Commentary on: A Call to Action: Facing the Shadow Pandemic of Complicated Forms of Grief.

In this contribution, we respond to a letter in Omega: Journal of Death and Dying by Doka. Signatories of this letter to the President of the United States convey concerns that deaths during the COVID-19 pandemic will lead to a higher prevalence of severe and persistent grief, i.e., prolonged grief disorder. We support their call to action to direct government funding to helping those who develop this condition during the COVID-19 pandemic. However, we think that concerns about prolonged grief disorder during the pandemic can be more convincingly conveyed by firmly embedding such concerns within scientific literature. Therefore, we highlight prior scientifically informed opinion pieces from various international researchers who voiced similar concerns in the early months of the pandemic. Additionally, we provide an overview of pioneering empirical research elucidating whether prolonged grief disorder and related mental health problems will become more prevalent during the pandemic.

French-Canadian validation of the Traumatic Grief Inventory-Self Report (TGI-SR).

The Traumatic Grief Inventory Self-Report (TGI-SR), which aims to assess both Persistent Complex Bereavement Disorder and Prolonged Grief Disorder, has been validated in several languages. This study sought to validate the French-Canadian version. We conducted an online survey exploring the impact of the COVID-19 pandemic on grief. With data from 728 participants, the scale demonstrated high internal consistency, correlated significantly with three other scales known to measure similar concepts, and distinguished between groups known to be different. This study supports the use of the TGI-SR French-Canadian version by clinicians and researchers to assess complications of grief.

Restricted Mourning: Impact of the COVID-19 Pandemic on Funeral Services, Grief Rituals, and Prolonged Grief Symptoms.

Background: The COVID-19 pandemic has put various restrictions on grief rituals. Literature suggests that the restrictions on funerals and grief rituals may increase the chance of developing symptoms of prolonged grief (PG). In this study, we explored the possible impact of the pandemic on aspects of the funeral and grief rituals and examined their relationship with PG symptoms. Method: Bereaved individuals from different countries, who lost a loved one in the year prior to the pandemic (n = 50) or during the pandemic (n = 182), filled in an online questionnaire, including a rating of the impact of COVID-19 restrictions, five aspects of the funeral service, five aspects of grief rituals, and a measurement for PG symptoms. Results: Participants bereaved during the pandemic rated the impact of the restrictions on the experience of the funeral and grief rituals as negative. Nevertheless, no differences were found in attendance and evaluation of the funeral and grief rituals for people bereaved prior to vs. during the pandemic. Attendance and evaluation of the funeral services were related to levels of PG symptoms, whereas the performance and helpfulness of grief rituals were not related to these symptoms. Although not related to PG symptoms, half of the participants used helpful alternative rituals to cope with their loss. Discussion: Our study suggests that bereaved people respond resiliently to the COVID-19 pandemic, for example by creating alternative rituals to cope with their loss. Furthermore, it stresses the importance of looking beyond symptom levels when studying the importance of funeral and grief rituals.

Loneliness in Bereavement: Measurement Matters.

The role of loneliness in the bereavement experience has been reported as substantial, with the death of a close person leaving a considerable void in the life of the bereaved. Yet, there is lack of agreement about its precise role and, notably, whether loneliness should be included as a core symptom for diagnosis of grief complications. The ongoing threat of heightened social isolation due to the COVID-19 pandemic underlines the need to understand the impact of loneliness, and to accurately chart its prevalence, intensity, duration, and associated difficulties in the context of bereavement. Assessment issues are central to this endeavor. In this article, we review the scientific literature to examine how loneliness after bereavement has been operationalized and measured. Sixty-three articles analyzing 51 independent datasets were reviewed. Results show major disparities: approximately half of the projects assessed loneliness by means of one of two validated scales (spanning different versions); the remainder included only single- or few-item measures. Diverse instructions, content and answer categories were used. While one size does not fit all, awareness of assessment options and dis/advantages may aid selection of the most appropriate measure, to suit the goals of a particular study and the specific groups under investigation. Our conclusion is that, in selecting a loneliness measure, health care professionals should come to their own well-informed decision, aided by the information provided in our review.

Traumatic grief research and care in the aftermath of the COVID-19 pandemic.

BACKGROUND: A significant increase in the number of individuals suffering from prolonged grief disorder is expected in the aftermath of the COVID-19 pandemic for two main reasons. First, the number of excess deaths has contributed to an immense number of bereaved individuals. Second, recent literature has shown that circumstances associated with COVID-19 deaths may be contributing to increased risk for the development of prolonged grief disorder. OBJECTIVE: To best support those affected by loss during the COVID-19 pandemic, it is important to inform clinicians and researchers about the development, the nature and the treatment of prolonged grief disorder and employ sound research. METHOD: In this editorial, we discuss important themes regarding prolonged grief disorder in the aftermath of the COVID-19 pandemic, to gather and present useful information for clinicians and researchers. RESULTS: The following themes were addressed: 1. Harmonization in the diagnosis of prolonged grief disorder. 2. Screening tools and interventions. 3. Pharmacotherapy. 4. Special attention for the elderly. 5. Special attention for children and adolescents. 6. A causal system perspective for understanding grief and prolonged grief disorder. CONCLUSIONS: If those involved in bereavement research and care manage to collaborate, the tragic consequences of COVID-19 might catalyse improvement of care for those most impaired following the loss of a loved one.

Antecedentes: Se espera un aumento significativo en el número de personas que padecen de un trastorno de duelo prolongado como consecuencia de la pandemia de COVID-19 por dos razones principales. Primero, el número de muertes en exceso ha contribuido a un inmenso número de personas en duelo. En segundo lugar, la literatura reciente ha demostrado que las circunstancias asociadas con las muertes por COVID-19 pueden estar contribuyendo a un mayor riesgo de desarrollar un trastorno de duelo prolongado.Objetivo: Para apoyar mejor a los afectados por la pérdida durante la pandemia de COVID-19, es importante informar a los médicos e investigadores sobre el desarrollo, la naturaleza y el tratamiento del trastorno de duelo prolongado y emplear investigaciones sólidas.Método: En este editorial, discutimos temas importantes relacionados con el trastorno de duelo prolongado después de la pandemia de COVID-19, para recopilar y presentar información útil para médicos e investigadores.Resultados: Se abordaron los siguientes temas: 1. Armonización en el diagnóstico del trastorno de duelo prolongado. 2. Herramientas de tamizaje e intervenciones. 3. Farmacoterapia. 4. Atención especial para adultos mayores. 5. Atención especial para niños y adolescentes. 6. Una perspectiva del sistema causal para comprender el duelo y el trastorno de duelo prolongado.Conclusiones: Si los involucrados en la investigación y el cuidado del duelo logran colaborar, las trágicas consecuencias del COVID-19 podrían catalizar la mejora de la atención para los más afectados después de la pérdida de un ser querido.

A systematic review of loneliness in bereavement: Current research and future directions.

Bereaved people suffer from loneliness and loneliness is associated with poor mental health. In this study, this topic is reviewed. An agenda is suggested for future research. Research that is theory-driven, addresses measurement consistency, correlates of loneliness in bereaved and non-bereaved, and treatment is necessary for prevention and intervention.

Acute grief after deaths due to COVID-19, natural causes and unnatural causes: An empirical comparison.

BACKGROUND: There are now over 800,000 registered deaths due to the COVID-19 pandemic worldwide. Researchers have suggested that COVID-19 death characteristics (e.g., intensive care admission, unexpected death) and circumstances (e.g., secondary stressors, social isolation) will precipitate a worldwide increase of prolonged grief disorder (PGD) and persistent complex bereavement disorder (PCBD). Yet, no study has investigated this. Since acute grief is a strong predictor of future pathological grief, we compared grief levels among people recently bereaved due to COVID-19, natural, and unnatural causes. METHODS: People bereaved through COVID-19 (n = 49), natural causes (n = 1182), and unnatural causes (n = 210), completed self-report measures of demographic and loss-related characteristics and PGD and PCBD symptoms. RESULTS: COVID-19 bereavement yielded higher symptom levels of PGD (d = 0.42) and PCBD (d = 0.35) than natural bereavement (but not unnatural bereavement). Effects held when limiting analyses to recent losses and those who participated during the pandemic. Expectedness of the death explained this effect. LIMITATIONS: Limitations include using a convenience sample and self-report measures. CONCLUSIONS: Higher grief levels occur among people bereaved due to COVID-19 compared to people bereaved due to natural loss. We predict that pandemic-related increases in pathological grief will become a worldwide public health concern.

Developing and testing a nurse-led intervention to support bereavement in relatives in the intensive care (BRIC study): a protocol of a pre-post intervention study.

BACKGROUND: When a patient is approaching death in the intensive care unit (ICU), patients' relatives must make a rapid transition from focusing on their beloved one's recovery to preparation for their unavoidable death. Bereaved relatives may develop complicated grief as a consequence of this burdensome situation; however, little is known about appropriate options in quality care supporting bereaved relatives and the prevalence and predictors of complicated grief in bereaved relatives of deceased ICU patients in the Netherlands. The aim of this study is to develop and implement a multicomponent bereavement support intervention for relatives of deceased ICU patients and to evaluate the effectiveness of this intervention on complicated grief, anxiety, depression and posttraumatic stress in bereaved relatives. METHODS: The study will use a cross-sectional pre-post design in a 38-bed ICU in a university hospital in the Netherlands. Cohort 1 includes all reported first and second contact persons of patients who died in the ICU in 2018, which will serve as a pre-intervention baseline measurement. Based on existing policies, facilities and evidence-based practices, a nurse-led intervention will be developed and implemented during the study period. This intervention is expected to use 1) communication strategies, 2) materials to make a keepsake, and 3) a nurse-led follow-up service. Cohort 2, including all bereaved relatives in the ICU from October 2019 until March 2020, will serve as a post-intervention follow-up measurement. Both cohorts will be performed in study samples of 200 relatives per group, all participants will be invited to complete questionnaires measuring complicated grief, anxiety, depression and posttraumatic stress. Differences between the baseline and follow-up measurements will be calculated and adjusted using regression analyses. Exploratory subgroup analyses (e.g., gender, ethnicity, risk profiles, relationship with patient, length of stay) and exploratory dose response analyses will be conducted. DISCUSSION: The newly developed intervention has the potential to improve the bereavement process of the relatives of deceased ICU patients. Therefore, symptoms of grief and mental health problems such as depression, anxiety and posttraumatic stress, might decrease. TRIAL REGISTRATION: Netherlands Trial Register Registered on 27/07/2019 as NL 7875, www.trialregister.nl.