Prevalence of Prolonged Grief Disorder and Related Clinical Factors Among Turkish Psychiatric Outpatients During the COVID-19 Pandemic

Abstract

Prolonged grief disorder (PGD), a new diagnosis in some classification systems, has gained prominence due to the high mortality rates observed during the Covid-19 pandemic. Herein, the prevalence of PGD (diagnosed with structured clinical interviews), death-related features, and associated clinical factors were investigated among outpatient psychiatric patients who lost a first-degree relative within the past 12–24 months. PGD was diagnosed in 30/68 patients (44.1%). PGD development did not differ based on cause of death (Covid-19-related vs. other causes) but was associated with higher age of the bereaved, younger age of the deceased, and degree of kinship. Higher rates of depression, insomnia, and anxious attachment were also observed in PGD patients. Finally, the unexpectedness of death predicted the development of PGD. Due to the high prevalence of PGD among psychiatric patients, clinicians should be aware of the disorder, monitor grief processes in high-risk patients, and consider PGD in treatment planning.

Keywords

prolonged grief disorder bereavement COVID-19 pandemic psychiatric outpatients Türkiye

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References

Andrade

(2020). The limitations of online surveys. Indian Journal of Psychological Medicine, 42(6), 575–576. https://doi.org/10.1177/0253717620957496

Barry

L. C.

Kasl

S. V.

Prigerson

H. G.

(2002). Psychiatric disorders among bereaved persons: The role of perceived circumstances of death and preparedness for death. The American Journal of Geriatric Psychiatry, 10(4), 447–457. https://doi.org/10.1097/00019442-200207000-00011

Bastien

C. H.

Vallières

Morin

C. M.

(2001). Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Medicine, 2(4), 297–307. https://doi.org/10.1016/s1389-9457(00)00065-4

Becker

Xander

C. J.

Blum

H. E.

Lutterbach

Momm

Gysels

Higginson

I. J.

(2007). Do religious or spiritual beliefs influence bereavement? A systematic review. Palliative Medicine, 21(3), 207–217. https://doi.org/10.1177/0269216307077327

Boelen

P. A.

Lancee

(2013). Sleep difficulties are correlated with emotional problems following loss and residual symptoms of effective prolonged grief disorder treatment. Depression Research and Treatment, 2013, 739804. https://doi.org/10.1155/2013/739804

Boelen

P. A.

Prigerson

H. G.

(2007). The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life among bereaved adults: A prospective study. European Archives of Psychiatry and Clinical Neuroscience, 257(8), 444–452. https://doi.org/10.1007/s00406-007-0744-0

Boelen

P. A.

van den Hout

M. A.

van den Bout

(2006). A cognitive-behavioral conceptualization of complicated grief. Clinical Psychology: Science and Practice, 13(2), 109–128. https://doi.org/10.1111/J.1468-2850.2006.00013.X

Bowlby

(1973). Attachment and loss. Volume II: Separation, anxiety and anger. Basic Books.

Boysan

Güleç

Beşiroğlu

Kalafat

(2013). Psychometric properties of the insomnia severity Index in Turkish sample. Anadolu Psikiyatri Dergisi, 11, 248–252.

10.

Breen

L. J.

Mancini

V. O.

Lee

S. A.

Pappalardo

E. A.

Neimeyer

R. A.

(2022). Risk factors for dysfunctional grief and functional impairment for all causes of death during the COVID-19 pandemic: The mediating role of meaning. Death Studies, 46(1), 43–52. https://doi.org/10.1080/07481187.2021.1974666

11.

Burke

L. A.

Neimeyer

R. A.

(2012). Prospective risk factors for complicated grief: A review of the empirical literature. In van der B.

H. S. J.

Stroebe

P. B. M. S.

(Eds), Complicated grief: Scientific foundations for healthcare professionals (pp. 145–161). Routledge. https://www.researchgate.net/publication/262603110_Prospective_Risk_Factors_for_Complicated_Grief_A_Review_of_the_Empirical_Literature

12.

Castle

Phillips

W. L.

(2003). Grief rituals: Aspects that facilitate adjustment to bereavement. Journal of Loss and Trauma, 8(1), 41–71. https://doi.org/10.1080/15325020305876

13.

Dadfar

Kalibatseva

Lester

(2018). Reliability and validity of the farsi version of the patient health questionnaire-9 (PHQ-9) with Iranian psychiatric outpatients. Trends in Psychiatry and Psychotherapy, 40(2), 144–151. https://doi.org/10.1590/2237-6089-2017-0116

14.

Diyanet İşleri Başkanlığı (2014). Türkiye’de Dinî Hayat Araştırması. http://www.ceidizleme.org/ekutuphaneresim/dosya/914_1.pdf

15.

Djelantik

A. A. A. M. J.

Smid

G. E.

Mroz

Kleber

R. J.

Boelen

P. A.

(2020). The prevalence of prolonged grief disorder in bereaved individuals following unnatural losses: Systematic review and meta regression analysis. Journal of Affective Disorders, 265, 146–156. https://doi.org/10.1016/J.JAD.2020.01.034

16.

Doering

B. K.

Barke

Vogel

Comtesse

Rosner

(2022). Predictors of prolonged grief disorder in a German representative population sample: Unexpectedness of bereavement contributes to grief severity and prolonged grief disorder. Frontiers in Psychiatry, 13, 793. https://doi.org/10.3389/fpsyt.2022.853698

17.

Downar

Parsons

H. A.

Cohen

Besserer

Adeli

Gratton

Murphy

Warmels

Bruni

Bhimji

Dyason

Enright

Desjardins

Wooller

Kabir

Noel

Heidinger

Anderson

Arsenault-Mehta

Lawlor

(2022). 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. Palliative Medicine, 36(8), 1305–1312. https://doi.org/10.1177/02692163221109711

18.

Eisma

M. C.

Tamminga

Smid

G. E.

Boelen

P. A.

(2021). Acute grief after deaths due to COVID-19, natural causes and unnatural causes: An empirical comparison. Journal of Affective Disorders, 278, 54–56. https://doi.org/10.1016/J.JAD.2020.09.049

19.

Ergün

Şenyüz

(2022). Prolonged grief disorder among bereaved survivors after the 2011 Van Earthquake in Turkey. Death Studies, 46(6), 1364–1371. https://doi.org/10.1080/07481187.2021.1884624

20.

Feldman

D. B.

Fischer

I. C.

Gressis

R. A.

(2016). Does religious belief matter for grief and death anxiety? Experimental philosophy meets psychology of religion. Journal for the Scientific Study of Religion, 55(3), 531–539. https://doi.org/10.1111/JSSR.12288

21.

Fraley

R. C.

Bonanno

G. A.

(2004). Attachment and loss: A test of three competing models on the association between attachment-related avoidance and adaptation to bereavement. Personality & Social Psychology Bulletin, 30(7), 878–890. https://doi.org/10.1177/0146167204264289

22.

Fresco

D. M.

Coles

M. E.

Heimberg

R. G.

Liebowitz

M. R.

Hami

Stein

M. B.

Goetz

(2001). The Liebowitz social anxiety scale: A comparison of the psychometric properties of self-report and clinician-administered formats. Psychological Medicine, 31(6), 1025–1035. https://doi.org/10.1017/S0033291701004056

23.

Fujisawa

Miyashita

Nakajima

Ito

Kato

Kim

(2010). Prevalence and determinants of complicated grief in general population. Journal of Affective Disorders, 127(1–3), 352–358. https://doi.org/10.1016/J.JAD.2010.06.008

24.

Gang

Falzarano

She

W. J.

Winoker

Prigerson

H. G.

(2022). Are deaths from COVID-19 associated with higher rates of prolonged grief disorder (PGD) than deaths from other causes? Death Studies, 46(6), 1287–1296. https://doi.org/10.1080/07481187.2022.2039326

25.

Goveas

J. S.

Shear

M. K.

(2020). Grief and the COVID-19 pandemic in older adults. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 28(10), 1119–1125. https://doi.org/10.1016/J.JAGP.2020.06.021

26.

Granek

(2010). Grief as pathology: The evolution of grief theory in psychology from Freud to the present. History of Psychology, 13(1), 46–73. https://doi.org/10.1037/A0016991

27.

Hall

(2014). Bereavement theory: Recent developments in our understanding of grief and bereavement. Bereavement Care, 33(1), 7–12. https://doi.org/10.1080/02682621.2014.902610

28.

Heeke

Kampisiou

Niemeyer

Knaevelsrud

(2019). A systematic review and meta-analysis of correlates of prolonged grief disorder in adults exposed to violent loss. European Journal of Psychotraumatology, 10(1), 1583524. https://doi.org/10.1080/20008198.2019.1583524

29.

Heerwegh

Loosveldt

(2008). Face-to-Face versus web surveying in a high-internet-coverage Population differences in response quality. Public Opinion Quarterly, 72(5), 836–846. https://doi.org/10.1093/POQ/NFN045

30.

Horowitz

M. J.

Siegel

Holen

Bonanno

G. A.

Milbrath

Stinson

C. H.

(1997). Diagnostic criteria for complicated grief disorder. The American Journal of Psychiatry, 154(7), 904–910. https://doi.org/10.1176/AJP.154.7.904

31.

Huh

H. J.

Kim

K. H.

Lee

H. K.

Chae

J. H.

(2017). Attachment styles, grief responses, and the moderating role of coping strategies in parents bereaved by the Sewol ferry accident. European Journal of Psychotraumatology, 8(sup6), 1424446. https://doi.org/10.1080/20008198.2018.1424446

32.

Ishikawa

R. Z.

(2020). I may never see the ocean again: Loss and grief among older adults during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice and Policy, 12(S1), S85–S86. https://doi.org/10.1037/TRA0000695

33.

Işıklı

Keser

Prigerson

H. G.

Maciejewski

P. K.

(2020). Validation of the prolonged grief scale (PG-13) and investigation of the prevalence and risk factors of prolonged grief disorder in Turkish bereaved samples. Death Studies, 46(3), 628–638. https://doi.org/10.1080/07481187.2020.1745955

34.

Kersting

Brähler

Glaesmer

Wagner

(2011). Prevalence of complicated grief in a representative population-based sample. Journal of Affective Disorders, 131(1–3), 339–343. https://doi.org/10.1016/J.JAD.2010.11.032

35.

Lancel

Stroebe

Eisma

M. C.

(2020). Sleep disturbances in bereavement: A systematic review. Sleep Medicine Reviews, 53, 101331. https://doi.org/10.1016/J.SMRV.2020.101331

36.

Lenferink

L. I. M.

Boelen

P. A.

(2023). DSM-5-TR prolonged grief disorder levels after natural, COVID-19, and unnatural loss during the COVID-19 pandemic. Journal of Affective Disorders Reports, 12, 100516. https://doi.org/10.1016/J.JADR.2023.100516

37.

LeRoy

A. S.

Gabert

Garcini

Murdock

K. W.

Heijnen

Fagundes

C. P.

(2020). Attachment orientations and loss adjustment among bereaved spouses. Psychoneuroendocrinology, 112, 104401. https://doi.org/10.1016/J.PSYNEUEN.2019.104401

38.

Lundorff

Holmgren

Zachariae

Farver-Vestergaard

O’Connor

(2017). Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis. Journal of Affective Disorders, 212, 138–149. https://doi.org/10.1016/J.JAD.2017.01.030

39.

Marques

Bui

Leblanc

Porter

Robinaugh

Dryman

M. T.

Nadal-Vicens

Worthington

Simon

(2013). Complicated grief symptoms in anxiety disorders: Prevalence and associated impairment. Depression and Anxiety, 30(12), 1211–1216. https://doi.org/10.1002/DA.22093

40.

Newson

R. S.

Boelen

P. A.

Hek

Hofman

Tiemeier

(2011). The prevalence and characteristics of complicated grief in older adults. Journal of Affective Disorders, 132(1–2), 231–238. https://doi.org/10.1016/J.JAD.2011.02.021

41.

Olaolu

Tumenta

Adeyemo

Popoola

Oladeji

Olupona

(2020). Two cases of persistent complex bereavement disorder diagnosed in the acute inpatient unit. Case Reports in Psychiatry, 2020, 3632060. https://doi.org/10.1155/2020/3632060

42.

Piper

W. E.

Ogrodniczuk

J. S.

Azim

H. F.

Weideman

(2001). Prevalence of loss and complicated grief among psychiatric outpatients. Psychiatric Services (Washington, D.C.), 52(8), 1069–1074. https://doi.org/10.1176/APPI.PS.52.8.1069

43.

Prigerson

Ahmed

Silverman

G. K.

Saxena

A. K.

Maciejewski

P. K.

Jacobs

S. C.

Kasl

S. V.

Aqeel

Hamirani

(2002). Rates and risks of complicated grief among psychiatric clinic patients in Karachi, Pakistan. Death Studies, 26(10), 781–792. https://doi.org/10.1080/07481180290106571

44.

Prigerson

H. G.

Boelen

P. A.

Smith

K. V.

Maciejewski

P. K.

(2021). Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 20(1), 96–106. https://doi.org/10.1002/WPS.20823

45.

Prigerson

H. G.

Horowitz

M. J.

Jacobs

S. C.

Parkes

C. M.

Aslan

Goodkin

Raphael

Marwit

S. J.

Wortman

Neimeyer

R. A.

Bonanno

Block

S. D.

Kissane

Boelen

Maercker

Litz

B. T.

Johnson

J. G.

First

M. B.

Maciejewski

P. K.

(2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), e1000121-e1000137. https://doi.org/10.1371/JOURNAL.PMED.1000121

46.

Prigerson

H. G.

Shear

M. K.

Jacobs

S. C.

Reynolds

C. F.

Maciejewski

P. K.

Davidson

J. R. T.

Rosenheck

Pilkonis

P. A.

Wortman

C. B.

Williams

J. B. W.

Widiger

T. A.

Frank

Kupfer

D. J.

Zisook

(1999). Consensus criteria for traumatic grief. A preliminary empirical test. The British Journal of Psychiatry: The Journal of Mental Science, 174(JAN), 67–73. https://doi.org/10.1192/BJP.174.1.67

47.

Reitsma

Killikelly

Müller

Larsen

Boelen

Lenferink

(2023). Prevalence and correlates of positive and negative psychological effects of bereavement due to COVID-19: A living systematic review. F1000 Research Limited, 12, 237. https://doi.org/10.12688/f1000research.130397.1

48.

Rosner

Comtesse

Vogel

Doering

B. K.

(2021). Prevalence of prolonged grief disorder. Journal of Affective Disorders, 287, 301–307. https://doi.org/10.1016/J.JAD.2021.03.058

49.

Sari

Y. E.

Kokoglu

Balcioglu

Bilge

Colak

Unluoglu

(2016). Turkish reliability of the patient health questionnaire-9. Biomedical Research, 0(0). https://www.biomedres.info/biomedical-research/turkish-reliability-of-the-patient-health-questionnaire9.html

50.

Savci

Aysan

(2016). Yakın İlişkilerde Yaşantılar Ölçeği Kısa Formu’nun Türkçe uyarlaması: Geçerlik ve güvenirlik çalışması. VIII. Uluslararası Eğitim Araştırmaları Kongresi içinde (pp. 837–846). Uluslararası Eğitim Araştırmaları Kongresi. https://toad.halileksi.net/olcek/yakin-iliskilerde-yasantilar-olcegi-kisa-formu/.

51.

Schroeder

Tan

C. M.

Urlacher

Heitkamp

(2021). The role of rural and urban geography and gender in community stigma around mental illness. Health Education & Behavior, 48(1), 63–73. https://doi.org/10.1177/1090198120974963

52.

Sekowski

Prigerson

H. G.

(2021). Associations between interpersonal dependency and severity of prolonged grief disorder symptoms in bereaved surviving family members. Comprehensive Psychiatry, 108, 152242. https://doi.org/10.1016/J.COMPPSYCH.2021.152242

53.

Simon

N. M.

Shear

K. M.

Thompson

E. H.

Zalta

A. K.

Perlman

Reynolds

C. F.

Frank

Melhem

N. M.

Silowash

(2007). The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief. Comprehensive Psychiatry, 48(5), 395–399. https://doi.org/10.1016/J.COMPPSYCH.2007.05.002

54.

Singer

McLean

Kahler

Papa

(2022). An evaluation of common risk factors for prolonged grief disorder using the international classification of diseases-11 criteria. Aging & Mental Health, 26(11), 2202–2207. https://doi.org/10.1080/13607863.2021.1998359

55.

Specht

Vöhringer

Knaevelsrud

Wagner

Stammel

Böttche

(2022). Prolonged grief disorder in Arabic-speaking treatment-seeking populations: Relationship with socio-demographic aspects, loss- and trauma-related characteristics, and mental health support. Frontiers in Psychiatry, 13, 933848. https://doi.org/10.3389/fpsyt.2022.933848

56.

Stelzer

E. M.

Zhou

Maercker

O’Connor

M. F.

Killikelly

(2019). Prolonged grief disorder and the cultural crisis. Frontiers in Psychology, 10, 2982. https://doi.org/10.3389/FPSYG.2019.02982

57.

Sung

S. C.

Dryman

M. T.

Marks

Shear

M. K.

Ghesquiere

Fava

Simon

N. M.

(2011). Complicated grief among individuals with major depression: Prevalence, comorbidity, and associated features. Journal of Affective Disorders, 134(1–3), 453–458. https://doi.org/10.1016/J.JAD.2011.05.017

58.

Szuhany

K. L.

Young

Mauro

Garcia de la Garza

Spandorfer

Lubin

Skritskaya

N. A.

Hoeppner

S. S.

Pace-Schott

Zisook

Reynolds

C. F.

Shear

M. K.

Simon

N. M.

(2020). Impact of sleep on complicated grief severity and outcomes. Depression and Anxiety, 37(1), 73–80. https://doi.org/10.1002/DA.22929

59.

Taymur

İ.

Özdel

Aypak

Duyan

Türedi

Ö.

Güngör

B. B.

Selvi

(2016). Evaluation of the relationship between major depressive disorder and bereavement symptoms in elderly patients who present either to psychiatry or family medicine. Nöro Psikiyatri Arşivi, 53(2), 108–114. https://doi.org/10.5152/NPA.2015.10095

60.

Vanderwerker

L. C.

Prigerson

H. G.

(2004). Social support and technological connectedness as protective factors in bereavement. Journal of Loss and Trauma, 9(1), 45–57. https://doi.org/10.1080/15325020490255304

61.

Wang

Verdery

A. M.

Margolis

Smith-Greenaway

(2022). Bereavement from COVID-19, gender, and reports of depression among older adults in europe. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 77(7), e142-e149. https://doi.org/10.1093/GERONB/GBAB132

62.

Wei

Russell

D. W.

Mallinckrodt

Vogel

D. L.

(2007). The experiences in close relationship scale (ECR)-short form: Reliability, validity, and factor structure. Journal of Personality Assessment, 88(2), 187–204. https://doi.org/10.1080/00223890701268041

63.

WHO (2023). WHO coronavirus (COVID-19) dashboard with vaccination data. https://covid19.who.int/

64.

Yuan

M. D.

Wang

Z. Q.

Fei

Zhong

B. L.

(2022). Prevalence of prolonged grief disorder and its symptoms in Chinese parents who lost their only child: A systematic review and meta-analysis. Frontiers in Public Health, 10, 3547. https://doi.org/10.3389/FPUBH.2022.1016160/BIBTEX