As of 17 October 2022, the COVID-19 pandemic has claimed more than 6.5 million lives globally, with 1,639 deaths reported in Singapore.1 With numerous countries imposing measures such as lockdowns and social distancing measures that isolate individuals, there has been a steady increase in a variety of mental disorders like anxiety, depression and stress disorders.2 This is worsened by uncertainty surrounding the COVID-19 pandemic, resulting in the instability and anxiety in many aspects of life such as finances and relationships.3,4 Grief experienced by the family from the death of a loved one has been further exacerbated during the pandemic. Proper farewells, consisting of funerals with burial or cremation procedures in accordance with traditions and cultural practices, have been hindered by the restrictions imposed by the respective governments.5 In Singapore, Hindus had to alter their practices as those infected with COVID-19 could not be brought back to their home to comply with their religion. With the inability to carry out these rituals properly, it hampers their grief process, preventing the families from conducting proper farewell rituals for their loved ones.6
The process of grief in the COVID-19 era has been complicated by the voluntary or involuntary isolation from others in fear of the virus. Many were unable to attend the wakes in view of the restrictions in attendances and rituals during such processions. Many felt guilty due to the inability to bid their loved ones a proper farewell in person, leading to ruminations and excessive thoughts for the dead, thereby complicating and the grieving process.7 Such a lengthened process can lead to prolonged grief disorder (PGD) associated with intense yearning and longing for the loved one, which impacts their daily living.8 This is seen in a cross-sectional study conducted in China where the prevalence of PGD was close to 40% due to the COVID-19 pandemic.9 Thus, PGD is an important disorder to be identified early, with its associations with increased suicidal ideation and reductions in quality of life.10
While the loss of a loved one is a primary reason for grief during the pandemic, patients who survived the COVID-19 infection also experience grief. A loss of physical and mental well-being has been reported in patients after infection as they experience fatigue and psychiatric disorders such as anxiety, depression and sleep disturbances.11,12 Many have a difficult recovery back to their usual baseline; additionally, some experienced a sense of isolation when hospitalised, feeling that they had been abandoned by their relatives.12
In this issue of the Annals, Tao et al.13 published a scoping review on loss and grief in various groups such as patients, families and healthcare professionals during the COVID-19 pandemic. It described the grief experienced during the pandemic to be multidimensional, affecting the mental, social, physical and existential realms. The reasons identified leading to loss and grief during the pandemic included unsatisfactory farewells and issues with funeral arrangements as a result of pandemic restrictions, social isolation, financial strain and stigmatisation.
Tao et al. proposed a multidisciplinary approach to tackling the domains of communications, finance, counselling, education and spiritual care identified in the review. They suggested that these domains identified could be further categorised into 3 main themes: communication, reassurance, and preparedness to be applied in the Singapore context.
Firstly, high-quality communication and transparency between all parties, including the patient, should take place. Information that is understandable should be passed between the involved parties. Secondly, reassurance is essential in calming fears and anxiety among the groups. Finally, preparedness is imperative in allowing one to come to terms with loss and grief, and prevent the development of prolonged grief. Tao et al. also emphasised that current guidelines and management of grief during the pandemic have been lacklustre, and modifications of such guidelines should be done to better identify and manage grief during the present and future pandemics.
With mental health issues such as grief and loss being increasingly prevalent during the COVID-19 pandemic, more effort has to be invested to better manage these issues. Further research is needed to determine if the proposed strategies can be effectively translated into practice.
- World Health Organization. WHO COVID-19 Dashboard. https://covid19.who.int/. Accessed 17 October 2022.
- Han E, Tan MMJ, Turk E, et al. Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe. Lancet 2020;396:1525-34.
- Ben Salah A, DeAngelis BN, al’Absi M. Uncertainty and psychological distress during COVID-19: What about protective factors? Curr Psychol 2022. doi: 10.1007/s12144-022-03244-2.
- Xie Y, Xu E, Al-Aly Z. Risks of mental health outcomes in people with covid-19: cohort study. BMJ 2022;376:e068993.
- Yap JFC, Garcia LL, Alfaro RA, et al. Anticipatory grieving and loss during the COVID-19 pandemic. J Public Health (Oxf) 2021;43:e279-80.
- Mitima-Verloop HB, Mooren TTM, Boelen PA. Facilitating grief: An exploration of the function of funerals and rituals in relation to grief reactions. Death Stud 2021;45:735-45.
- Kumar RM. The Many Faces of Grief: A Systematic Literature Review of Grief During the COVID-19 Pandemic. Illness, Crisis & Loss 2021. doi: 10.1177/10541373211038084.
- Boelen PA, Eisma MC, Smid GE, et al. Prolonged grief disorder in section II of DSM-5: a commentary. Eur J Psychotraumatol 2020;11:1771008.
- Tang S, Xiang Z. Who suffered most after deaths due to COVID-19? Prevalence and correlates of prolonged grief disorder in COVID-19 related bereaved adults. Global Health 2021;17:19.
- Eisma MC, Tamminga A. Grief Before and During the COVID-19 Pandemic: Multiple Group Comparisons. J Pain Symptom Manage 2020;60:e1-4.
- Premraj L, Kannapadi NV, Briggs J, et al. Mid and long-term neurological and neuropsychiatric manifestations of post-COVID-19 syndrome: A meta-analysis. J Neurol Sci 2022;434:120162.
- Kürtüncü M, Kurt A, and N. Arslan. The Experiences of COVID-19 Patients in Intensive Care Units: A Qualitative Study, Omega (Westport) 2021. doi: 10.1177/00302228211024120.
- Tao X, Yu CC, Low JA. Exploring loss and grief during the COVID-19 pandemic: A scoping review of qualitative studies. Ann Acad Med Singap 2022;51:619-28.