Parental Death and Psychiatric Disorders Among Individuals with and Without Experience of Out-of-Home Care: A Swedish Nationwide Cohort Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The influence of institutional upbringing on mental health has long been a subject of interest for clinical psychologists and developmental psychiatrists. Numerous research studies have demonstrated that being separated from one’s family and placed in an institutional setting, such as orphanages or boarding schools, can significantly increase the risk of developing attachment disorders, difficulties with emotional regulation, and a higher susceptibility to a variety of mental health issues in adulthood. Nevertheless, our comprehension of these processes is marred by a notable degree of fragmentation. In the traditional framework of “institutionalization-psychopathology,” the experience of family loss is often viewed as a singular and unchanging event. However, in reality, it can trigger a series of potentially psychologically distressing circumstances.

Despite the clear-cut clinical rationale, this issue continues to be overlooked in comprehensive research based on evidence. The vast majority of research either concentrates on children from nuclear families who experience the loss of a parent or on the outcomes of orphanhood, disregarding subsequent significant stressors. Consequently, we are faced with a critical lack of data on the extent to which experiencing the loss of parents contributes to the prevalence of mental health issues.

A methodologically sound answer to this question can only be obtained through a national cohort study, which is the only design capable of surmounting the constraints imposed by small sample sizes and selection biases that are inherent in convenience sampling. Using objective data from the registry (the official record of a parent’s death and clinical psychiatric diagnoses, not just subjective surveys) allows for a precise statistical analysis of potential confounding factors – gender, age at admission, socioeconomic status, and comorbid family psychiatric history. Therefore, we can approach the comprehension of causal processes by distinguishing the impact of trauma from the ultimate and irreversible harm caused by the effects of long-term family dysfunction and environmental deprivation.

Comments and issues that need to be addressed:

1. The introductory section falls short in its impact. It is embellished with the findings of analogous cohort studies, notions, and hypotheses.
2. The practical aspect of the research is not adequately described. Who and in what contexts can put the findings to use? What are the particulars of averting prolonged pathological responses to loss? How might the burden of chronic mental illnesses be alleviated among the most vulnerable demographic?
3. And perhaps this is a desire for the future: it would be intriguing to contrast different age groups – to investigate the impact of parental loss on ontogenetic development.

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

1. The paper contributes to an essential void by exploring the moderation effect of parental mortality on the relationship between OHC and mental illnesses. Nevertheless, the uniqueness of the research can be further highlighted in the Introduction section, especially concerning its distinction from previous studies that have relied on Swedish registers.
2. The application of both cumulative disadvantage and disadvantage-saturation theories is justified; nonetheless, the connection between the two theories lacks theoretical rigor. It would help to elaborate further on how these theories generate hypotheses and how the results may favor one theory over the other.
3. Parental mortality has been considered at ages ranging from 0 to 19, thus overlapping with the OHC exposure time frame. This poses a challenge in determining whether parental mortality happened before, during, or after OHC.
4. Mental health disorders rely on in-patient data, limiting their scope to only the worst cases. This needs to be stated explicitly, as there are concerns about the issue of underreporting, along with the problem of differential misclassification.
5. The fact that the effect of parental death is reduced among OHC respondents is used as an indication of disadvantage saturation. Other possibilities need to be explored to prevent overinterpretation of results, such as ceiling effects or differences in healthcare access.
6. The stratification of analyses by sex is necessary, but reasons why an interaction was not sought need to be provided. In addition, it may be useful to explore other analytical models, such as multilevel analysis or competing risks.
7. The discussion provides insight into the Swedish context, but policy implications can be more specific. How will interventions need to change given the finding that additional adversities offer no additional risk in highly disadvantaged cases?

Author Response

Please see attachment

Author Response File: Author Response.pdf