Grief Before and During the COVID-19 Pandemic: Multiple Group Comparisons

Context Grief researchers are concerned that the coronavirus disease 2019 (COVID-19) pandemic will precipitate increases in severe, persistent, and disabling grief, termed prolonged grief disorder or persistent complex bereavement disorder. We recently demonstrated that higher grief levels are experienced after COVID-19-related bereavement than natural bereavement. Death circumstances during the pandemic (e.g., reduced social support, limited opportunities for death rituals) may also hamper the grief process for non-COVID-19-related bereavement, yet no quantitative research has specifically addressed this issue. Objectives To test if grief severity is higher during than before the lockdown after non-COVID-19-related bereavement. Methods A cross-sectional survey including questions on sociodemographic and loss-related variables and a grief measure was conducted among a sample of 1600 bereaved adults (78% females), participating before (n = 731) or during (n = 869) the pandemic, including people who had experienced a loss before the pandemic (n = 456) or during the pandemic (n = 200) recently (five months ago or less). Results No significant differences emerged between grief levels in people participating before or during the pandemic. However, being recently bereaved during the pandemic elicited more severe grief than before it (d = 0.17; d = 0.18). Effects remained significant after controlling analyses for relevant loss-related variables. Conclusion Among all bereaved persons, grief severity was no different during the pandemic compared with before the pandemic. However, experiencing a recent loss during the pandemic elicited more severe acute grief reactions than before the pandemic, suggesting that dealing with loss may be more difficult during this ongoing health crisis.


Introduction
With more than 35 million confirmed cases and one million deaths worldwide, coronavirus disease 2019 (COVID-19) is one of the deadliest and widespread viral outbreaks of the past century. 1 To reduce the spread of COVID-19, governments have introduced policy measures, such as social distancing and restrictions on assembly and travel. This resulted in substantial societal changes affecting many aspects of our everyday lives, including how we die and mourn our dead.
Researchers have voiced concerns that COVID-19 loss characteristics (e.g., experiencing sudden death, after intensive care admission) and circumstances (e.g., limited opportunities to shape death rituals, difficulties receiving social support, co-occurrence of secondary stressors, e.g., social isolation, infection, job loss) will hamper the grief process (e.g., Refs. 2,3 ). In addition, researchers have argued that aforementioned circumstances of loss may also disturb the grief process for those experiencing losses unrelated to COVID-19 during the pandemic, potentially leading to more severe grief reactions in the larger population of bereaved persons (e.g., Ref. 2 ). Accordingly, researchers have predicted long-term increases in prevalence of severe, persistent, and disabling grief, also termed prolonged grief disorder (PGD: International Classification of Diseases, Eleventh Revision) or persistent complex bereavement disorder (PCBD: Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) in both populations. 4 Such disturbed grief reactions are distinct from related disorders of depression and post-traumatic stress disorder, relate to reductions in quality of life and increased suicidal ideation, and appear best treated with grief-specific treatments. 5 Identifying whom among the bereaved may be at heightened risk for severe grief reactions is critical for palliative care providers, grief counselors, and policy makers. For instance, it is important to anticipate a heightened need for remotely delivered treatments for disturbed grief if becoming bereaved during COVID-19 elevates risk for PGD and PCBD. 2 Despite the clinical importance of the topic, a recent review demonstrated that no quantitative research had been conducted on health consequences of bereavement after viral outbreaks and the COVID-19 pandemic specifically. 6 To fill this knowledge gap, we recently demonstrated in a first quantitative study that people bereaved because of COVID-19 experience higher acute grief levels than people bereaved because of natural causes but not compared with those bereaved because of unnatural causes. 7 As acute grief is one of the strongest predictors of future disturbed grief, 8 this supports the prediction that prevalence of grief disorders will rise because of the pandemic within this specific population.
However, the prediction that grief may be more severe among bereaved people who experience losses unrelated to COVID-19 during the pandemic yet remains untested. So far, only qualitative studies have shed light on this issue. For example, one qualitative study among parents who lost a child to cancer before the pandemic identified both negative and positive effects of the pandemic on the grief process. 9 Although the pandemic made some feel more isolated because of decreased possibilities for social interaction, some experienced no differences, whereas others welcomed the pandemic as it provided more opportunity to engage in 'grief work'. Another qualitative study focused specifically on the experience of people bereaved during the pandemic. It illustrated additional grief-related problems of this population, such as death occurring in isolation, missing the last moments with the deceased, and a limited ability to shape death rituals. 10 Although this work is informative, a quantitative test of whether grief is more severe during the pandemic appears critical. The impact of a small effect on the grief severity after non-COVID-19 losses (>98% yearly deaths worldwide) may far exceed a larger effect on grief severity because of COVID-19 deaths alone (<2% of yearly deaths worldwide) and could therefore be similarly clinically relevant. Therefore, we aimed to examine grief reactions to non-COVID-19 deaths during the pandemic within a large cross-sectional survey. First, we hypothesized that reported grief levels would be higher during the pandemic than before it. Second, we hypothesized that experiencing a recent loss during the pandemic would elicit more severe grief reactions than experiencing a recent loss before the pandemic. Because PGD and PCBD cannot be established in the first months after bereavement because of their time criteria (six and 12 months postloss, respectively), examining acute grief is the best available strategy to test if non-COVID-19-related bereavement during the pandemic will precipitate more disturbed grief reactions over time.

Methods
A local ethics committee approved this ongoing study. Adult bereaved participants were recruited online on a Web site (www.psyned.nl) of a Dutch national mental health care organization (Psyned) where they could complete an online self-test for PCBD. Before filling in the survey, participants read information about the study procedure and background (e.g., study aims, data handling, and voluntariness). If they wished to participate, they provided informed consent. People who did not provide informed consent could still use the self-test, but their data were not used for research purposes. After survey completion, participants received a preliminary indication if they met criteria for PCBD (including information on the PCBD time criterion and the message that only a licensed health care professional can establish diagnoses).
Participants completed a self-constructed measure of sociodemographic (i.e., age, gender) and lossrelated characteristics (i.e., time since loss, relationship with the deceased, cause of loss, expectedness of the loss), a single-item assessing satisfaction with social support (ranging from 1 ¼ very unsatisfied to 5 ¼ very satisfied), and the Traumatic Grief Inventory Self Report. 11 This 18-item scale assesses current criteria for PCBD per Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) and PGD per Prigerson et al. 12 on a five-point Likert scale (from 1 ¼ never to 5 ¼ always). We summed items assessing PCBD (a ¼ 0.89) and PGD (a ¼ 0.86) to measure grief severity.
Before conducting the main analyses, we removed duplicates (n ¼ 79), nonadults (n ¼ 117), and people who experienced bereavement because of COVID-19 (n ¼ 49) from the data set, leaving 1600 adult bereaved participants. We examined differences between people who participated before the pandemic (before March ninth, when Dutch policy on COVID-19 was implemented nationally) (n ¼ 731) and during the pandemic (n ¼ 869) and between people experiencing a loss before (n ¼ 456) and during the pandemic (n ¼ 200) recently (five months ago and less as we included collected data until five months after March ninth). We compared the first two groups and the second two groups on demographic and loss-related variables and grief symptom levels using Fisher's exact test for categorical variables and t-test for continuous variables. Analyses were performed in SPSS 25.0 (IBM Corp., Armonk, NY) with a two-sided significance level of 0.05. Table 1 summarizes main findings. Bereaved people who participated during the pandemic did not differ from bereaved people who participated before the pandemic on demographic variables, loss-related variables, social support satisfaction, or grief severity (PCBD symptoms, t

Results
People who became bereaved during the pandemic did not significantly differ from people who were recently bereaved before the pandemic on demographic variables and loss-related variables except on time since loss (t[654] ¼ 8.19; P < 0.001). However, experiencing a recent loss during the pandemic did elicit higher levels of grief severity than

Discussion
To the best of our knowledge, this is the first quantitative study to compare grief before and during the COVID pandemic among people bereaved through other causes of death than COVID-19. We demonstrated that in general grief severity was not significantly different during and before the pandemic. However, people who experienced a recent loss during the pandemic had higher grief levels than people who experienced a recent loss before the pandemic. Because acute grief is a strong predictor of future disturbed grief, 8 this lends support to predictions that the pandemic will eventually lead to a higher prevalence of grief disorders (e.g., Ref. 2 ). Palliative care professionals, grief counselors, and policy makers should anticipate that the pandemic elicits heightened levels of grief in people bereaved during the pandemic.
Limitations of the study include voluntary-response sampling, which has led to an overrepresentation of women. This is common in bereavement research and may reflect a stronger need of women to share their feelings. Moreover, online recruitment appears to have resulted in a relatively young bereaved sample. However, the recruitment process was the same throughout the study, and people participating before and after the pandemic showed no significant differences on sociodemographic and loss-related variables. The fact that the sample was nonrepresentative is therefore unlikely to have affected our main findings. We also used a self-report measure of grief precluding formal assessment of grief disorder diagnoses. Moreover, longitudinal research is required to establish if within-person effects of the pandemic on grief underlie the present findings.
Nevertheless, results from this pioneering study suggest that the pandemic has a small but robust negative effect on psychological adjustment after non-COVID-19-related deaths during the pandemic. We predict that these more severe acute grief responses may eventually lead to a higher prevalence of PGD and PCBD in the general bereaved population.