Associations between depressive symptoms, attachment style, and continuing bonds among Japanese bereaved family members of patients with cancer: a nationwide cross-sectional study.

BACKGROUND

Depressive symptoms are highly prevalent among bereaved family members, yet their psychosocial determinants remain unclear. Attachment styles and continuing bonds are recognized as important factors influencing bereavement outcomes. However, evidence regarding their associations with depressive symptoms and adaptiveness of continuing bonds remains inconclusive and varies across cultures. This study examined the associations of attachment styles and continuing bonds with depressive symptoms, including potential interactions, among bereaved Japanese families.

METHODS

This cross-sectional study was conducted as part of the fifth Japan Hospice and Palliative Evaluation, which enrolled 539 bereaved family members of patients who died of cancer between February 2023 and January 2024. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), attachment styles with the Relationship Questionnaire, and continuing bonds with the Continuing Bonds Scale. PHQ-9 scores were dichotomized at a cut-off of ≥ 10 (screen-positive vs. screen-negative for depression). Multivariable logistic regression analyses were performed, adjusting for 15 covariates, and the association between attachment styles and continuing bonds was evaluated.

RESULTS

Of the 539 participants, 81 (15.9%) screened positive for depression. Individuals with a fearful attachment style had significantly higher odds of screen-positive depression than those with a secure attachment style (adjusted odds ratio [aOR] = 3.10, 95% CI = 1.32-7.29, p = 0.01). In addition, higher continuing bonds scores were significantly associated with increased odds of screen-positive depression (aOR = 1.05, 95% CI = 1.01-1.09, p = 0.01).

CONCLUSIONS

Among bereaved family members, fearful attachment styles and stronger continuing bonds were associated with depressive symptoms, whereas their interaction was not. These findings provide important insights into the psychosocial mechanisms underlying bereavement-related depression.