Interventions to Improve Care of Bereaved Persons

There is a rising concern for the epidemic of bereavement and grief related to the Coronavirus disease 2019 (COVID-19) pandemic. Even pre-pandemic bereavement is associated with excess risk of mortality, particularly in the early weeks and months after loss. It is related to impairment in both behavioral and physical health, indicated by the presence of symptoms and illnesses, and by the increased use of medical services.

The term bereavement refers to the experience of the death of someone with whom the individual had a close relationship. Grief is a natural reaction in response to a death and refers to the psychobiological and sometimes spiritual response to bereavement.^1,2,3Integrated grief is the permanent response after adaptation to the loss, in which satisfaction with ongoing life is renewed. While most individuals do not require specialized interventions, a subset will struggle with their grief and may develop prolonged or complicated grief reactions.⁴ Grief processes are impacted by sociocultural factors.^5,6

Even people experiencing acute grief sometimes need supportive interventions.⁷  Some bereaved persons are at higher risk for grief disorders: risk factors include older age, female gender, lower socio-economic status or history of pre-existing anxiety and depression. Some research suggests that early identification and intervention for at risk bereaved people can decrease the onset of prolonged grief disorders.

Pre-pandemic, prevalence estimates suggested that 60% of older adults experienced bereavement, but only about 7% develop complicated grief.  Complicated grief has been defined when the person exhibits high-distress levels or grief-related impairment persisting more than 6-12 months following the death of a loved one, with symptoms out of proportion to cultural, religious, or age-appropriate norms. (Simon, JAMA, 2015). In 2018, the WHO- ICD-11 proposed the term "prolonged grief disorder"⁸ which was also endorsed by the American Psychological Association in 2020. Persistent Complex Bereavement Disorder) was listed in Section III of DSM 5 as a "Condition for Further Study" and was eventually adopted as a formal disorder in the DSM 5-TR in 2022.⁹ For the purposes of this brief, we will use the term "prolonged grief disorder" (PGD) to denote the type of maladaptive, non-normative grief which requires clinical intervention.

Some experts recommend a stepwise approach to interventions across a continuum of grief.  Providers should acknowledge bereavement and provide care based on the bereaved person's distress. Interventions range from the purely informational to structured clinical treatment. These can be described as universal, selective, and indicated grief interventions. Universal  interventions are those preventive/screening measures in which bereavement is acknowledged and resources are available to all bereaved individuals. Selective interventions are designed to prevent maladaptive grief reactions in bereaved individuals who are more vulnerable or at risk for grief disorders. Indicated interventions are those that provide therapy for maladaptive grief or grief disorders.

While SAMHSA has endorsed some therapies for complicated grief (based on a few RCTs), these therapies have not undergone a comparative effective analysis.¹⁰ A recent review of the quality of existing guidelines found one US-based guidance on suicide (no longer avail on website)¹¹ Another found one guideline from the American College of Obstetrics and Gynecology on bereavement due to stillbirth.¹² However guidance was not based on a systematic review and the quality was rated as "B, recommend with modification":  The National Quality Forum lists one endorsed measure related to bereavement.¹³

This review was commissioned to provide a synthesis of the published literature and may be used to inform clinical care, policy, and future research.

KQ 1. What is the effectiveness and harms of universal screening people for bereavement and response to loss?

      1a. Timing: predeath, acute, or 6-12 months post loss?

      1b. Does effectiveness vary by patient characteristic (e.g., demographic characteristics, pre-existing mental health condition) or setting (e.g., primary care, behavioral health provider, school, palliative and hospice care)?

KQ 2. How accurate are tools to identify bereaved persons at risk for or with grief disorders?

KQ 3. What are the effectiveness, comparative effectiveness, and harms of selective interventions for at risk bereaved people?

      3a. Timing: predeath, acute, or 6-12 months post loss?

      3b. Does effectiveness vary by patient characteristic (e.g., demographic characteristics, pre-existing mental health condition) or setting (e.g., primary care, behavioral health settings, school, palliative and hospice care)?

KQ 4. What are the effectiveness, comparative effectiveness and harms of indicated interventions for people diagnosed with maladaptive grief-related disorders?

      4a. Does effectiveness vary by patient characteristic (e.g., demographic characteristics, pre-existing mental health condition) or setting (e.g., primary care, school, palliative and hospice care)?

Draft Contextual Question

CQ 1. What is the quality of current [standards of care/guidelines/policies] for bereavement/grief care? (potential update of Kent 2019, search ended 2017)¹¹

PICOTS

¹Excludes medical personnel and paid caregivers

1. Burke LA, Neimeyer RA. The Inventory of Complicated Spiritual Grief: Assessing Spiritual Crisis Following Loss. Religions. 2016;7(6):67. PMID: doi:10.3390/rel7060067.
2. Walsh K, King M, Jones L, et al. Spiritual beliefs may affect outcome of bereavement: prospective study. Bmj. 2002 Jun 29;324(7353):1551. doi: 10.1136/bmj.324.7353.1551. PMID: 12089091
3. Biancalani G, Azzola C, Sassu R, et al. Spirituality for Coping with the Trauma of a Loved One’s Death During the COVID-19 Pandemic: An Italian Qualitative Study. Pastoral Psychology. 2022 04/01;71:1-13. doi: 10.1007/s11089-021-00989-8
4. Shear MK, Ghesquiere A, Glickman K. Bereavement and complicated grief. Curr Psychiatry Rep. 2013 Nov;15(11):406. doi: 10.1007/s11920-013-0406-z. PMID: 24068457.
5. Smid GE, Groen S, de la Rie SM, et al. Toward Cultural Assessment of Grief and Grief-Related Psychopathology. Psychiatr Serv. 2018 Oct 1;69(10):1050-2. doi: 10.1176/appi.ps.201700422. PMID: 30041592.
6. Institute of Medicine Committee for the Study of Health Consequences of the Stress of Bereavement. Sociocultural Influences. In: Osterweis M, Solomon F, M G, eds. Bereavement: Reactions, Consequences, and Care. Washington (DC): National Academies Press (US); 1984.
7. Powell CC. Caring for the psychosocial needs of the acutely traumatized patient. Jaapa. 2021 Nov 1;34(11):24-9. doi: 10.1097/01.JAA.0000794980.31616.fa. PMID: 34608014
8. WHO Family of International Classifications (WHO-FIC). 6B42 Prolonged grief disorder. In ICD-11 for Mortality and Morbidity Statistics. 2018.
9. American Psychiatric Association. Trauma-and Stressor-Related Disorders.  Diagnostic and statistical manual of mental disorders (5th ed, text rev),. 2022.
10. Mental Health Technology Transfer Center (MHTTC) Network. Fact Sheet #5: Evidence-Based Treatments for Grief. 2020.
11. Kent K, Jessup B, Marsh P, et al. A systematic review and quality appraisal of bereavement care practice guidelines. J Eval Clin Pract. 2020 Jun;26(3):852-62. doi: 10.1111/jep.13225. PMID: 31287214
12. Zhuang S, Ma X, Xiao G, et al. Clinical practice guidelines for perinatal bereavement care: A systematic quality appraisal using AGREE II instrument. J Pediatr Nurs. 2022 Sep-Oct;66:49-56. doi: 10.1016/j.pedn.2022.04.007. PMID: 35636000.
    https://www.pediatricnursing.org/article/S0882-5963(22)00097-5/fulltext
13. Forum NQ. 1623, Bereaved Family Survey. In: Department of Veterans Affairs / Hospice and Palliative Care, editor: NQF; 2012.