Grief and Depression in Relatives of Deceased Individuals during Social Isolation. Risk and Protective Factors

doi:10.21203/rs.3.rs-3900430/v1

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Grief and Depression in Relatives of Deceased Individuals during Social Isolation. Risk and Protective Factors

https://doi.org/10.21203/rs.3.rs-3900430/v1

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The COVID-19 pandemic resulted in the loss of thousands of lives, leading to a global phenomenon where numerous families are undergoing a grieving process. Simultaneously, health restrictions to prevent the disease´s transmission have prevented individuals from bidding farewell to their loved ones and conducting cultural farewell rituals.

Through a cross-sectional study, we investigated, via social media surveys, the Mexican population that experienced the death of a close family member from November 2020, regardless of the cause. The aim was to determine whether those who did not have the opportunity to say goodbye to their loved one prior to their death and/or those who could not perform farewell rituals according to their culture were at a different risk of developing depressive disorders and/or complicated grief compared to those who did have the opportunity to bid farewell and practice their rituals.

Contrary to our initial hypothesis, we found no statistically significant difference in the likelihood of developing major depressive disorders or complicated grief based on whether individuals said their goodbyes or not. However, we did identify risk and protective factors by analyzing other variables such as the initiation or increase in substance consumption following the loss, religious attachment, and age.

Biological sciences/Psychology/Human behaviour

Biological sciences/Neuroscience/Social behaviour

Health sciences/Diseases/Psychiatric disorders/Addiction

Health sciences/Diseases/Psychiatric disorders/Depression

The experience of grief, an intrinsic phenomenon to the human condition, manifests as a mixture of emotions, physical sensations, and behavioral changes following the loss of a loved one, shaping what is commonly referred to as normal or uncomplicated grief (1). This process, in most cases, unfolds without generating incapacitating medical or psychological consequences for those undergoing it, being a common response to the inevitable departure of a loved one.

However, grief can take on a more complex and prolonged nature, presenting as complicated grief, characterized by a duration extending beyond culturally and socially expected norms, affecting the overall functioning of the individual (2). The prevalence of this type of grief is estimated to be around 2–3% in the general population, being particularly more frequent among family members facing the sudden, violent, or critical loss of a loved one, with a reported incidence of up to 52% in intensive care settings (3).

The COVID-19 pandemic introduced unique challenges to the grieving process, increasing vulnerability to various losses such as economic security, physical connection between individuals, and the autonomy of movement. Furthermore, it altered the usual experiences of grief, especially in the hospital context. Necessary restrictions to control the virus's spread resulted in the indefinite separation of families from their hospitalized loved ones, hindering emotional preparedness for potential loss (4). Even after the passing, funeral rituals underwent significant transformations, taking place remotely and depriving mourners of the support and traditional comfort offered by close family members (5).

This study aims to address crucial questions: How does the grieving process differ between those who have had the opportunity to say goodbye and those who have not? These questions, essential for understanding the complexity of grief in the context of the pandemic, will guide us in exploring fundamental aspects of this human experience.

Participants and Procedure

This study was configured as a cross-sectional, analytical, and observational design. Participant selection was conducted through electronic surveys directed at individuals who had experienced the loss of a close family member (father, mother, sibling, child, spouse, or partner) due to any illness from November 2020 onward.

A non-probabilistic sampling approach was implemented using a survey developed on Google Forms, distributed through electronic platforms such as Facebook, Twitter, Instagram, and WhatsApp. Additionally, flyers with QR codes were distributed in the general population, inviting voluntary participation in the survey by accessing the provided code.

Ethical Approval and Informed Consent.

The protocol for this research study was reviewed and approved by the Ethics Committee of the Research Sub Directorate at the "José Eleuterio González" University Hospital of the Autonomous University of Nuevo León. The Ethics Committee ensured that the research project adhered to the guidelines and regulations of our country, Mexico. The study was approved by the Ethics Committee on October 18, 2021, allowing the recruitment of participants to commence.

This process underscored our commitment to conducting research in accordance with ethical standards and regulatory requirements, thereby safeguarding the rights and welfare of the participants involved in the study.

Participants in this study were provided with a virtual questionnaire, which included an informed consent form. Prior to accessing the questionnaire, participants were presented with detailed information regarding the nature of the study, emphasizing its voluntary nature and the confidentiality of their responses. Participation in the study was contingent upon the participants' acceptance of the informed consent, which was obtained electronically before proceeding with the questionnaire. It is worth noting that participants who declined to accept the informed consent were unable to proceed with the questionnaire to participate.

The first survey question determined whether the participant had suffered the loss of a loved one due to any illness since November 2020 to February 2022. Only those who responded affirmatively proceeded with the study.

The second question aimed to ascertain whether the participant had the opportunity to say goodbye to their loved one, either in person, through a funeral, or another ceremony. In the case of a negative response, further inquiry was made regarding whether COVID-19 health restrictions were the reason for the lack of a farewell.

Measures

The Prolonged Grief Disorder-13 was administered, a questionnaire designed to diagnose complicated grief through 13 items (6). This instrument assesses five criteria related to the loss of a loved one, symptoms of separation anxiety, duration of grief, cognitive, emotional, or behavioral symptoms, and functional impairment.

A diagnosis of complicated grief was established when all five criteria were present. For the anxiety symptoms domain, both questions had to be answered with a score of 4 or 5 on the Likert scale. For cognitive symptoms, it was considered positive if five out of the nine elements had a score of 4 or 5 on the Likert scale. Questions about symptom duration and functional impairment had yes/no responses.

Depression assessment was carried out using the Beck Depression Inventory (BDI), (7). This instrument consists of 21 items on a 4-point Likert scale, with scores ranging from 0 to 63, proportional to the severity of depression.

Sample size calculation was performed using a formula for comparing two proportions, considering a 95% confidence level and 80% power. A prevalence of complicated grief was estimated to be 2-3% in the general population and up to 52% in special cases (8).

Eligibility Criteria

Inclusion criteria covered individuals who had experienced the death of a family member since November 2020, were 18 years or older, and willing to participate in the study.

Exclusion criteria included patients with pre-existing psychiatric diagnoses before the loss of the loved one and those diagnosed with hypothyroidism. Partial or incorrect responses and those from individuals under 18 years old were excluded from the analysis.

Analytic Approach

The collected information was recorded in Microsoft Excel and analyzed using SPSS v. 23. Descriptive statistics were performed for sociodemographic variables, employing measures of central tendency and dispersion. Categorical variables were summarized using frequencies and percentages. Group comparisons were conducted using the Pearson chi-square test or Fisher's exact test for 2x2 tables. Additionally, a qualitative analysis of open-ended survey responses about personal experiences during the grieving process was carried out.

Farewell and Its Impact on Participants' Mental Health

Population Demographics

We enrolled a total of 261 participants who met the criteria of having experienced the loss of a loved one. Within the population, 32.4% reported the loss of an intimate family member such as parents, children, siblings, or a partner. Demographically, the study cohort comprised 78.9% women, 85.4% identified as heterosexual, 34.9% were married, and 81.6% considered themselves religious. The median age of the sample was 28 years (23-41, Table 2).

Among the entire sample, 129 participants were able to bid farewell, while 132 were unable, representing 49.4% and 50.6%, respectively. Notably, within the latter group, 77.3% experienced the inability to bid farewell due to the preventive measures imposed by the COVID-19 pandemic.

Depression Diagnosis

Depression levels among participants were evaluated and classified based on their scores in the Beck Depression Inventory (BDI). The categorization included minimal depression (0-13 points), mild depression (14-19 points), moderate depression (20-28 points), and severe depression (29 points or higher) (9). No significant differences were observed in depression levels between those who could bid farewell and those who could not. However, it is noteworthy that 15.2% of participants who could not bid farewell experienced severe depression, compared to 7.8% of those who bid farewell (p=0.108, Table 1).

Depression Scale

The total score on Beck's Depression Inventory was analyzed, showing a median of 11.0 (interquartile range: 3.5-20.5) for those who could bid farewell and 13.0 (2.2-21.0) for participants who could not. Notably, no significant differences were found between the groups (p=0.411, Table 1).

Complicated Grief Diagnosis and Criteria

The incidence of complicated grief was explored among participants. 3.8% of those who could not bid farewell received a complicated grief diagnosis, compared to 2.3% of those who bid farewell. No significant differences were observed (p=0.744). The median number of criteria met for complicated grief was 1.0 (0.0-1.0) for those who bid farewell and 0.0 (0.0-1.0) for those who did not, without significant differences (p=0.474, Table 1).

Farewell and Risk Factors for Depression

Risk Factors and Protectors for Moderate to Severe Depression

Various risk factors and protectors associated with the classification of moderate to severe depression after the loss of a loved one were identified. Significant results are presented below:

Risk Factors:

1. Age Under 30: Being younger than 30 years old was significantly associated with a higher risk of experiencing moderate to severe depression (OR=2.02, 95% CI: 1.13-3.59, p=0.023). The median age for those with minimal and mild depression was 30.0 (24.0-44.5), while for those with moderate and severe depression, it was 26.0 (21.0-34.5, p=0.001).

2. History of Psychiatric Diagnosis: Individuals with a prior psychiatric diagnosis were present in 17% of minimal and mild cases, compared to 41.7% of moderate and severe depression cases (OR=3.37, 95% CI: 1.85-6.17, p=0.001).

3. Initiation or Increase in Substance Use: A total of 31.9% of cases with moderate and severe depression reported initiating or increasing alcohol consumption after the loss, in contrast to only 6.3% in the minimal and mild depression group (OR=6.9, 95% CI: 3.21-14.89, p=0.001). Similar trends were observed for the initiation or increased consumption of tobacco (OR=2.89, 95% CI: 1.30-6.79, p=0.014).

4. History of Analgesic Use: Individuals who used analgesics before the family member's death had a significantly higher risk of moderate to severe depression (OR=2.88, 95% CI: 1.14-7.26), with 13.9% of moderate and severe cases reporting analgesic use compared to 5.3% in the minimal and mild group.

Protective Factors:

1. Religiosity: Identification as a person adhering to their religion emerged as a significant protective factor against moderate to severe depression (OR=0.42, 95% CI: 0.23-0.78, p=0.008). This characteristic was present in 45.5% of participants in the minimal and mild depression group, as opposed to only 26.4% in the moderate and severe group.

Impact of Bidding Farewell on Depression and Subgroups:

Contrary to the initial hypothesis, no statistically significant differences were found in the levels of moderate to severe depression between individuals who had the opportunity to bid farewell to a close loved one (including parents, children, siblings, or a partner) and those who did not. Among the participants who could bid farewell, a total of 34.9% exhibited moderate or severe depression, while in the group unable to bid farewell, 32.4% of participants experienced moderate or severe depression (p=1.000).

Moreover, when exploring specific subgroups, no categories were identified where the ability to bid farewell had a significant impact on levels or severity of depression.

These results highlight the complexity of factors influencing mental health after the loss of a loved one and underscore the importance of considering various contextual and demographic elements in future research on this delicate topic.

Our study aimed to investigate whether there is any difference in the grief process among individuals who did not have the opportunity to bid farewell or practice farewell rituals before the death of their loved ones compared to those who did. We also sought to identify any distinct risk of developing major depressive disorder and associated risk or protective factors.

The results led us to conclude that there is no statistically significant difference in the risk of developing major depressive disorder, contrary to our initial hypothesis. Similarly, we could not demonstrate a higher risk of experiencing complicated grief among relatives who did not have the chance to say goodbye or engage in farewell rituals, differing from the expected outcome.

This suggests that bidding farewell or not bidding farewell before the death of a loved one, as well as the opportunity to practice corresponding farewell rituals, do not pose a greater risk for developing major depressive disorder and/or complicated grief.

On the other hand, we identified risk factors associated with a higher likelihood of developing major depressive disorder if present. These factors include being younger than 30 years, having a previous psychiatric diagnosis, initiating or increasing substance use after the death of a loved one, and chronic use of analgesics before death. Considering oneself religious emerged as a protective factor, while religious identification did not show a significant difference.

Our results align with the findings of Braam et al. (10), indicating that religiosity predicts a decrease in depression over time, especially in individuals with psychiatric symptoms. Additionally, they corroborate the work of Awaworyi et al. (11), linking alcohol consumption as a promoter of depression.

Limitations of our study include the use of self-administered clinimetry to determine depressive episodes conducted electronically, limiting in-person participant assessment. Moreover, a specific quantity or range of substance consumption was not established to standardize or relate past and current consumption to current symptomatology. Larger-scale studies are warranted.

This information holds clinical relevance as it allows anticipation of future depressive episodes in patients who have experienced the death of a loved one. Particularly, those who cope through substance use or do not identify with a religion, missing the additional protective factor of religiosity.

In conclusion, this study provides insight into the grieving process and depressive tendencies in the Mexican population, highlighting the significant role of substance consumption as a risk factor for affective episodes, along with the protective factor of religiosity.

Author contributions statement:

Dr. Carlos Augusto López Acevo: Conceived the research idea, designed the study methodology, supervised patient recruitment, and contributed to manuscript writing. Also actively sought an indexed scientific journal for publication.

Dr. Nancy Valeria García Leal: Drafted the comprehensive research protocol, managed patient recruitment, facilitated data entry into the database, interpreted clinimetry within the distributed questionnaire, and contributed to the current manuscript writing.

Dra. Giovanna Castelló: Contributed to the comprehensive research protocol drafting, participated in patient recruitment and data collection, and contributed to the current manuscript writing.

Dr. Neri Alejandro Álvarez Villalobos: Contributed to data acquisition, performed statistical analysis, participated in study design, and supervised the study.

Dr. Juan Pablo Ruiz Padilla: Developed the electronic questionnaire for data collection, contributed to statistical analysis, and wrote the report of the obtained results.

Additional information: (Competing interests statement).

The authors declare no financial or non-financial conflicts of interest during the preparation of this study for publication in a medical scientific journal.

Data availability statement.

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Raw data will be made available to researchers for the purpose of reproducing or validating the findings presented in this manuscript. Access to the data will be provided in compliance with ethical standards and subject to any relevant data sharing agreements.

Acknowledgements:

All authors extend a sincere appreciation to the Psychiatric Department, Hospital Universitario “José Eleuterio González” and the Department of Continuing Education for its continuous support during the course of this research.

Special gratitude is extended to the Research Division and the Ethics Committee of our institution for their invaluable support and guidance throughout the research process. Their expertise and commitment significantly contributed to the successful completion of this study.

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Tables 1 to 2 are available in the Supplementary Files section

No competing interests reported.

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Grief and Depression in Relatives of Deceased Individuals during Social Isolation. Risk and Protective Factors

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