families, with 3,102 (43%) being in the lowest income quintile. Sixty‐two percent (N=1,961) of the deceased children died under the age of 5, with a median age of 1.4. The leading cause of death was accidents. Diseases in infancy (perinatal conditions, congenital abnormalities) also accounted for many deaths. The bereaved siblings ranged in age from 0 to 39 years, with a median age of 8 years and 95% of the sample being under age 24.

Table 1.

Characteristics of index children and sibling groups

	Index children (N=3,185)
Age of index child at death (years)
Mean±SD	5.6 ± 6.7
Median	1.4
0‐4, N (%)	1,961 (61.6)
5‐17, N (%)	1,224 (38.4)
Cause of death of index child, N (%)
Accidents	712 (22.4)
Other diseasesa	711 (22.3)
Perinatal conditions	571 (17.9)
Congenital anomalies	539 (16.9)
Suicide	204 (6.4)
Sudden infant death syndrome	161 (5.1)
Malignant neoplasms	156 (4.9)
Other external causes of deathb	131 (4.1)
	Bereaved siblings (N=7,243)	Non‐bereaved sibling controls (N=21,729)	Χ2
Relation of sibling to index child, N (%)
Brother	3,616 (49.9)	10,848 (49.9)	0.00
Sister	3,627 (50.1)	10,881 (50.1)
Marital status of sibling at index child's death, N (%)
Married	170 (2.3)	493 (2.3)	0.15
Single	7,073 (97.7)	21,236 (97.7)
Total number of children in the family (excluding the index child), N (%)			1010.1*
1	1,325 (18.3)	1,290 (5.9)
2+	5,918 (81.8)	20,439 (94.1)
Age of sibling at time of index child's death (years)
Mean±SD	9.6 ± 7.3	NA	NA
Median	7.8	NA
0‐4, N (%)	2,523 (34.8)	NA
5+, N (%)	4,720 (65.2)	NA
Income quintile of sibling at time of index child's death, N (%)
Lowest quintile	3,102 (42.8)	9,339 (43.0)	1.38
Second lowest quintile	1,412 (19.5)	4,232 (19.5)
Middle quintile	1,044 (14.4)	3,152 (14.5)
Second highest quintile	890 (12.3)	2,662 (12.3)
Highest quintile	717 (9.9)	2,143 (9.9)
Unknown	78 (1.1)	201 (1.0)

*p<0.001, NA – not available

^aNon‐external causes not captured by any of the other categories

^bCauses not classified as accidental or self‐inflicted (e.g., abuse, homicide, injuries of undetermined cause)

Adjusted mental disorder prevalence among bereaved and control siblings in the pre‐ and post‐death/index periods is presented in Figure 2. The percentage of bereaved siblings with any physician‐diagnosed mental disorder rose from 4.9 to 8.0 after the death. Corresponding prevalence figures among control siblings were 4.0% before index date and 5.3% afterwards. This rate change across the time periods among bereaved siblings was significantly greater than the rate change among control siblings (pre‐post x sibling group interaction term: p<0.001). Twenty‐five percent of the 13+ age group were diagnosed with a mental disorder in the two‐year period after the death of their sibling, compared to 16.5% of control siblings.

Figure 2.

Adjusted prevalence (%) of any mental disorder diagnosis among control and bereaved siblings in the 2‐year periods before and after the index date. Error bars indicate confidence intervals. Pre‐post rate changes were significantly greater for bereaved siblings compared to controls, based on pre‐post x sibling group interaction terms, with the following levels of significance: all siblings (p<0.001), siblings aged <13 (p<0.05), and siblings aged 13+ (p<0.01)

Table 2 compares outcomes in the two years after sibling death to the two years prior among the bereaved group. Significant age interactions were noted for outcomes of depression, ADHD, any mental disorder, physician visit for mental illness, and physician visit or hospitalization for any reason. While both age groups had elevated rates of depression in the post‐death period, siblings under 13 years of age showed a more than 7‐fold increased rate compared to the pre‐death period (ARR=7.25, 95% CI: 3.65‐14.43), and this rate increase was significantly greater than the rate doubling observed in the 13+ age group (ARR=2.27, 95% CI: 1.89‐2.73, interaction p<0.0001). Bereaved siblings under 13 years of age also had increased rates of anxiety disorders, ADHD, and any mental disorder. The under‐13 age group had 3‐fold rate increases in physician visits and hospitalizations for mental illness, but less health care service utilization in general. Similar findings in mental disorder outcomes were observed in bereaved siblings aged 13+, albeit with smaller magnitudes. Differences in this age group were the 40% increased risk of drug use disorders in the post‐death period (ARR=1.40, 95% CI: 1.11‐1.76), and the likelihood of ADHD reduced by half (ARR=0.47, 95% CI: 0.29‐0.77).

Table 2.

Pre‐death and post‐death comparisons of mental disorders and treatment utilization among bereaved siblings aged <13 and bereaved siblings aged 13+

	Post‐death outcome rates vs. pre‐death outcome rates
	Bereaved siblings <13 (N = 5,150) ARR (95% CI)	Pre‐post time period x sibling age group interaction (p value)	Bereaved siblings 13+ (N = 2,093) ARR (95% CI)
Mental disorders
Depression	7.25 (3.65‐14.43)**	<0.0001	2.27 (1.89‐2.73)**
Anxiety disorder	2.17 (1.48‐3.17)**	NS	1.48 (1.26‐1.75)**
Alcohol use disorder	1.00 (0.25‐4.00)	NS	1.37 (0.98‐1.91)
Drug use disorder	1.71 (0.75‐3.92)	NS	1.40 (1.11‐1.76)*
ADHD	1.69 (1.34‐2.12)**	<0.0001	0.47 (0.29‐0.77)*
Suicide attempt	6.08 (0.73‐50.55)	NS	1.20 (0.73‐1.97)
Any mental disorder	2.06 (1.71‐2.48)**	0.0026	1.50 (1.34‐1.67)**
Treatment utilization
Physician visit for mental illness	3.06 (2.40‐3.91)**	0.0005	1.66 (1.31‐2.09)**
Physician visit for any reason	0.90 (0.87‐0.93)**	<0.0001	1.08 (1.02‐1.13)*
Hospitalization for mental illness	3.78 (1.47‐9.72)*	NS	1.33 (0.96‐1.85)
Hospitalization for any reason (other than birth)	0.75 (0.66‐0.86)**	0.0003	1.05 (0.92‐1.20)

*p<0.01, **p<0.001, NS – non‐significant

ARR – Adjusted relative rate, CI – confidence interval, ADHD – attention deficit hyperactivity disorder

Table 3 displays the comparison between bereaved and non‐bereaved siblings across the pre‐ and post‐index date, by age group. For the pre‐adolescent sibling group, bereavement was associated with significant rate increases in depression, any mental disorder, outpatient physician visits for mental illness, and physician visits and hospitalization for any health reason (based on significant interaction terms). Bereaved siblings had higher rates of depression in the two years after the death compared to controls (ARR=2.71, 95% CI: 1.94‐3.79). The significant interaction analysis (p<0.0001) accounts for pre‐death depression rates and confirms that these higher post‐death depression rates among bereaved siblings also indicate a pre‐post rate increase that is significantly different from the pre‐post rate change among the control siblings. Rates of drug use disorders were significantly higher after sibling death when compared to non‐bereaved controls. However, the non‐significant interaction term reflects the higher pre‐death rates among the bereaved cohort. Bereaved children were more likely to be hospitalized in both periods, with these higher rates significantly increasing after the death of their sibling.

Table 3.

Pre‐death and post‐death comparisons of bereaved siblings and non‐bereaved matched sibling controls, by age group

	Bereaved sibling ages <13 (N=5,150) vs. non‐bereaved siblings (N=15,450)			Bereaved sibling ages 13+ (N=2,093) vs. non‐bereaved siblings (N=6,279)
	2 years pre‐death ARR (95% CI)	Pre‐post time period x sibling interaction (p value)	2 years post‐death ARR (95% CI)	2 years pre‐death ARR (95% CI)	Pre‐post time period x sibling interaction (p value)	2 years post‐death ARR (95% CI)
Mental disorders
Depression	0.57 (0.28‐1.17)	<0.0001	2.71 (1.94‐3.79)***	1.20 (0.97‐1.48)	<0.0001	2.27 (1.94‐2.65)***
Anxiety disorder	1.07 (0.73‐1.59)	NS	1.43 (1.08‐1.88)*	1.16 (0.98‐1.37)	NS	1.35 (1.17‐1.54)***
Alcohol use disorder	3.26 (0.84‐12.62)	NS	1.09 (0.35‐3.42)	2.17 (1.51‐3.13)***	NS	2.15 (1.56‐2.96)***
Drug use disorder	3.64 (1.22‐10.82)*	NS	2.34 (1.11‐4.93)*	1.44 (1.13‐1.84)**	NS	1.55 (1.25‐1.91)***
ADHD	1.11 (0.84‐1.47)	NS	1.19 (0.96‐1.48)	1.27 (0.78‐2.04)	NS	0.76 (0.40‐1.46)
Suicide attempt	‐	‐	‐	1.72 (1.06‐2.80)*	NS	2.01 (1.29‐3.12)**
Any mental disorder	1.17 (0.95‐1.45)	0.0153	1.53 (1.32‐1.78)***	1.23 (1.10‐1.39)***	0.004	1.48 (1.35‐1.63)***
Treatment utilization
Physician visit for mental illness	0.73 (0.55‐0.99)*	0.0034	1.18 (0.91‐1.54)	1.22 (0.92‐1.61)	NS	1.48 (1.15‐1.91)**
Physician visit for any reason	0.93 (0.91‐0.96)***	<0.0001	1.02 (0.98‐1.05)	1.01 (0.95‐1.08)	NS	0.99 (0.93‐1.05)
Hospitalization for mental illness	2.86 (0.80‐10.18)	NS	2.42 (1.03‐5.69)*	1.57 (1.14‐2.17)**	NS	1.78 (1.37‐2.30)***
Hospitalization for any reason (other than birth)	1.34 (1.19‐1.51)***	0.0134	1.63 (1.42‐1.86)***	1.29 (1.13‐1.48)***	NS	1.19 (1.06‐1.33)**

*p<0.05, **p<0.01, ***p<0.001, NS – non‐significant

ARR – Adjusted relative rate, CI – confidence interval, ADHD – attention deficit hyperactivity disorder

There was a slightly different pattern for the bereaved siblings who were adolescent age and older. Like their pre‐adolescent counterparts, they suffered significant rate increases in depression and any mental disorder when compared to their non‐bereaved matches over the same time period. However, this age group had marked differences in mental disorder comorbidity in the pre‐death period, with higher rates of alcohol use disorders (ARR=2.17; 95% CI: 1.51‐3.13), drug use disorders (ARR=1.44; 95% CI: 1.13‐1.84), and suicide attempts (ARR=1.72; 95% CI: 1.06‐2.80) even before the death of their sibling. These higher rates compared to non‐bereaved controls continued in the post‐death period, resulting in a pattern of considerable mental disorder burden across almost all outcomes.

A sensitivity analysis was performed to examine the influence of being bereaved from multiple sibling losses, as well as index events that resulted in injury to the bereaved sibling in addition to the death of the index child. There were 59 siblings who lost multiple siblings in the same event, and 19 siblings who were hospitalized with an injury related to the cause of death of their sibling (such as a motor vehicle collision). Removing these siblings (and their corresponding controls) did not alter statistical significance of any of the interaction terms in Table 2 or Table 3. Among the statistically significant ARRs in Tables 2 and 3, most were unchanged in the sensitivity analysis, but three were slightly attenuated and only achieved borderline significance: bereaved siblings under age 13 diagnosed with drug use disorder in the two years post‐death (ARR=2.14, 95% CI: 1.00‐4.58, p=0.051) and hospitalized for mental illness in the two years post‐death (ARR=2.33, 95% CI: 0.97‐5.99, p=0.058), and bereaved siblings ages 13+ attempting suicide in the 2‐year pre‐death period (ARR=1.59, 95% CI: 0.97‐2.61, p=0.068).

DISCUSSION

This study provides the first findings on mental health outcomes of bereaved siblings in the general population. It deepens the knowledge of bereavement effects by separately examining outcomes among children and adolescents, revealing that, while some experiences are similar, there are important differences depending on the age at which one loses a sibling. The results emphasize bereavement as a period of vulnerability and thus an important focus for treatment and public awareness efforts.

Our results suggest that bereavement experiences vary according to the age of the surviving sibling. Of particular concern were the higher rate increases in depression in pre‐adolescent children versus the 13+ age group. Losing a sibling led to a more than 7‐fold rate increase in physician‐diagnosed depression among the under‐13 age group when compared to rates before the death. This finding could indicate an enhanced vulnerability to the damaging emotional consequences of bereavement among younger children, or may reflect the lower baseline population incidence of mood disorders in this age group, although the lack of significant pre‐death rate differences in depression in both age groups when compared to controls argues against the latter hypothesis.

Very few studies have compared sibling reactions based on age. Risk for behavioral and emotional problems has been reported to be higher in adolescent age groups22, whereas younger children have been found to have social difficulties including being more isolated, less accepted, and having fewer friends23. The current study provides information that supports both perspectives. When compared to non‐bereaved controls, bereaved siblings aged 13 or older had higher rates of almost every mental disorder examined. They also had a higher likelihood of both inpatient and outpatient treatment. This concerning profile of poor health, however, was not restricted to adolescents. Children younger than 13 had higher post‐death rates of depression, anxiety, and drug use disorders when compared to age‐matched non‐bereaved controls. These outcomes suggest that the effects among young children are not limited to measures of social connectedness. This presents important considerations for general practitioners and pediatricians managing the care of young bereaved children, highlighting the importance of evaluation and treatment in a population that might otherwise not raise a high index of suspicion for serious mental disorders.

A striking finding from this study is the health and social adversity faced by siblings even before the death of their brother and sister. At the time of the child's death, almost half of the affected families occupied the lowest income quintile, demonstrating a marked over‐representation of income inequality. Even prior to their siblings’ death, children under 13 who were to become bereaved were already diagnosed with drug use disorders at a rate almost four times that of the non‐bereaved controls. The older group of soon‐to‐be bereaved siblings had an even more concerning profile of mental health adversity compared to controls, including higher rates of alcohol and drug use disorders and suicide attempts in the two years prior to their sibling's death. Together these findings present a picture of substantial disadvantage for these families, both socially and health‐related. Adjusting analyses by income did not attenuate the health findings, which emphasizes that social deprivation is not the sole explanatory factor. Shared genetic factors likely contribute in a complex interplay with unmeasured environmental variables such as tobacco use, poor nutrition, and low health literacy, all factors that share relationships with mental and physical disorders, infant mortality, and poverty24, 25.

There are some limitations that should be considered in this study. Stratifying analyses by factors such as sibling sex or age of death of index child were not conducted. These factors were examined as covariates, however, and not found to correlate with the outcomes examined, hence the decision to not perform additional stratification. This study examined all bereaved siblings from the population, and therefore, in families where there were several bereaved siblings, all were included in the cohort. Sibling pairs in the bereaved cohort were not matched to non‐bereaved sibling pairs in the general population, which could introduce some confounding. Parental illness was not included and could influence outcomes. The cause of death could be a marker of family pathology and likewise influence the mental health of the bereaved sibling. These are certainly important avenues for future research, but would introduce a level of complexity that was felt beyond the scope of this first examination of sibling bereavement in the population.

This study examined bereavement related to any cause of death, thereby grouping together people bereaved by sudden death along with those who had a sibling die as a result of a prolonged illness. While these represent very different situations, we decided to examine sibling bereavement broadly as it is the first population study on health outcomes. The birth of a new child into the family may have influenced bereavement reactions, and this was not accounted for in this study. The outcomes of this study were dependent on treatment seeking and thus do not capture all health outcomes in the population. Administrative data cannot assess certain emotional consequences such as complicated grief, which may be highly prevalent in bereaved siblings26. Post‐traumatic stress disorder represents another outcome that is not accurately captured in the datasets; this is a significant limitation given the traumatic nature of sibling loss. Not all people with mental disorders seek care despite a perceived need27, and therefore the results of this study likely underestimate the true burden of bereavement.

In summary, bereavement among siblings is clearly a distressing experience with consequent risk for mental disorders, especially depression. The sibling relationship is a close bond for many and often the longest interpersonal connection a person will have, and these results show that its disruption even early in life leads to profound impairment among the survivors. Families who lose a child frequently struggle with impoverishment and illness among their offspring, yet the death of the child exerts a damaging effect on the remaining siblings that exceeds the pre‐existing health and social adversity. Practitioners, both within mental health and general medicine communities, should be aware of these vulnerabilities.