Prolonged grief disorder following the Coronavirus (COVID-19) pandemic.

Dear editor,

The consequences of the COVID-19 pandemic are undeniably severe. As of the 18th of April 2020, there are nearly 2.2 million confirmed cases and more than 146,000 deaths of registered infected individuals worldwide (World Health Organization, 2020). Additionally, the COVID-19 outbreak may indirectly increase its death toll because treatments of people with other life-threatening diseases may be postponed and people experiencing other health issues may avoid visiting health care facilities to avoid getting infected. Eventually, worldwide, the number of casualties can therefore be expected to exceed some of the most deadly natural disasters in recent history, including the 2004 East-Asia Tsunami (230,000 deaths) and the 2010 Haiti earthquake (highest estimate: 316,000 deaths). The pandemic and governmental policies to curb its impact can yield additional stressors, e.g., social isolation, job-loss, risk of viral infection for some workers, severe illness, quarantine, and intensive care admission.

Consequently, as demonstrated in recent pioneering studies in Psychiatry Research, increased psychiatric complaints, including anxiety and depression, are common among the general public in COVID-19 affected areas (e.g., Cao et al., 2020). While increases in mental health problems following natural disasters and viral outbreaks have been previously documented, there is historically less attention for severe, disabling and protracted grief responses, termed complicated grief or prolonged grief (PG) (Eisma et al., 2019). This is at least partly due to the fact that, until recently, disturbed grief was not included as a disorder in psychiatric classification systems. In 2018, this changed when prolonged grief disorder (PGD) was added to the International Classification of Diseases eleventh edition (ICD-11). PGD is characterized by distressing and disabling yearning for the deceased and/or preoccupation with the deceased, accompanied by anger, guilt, and other symptoms indicative of intense emotional pain experienced for at least 6 months after the loss. In 2013, the 5th Diagnostical and Statistical Manual of Mental Disorders (DSM-5) included Persistent Complex Bereavement Disorder in section 3; this will likely be replaced by a diagnosis also named Prolonged Grief Disorder in section 2 of the forthcoming revision of the DSM-5 (Boelen and Lenferink, 2020). Despite a paucity of research on grief after global viral outbreaks, we argue that there are at least two reasons why the COVID-19 pandemic may cause a worldwide rise of PGD cases.

First, disasters with many casualties generally result in higher levels of PG symptoms among bereaved survivors, than observed following other modes of death. Moreover, PG symptoms in these survivors are often distinct from comorbid disorders, such as post-traumatic stress disorder (PTSD) or depression (for a brief review: Eisma et al., 2019). For instance, one year after the Sichuan earthquake, latent class analyses demonstrated that approximately a quarter of bereaved survivors experienced high PTSD and PG symptom levels and another quarter exclusively experienced high PG symptoms (Eisma et al., 2019). Given the considerable similarities of disasters with the COVID-19 pandemic (i.e., high death toll, many secondary stressors, severe societal disruption), we anticipate that similar patters in mental health symptoms will be observed among people bereaved by this pandemic.

Second, increased PGD rates can be expected considering the circumstances of many COVID-19 deaths. PG symptoms are typically elevated when deaths are unexpected, traditional grief rituals (e.g., saying goodbye, viewing and burial of body) are absent (Castle and Phillips, 2003), and physical social support is lacking (Lobb et al., 2010). Moreover, due to government policy targeting the pandemic, the same potential risk factors could also increase grief severity of people whose family members died through other causes than COVID-19.

To conclude, in the development and aftermath of the COVID-19 pandemic, we anticipate that, worldwide, PGD will become a major public health concern. Provided that future research corroborates these scientifically-founded predictions, it appears critical to anticipate a heightened need for effective PGD treatments. Currently available care will likely not suffice, as evidence-based treatments for PGD are not widely available worldwide and there may be less availability of qualified health care professionals to deliver such treatments during the pandemic. Therefore, we should collectively work toward improving accessibility of evidence-based PGD interventions, including cognitive-behavioral treatments in both face-to-face and online formats (for a review: Johannsen et al., 2019). It is particularly vital to stimulate the development and dissemination internet-based PGD treatments, as such interventions can be applied even if the pandemic persists for extended periods of time.

Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Credit author statement

Conceptualization: MCE, LIML; Writing – first draft: MCE, LIML; Writing – reviewing and editing: PAB

Declaration of Competing Interest

The authors declare no conflicts of interests.