Background: The COVID-19 pandemic has caused millions of deaths worldwide, leading to symptoms of grief among the bereaved. Neither the burden of severe grief nor its predictors are fully known within the context of the pandemic. Aim: To determine the prevalence and predictors of severe grief in family members who were bereaved early in the COVID-19 pandemic. Design: Prospective, matched cohort study. Setting/Participants: Family members of people who died in an acute hospital in Ottawa, Canada between November 1, 2019 and August 31, 2020. We matched relatives of patients who died of COVID (COVID +ve) with those who died of non-COVID illness either during wave 1 of the pandemic (COVID −ve) or immediately prior to its onset (pre-COVID). We abstracted decedents’ medical records, contacted family members >6 months post loss, and assessed grief symptoms using the Inventory of Complicated Grief-revised. Results: We abstracted data for 425 decedents (85 COVID +ve, 170 COVID −ve, and 170 pre-COVID), and 110 of 165 contacted family members (67%) consented to participate. Pre-COVID family members were physically present more in the last 48 h of life; the COVID +ve cohort were more present virtually. Overall, 35 family members (28.9%) had severe grief symptoms, and the prevalence was similar among the cohorts (p = 0.91). Grief severity was not correlated with demographic factors, physical presence in the final 48 h of life, intubation, or relationship with the deceased. Conclusion: Severe grief is common among family members bereaved during the COVID-19 pandemic, regardless of the cause or circumstances of death, and even if their loss took place before the onset of the pandemic. This suggests that aspects of the pandemic itself contribute to severe grief, and factors that normally mitigate grief may not be as effective.

https://journals.sagepub.com/doi/pdf/10.1177/02692163221109711

Bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study

The COVID-19 pandemic evokes high levels of post-traumatic stress (PTS) in some people as well as positive personal changes, a phenomenon known as post-traumatic growth (PTG). Experiencing an adverse event as traumatic is crucial for triggering PTG, therefore higher PTS is often associated with higher PTG. This longitudinal study examined the protective role of psychological flexibility in fostering PTG in a group of people reporting high PTS related to COVID-19 as compared to those with low PTS. We hypothesized that higher psychological flexibility will be associated with higher PTG in those with high PTS and that psychological flexibility would be unrelated to PTG in those with low PTS. Secondary data analysis was conducted on data from a larger project investigating the psychological impacts of COVID-19. Adult Italians (N = 382) completed online surveys at Time 1 (three months after the first national lockdown, July 2020) and Time 2 (three months later when the number of COVID-19 cases increased, October 2020). Based on the Impact of Event Scale-Revised cut-off score, two PTS groups were identified at Time 2: low PTS (below cut-off) and high PTS (above cut-off). As predicted, moderation analyses showed that after controlling for Time 1 PTS and PTG and confounding variables, Time 1 psychological flexibility was associated with higher Time 2 PTG in the high PTS group, whereas psychological flexibility was unrelated to PTG in the low PTS group. Four psychological flexibility sub-processes (present moment awareness, defusion, values, committed action) at Time 1 were related to higher Time 2 PTG in only the high PTS group. Findings advance understanding of the role of psychological flexibility in trauma reactions and pandemic mental health adjustment. Evidence-based approaches that target psychological flexibility, like Acceptance and Commitment Therapy, are likely to foster PTG and ultimately adjustment in people with high PTS during and after the pandemic. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9420208

Post-traumatic growth in people experiencing high post-traumatic stress during the COVID-19 pandemic: The protective role of psychological flexibility

Background: The COVID-19 pandemic has affected millions of people's experiences of bereavement. We aimed to identify risk factors for grief and support needs. Methods: Online survey of people bereaved in the UK (deaths 16 March 2020-2 January 2021), recruited via media, social media, national associations/organisations. Grief was assessed using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36). Practical and emotional support needs were assessed in 13 domains. Results: 711 participants, mean age 49.5 (SD 12.9, range 18-90). 628 (88.6%) were female. Mean age of the deceased 72.2 (SD 16.1). 311 (43.8%) deaths were from confirmed/suspected COVID-19. Mean IOV was 20.41 (95% CI = 20.06 to 20.77). 28.2% exhibited severe vulnerability (IOV [≥] 24). In six support domains relating to psycho-emotional support, 50% to 60% of respondents reported high/fairly high levels of need. Grief and support needs increased strongly for close relationships with the deceased (versus more distant) and with reported social isolation and loneliness (P < 0.001), whereas they reduced with age of the deceased above 40 to 50. Other risk factors were place of death and reduced support from health professionals after death (P < 0.05). Conclusions: High overall levels of vulnerability in grief and support needs were observed. Relationship with the deceased, age of the deceased, and social isolation and loneliness are potential indicators of those at risk of even higher vulnerability in grief and support needs. Healthcare professional support after death is associated with more positive bereavement outcomes.

https://www.medrxiv.org/content/medrxiv/early/2022/02/08/2022.02.07.22270593.full.pdf

Factors associated with higher levels of grief and support needs among people bereaved during the pandemic: Results from a national online survey

This special issue of the European Journal of Psychotraumatology (EJPT) presents the first studies published by EJPT on COVID-19. We present 26 qualitative and quantitative studies assessing the prevalence of trauma-related symptoms and psychopathology within specific vulnerable populations such as health-care workers, students, children, and managers, or more broadly at a country level with a diverse set of outcomes including post-traumatic stress, moral injury, grief and post-traumatic growth. Intervention studies focus on whether telehealth delivery of mental health therapy in the pandemic environment was useful and effective. It is clear that the pandemic has brought with it a rise in trauma exposure and consequently impacted on trauma-related mental health. While for many individuals, COVID-19-related events met criteria for a DSM-5 Criterion A event, challenges remain in disentangling trauma exposure from stress, anxiety, and other phenomena. It is important to determine the contexts in which a trauma lens makes a useful contribution to understanding the mental health impacts of COVID-19 and the ways in which this may facilitate recovery. The papers included in this Special Issue provide an important and much-needed evidence-based foundation for developing trauma-informed understanding and responses to the pandemic.

Understanding the mental health impacts of COVID-19 through a trauma lens.

Background: Over one million Americans have died from coronavirus disease 2019 (COVID-19). Increased isolation resulting from social distancing, public health restrictions, and hospital visit limitations may affect the ability to perform normal mourning practices. Grief experts expect higher rates of prolonged grief disorder (PGD) because of the pandemic, but empirical evidence is limited. Objectives: To compare grief severity using PG-13-R scores among those bereaved during the COVID-19 pandemic to prepandemic controls. Design: Prospective cohort trial. Setting/Subjects: One hundred twenty-three next-of-kin of deceased individuals at a secondary medical center in the United States. Measurements: We compared the PG-13-R score and demographic characteristics across three periods based on the time of their relative's death: prepandemic (n = 42, November 2019-March 19, 2020), early-pandemic (n = 42, March 20, 2020-June 2020), and mid-pandemic (n = 39, July 2020-October 2020). Linear regression investigated the association between the PG-13-R score and COVID-19-related death, hospice use, and grief support services while controlling for demographic characteristics. Results: There were no statistical differences in unadjusted PG-13-R score, individual PG-13-R questions, and demographic characteristics across three periods. In adjusted analyses, COVID-19-related death was associated with an increased PG-13-R score (coefficient: 6.17; p = 0.031), while hospice use was associated with a decline in the PG-13-R score (coefficient: -3.68; p = 0.049). Conclusion: Individuals have adapted to COVID-19 societal changes, including how they grieve. However, COVID-19-related deaths may lead to a higher risk for PGD, consistent with COVID-19 grief studies globally.

Effects of the COVID-19 Pandemic on Grief: A Prospective Survey among Community Hospital Next-of-Kin.

Background COVID-19 deaths elevate the prevalence of prolonged grief and post-traumatic stress symptoms among the bereaved, yet few studies have examined potential positive outcomes. Moreover, how COVID-19 bereavement affects individual-level mental health outcomes is under-researched. Objective This is the first study to use latent profile analysis (LPA) to identify heterogeneous profiles of prolonged grief, post-traumatic stress and post-traumatic growth among people bereaved due to COVID-19 and to identify predictors of latent class membership. Methods Four hundred and twenty-two Chinese participants who were bereaved due to COVID-19 completed an online survey between September and October 2020. The survey included the International (ICD-11) Prolonged Grief Disorder Scale (IPGDS), the Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5) and the Post-traumatic Growth Inventory (PTGI). LPA was run in Mplus, and the 3-step auxiliary approach was used to test the predicting effects of potential predictors of latent class membership identified with chi-square tests and ANOVAs. Results Four latent profiles were identified: resilience (10.7%), growth (20.1%), moderate-combined (42.2%) and high-combined (27.0%). The bereaved who shared a close relationship with the deceased and identified COVID-19 as the fundamental cause of death were more likely to be in the high-combined group. A conflictful bereaved-deceased relationship reduces the chance of being in the growth group. Moreover, the death of a younger person and loss of a partner attributed to maladaptive outcomes. Conclusions Serious attention needs to be paid to the mental health issues of people bereaved due to COVID-19 because nearly 70% of this group would have a moderate-combined or high-combined symptom profile. Special care should be given to those who lost someone younger, lost a partner or shared a close relationship with the deceased. Grief therapies that work on the conflicts between the deceased and the bereaved and unfinished business can be applied to facilitate growth.

Chuqian Chen

Papers

Profiles of grief, post-traumatic stress, and post-traumatic growth among people bereaved due to COVID-19.