Grief in the time of COVID-19: An editorial

In this issue of the International Journal of Mental Health, Jegede et al. (2021) found that 28% of individuals with a mental disorder who were hospitalized for the 2019 Coronavirus Disease (COVID-19), passed away. The ongoing COVID-19 pandemic crisis has certainly affected and is still affecting individuals across populations and cultures, with a rising death toll. In addition to the undisputed direct effect of the pandemic on mental health globally, we would like to highlight here the secondary impact of the death of a loved one to this disease, with consequences likely to be felt in the coming months and years.

The death of a loved one is a major life stressor, often described as one of the most painful experiences an individual will face in their lifetime (Bonanno & Kaltman, 1999). For most bereaved individuals, symptoms such as ruminations around the death or the deceased, yearning about the deceased, intense and persistent pangs of grief, or social withdrawal, subside in the weeks or months following the loss. However, for a subset of bereaved individuals, this grief will become chronic, becoming a source of major distress and impairment that can last years after death (Shear, 2015). This condition of persisting grief, called Prolonged Grief Disorder (PGD) was recently included in the International Classification of Diseases (ICD-11) (World Health Organization, 2020), with proposed criteria recently approved by the American Psychiatric Association for inclusion into the Text Revision of the DSM-5.

As of December 11, 2020, over 1.5 million deaths from COVID-19 were confirmed in the world (World Health Organization, 2020). With an estimate of four bereaved individuals for each death and an incidence of PGD ranging from 10% to 30% due to high risk factors, we can estimate that between 600,000 and 1.8 million people may develop PGD due to the death of a loved one caused directly by COVID-19 in the coming year. This potential wave of PGD linked to deaths directly attributable to COVID-19, but also those occurring in a context of generalized confinement and for which the mourning process has been or will be altered, therefore highlights three urgent needs that must be addressed.

Firstly, screening of grievers at risk for developing PGD during this period is warranted. The COVID-19 pandemic is associated with specific risk factors for PGD, related to the disease itself, as well as to the measures taken to combat the spread of the virus (Mayland et al., 2020) including: immediate psychological response to the death (Bui et al., 2013) (e.g., being directly responsible for the contamination of the deceased, impaired communication between doctors and family); separation at the time of death and the absence of usual funeral rites (Mutabaruka et al., 2012) (e.g., inability “to say a last goodbye”, absence of funeral rites and practices); and co-occurring environmental stressors and lack of perceived social support (Shear, 2015) (e.g., loss of employment, professional and financial insecurity, increased work burden, social isolation due to confinement measures, and uncertainty about the future). Efforts should thus be devoted to identify those at risk for developing PGD as well as PGD itself, including in primary care settings, and through health literacy promotions (e.g., by the media).

Secondly, in order to manage the expected surge of PGD cases, we need to build capacity for providing treatment. To date, no pharmacological approach has proven effective for PGD (Vance & Bui, 2018), and the therapeutic strategy with the most consistent evidence base is Complicated Grief Treatment (CGT), a 16-session loss-focused individual therapy. However, this approach is only available in English, and up to one in four patients drop out prior to completing treatment (Shear et al., 2016). Clearly, adaptations of CGT to other languages and cultures are warranted, as well as innovative model of care that can limit drop-outs (Ohye et al., 2020).

Thirdly, no treatment has shown efficacy in preventing PGD to date (Currier et al., 2008; Wittouck et al., 2011). Preventive strategies are necessary to preemptively address a rise in PGD rates and avoid long-term distress and impairment at a broader level. Effective preventative interventions are crucial in ensuring the mental health community is equipped to treat those who do end up developing PGD, further reinforcing the importance of innovation at this time. Recent advances in artificial intelligence have enabled automated analytics of large amounts of health data, and can be leveraged to detect early emerging mental health symptoms through digital phenotyping using multimodal digital data sources including self-reports, actigraphy, social network, phone usage, and provide just-in-time adaptive responses to those emerging symptoms (Fuller-Tyszkiewicz et al., 2019). Finally, implementing social and health policies such as supporting funerals that can adhere to strict social distancing measures, may also help mitigate the impact of the pandemic on grievers.

These unprecedented times require an intensive, adaptive, and forward-thinking response from the mental health community. It is on us as a field to consider how to best promote resilience and support individuals facing not just loss, but loss under challenging and unique conditions. As this first 2021 issue of the International Journal of Mental Health is coming out, 12 months after the peak of the first wave of the COVID-19 pandemic, we should keep in mind that our clinical settings will start seeing the first wave of patients with PGD.