Skip to main content
NCBI home page
Cambridge Prisms: Global Mental Health logoLink to Cambridge Prisms: Global Mental Health
. 2023 Jun 20;10:e32. doi: 10.1017/gmh.2023.28

Bereavement issues and prolonged grief disorder: A global perspective

Charlotte E Hilberdink 1,✉, Kevin Ghainder 2, Alexandre Dubanchet 2, Devon Hinton 3,4, A A A Manik J Djelantik 5, Brian J Hall 6, Eric Bui 1,2,3
PMCID: PMC10579660  PMID: 37854407

Abstract

The death of a loved one – bereavement – is a universal experience that marks the human mental health condition. Grief – the cognitive, emotional, and behavioral responses to bereavement – is thus experienced by virtually everyone at some point in life, while mourning is a process through which grievers come to terms with the loss envisioning life without the deceased. Although distress subsides over time among most bereaved individuals, a minority will develop a condition recently identified as prolonged grief disorder (PGD). The present review provides a global perspective on bereavement, grief reactions, and PGD. Although the loss of a loved one and grief reactions are in general experienced consistently across different cultures, differences and variations in their expression may exist across cultures. Especially within specific populations that may be more at risk for PGD, possibly due to risk factors associated with the mechanisms of loss (e.g., refugees, migrants, and conflict survivors). The diagnostic criteria for PGD are mostly based on Western grieving populations, and cultural adaptations of PGD treatments are limited. Therefore, cross-cultural development and validation of PGD screening/assessment is critical to support future research on grief reactions and PGD, especially in non-Western contexts, and concerning the potential future global changes and challenges that appear to have a major impact on PGD. More transcultural research on PGD is needed to contextualize and will lead to culture-bound symptom identification of PGD, and the adaptation of current treatment protocols, which may ultimately improve health at the individual level, and health-care systems.

Keywords: prolonged grief disorder, global, bereavement, grief reactions

Impact statement

A minority of people who experience cognitive, emotional, and behavioral grief responses to bereavement will develop a mental health condition recently identified as prolonged grief disorder (PGD). In this review, we provided a global perspective on bereavement, grief reactions, and PGD, and we suggested that grief reactions seem to be consistent across different cultures, although differences and variations in the expression of symptoms may exist across cultures. Given the heterogeneity in PGD prevalence estimates across the globe, specific populations may be at more risk for PGD, possibly due to risk factors associated with the mechanisms of loss, such as population specificities (e.g., refugees, migrants, and conflict survivors).

As evidence-based treatment for PGD has limited cultural adaptations, cross-cultural development and validation of PGD screening and assessment may be critical to support future research on grief reactions and PGD. We therefore suggested that more transcultural research is needed to contextualize PGD, which may lead to the identification of culture-bound symptoms of PGD and the adaptation of current treatment protocols. Thereby it could improve health at the individual level and health-care systems for people who suffer from PGD. In general, there is a lack of trained therapists worldwide and existing PGD therapy is costly in therapist time. We will therefore need more cost- and time-efficient health-care strategies if we want to be able to address this major public health problem, given the sheer number of individuals suffering from PGD worldwide. To be able to address PGD at the global level, we will thus need to develop a stepped-care model in which the most effective, yet least resource-taxing treatment is delivered first, only stepping up to more resource-using treatments as required, which could decrease the health burden at the individual’s level while controlling costs and improving health-care systems efficiency.

Grief reactions across cultures

From acute grief to integrated grief or prolonged grief

The death of a loved one is one of the most painful experiences in one’s life. Most bereaved individuals experience distressing grief reactions to such a loss, including intense longing for the deceased, emotional pain and/or pangs of grief, loss of interest in ongoing life, and social withdrawal (Bui, 2018). These ‘acute grief’ responses are normal reactions to the death of a loved one that occur during the period that immediately follows the loss (Shear, 2012). This acute phase usually subsides in the first few months following the loss, and most individuals will successfully adjust, regaining their interest and engagement in their ongoing life (Bonanno and Kaltman, 1999; Shear et al., 2011). Transitioning from this state of ‘acute grief’ to a state of ‘integrated grief’, in which the grief reactions and distress are still present but no longer pervasive nor impairing, requires acknowledgment of the reality of the loss, integration of positive and negative emotions and cognitions regarding this loss, and successful updating of the working model (i.e., envisioning the world and the future without the deceased [Shear and Shair, 2005; Shear and Mulhare, 2008]). Yet, a substantial minority of bereaved individuals do not successfully adapt, in which grief reactions become pathological and symptomatic, and they exhibit continued, prolonged, distressing, and impairing grief reactions that can last years and sometimes decades after the death (Shear et al., 2013; Lundorff et al., 2017; Djelantik et al., 2020). For example, according to data from three bereavement and grief studies worldwide, 5–15% of community-based bereaved had a diagnosis of PGD one year after losing a loved one (Prigerson et al., 2021a).

Prolonged grief disorder in ICD-11 and DSM-5

After decades of heated debate about the inclusion of a psychiatric mental health condition characterized by prolonged, distressing, and impairing grief into international nosological classifications (Lichtenthal et al., 2004; Shear et al., 2011; Bryant, 2012), prolonged grief disorder was included in the 11th Edition of the International Classification of Diseases in 2018 (ICD-11, World Health Organization [WHO], 2022). In 2022, PGD was also added to the text revision of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR, American Psychological Association [APA], 2022) under the trauma and stressor-related disorders section. Although the classifications for PGD are included both in the ICD-11 and the DSM-5-TR, they only show moderate overlap as they differ in their number and content of symptoms, time criteria (6 months for ICD-11 and 12 months for DSM-5-TR), and diagnostic algorithms (Boelen and Lenferink, 2020; Prigerson et al., 2021b). A detailed overview of these discrepancies is given by Eisma (2023). An overview of the diagnostic criteria for the ICD-11 and DSM-5-TR is provided in Table 1. For the rest of this review, we will use the term PGD to refer to this clinical condition of maladaptive prolonged grieving, although previous research has used other terms including complicated grief, or traumatic grief.

Table 1.

The diagnostic criteria of prolonged grief disorder (PGD) according to the 11th Edition of the International Classification of Diseases (ICD-11) and the text revision of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)

Diagnostic criteria ICD-11 Requirements for diagnosis
Criteria A
Exposure		 A history of bereavement following the death of someone close
Criteria B
Types of grief reactions		 If the following persistent and pervasive grief reactions are present:
  • Longing for the deceased
  • Persistent preoccupation with the deceased
Criteria C
Accompanying impairments		 If the following impairments are present:
  • Intense emotional pain (e.g., sadness, guilt, anger, denial, and blame)
  • Difficulty accepting the death
  • Feeling that one’s has lost a part of one’s self
  • An inability to experience a positive mood
  • Emotional numbness
  • Difficulty engaging with social or other activities
Criteria D
Significant distress/impairment		 If the impairments of criteria B and C result in significant impairment in daily life (e.g., personal, family, social, educational, occupational, or other areas of functioning), or if functioning is maintained, but only through significant additional effort.
Criteria E
Cultural and time		 If the pervasive grief reactions and impairments of criteria B and C have persisted for an atypically long period of time after the loss, markedly exceeding expected social, cultural, or religious norms for the individual’s culture and context, except if grief responses last for <6 months, of which this duration norm can depend on some cultural contexts.
Diagnostic criteria for DSM-5-TR Requirements for diagnosis
Exposure Bereavement – the death of someone close
Criteria A
Timing		 Loss experienced…
>12 months prior in adults
>6 months prior in children/adolescents
Criteria B
Types of grief reactions		 If the following grief reactions are present, nearly daily in the prior month:
  • Intense yearning and longing for the deceased
  • Preoccupation with thoughts or memories of the deceased
Criteria C
Accompanying impairments		 If at least three of the following impairments are present, nearly daily in the prior month:
  • Marked sense of disbelief about the loss
  • Identity issues (e.g., feelings as if a part of oneself has passed)
  • Avoidance of reminders of the deceased
  • Emotional pain
  • Decreased emotional experiences and numbness
  • Meaninglessness
  • Intense loneliness
  • Difficulties in social interactions and/or engaging in daily activities due to the loss
Criteria D
Significant distress/impairment		 If the impairments of criteria B and C cause significant distress and/or impairment.
Criteria E
Cultural and contextual norms		 If the duration and severity of the impairments of criteria B and C exceed the individual’s expected social, cultural, or religious norms.
Criteria F
Other mental health conditions		 Grief reactions and impairments differentiate from the physiological effects of substance use, a major depressive disorder, posttraumatic stress disorder, or any other mental or medical disorder.
Open in a new tab

Grief reactions across cultures

Culture is defined as a set of traditions, rituals, values, and beliefs that are shared between members of a group of human beings (Jones, 2005). Although bereavement is a life stressor experienced ubiquitously across the globe, some data suggest that normal grief reactions might vary in their expected expression, their length, and their intensity across cultural and religious backgrounds (Eisenbruch, 1984). This might be the case because of the way people across different cultures communicate and express their grief responses (i.e., which pathological reactions they report), the existence of culture-bound symptoms, variations in help-seeking behavior, type of help and access to social support, culture-specific coping strategies, as well as variance in the meanings of symptoms and disorders, and stigmatization concerning mental health problems (Gureje et al., 2019, 2020). Therefore, cultural rituals, practices, and societal norms might have a significant impact on the way people grieve, mourn, and adjust to a loss (Casarett et al., 2001; Rosenblatt, 2001). The cultural norm hypothesis offers a potential explanation for cultural variability in the expression and duration of pathological grief, as this hypothesis suggests that disrupted emotional behavior, such as emotional reactivity, will become dysregulated and symptomatic if they differ from their culturally-determined normative or standard experiences and expressions (Chentsova-Dutton et al., 2010). For example, European Americans with depression, who normally express their emotions openly, showed diminished positive emotional reactivity to an amusing movie clip than those without depression; however, Asian Americans with depression showed similar and increased emotional reactivity to the same clip, although they normally dampen and control their emotions. Grief expressions and duration may thus be dependent on cultural norms and beliefs about emotional behavior, and could complicate cross-cultural interpretation of symptoms and behaviors, and influence diagnostic validity and accuracy.

Variations across cultures in the expected normal expression of grief

Although there are communalities in the (non)pathological responses of grief across cultures, as, for example, all (Western) PGD symptoms were recognized as familiar grieving and mourning emotions in the Balinese society (Djelantik et al., 2021), the expression of normal grief reactions and PGD symptoms may also be culturally sensitive, varying across societies and ethnic populations. For example, a study on Cambodian refugees reported that dreams and hallucinations of the deceased are a crucial part of normal grief and bereavement, whereas these types of re-experiences are often considered pathological in Western cultures (Hinton et al., 2013). Also, the Chinese bereaved may report more somatic stress symptoms in response to bereavement, including increased headaches and stomach or back pains (Ho et al., 2002). In line with this, Swiss and Chinese parents also exhibit differences regarding their symptom patterns after the loss of a child at least 6 months ago; Swiss ones experienced more severe grief-related preoccupation, whereas their Chinese counterparts reported more functional impairments, depression, and a sense of a meaningless and empty life (Xiu et al., 2016). Further, a similar expression may be defined as pathological and symptomatic in some cultures, whereas they may be considered part of the normal mourning process in other cultures (Li and Prigerson, 2016). Finally, the actual expression of grief reactions across cultures seems to be influenced by cultural norms and beliefs. For example, widows in Taiwan are highly encouraged not to cry in front of the deceased (Hsu et al., 2004).

Variations across cultures in the expected normal duration of grief

There also appears to be variation across cultures in the expected length of mourning, during which ‘acute grief’ is considered normal. For example, in Germany, a Western society in which a Christian tradition prevails, a mourning period of one year is culturally accepted (Hays and Hendrix, 2008). This mourning period can be much longer in non-Western cultures, such as traditional Chinese culture. In some Chinese traditions, a long-lasting self-restricted period of three years is expected after the loss of a child or parent, which implies respect for the deceased relative (Braun and Nichols, 1997; Klass and Chow, 2011). In Bali, Indonesia, numerous mourning rituals with social gatherings take place up to 10 years after the loss (Djelantik et al., 2021). This may indicate a cross-cultural caveat in regard to the expected duration of a ‘normal’ mourning process (Rosenblatt, 2008), with implications for the validity of PGD diagnostic criteria across cultures.

Variations across cultures in mourning rituals

Although most religion-related rituals have been declining in Western cultures, they seem to show a large cross-cultural overlap. Rituals mostly focus on the transfer of the deceased to another life or a ruler of a religious belief (Lobar et al., 2006), and provide a communal framework to increase an individual’s ability to adjust to changes in social identifies, (re)constructing social relationships, and form a memory of the deceased within the society (Silverman et al., 2021). Rituals also assist in later apology from the bereaved to the lost one and gratitude for the deceased (Hinton et al., 2013), and therefore offer a context to appropriately and safely express strong emotions by focusing on meaning-making, social narratives, as well as cultural standards. For example, a 2-day mourning ritual of the Papua New Guinean society, Lihir, consists of an initial emotional phase followed by a phase of forgetting and remembering (Hemer, 2010). Also, a funeral provides a safe and structured event to make space for the mourning process (Giblin and Hug, 2006; Mathew, 2021). On the other hand, Western grief rituals seem to mostly concentrate on individual grief and include less social context compared to most non-Western practices. For example, in Balinese mourning rituals, the purpose is predominantly focused on expressing care and respect for the deceased, and not on an individual’s own emotional grief process. It could be that this serves as a protective cultural practice against the development of mental health issues (Djelantik et al., 2021). A recent review of 22 studies on ritual and symbolic interventions as sizeable part of grief therapy accordingly showed significant positive effects on trauma-related symptoms in individuals with PGD, although these effects were mostly an effect of the treatment as a whole and not depending on specific ritual interventional elements (e.g., symbolic expression, farewell ceremonies, dialogue with the deceased, [Wojtkowiak et al., 2021]).

All these mourning rituals have thus been suggested to prevent the development of PGD, by providing specific guidance for grief recovery, offering coping strategies, and direct the process of the death (Cacciatore and DeFrain, 2015), as well as giving social support during the mourning period. However, their protective effect may be compounded by confounding factors such as spiritual and religious beliefs and affiliations that may be associated with the development of PGD, though the direction of this association varies across study settings and populations (Easterling et al., 2000; Hebert et al., 2007; Schaal et al., 2014; Christian et al., 2019). Here again, the cultural context might moderate the relationship between mourning rituals (and spirituality in a global sense) and the development of PGD.

Prolonged grief disorder prevalence across the world

Research has investigated the prevalence of PGD across the globe using mostly standard grief questionnaires, developed in and for Westernized countries (North American and Europe). Below we describe these studies.

All deaths

According to the meta-analysis of Lundorff et al. (2017), a pooled prevalence rate of 9.8% (95% CI 6.8–14.0) was found in 14 studies across the world (pooled N = 8,035) among bereaved adults who experienced mostly nonviolent deaths of a loved one. In Westernized countries, which consist of higher-income countries based on the Organization for Economic Co-Operations and Development (OECD, 2023), studies have reported somewhat heterogeneous but relatively high prevalence rates for PGD across populations (children, adults) and across types of deaths. For example, cross-sectional studies reported prevalence estimates among bereaved adults who lost their partner, friend, family member, or other loved one due to mostly natural deaths ranging from a lower rate of 2% in Israel (Killikelly et al., 2019) to a high rate of 25.4% in the Netherlands (Newson et al., 2011), although the latter included somewhat older bereaved adults. This is comparable to prevalence among bereaved college students (aged >18 years old) from the United States (US), ranging from 1.7% (Balk et al., 2010) and 13.4% (Glickman, 2020) in an ethnically diverse student population. Although few studies exist on PGD prevalence in younger populations, the few studies that estimated the prevalence of PGD among bereaved children and adolescents were comparable, ranging between 1.2–6.7% in a German population including adolescents and adults (Kersting et al., 2011; Rosner et al., 2021) and 3.4–12.4% in Dutch children (Boelen et al., 2019).

In non-Westernized lower-to-middle-income countries, which predominantly consist of most Asian countries, Latin America, and the Middle East and North Africa (OECD, 2023), PGD prevalence appears to be relatively higher than in high-income countries, but also shows heterogeneity across countries. Prevalence of PGD after loss mostly due to a nonviolent natural death was found to be between 7.1–12.6% in Chinese adults (Killikelly et al., 2021), but lower (pooled 3.7%, 95% CI 3.1–4.5%, N = 2,524) in an African adult population (Ghana: 2.6%, Kenya: 3.4%, Nigeria: 4.6% [Ben-Ezra et al., 2020]). Cross-sectional studies that studied prevalence in bereaved adolescents as well as adults, found a rate of 1.8% in Chinese individuals (He et al., 2014) and 12% in Saudi Arabian university students (Al-Gamal et al., 2019), who were adolescent or adult.

Violent deaths

Higher prevalence estimates have been found in bereaved after losing a loved one due to an unnatural cause of death. Djelantik et al. (2020) found a pooled PGD prevalence of 49% (95% CI 33.6–65.4%) in N = 4,774 adults across the globe who experienced an unexpected and/or violent death (traumatic accidents, suicide, homicide, or disasters) in 25 studies across OECD and non-OECD membership countries. Studies in bereaved individuals due to unnatural deaths predominantly investigated PGD after the (unexpected) loss of a child, the loss of a family member, close friend, or other relative in bereaved caregivers, or survivors of a (natural) disaster. PGD prevalence estimates among bereaved caregivers seem to vary greatly according to studies across Westernized countries. For instance, Swiss adult caregivers had a relatively lower prevalence of 4.9% (Wagner et al., 2012), whereas in Portuguese caregivers a higher prevalence estimate of 28.8% was reported 6 months post-loss (Coelho et al., 2015), although samples were not necessarily representative and therefore difficult to compare. In bereaved adults who lost a close family member, friend, or colleague 2.5–3.5 years after the 9/11 terrorist attacks in New York, the US, even a higher prevalence of 43% was reported (Neria et al., 2007).

The existing cross-sectional studies on PGD in non-Westernized populations predominantly investigated adult refugee populations living in Westernized countries, as they are at high risk for traumatization and loss, and relatively high prevalence rates have been reported. For example, bereaved female refugees from several Middle East and Northern African countries, who were living in shared accommodations in Germany at the time PGD symptoms were measured, had a somewhat lower PGD prevalence of 9.4% (Steil et al., 2019), although also high rates of 54% have been reported in Bosnian refugees who were living in the southeastern US for more than 5 years (Craig et al., 2009).

Prevalence estimates in non-Westernized populations living in non-Western countries appear to be somewhat lower than in refugee populations, although still relatively high; in adult survivors of the Rwandan genocide, PGD prevalence was 8% after losing a family member, child, or parent (Schaal et al., 2010), and was found to be 14.3% in Cambodian adult survivors of the Khmer Rouge regime after losing at least one family member due to a war-related violent death (Stammel et al., 2012). A recent meta-analysis accordingly showed that PGD prevalence rates in populations living in higher-income Westernized countries were lower than in lower-income non-Western countries (Djelantik et al., 2020). Furthermore, after the loss of a child, spouse, parent, or other family member due to a disaster, a prevalence of 8.5% was reported in bereaved adult survivors of the Wenchuan earthquake in China (Yi et al., 2018). The limited studies that exist on children and adolescents were mostly included in a pooled population that also included adults. One study, for example, found a PGD prevalence of 15.8% after losing someone close in a bereaved refugee population consisting of children, adolescents, and adults who were in Australia (Bryant et al., 2019). Moreover, a study on child, adolescent, and adult survivors of a tsunami in India reported that 25.9% had PGD after losing a spouse, child, or family member (Rajkumar et al., 2015), although this was found to be 34.6% in bereaved children after losing a parent due to war-related violence in Kosovo (Morina et al., 2011). In contrast, in a study among 301 bereaved family members of traffic accidents in Bali, Indonesia, PGD symptoms existed but none met the criteria for PGD (Djelantik et al., 2021).

Risk factors for prolonged grief disorder in the global context

Previous studies identified several factors present before, during, and after the loss, or related to the loss that increased or decreased the risk for PGD development. However, there are indications of important cross-cultural discrepancies between Westernized and non-Westernized countries that define the specific risk for PGD, as some factors may not be applicable across different cultures (Chukwuorji et al., 2018) or could be attributable to racial and socioeconomic inequalities. These risk factors exist globally, but may be more pronounced in the non-Western World.

Pre-loss risk factors

Studies found several demographic factors that increase the risk for development of PGD, such as lower socioeconomic status, being female, and being older (Gilbar and Ben-Zur, 2002; Ferrario et al., 2004; Simon et al., 2005; Vanderwerker et al., 2006; Kersting et al., 2011; Newson et al., 2011; Sung et al., 2011; Hu et al., 2015; Fernández-Alcántara and Zech, 2017; Heeke et al., 2017; Lundorff et al., 2017; Specht et al., 2022). As these factors vary across cultural contexts and are related to cultural diversity, such as race, common mental health problems, socioeconomic constructs, and cultural norms and beliefs, they might affect the experience of losing a loved one and consequently the likelihood of developing PGD. For example, a study that compared Westernized French and (non-Westernized) Togolese bereaved populations found that being male was a significant predictor for PGD in Togolese, but not in French adults (Kokou-Kpolou et al., 2020). Other personal characteristics present before the loss, such as exposure to childhood adversity, psychological and physical health history, pre-loss alcohol consumption, and maternal age in case of losing an infant, appear to influence PGD risk (Simon et al., 2005; Sung et al., 2011; Goldstein et al., 2019). As some pre-loss factors may be more common in specific cultures and the perception of certain factors appears to be culture dependent, they might vary in their risk for PGD. For example, in a population that mostly consisted of South African women, having depressive symptoms, older maternal age, and consuming a minimum of two alcohol units per day before the loss predicted PGD diagnosis during the two years after losing their infant (Goldstein et al., 2019).

Loss-related risk factors

Studies also found factors that are related to the loss and increased risk for PGD, such as the type and duration of the relationship with the deceased (Kokou-Kpolou et al., 2020; Smith and Ehlers, 2020). For example, Burke and Neimeyer (2012) reported in their review that PGD is more severe in individuals that have lost a close family member, spouse, or life partner compared to those who have lost a distant relative. Similarly, losing or missing a close family member and uncertainty about knowing who does or does not belong to the family system significantly predicted prolonged grief severity in treatment-seeking Syrian refugees (Renner et al., 2021). The number of family members additionally appears to be a significant predictor for PGD, as more core family members lost was associated with PGD severity in asylum seekers living in collective accommodations in Germany (Comtesse and Rosner, 2019). Also, elderly who had lost a spouse were at increased risk for developing grief symptoms than those who lost someone else (Fujisawa et al., 2010). Furthermore, as discussed above, an increased prevalence of PGD has been reported in the case of unexpected and/or violent death (traumatic accidents, suicide, homicide, or disasters [Djelantik et al., 2020]). The subjective impact of a life stressor (e.g., life-threatening situation, death of a loved one) may be indexed by psychological reactions occurring during or immediately after exposure to a major stressor. Those peritraumatic reactions (distress and dissociation) have been shown to consistently predict the development of posttraumatic stress disorder across populations (e.g., Bui et al., 2010; Vance et al., 2018), and recent data suggest that they may also predict the development of PGD in adults (Hargrave et al., 2012; Mutabaruka et al., 2012; Bui et al., 2013) and children (Revet et al., 2021).

Post-loss risk factors

The lack of social support after a loss has been identified as a risk factor for the development of PGD (Stroebe and Schut, 2001; van der Houwen et al., 2010). Culture could be a determining factor in social support, as for example more individualistic societies were hypothesized to isolate themselves more and have more difficulties with receiving and asking for professional support (Kumar et al., 2012). Yet, some cultural norms could also be of importance for this, as in Asian populations, it is less common to ask for and accept social support for coping with stress, which could increase PGD risk (Hashimoto et al., 1999; Taylor et al., 2004; Taylor and Lynch, 2004; Kim et al., 2008; Shi et al., 2020). Finally, low social support may be a risk factor for PGD (Vanderwerk and Prigerson, 2004) and may vary across cultures (Hofstede and Hofstede, 2005; Bauman, 2012; Kumar et al., 2012).

Discussion

The present paper reviewed grief reactions and symptoms across cultures, the prevalence estimates, and risk factors for PGD across countries and regions of the globe that may impact PGD on the global stage. Implications of our findings include recommendations for researching, assessing, preventing, and treating PGD across the globe.

Prevalence estimates for PGD appear to be quite similar across Western and non-Western countries (e.g., Killikelly et al., 2018), with the apparent higher rates in non-Western countries (at least partially) explained by confounding factors including the specificities of the specific populations studied (e.g., refugees, migrants, and conflict survivors) that may be more at risk for PGD (Nickerson et al., 2014; Hollander, 2016; Chukwuorji et al., 2018; Comtesse et al., 2021). Overall, the existing literature supports that about 10% of individuals have been shown to go on developing PGD after the loss of a loved one (Lundorff et al., 2017). Yet, differences in prevalence rates worldwide could also be related to different diagnostic criteria sets and tools, and there is a lack of culturally-specific research on these criteria (Stelzer et al., 2020). Therefore, no globally applicable criteria set exists yet.

So far, most measures used to assess PGD have been developed in the US and their validity is yet to be established across cultures. For example, the Inventory of Complicated Grief, the measure that has been most used to assess pathological grief, has been validated in eight languages, including Hebrew (Lifshitz et al., 2020), Korean (Han et al., 2016), Polish (Ludwikowska-Świeboda and Lachowska, 2019), Italian (Carmassi et al., 2014), and Spanish (Spanish version [Limonero et al., 2009], Colombian-Spanish version [Gamba-Collazos et al., 2017], Mexican-Spanish version [Dominguez-Rodriguez et al., 2021]). However, it is based on older diagnostic criteria for PGD. More recently developed measures of PGD, including the prolonged grief disorder scale (PG-13) and Structured Clinical Interview for Complicated Grief (SCI-CG), do assess the ICD-11 and DSM-5-TR diagnostic criteria, but are only available in a limited number of languages (Bui et al., 2015; Prigerson et al., 2021a). Is it however important to keep in mind that currently available data on PGD symptom severity and prevalence rates is based on both (self-reported) diagnostic questionnaires and clinical diagnostic interviews, which could hamper the generalizability of study results. Validating and/or developing screening and assessment measures that are reliable across cultures is critical to support future cross-cultural research on grief reactions and PGD. The International Prolonged Grief Disorder Scale assesses PGD for the ICD-11 and includes a cultural supplement that offers information on culturally-relevant grief symptoms (Killikelly et al., 2020). This tool seems to be suitable for operationalizing the cultural caveat for PGD in specific clinical settings, and thus might improve global applicability for researchers and clinicians, although further research is needed (Killikelly and Maercker, 2022).

Further, although certain types of grief reactions and symptoms have been consistently found across different cultures, including difficulties accepting the loss, losing interest in relationships, and feeling dazed and stunned (Xiu et al., 2016; McNeil et al., 2020), differences and variations in symptom expression may exist across cultures. In fact, diagnostic criteria for PGD were mostly based on knowledge of Western grieving populations (Prigerson et al., 2009; Boelen et al., 2010; Newson et al., 2011; Schaal et al., 2014), and though yearning or longing for the deceased may be found across cultures (Prigerson et al., 2009; He et al., 2014; Li and Prigerson, 2016; Xiu et al., 2016), there may be other culturally-specific symptoms of grief that are not currently included in PGD criteria sets (Killikelly et al., 2018). Thus, important cross-cultural knowledge is still lacking and hampers the validity of DSM-5-TR or ICD-11 PGD diagnostic criteria across other cultures, and further research on the specific cultural expressions and symptoms of PGD, and how these differential symptom expressions may impact screening and treatment strategies, are warranted.

To date, the treatment with the most empirical support for PGD is a 16-session individual therapy that has shown efficacy across three large randomized controlled trials (Shear et al., 2005; 2014; 2016). However, the three trials have been conducted in the US, limiting the generalizability of the results to populations outside the US and outside the Western World. The identification of key culture-bound symptoms of anxiety and trauma-related disorders has previously supported their inclusion in DSM-5 and shows how trauma may result in particular symptoms in a specific cultural context (Hinton et al., 2010), and the development of specific treatment protocols (Hinton et al., 2005). It is thus possible that more transcultural research on other trauma-related issues such as PGD will lead to the identification of specific culture-bound symptoms of PGD and the adaptation of current treatment protocols.

Next to the differences and variations in PGD between Western and non-Western cultures, which seem to be mostly confounded by exposure to unsafe, violent, and unpredictable living areas, this diversity may certainly also exist within Western or non-Western cultures across different living areas. This also applies to diversity in religions and beliefs across the entire globe, even within specific countries, and to different norms in general that exist across and within cultural contexts which can be individually determined within a culture or within a specific cultural subgroup. It seems that the main dimensions of cross-cultural differences relevant for PGD across the globe are individualism, social(economic) support, coping mechanisms, and accessibility to mental health systems. These findings are not solely important for PGD, but might additionally offer important implications for cross-cultural differences for other trauma- and nontrauma-related health problems.

Recent changes on the global stage could also be of importance to acknowledge as they also might have a major impact on PGD across populations, countries, and cultures. Situations that create a risk for PGD development all have in common the occurrence of many sudden and/or violent deaths within a community in a limited timeframe. This could exceed the capacity to offer appropriate social support and could be associated with other risk factors such as ongoing stressors (e.g., material, fear of being contaminated, social distancing, and financial insecurity), such as during the COVID-19 pandemic and climate change. The COVID-19 health crisis, for example, could have been a risk factor for PGD and blocking the mourning process as the death was accompanied by extremely inconvenient circumstances (e.g., no possibility for funeral rites), feelings of guilt (potential contamination), and suddenness of the death. Although some studies demonstrated increased impact of COVID-related losses on PGD severity compared to natural losses (e.g., Eisma and Tamminga, 2020; Eisma et al., 2021; Edwards et al., 2023), other studies did not find a different impact of COVID- versus nonCOVID-related (unnatural, natural) deaths on PGD severity (Lenferink and Boelen, 2023). Differences between studies may be due to methodological differences including the used measurement tools and time since loss. The exact impact of the COVID-19 pandemic as a risk factor for PGD remains to be investigated. Moreover, climate change and potential associated disasters (e.g., hurricanes, floods, and droughts) may directly as well as indirectly contribute to an increased risk for developing PGD worldwide (Scott et al., 2012a, 2012b), as they include sudden and/or violent deaths, with financial and material insecurity, and disorganized social support systems. Taken together with recent trends worldwide towards individualism and social isolation (Hofstede and Hofstede, 2005; Bauman, 2012; Kumar et al., 2012), major world events such as pandemics, conflicts, and climate-change-induced natural disasters could have a profound impact on rates of PGD in the world in the near future. This could be in line with the fact that prevalence estimates seem to be highest after a loss that is characterized by unexpectedness and with a violent and unnatural feature.

As we indicate, an evidence-based treatment for PGD is available (Shear and Gribbin Bloom, 2017), but with limited cultural adaptations. Further, there is a lack of trained therapists worldwide, and although this therapy is efficacious, it is costly in therapist time. About 16 h of a trained therapist is needed to successfully treat an individual with PGD, and given the sheer number of individuals suffering from PGD in the world, we will need more cost- and time-efficient health-care strategies if we want to be able to address this major public health problem. Strategies to address mental (and physical) health problems after a major life stressor such as bereavement exist on a continuum from psychoeducation to relaxation techniques, to medications and psychotherapy with a trained professional. To be able to address PGD at the global level, we will need to develop a stepped-care model in which the most effective yet least resource-taxing treatment is delivered first, only stepping up to more resource-using treatments as required; this could decrease the health burden at the individual level while controlling costs and improving health-care systems efficiency. For instance, integrating a phased approach and looking into potential models could guide the allocation of resources that are needed at the efficient level (system level, self-directed level, or mental health-supported brief interventions) and timing (during the initial impact, post-impact, or longer-term after the impact) and might ultimately provide evidence-based clinical care (Rauch et al., 2021). To facilitate more cross-cultural research on specific cultural aspects, influences, and cultural-bound risk factors for PGD, we suggest the standard use of the cultural caveat in clinical and research settings, as this may offer important cultural contexts in PGD to add to the growing literature. Also, the development and/or adjustment of existing measurement tools are necessary to increase its global applicability and use, and to reduce diagnostic discrepancies across communities. In this way, a more valid investigation of its etiology and potential (inter)cultural differences that influence grief symptoms is feasible, which may provide important cultural factors and contexts that can be proactively used by researchers and clinicians. For example, accurate identification of overlapping and dissimilar cultural aspects in PGD could increase accuracy for and cultural sensitivity in diagnosis and interventions across the globe.

Although further research is needed across cultures and populations, PGD is now a condition recognized in international classifications with specific diagnostic criteria. Events affecting communities worldwide, including the recent COVID-19 pandemic and those related to climate change, have the potential to increase the rates of PGD on the global stage. PGD treatment capacity building worldwide is needed but will likely not be enough. The development and rolling out on a large scale of a stepped-care approach to PGD seems to be the only viable solution to address this societal challenge in the long run.

Open peer review

To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2023.28.

Data availability statement

N/A for a review of the literature.

Author contribution

All authors have contributed sufficiently to the work described in this manuscript to be included as authors. All authors have read and approved the final manuscript.

Financial support

C.E.H. was supported by a postdoctoral grant from the Normandy region.

Competing interest

E.B. reports grants from the National Institutes of Health and the US Department of Defense, licenses or royalties from Springer and Wolters Kluwyer, and consulting fees from Cerevel Therapeutics. The other authors report no competing interests.

References

  1. Al-Gamal E, Saeed SB, Victor A and Long T (2019) Prolonged grief disorder and its relationship with perceived social support and depression among university students. Journal of Psychosocial Nursing and Mental Health Services 57(2), 44–51. 10.3928/02793695-20181023-03 [DOI] [PubMed] [Google Scholar]
  2. Balk DE, Walker AC and Baker A (2010) Prevalence and severity of college student bereavement examined in a randomly selected sample. Death Studies 34(5), 459–468. 10.1080/07481180903251810 [DOI] [PubMed] [Google Scholar]
  3. Bauman Z (2012) Liquid Modernity. Cambridge: Polity Press. [Google Scholar]
  4. Ben-Ezra M, Hyland P, Karatzias T, Maercker A, Hamama-Raz Y, Lavenda O, Mahat-Shamir M and Shevlin M (2020) A cross-country psychiatric screening of ICD-11 disorders specifically associated with stress in Kenya, Nigeria and Ghana. European Journal of Psychotraumatology 11(1), 1720972. 10.1080/20008198.2020.1720972 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Boelen PA and Lenferink LIM (2020) Symptoms of prolonged grief, posttraumatic stress and depression in recently bereaved people: Symptom profiles, predictive value and cognitive behavioural correlates. Social Psychiatry and Psychiatric Epidemiology 55(6), 765–777. 10.1007/s00127-019-01776-w [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Boelen PA, Spuij M and Lenferink LIM (2019) Comparison of DSM-5 criteria for persistent complex bereavement disorder and ICD-11 criteria for prolonged grief disorder in help-seeking bereaved children. Journal of Affective Disorders 250, 71–78. 10.1016/j.jad.2019.02.046 [DOI] [PubMed] [Google Scholar]
  7. Boelen PA, van de Schoot R, van den Hout MA, de Keijser J and van den Bout J (2010) Prolonged grief disorder, depression and posttraumatic stress disorder are distinguishable syndromes. Journal of Affective Disorders 125(1), 374–378. 10.1016/j.jad.2010.01.076 [DOI] [PubMed] [Google Scholar]
  8. Bonanno G and Kaltman S (1999) Toward an integrative perspective on bereavement. Psychological Bulletin 125, 760–776. 10.1037//0033-2909.125.6.760 [DOI] [PubMed] [Google Scholar]
  9. Braun KL and Nichols R (1997) Death and dying in four Asian American cultures: A descriptive study. Death Studies 21, 327–359. 10.1080/074811897201877 [DOI] [PubMed] [Google Scholar]
  10. Bryant RA (2012) Grief as a psychiatric disorder. British Journal of Psychiatry 201(1), 9–10. 10.1192/bjp.bp.111.102889 [DOI] [PubMed] [Google Scholar]
  11. Bryant RA, Edwards B, Creamer M, O’Donnell M, Forbes D, Felmingham KL, Silove D, Steel Z, McFarlane AC, van Hooff M, Nickerson A and Hadzi-Pavlovic D (2019) A population study of prolonged grief in refugees. Epidemiology and Psychiatric Sciences 29, e44. 10.1017/S2045796019000386 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Bui E (2018) Grief: From normal to pathological reactions. In Bui E (ed.), Clinical Handbook of Bereavement and Grief Reactions. Cham: Springer International Publishing, pp. 85–101. 10.1007/978-3-319-65241-2_5 [DOI] [Google Scholar]
  13. Bui E, Brunet A, Allenou C, Camassel C, Raynaud J-P, Claudet I, Fries F, Cahuzac J-P, Grandjean H, Schmitt L and Birmes P (2010) Peritraumatic reactions and posttraumatic stress symptoms in school-aged children victims of road traffic accident. General Hospital Psychiatry 32(3), 330–333. 10.1016/j.genhosppsych.2010.01.014 [DOI] [PubMed] [Google Scholar]
  14. Bui E, Mauro C, Robinaugh DJ, Skritskaya NA, Wang Y, Gribbin C, Ghesquiere A, Horenstein A, Duan N, Reynolds C, Zisook S, Simon NM and Katherine Shear M (2015) The structured clinical interview for complicated grief: Reliability, validity and exploratory factor analysis. Depression and Anxiety 32(7), 485–492. 10.1002/da.22385 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Bui E, Simon NM, Robinaugh DJ, Leblanc NJ, Wang Y, Skritskaya NA, Mauro C and Shear MK (2013) Periloss dissociation, symptom severity and treatment response in complicated grief. Depression and Anxiety 30(2), 123–128. 10.1002/da.22029 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Burke L and Neimeyer R (2012) Prospective risk factors for complicated grief: A review of the empirical literature. In Stroebe M, Schut H and van den Bout J (eds.), Complicated Grief: Scientific Foundations for Health Care Professionals. Abingdon: Routledge/Taylor & Francis Group, pp. 145–161. [Google Scholar]
  17. Cacciatore J and DeFrain J (2015) The World of Bereavement. Cultural perspectives on death in families, International and Cultural Psychology (ICUP). Cham: Springer. 10.1007/978-3-319-13945-6 [DOI] [Google Scholar]
  18. Carmassi C, Shear MK, Massimetti G, Wall M, Mauro C, Gemignani S, Conversano C and Dell’Osso L (2014) Validation of the Italian version inventory of complicated grief (ICG): A study comparing CG patients versus bipolar disorder, PTSD and healthy controls. Comprehensive Psychiatry 55, 1322–1329. 10.1016/j.comppsych.2014.03.001 [DOI] [PubMed] [Google Scholar]
  19. Casarett D, Kutner JS, Abrahm J and For the End-of-Life Care Consensus Panel (2001) Life after death: A practical approach to grief and bereavement. Annals of Internal Medicine 134(3), 208. 10.7326/0003-4819-134-3-200102060-00012 [DOI] [PubMed] [Google Scholar]
  20. Chentsova-Dutton YE, Tsai JL and Gotlib IH (2010) Further evidence for the cultural norm hypothesis: Positive emotion in depressed and control European American and Asian American women. Cultural Diversity and Ethnic Minority Psychology 16(2), 284–295. 10.1037/a0017562 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Christian KM, Aoun SM and Breen LJ (2019) How religious and spiritual beliefs explain prolonged grief disorder symptoms. Death Studies 43(5), 316–323. 10.1080/07481187.2018.1469054 [DOI] [PubMed] [Google Scholar]
  22. Chukwuorji JC, Ifeagwazi CM and Eze JE (2018) Prolonged grief disorder symptoms in bereaved internally displaced Tiv persons in Nigeria: Associations with rumination, rebirth concerns and gender. Mental Health, Religion & Culture 21(6), 549–563. 10.1080/13674676.2018.1505838 [DOI] [Google Scholar]
  23. Coelho A, Delalibera M, Barbosa A and Lawlor P (2015) Prolonged grief in palliative family caregivers: A pilot study in a Portuguese sample. Omega 72(2), 151–164. 10.1177/0030222815574833 [DOI] [PubMed] [Google Scholar]
  24. Comtesse H, Ertl V, Hengst SMC, Rosner R and Smid GE (2021) Ecological grief as a response to environmental change: A mental health risk or functional response? International Journal of Environmental Research and Public Health 18(2), 734. 10.3390/ijerph18020734 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Comtesse H and Rosner R (2019) Prolonged grief disorder among asylum seekers in Germany: The influence of losses and residence status. European Journal of Psychotraumatology 10(1), 1591330. 10.1080/20008198.2019.1591330 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Craig CD, Sossou M-A, Schnak M and Essex H (2009) Complicated grief and its relationship to mental health and well-being among Bosnian refugees after resettlement in the United States: Implications for practice, policy and research. Traumatology 14(4), 103. 10.1177/1534765608322129 [DOI] [Google Scholar]
  27. Djelantik AAAMJ, Aryani P, Boelen PA, Lesmana CBJ and Kleber RJ (2021) Prolonged grief disorder, posttraumatic stress disorder and depression following traffic accidents among bereaved Balinese family members: Prevalence, latent classes and cultural correlates. Journal of Affective Disorders 292, 773–781. 10.1016/j.jad.2021.05.085 [DOI] [PubMed] [Google Scholar]
  28. Djelantik AAAMJ, Smid GE, Mroz A, Kleber RJ and Boelen PA (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. 10.1016/j.jad.2020.01.034 [DOI] [PubMed] [Google Scholar]
  29. Dominguez-Rodriguez A, Martínez-Luna SC, Hernández Jiménez MJ, De La Rosa-Gómez A, Arenas-Landgrave P, Esquivel Santoveña EE, Arzola-Sánchez C, Alvarez Silva J, Solis Nicolas AM, Colmenero Guadián AM, Ramírez-Martínez FR and Castellanos Vargas RO (2021) A self-applied multi-component psychological online intervention based on UX, for the prevention of complicated grief disorder in the Mexican population during the COVID-19 outbreak: Protocol of a randomized clinical trial. Frontiers in Psychology 12, 644782. 10.3389/fpsyg.2021.644782 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Easterling LW, Sewell KW, Gamino LA and Stirman LS (2000) Spiritual experience, church attendance and bereavement. Journal of Pastoral Care 54(3), 263–275. 10.1177/002234090005400304 [DOI] [PubMed] [Google Scholar]
  31. Edwards A, Do D and Dao T (2023) Effects of the COVID-19 pandemic on grief: A prospective survey among community hospital next-of-kin. Journal of Palliative Medicine 26(5), 653–661. 10.1089/jpm.2022.0218 [DOI] [PubMed] [Google Scholar]
  32. Eisenbruch M (1984) Cross-cultural aspects of bereavement. II: Ethnic and cultural variations in the development of bereavement practices. Culture, Medicine and Psychiatry 8(4), 315–347. 10.1007/BF00114661 [DOI] [PubMed] [Google Scholar]
  33. Eisma MC (2023) Prolonged grief disorder in ICD-11 and DSM-5-TR: Challenges and controversies. Australian & New Zealand Journal of Psychiatry 57, 48674231154206. 10.1177/00048674231154206 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Eisma MC and Tamminga A (2020) Grief before and during the COVID-19 pandemic: Multiple group comparisons. Journal of Pain and Symptom Management 60(6), e1–e4. 10.1016/j.jpainsymman.2020.10.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Eisma MC, Tamminga A, Smid GE and Boelen PA (2021) Acute grief after deaths due to COVID-19, natural causes and unnatural causes: An empirical comparison. Journal of Affective Disorders 278, 54–56. 10.1016/j.jad.2020.09.049 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Fernández-Alcántara M and Zech E (2017) One or multiple complicated grief(s)? The role of kinship on grief reactions. Clinical Psychological Science 5(5), 851–857. 10.1177/2167702617707291 [DOI] [Google Scholar]
  37. Ferrario SR, Cardillo V, Vicario F, Balzarini E and Zotti AM (2004) Advanced cancer at home: Caregiving and bereavement. Palliative Medicine 18(2), 129–136. 10.1191/0269216304pm870oa [DOI] [PubMed] [Google Scholar]
  38. Fujisawa D, Miyashita M, Nakajima S, Ito M, Kato M and Kim Y (2010) Prevalence and determinants of complicated grief in general population. Journal of Affective Disorders 127(1–3), 352–358. 10.1016/j.jad.2010.06.008 [DOI] [PubMed] [Google Scholar]
  39. Gamba-Collazos HA, Navia CE, Gamba-Collazos HA and Navia CE (2017) Adaptation of the complicated grief inventory to the Colombian population. Revista Colombiana de Psicología 26(1), 15–30. 10.15446/rcp.v26n1.51205 [DOI] [Google Scholar]
  40. Giblin P and Hug A (2006) The psychology of funeral rituals. Liturgy 21(1), 11–19. 10.1080/04580630500285956 [DOI] [Google Scholar]
  41. Gilbar O and Ben-Zur H (2002) Bereavement of spouse caregivers of cancer patients. American Journal of Orthopsychiatry 72, 422–432. 10.1037/0002-9432.72.3.422 [DOI] [PubMed] [Google Scholar]
  42. Glickman K (2020) Prolonged grief disorder in a diverse college student sample. Frontiers in Psychology 11, 604573. 10.3389/fpsyg.2020.604573 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Goldstein RD, Petty CR, Morris SE, Human M, Odendaal H, Elliott A, Tobacco D, Angal J, Brink L, Kinney HC, Prigerson HG and PASS Network (2019) Pre-loss personal factors and prolonged grief disorder in bereaved mothers. Psychological Medicine 49(14), 2370–2378. 10.1017/S0033291718003264 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Gureje O, Lewis-Fernandez R, Hall BJ and Reed GM (2019) Systematic inclusion of culture-related information in ICD-11. World Psychiatry 18(3), 357–358. 10.1002/wps.20676 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Gureje O, Lewis-Fernandez R, Hall BJ and Reed GM (2020) Cultural considerations in the classification of mental disorders: Why and how in ICD-11. BMC Medicine 18(1), 25. 10.1186/s12916-020-1493-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Han DH, Lee JJ, Moon D-S, Cha M-J, Kim MA, Min S, Yang JH, Lee EJ, Yoo SK and Chung U-S (2016) Korean version of inventory of complicated grief scale: Psychometric properties in Korean adolescents. Journal of Korean Medical Science 31, 114. 10.3346/jkms.2016.31.1.114 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Hargrave PA, Leathem JM and Long NR (2012) Peritraumatic distress: Its relationship to posttraumatic stress and complicated grief symptoms in sudden death survivors. Journal of Traumatic Stress 25(3), 344–347. 10.1002/jts.21703 [DOI] [PubMed] [Google Scholar]
  48. Hashimoto K, Kurita H, Haratani T, Fujii K and Ishibashi T (1999) Direct and buffering effects of social support on depressive symptoms of the elderly with home help. Psychiatry and Clinical Neurosciences 53(1), 95–100. 10.1046/j.1440-1819.1999.00478.x [DOI] [PubMed] [Google Scholar]
  49. Hays JC and Hendrix CC (2008) The role of religion in bereavement. In Stroebe MS, Hansson RO, Schut H and Stroebe W (eds.) Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, DC, US: American Psychological Association, pp. 327–348. 10.1037/14498-016 [DOI] [Google Scholar]
  50. He L, Tang S, Yu W, Xu W, Xie Q and Wang J (2014) The prevalence, comorbidity and risks of prolonged grief disorder among bereaved Chinese adults. Psychiatry Research 219(2), 347–352. 10.1016/j.psychres.2014.05.022 [DOI] [PubMed] [Google Scholar]
  51. Hebert RS, Dang Q and Schulz R (2007) Religious beliefs and practices are associated with better mental health in family caregivers of patients with dementia: Findings from the REACH study. American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry 15(4), 292–300. 10.1097/01.JGP.0000247160.11769.ab [DOI] [PubMed] [Google Scholar]
  52. Heeke C, Kampisiou C, Niemeyer H and Knaevelsrud C (2017) A systematic review and meta-analysis of correlates of prolonged grief disorder in adults exposed to violent loss. European Journal of Psychotraumatology 8(sup6), 1583524. 10.1080/20008198.2019.1583524 [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Hemer SR (2010) Grief as social experience: Death and bereavement in Lihir, Papua New Guinea1. Australian Journal of Anthropology 21(3), 281–297. 10.1111/j.1757-6547.2010.00097.x [DOI] [Google Scholar]
  54. Hinton DE, Chhean D, Pich V, Safren SA, Hofmann SG and Pollack MH (2005) A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: A cross-over design. Journal of Traumatic Stress 18(6), 617–629. 10.1002/jts.20070 [DOI] [PubMed] [Google Scholar]
  55. Hinton DE, Field NP, Nickerson A, Bryant RA and Simon N (2013) Dreams of the dead among Cambodian refugees: Frequency, phenomenology and relationship to complicated grief and posttraumatic stress disorder. Death Studies 37(8), 750–767. 10.1080/07481187.2012.692457 [DOI] [PubMed] [Google Scholar]
  56. Hinton DE, Pich V, Marques L, Nickerson A and Pollack MH (2010) Khyâl attacks: A key idiom of distress among traumatized Cambodia refugees. Culture, Medicine and Psychiatry 34(2), 244–278. 10.1007/s11013-010-9174-y [DOI] [PubMed] [Google Scholar]
  57. Ho SMY, Chow AYM, Chan CLW and Tsui YKY (2002) The assessment of grief among Hong Kong Chinese: A preliminary report. Death Studies 26(2), 91–98. 10.1080/074811802753455226 [DOI] [PubMed] [Google Scholar]
  58. Hofstede G and Hofstede G (2005) Cultures and Organizations: Software of the Mind. New York, NY, US: McGraw-Hill. [Google Scholar]
  59. Hollander T (2016) Ambiguous loss and complicated grief: Understanding the grief of parents of the disappeared in Northern Uganda. Journal of Family Theory & Review 8(3), 294–307. 10.1111/jftr.12153 [DOI] [Google Scholar]
  60. Hsu M-T, Kahn DL, Yee D-H and Lee W-L (2004) Recovery through reconnection: A cultural design for family bereavement in Taiwan. Death Studies 28(8), 761–786. 10.1080/07481180490483391 [DOI] [PubMed] [Google Scholar]
  61. Hu X-L, Li X-L, Dou X-M and Li R (2015) Factors related to complicated grief among bereaved individuals after the Wenchuan Earthquake in China. Chinese Medical Journal 128(11), 1438–1443. 10.4103/0366-6999.157647 [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Jones P (2005) Introducing Social Theory. New Delhi: Atlantic. [Google Scholar]
  63. Kersting A, Brähler E, Glaesmer H and Wagner B (2011) Prevalence of complicated grief in a representative population-based sample. Journal of Affective Disorders 131(1), 339–343. 10.1016/j.jad.2010.11.032 [DOI] [PubMed] [Google Scholar]
  64. Killikelly C, Bauer S and Maercker A (2018) The assessment of grief in refugees and post-conflict survivors: A narrative review of etic and emic research. Frontiers in Psychology 9, 1957. 10.3389/fpsyg.2018.01957 [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Killikelly C, Lorenz L, Bauer S, Mahat-Shamir M, Ben-Ezra M and Maercker A (2019) Prolonged grief disorder: Its co-occurrence with adjustment disorder and post-traumatic stress disorder in a bereaved Israeli general-population sample. Journal of Affective Disorders 249, 307–314. 10.1016/j.jad.2019.02.014 [DOI] [PubMed] [Google Scholar]
  66. Killikelly C and Maercker A (2023) The cultural supplement: A new method for assessing culturally relevant prolonged grief disorder symptoms. Clinical Psychology in Europe 5, e7655. 10.23668/PSYCHARCHIVES.8413 [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. Killikelly C, Merzhvynska M, Zhou N, Stelzer E-M, Hyland P, Rocha J, Ben-Ezra M and Maercker A (2021) Examination of the new ICD-11 prolonged grief disorder guidelines across five international samples . Clinical Psychology in Europe 3(1), 1–16. 10.32872/cpe.4159 [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Killikelly C, Zhou N, Merzhvynska M, Stelzer E-M, Dotschung T, Rohner S, Sun LH and Maercker A (2020) Development of the international prolonged grief disorder scale for the ICD-11: Measurement of core symptoms and culture items adapted for chinese and german-speaking samples. Journal of Affective Disorders 277, 568–576. 10.1016/j.jad.2020.08.057 [DOI] [PubMed] [Google Scholar]
  69. Kim HS, Sherman DK and Taylor SE (2008) Culture and social support. The American Psychologist 63(6), 518–526. 10.1037/0003-066X [DOI] [PubMed] [Google Scholar]
  70. Klass D and Chow AYM (2011) Culture and ethnicity in experiencing, policing and handling grief. In Grief and Bereavement in Contemporary Society: Bridging Research and Practice, New York, NY: Routledge, pp. 341–353. [Google Scholar]
  71. Kokou-Kpolou CK, Cénat JM, Noorishad P-G, Park S and Bacqué M-F (2020) A comparison of prevalence and risk factor profiles of prolonged grief disorder among French and Togolese bereaved adults. Social Psychiatry and Psychiatric Epidemiology 55(6), 757–764. 10.1007/s00127-020-01840-w [DOI] [PubMed] [Google Scholar]
  72. Kumar S, Calvo R, Avendano M, Sivaramakrishnan K and Berkman LF (2012) Social support, volunteering and health around the world: Cross-national evidence from 139 countries. Social Science & Medicine 74(5), 696–706. 10.1016/j.socscimed.2011.11.017 [DOI] [PubMed] [Google Scholar]
  73. Lenferink LIM and Boelen PA (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. 10.1016/j.jadr.2023.100516 [DOI] [PMC free article] [PubMed] [Google Scholar]
  74. Li J and Prigerson HG (2016) Assessment and associated features of prolonged grief disorder among Chinese bereaved individuals. Comprehensive Psychiatry 66, 9–16. 10.1016/j.comppsych.2015.12.001 [DOI] [PubMed] [Google Scholar]
  75. Lichtenthal WG, Cruess DG and Prigerson HG (2004) A case for establishing complicated grief as a distinct mental disorder in DSM-V. Clinical Psychology Review 24(6), 637–662. 10.1016/j.cpr.2004.07.002 [DOI] [PubMed] [Google Scholar]
  76. Lifshitz R, Ifrah K, Markovitz N, Bluvstein I and Shmotkin D (2020) Inventory of complicated grief: Factor structure among middle-aged and older bereaved parents. Death Studies 46, 1–8. 10.1080/07481187.2020.1725931 [DOI] [PubMed] [Google Scholar]
  77. Limonero J, Lacasta M, García J, Méndez J and Prigerson H (2009) Adaptación al castellano del inventario de duelo complicado. Medicina Paliativa 16, 291–297. [Google Scholar]
  78. Lobar S, Youngblut J and Brooten D (2006) Cross-cultural beliefs, ceremonies and rituals surrounding death of a loved one. Pediatric Nursing 32, 44–50. [PubMed] [Google Scholar]
  79. Ludwikowska-Świeboda K and Lachowska B (2019) Polish version of the inventory of complicated grief - preliminary validation. Psychiatria Polska 53(5), 1069–1086. 10.12740/PP/91729 [DOI] [PubMed] [Google Scholar]
  80. Lundorff M, Holmgren H, Zachariae R, Farver-Vestergaard I and O’Connor M (2017) Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis. Journal of Affective Disorders 212, 138–149. 10.1016/j.jad.2017.01.030 [DOI] [PubMed] [Google Scholar]
  81. Mathew LE (2021) Braiding western and eastern cultural rituals in bereavement: An autoethnography of healing the pain of prolonged grief. British Journal of Guidance & Counselling 49(6), 791–803. 10.1080/03069885.2021.1983158 [DOI] [Google Scholar]
  82. McNeil MJ, Namisango E, Hunt J, Powell RA and Baker JN (2020) Grief and bereavement in parents after the death of a child in low- and middle-income countries. Children (Basel, Switzerland) 7(5), 39. 10.3390/children7050039 [DOI] [PMC free article] [PubMed] [Google Scholar]
  83. Morina N, von Lersner U and Prigerson HG (2011) War and bereavement: Consequences for mental and physical distress. PLoS One 6(7), e22140. 10.1371/journal.pone.0022140 [DOI] [PMC free article] [PubMed] [Google Scholar]
  84. Mutabaruka J, Séjourné N, Bui E, Birmes P and Chabrol H (2012) Traumatic grief and traumatic stress in survivors 12 years after the genocide in Rwanda. Stress and Health 28(4), 289–296. 10.1002/smi.1429 [DOI] [PubMed] [Google Scholar]
  85. Neria Y, Gross R, Litz B, Maguen S, Insel B, Seirmarco G, Rosenfeld H, Suh EJ, Kishon R, Cook J and Marshall RD (2007) Prevalence and psychological correlates of complicated grief among bereaved adults 2.5–3.5 years after September 11th attacks. Journal of Traumatic Stress 20(3), 251–262. 10.1002/jts.20223 [DOI] [PubMed] [Google Scholar]
  86. Newson RS, Boelen PA, Hek K, Hofman A and Tiemeier H (2011) The prevalence and characteristics of complicated grief in older adults. Journal of Affective Disorders 132(1), 231–238. 10.1016/j.jad.2011.02.021 [DOI] [PubMed] [Google Scholar]
  87. Nickerson A, Liddell BJ, Maccallum F, Steel Z, Silove D and Bryant RA (2014) Posttraumatic stress disorder and prolonged grief in refugees exposed to trauma and loss. BMC Psychiatry 14(1), 106. 10.1186/1471-244X-14-106 [DOI] [PMC free article] [PubMed] [Google Scholar]
  88. Prigerson HG, Boelen PA, Xu J, Smith KV and Maciejewski PK (2021a) 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. 10.1002/wps.20823 [DOI] [PMC free article] [PubMed] [Google Scholar]
  89. Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, Raphael B, Marwit SJ, Wortman C, Neimeyer RA, Bonanno GA, Block SD, Kissane D, Boelen P, Maercker A, Litz BT, Johnson JG, First MB and Maciejewski PK (2009) Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine 6(8), e1000121. 10.1371/journal.pmed.1000121 [DOI] [PMC free article] [PubMed] [Google Scholar]
  90. Prigerson HG, Kakarala S, Gang J and Maciejewski PK (2021b) History and status of prolonged grief disorder as a psychiatric diagnosis. Annual Review of Clinical Psychology 17, 109–126. 10.1146/annurev-clinpsy-081219-093600 [DOI] [PubMed] [Google Scholar]
  91. Rajkumar AP, Mohan TS and Tharyan P (2015) Lessons from the 2004 Asian tsunami: Nature, prevalence and determinants of prolonged grief disorder among tsunami survivors in South Indian coastal villages. International Journal of Social Psychiatry 61(7), 645–652. 10.1177/0020764015570713 [DOI] [PubMed] [Google Scholar]
  92. Rauch SAM, Simon NM and Rothbaum BO (2021) Rising tide: Responding to the mental health impact of the COVID-19 pandemic. Focus 19(2), 243–246. 10.1176/appi.focus.19204 [DOI] [PMC free article] [PubMed] [Google Scholar]
  93. Renner A, Jäckle D, Nagl M, Plexnies A, Röhr S, Löbner M, Grochtdreis T, Dams J, König H-H, Riedel-Heller S and Kersting A (2021) Traumatized Syrian refugees with ambiguous loss: Predictors of mental distress. International Journal of Environmental Research and Public Health 18(8), 3865. 10.3390/ijerph18083865 [DOI] [PMC free article] [PubMed] [Google Scholar]
  94. Revet A, Suc A, Auriol F, Manik J Djelantik AAA, Raynaud J-P and Bui E (2021) Peritraumatic distress predicts prolonged grief disorder symptom severity after the death of a parent in children and adolescents. European Journal of Psychotraumatology 12(1), 1936916. 10.1080/20008198.2021.1936916 [DOI] [PMC free article] [PubMed] [Google Scholar]
  95. Rosenblatt PC (2001) A social constructionist perspective on cultural differences in grief. In Stroebe MS, Hansson RO, Stroebe W and Stroebe H (eds.) Handbook of Bereavement Research: Consequences, Coping and Care. Washington, DC, US: American Psychological Association, pp. 285–300. 10.1037/10436-012 [DOI] [Google Scholar]
  96. Rosenblatt PC (2008) Grief across cultures: A review and research agenda. In Stroebe MS, Hansson RO, Schut H and Stroebe W (eds.) Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington, DC, US: American Psychological Association, pp. 207–222. 10.1037/14498-010 [DOI] [Google Scholar]
  97. Rosner R, Comtesse H, Vogel A and Doering BK (2021) Prevalence of prolonged grief disorder. Journal of Affective Disorders 287, 301–307. 10.1016/j.jad.2021.03.058 [DOI] [PubMed] [Google Scholar]
  98. Schaal S, Jacob N, Dusingizemungu J-P and Elbert T (2010) Rates and risks for prolonged grief disorder in a sample of orphaned and widowed genocide survivors. BMC Psychiatry 10(1), 55. 10.1186/1471-244X-10-55 [DOI] [PMC free article] [PubMed] [Google Scholar]
  99. Schaal S, Richter A and Elbert T (2014) Prolonged grief disorder and depression in a German community sample. Death Studies 38, 476–481. 10.1080/07481187.2013.809032 [DOI] [PubMed] [Google Scholar]
  100. Scott D, Gössling S and Hall CM (2012a) International tourism and climate change. WIREs Climate Change 3(3), 213–232. 10.1002/wcc.165 [DOI] [Google Scholar]
  101. Scott D, Hall CM and Stefan G (2012b) Impacts, Adaptation and Mitigation. London: Routledge. 10.4324/9780203127490 [DOI] [Google Scholar]
  102. Shear MK (2012) Grief and mourning gone awry: Pathway and course of complicated grief. Dialogues in Clinical Neuroscience 14(2), 119–128. 10.31887/DCNS.2012.14.2/mshear [DOI] [PMC free article] [PubMed] [Google Scholar]
  103. Shear K, Frank E, Houck PR and Reynolds CF (2005) Treatment of complicated grief: A randomized controlled trial. JAMA 293(21), 2601–2608. 10.1001/jama.293.21.2601 [DOI] [PMC free article] [PubMed] [Google Scholar]
  104. Shear MK, Ghesquiere A and Glickman K (2013) Bereavement and complicated grief. Current Psychiatry Reports 15(11), 406. 10.1007/s11920-013-0406-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  105. Shear MK and Gribbin Bloom C (2017) Complicated grief treatment: An evidence-based approach to grief therapy. Journal of Rational-Emotive & Cognitive-Behavior Therapy 35(1), 6–25. 10.1007/s10942-016-0242-2 [DOI] [Google Scholar]
  106. Shear MK and Mulhare E (2008) Complicated grief. Psychiatric Annals 38, 662–670. 10.3928/00485713-20081001-10 [DOI] [Google Scholar]
  107. Shear MK, Reynolds CF, Simon NM, Zisook S, Wang Y, Mauro C, Duan N, Lebowitz B and Skritskaya N (2016) Optimizing treatment of complicated grief: A randomized clinical trial. JAMA Psychiatry 73(7), 685–694. 10.1001/jamapsychiatry.2016.0892 [DOI] [PMC free article] [PubMed] [Google Scholar]
  108. Shear K and Shair H (2005) Attachment, loss and complicated grief. Developmental Psychobiology 47(3), 253–267. 10.1002/dev.20091 [DOI] [PubMed] [Google Scholar]
  109. Shear MK, Simon N, Wall M, Zisook S, Neimeyer R, Duan N, Reynolds C, Lebowitz B, Sung S, Ghesquiere A, Gorscak B, Clayton P, Ito M, Nakajima S, Konishi T, Melhem N, Meert K, Schiff M, O’Connor M-F, First M, Sareen J, Bolton J, Skritskaya N, Mancini AD and Keshaviah A (2011) Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety 28(2), 103–117. 10.1002/da.20780 [DOI] [PMC free article] [PubMed] [Google Scholar]
  110. Shear MK, Wang Y, Skritskaya N, Duan N, Mauro C and Ghesquiere A (2014) Treatment of complicated grief in elderly persons: A randomized clinical trial. JAMA Psychiatry 71(11), 1287–1295. 10.1001/jamapsychiatry.2014.1242 [DOI] [PMC free article] [PubMed] [Google Scholar]
  111. Shi W, Shen Z, Wang S and Hall BJ (2020) Barriers to professional mental health help-seeking among Chinese adults: A systematic review. Frontiers in Psychiatry 11, 442. 10.3389/fpsyt.2020.00442 [DOI] [PMC free article] [PubMed] [Google Scholar]
  112. Silverman GS, Baroiller A and Hemer SR (2021) Culture and grief: Ethnographic perspectives on ritual, relationships and remembering. Death Studies 45(1), 1–8. 10.1080/07481187.2020.1851885 [DOI] [PubMed] [Google Scholar]
  113. Simon NM, Pollack MH, Fischmann D, Perlman CA, Muriel AC, Moore CW, Nierenberg AA and Shear MK (2005) Complicated grief and its correlates in patients with bipolar disorder. Journal of Clinical Psychiatry 66(9), 3559. [DOI] [PubMed] [Google Scholar]
  114. Smith KV and Ehlers A (2020) Cognitive predictors of grief trajectories in the first months of loss: A latent growth mixture model. Journal of Consulting and Clinical Psychology 88(2), 93. 10.1037/ccp0000438 [DOI] [PMC free article] [PubMed] [Google Scholar]
  115. Specht F, Vöhringer M, Knaevelsrud C, Wagner B, Stammel N and Böttche M (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. 10.3389/fpsyt.2022.933848 [DOI] [PMC free article] [PubMed] [Google Scholar]
  116. Stammel N, Heeke C, Bockers E, Chhim S, Taing S, Wagner B and Knaevelsrud C (2012) Prolonged grief disorder three decades post loss in survivors of the Khmer rouge regime in Cambodia. Journal of Affective Disorders 144, 87–93. 10.1016/j.jad.2012.05.063 [DOI] [PubMed] [Google Scholar]
  117. Steil R, Gutermann J, Harrison O, Starck A, Schwartzkopff L, Schouler-Ocak M and Stangier U (2019) Prevalence of prolonged grief disorder in a sample of female refugees. BMC Psychiatry 19, 148. 10.1186/s12888-019-2136-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  118. Stelzer E-M, Zhou N, Maercker A, O’Connor M-F and Killikelly C (2020) Prolonged grief disorder and the cultural crisis. Frontiers in Psychology 10, 2982. 10.3389/fpsyg.2019.02982 [DOI] [PMC free article] [PubMed] [Google Scholar]
  119. Stroebe MS and Schut H (2001) Models of coping with bereavement: A review. In Stroebe MS, Hansson RO, Stroebe W and Schut H (eds.) Handbook of Bereavement Research: Consequences, Coping and Care. Washington, DC, US: American Psychological Association, pp. 375–403. 10.1037/10436-016 [DOI] [Google Scholar]
  120. Sung SC, Dryman MT, Marks E, Shear MK, Ghesquiere A, Fava M and Simon NM (2011) Complicated grief among individuals with major depression: Prevalence, comorbidity and associated features. Journal of Affective Disorders 134(1), 453–458. 10.1016/j.jad.2011.05.017 [DOI] [PMC free article] [PubMed] [Google Scholar]
  121. Taylor MG and Lynch SM (2004) Trajectories of impairment, social support and depressive symptoms in later life. Journals of Gerontology Series B: Psychological Sciences and Social Sciences 59(4), S238–S246. 10.1093/geronb/59.4.S238 [DOI] [PubMed] [Google Scholar]
  122. Taylor SE, Sherman DK, Kim HS, Jarcho J, Takagi K and Dunagan MS (2004) Culture and social support: Who seeks it and why? Journal of Personality and Social Psychology 87, 354–362. 10.1037/0022-3514.87.3.354 [DOI] [PubMed] [Google Scholar]
  123. van der Houwen K, Stroebe M, Stroebe W, Schut H, van den Bout J and Wijngaards-de Meij L (2010) Risk factors for bereavement outcome: A multivariate approach. Death Studies 34(3), 195–220. 10.1080/07481180903559196 [DOI] [PubMed] [Google Scholar]
  124. Vance MC, Kovachy B, Dong M and Bui E (2018) Peritraumatic distress: A review and synthesis of 15 years of research. Journal of Clinical Psychology 74(9), 1457–1484. 10.1002/jclp.22612 [DOI] [PubMed] [Google Scholar]
  125. Vanderwerk LC and Prigerson HG (2004) Social support and technological connectedness as protective factors in bereavement. Journal of Loss and Trauma 9(1), 45–57. 10.1080/15325020490255304 [DOI] [Google Scholar]
  126. Vanderwerker LC, Jacobs SC, Parkes CM and Prigerson HG (2006) An exploration of associations between separation anxiety in childhood and complicated grief in later life. Journal of Nervous and Mental Disease 194(2), 121. 10.1097/01.nmd.0000198146.28182.d5 [DOI] [PubMed] [Google Scholar]
  127. Wagner B, Müller J and Maercker A (2012) Death by request in Switzerland: Posttraumatic stress disorder and complicated grief after witnessing assisted suicide. European Psychiatry 27(7), 542–546. 10.1016/j.eurpsy.2010.12.003 [DOI] [PubMed] [Google Scholar]
  128. Wojtkowiak J, Lind J and Smid GE (2021) Ritual in therapy for prolonged grief: A scoping review of ritual elements in evidence-informed grief interventions. Frontiers in Psychiatry 11, 623835. 10.3389/fpsyt.2020.623835 [DOI] [PMC free article] [PubMed] [Google Scholar]
  129. World Health Organization (WHO) (2022) International Statistical Classification of Diseases and Related Health Problems, 11th Edn. Available at https://icd.who.int/.
  130. Xiu D, Maercker A, Woynar S, Geirhofer B, Yang Y and Jia X (2016) Features of prolonged grief symptoms in Chinese and Swiss bereaved parents. Journal of Nervous and Mental Disease 204(9), 693–701. 10.1097/NMD.0000000000000539 [DOI] [PubMed] [Google Scholar]
  131. Yi X, Gao J, Wu C, Bai D, Li Y, Tang N and Liua X (2018) Prevalence and risk factors of prolonged grief disorder among bereaved survivors seven years after the Wenchuan earthquake in China: A cross-sectional study. International Journal of Nursing Sciences 5(2), 157–161. 10.1016/j.ijnss.2018.04.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
Glob Ment Health (Camb). doi: 10.1017/gmh.2023.28.pr1

Author comment: Bereavement issues and prolonged grief disorder: A global perspective — R0/PR1

Charlotte Hilberdink 1

Dear Editors, Dear Marit,

Thank you for inviting us to submit a review article for the relaunch of the Cambridge Prisms: Global Mental Health. Hereby we would like to submit the attached manuscript entitled: “Bereavement Issues and Prolonged Grief Disorder: A Global Perspective” for consideration for publication.

Our review aimed to provide a global perspective on bereavement, grief reactions, and Prolonged Grief Disorder (PGD), a new diagnosis recently introduced into DSM5-TR.

Our findings suggested that grief reactions seem to be consistent across different cultures, although differences and variations in the expression of symptoms may exist across cultures. Given the heterogeneity in PGD prevalence rates across the globe, specific populations may be at more risk for PGD. This may possibly be due to confounding factors including population specificities (e.g., refugees, migrants and conflict survivors). We concluded that cross-cultural reliable validation and development of PGD screening and assessment may thus be critical to support future research of grief reactions and PGD, especially outside of the Westernized civilization. We suggest that more transcultural research on PGD and the use of a stepped-care approach is necessary, as it may lead to the identification of culture-bound symptom of PGD and the adaptation of current treatment protocols, making us able to improve health at the individual level and health care systems for people who suffer from PGD.

We hereby confirm that the data of this manuscript have not been submitted or published in another journal. All authors have contributed sufficiently to the work described in this manuscript to be included as authors. All authors have read and approved the final manuscript. To the best of our knowledge, no conflict of interest exists.

We hope that you consider the manuscript suitable for publication in your journal.

We are looking forward to your reply.

Sincerely,

Charlotte Hilberdink & Eric Bui

(on behalf of all authors)

Contact details:

Charlotte Elize Hilberdink, PhD

Normandie Université

UNICAEN, INSERM - U1237

PhIND - Physiopathology and Imaging of Neurological Disorders

NEUROPRESAGE Team (Institut Blood and Brain @ Caen-Normandie)

GIP Cyceron

14000 Caen

France

E-mail: hilberdink@cyceron.fr

Glob Ment Health (Camb). doi: 10.1017/gmh.2023.28.pr2

Review: Bereavement issues and prolonged grief disorder: A global perspective — R0/PR2

Reviewed by: Clare Killikelly1

The authors have prepared a well-researched and clearly written overview of relevant and timely PGD research. My main suggestions include recommendations for additional literature and citations that I believe to be foundational for the field.

Section 1.1

Here you could include the latest prevalence rates from Prigerson et al., 2021

Section 1.1.1

This section could be reduced and complemented with a clear table presenting the diagnostic definition differences.

Section 1.1.2

‘Culture is defined as a set of traditions, rituals, values, and beliefs that are shared between

members of a group of human beings.’ Please include a specific reference

In this section you could introduce the cultural norm hypothesis and how this might explain culturally variability in the expression, duration of grief responses

Chentsova-Dutton YE, Tsai JL, Gotlib IH. Further evidence for the cultural norm hypothesis: positive emotion in depressed and control European American and Asian American women. Cultur Divers Ethnic Minor Psychol. 2010 Apr;16(2):284-95. doi: 10.1037/a0017562. PMID: 20438167; PMCID: PMC2864927.

Chentsova-Dutton Y, Maercker A. Cultural Scripts of Traumatic Stress: Outline, Illustrations, and Research Opportunities. Front Psychol. 2019 Nov 15;10:2528. doi: 10.3389/fpsyg.2019.02528. PMID: 31803094; PMCID: PMC6872530.

Section 1.4

Please incorporate the findings from this recent and relevant review: Wojtkowiak J, Lind J and Smid GE (2021) Ritual in Therapy for Prolonged Grief: A Scoping Review of Ritual Elements in Evidence-Informed Grief Interventions. Front. Psychiatry 11:623835. doi: 10.3389/fpsyt.2020.623835

Section 2

Please consider including our paper below which clearly outlines several relevant hypotheses that may explain the difference prevalence rates worldwide

Stelzer, E.-M., Zhou, N., Maercker, A., O’Connor, M.-F., & Killikelly, C. (2020). Prolonged Grief Disorder and the Cultural Crisis. Frontiers in Psychology, 10. https://doi.org/10.3389/fpsyg.2019.02982

Section 3.4

You may consider adding the literature on ambiguous and refugees experiences of multiple losses and loss of homeland/culture

Renner, A., Jäckle, D., Nagl, M., Plexnies, A., Röhr, S., Löbner, M., Grochtdreis, T., Dams, J., König, H. H., Riedel-Heller, S., & Kersting, A. (2021). Traumatized Syrian Refugees with Ambiguous Loss: Predictors of Mental Distress. International Journal of Environmental Research and Public Health, 18(8). https://doi.org/10.3390/IJERPH18083865

Comtesse, H., & Rosner, R. (2019). Prolonged grief disorder among asylum seekers in Germany: the influence of losses and residence status. European Journal of Psychotraumatology, 10(1), 1591330. https://doi.org/10.1080/20008198.2019.1591330

Discussion

Please consider referring to the International Prolonged Grief Disorder scale and the cultural supplement as a tool that researchers and clinicians may use to assess PGD for the ICD-11 with global applicability.

Kokou-Kpolou, C. K. (2021). Letter to the Editor: Prolonged grief disorder, posttraumatic stress disorder, and depression following traffic accidents among bereaved Balinese family members: Prevalence, latent classes and cultural correlates. Journal of Affective Disorders, 295, 1–2. https://doi.org/10.1016/j.jad.2021.08.007

Killikelly, C., & Maercker, A. (2023). The cultural supplement: A new method for assessing culturally relevant prolonged grief disorder symptoms | PsychArchives. Clinical Psychology in Europe. https://www.psycharchives.org/en/item/12f7905c-ede6-4cfc-ba86-c7c7f2a529d5

Killikelly, C., Zhou, N., Merzhvynska, M., Stelzer, E. M., Dotschung, T., Rohner, S., Sun, L. H., & Maercker, A. (2020). Development of the international prolonged grief disorder scale for the ICD-11: Measurement of core symptoms and culture items adapted for chinese and german-speaking samples. Journal of Affective Disorders, 277, 568–576. https://doi.org/10.1016/j.jad.2020.08.057

Please clarify the reference to anxiety here? ‘The identification of key culture bound symptoms of anxiety have previously supported their inclusion in DSM-5 (Hinton et al., 2010), and the development of specific treatment protocols (Hinton et al., 2005),’

Please consider revising your statements on the impact of COVID-19 on PGD, see

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

In terms of the future directions and implications it would be interesting if the authors could propose a framework or ideas on how to foster, develop and facilitate transnational, cross-cultural research on PGD. What ideas for future research directions and initiatives might be possible and feasible?

Glob Ment Health (Camb). doi: 10.1017/gmh.2023.28.pr3

Review: Bereavement issues and prolonged grief disorder: A global perspective — R0/PR3

Reviewed by: Sebastian Trautmann

Thank you for giving me the opportunity to read this interesting piece of work. Both the aspect of PGD and cultural influences are of high importance. I made several suggestions which could in my opinion strengthen the manuscript. Most of them are rather minor. What I believe requires further attention is the discussion which is not as informative as it could be.

1. Abstract. It seems a bit contradictory that the sentence “Grief reactions are generally consistent across different cultures.” is followed by "differences and variation in their

expression may exist across cultures...", reformulating this passage could add to clarity.

2. The headline “From Acute Grief to Integrated Grief to Prolonged Grief” suggests that integrated grief is a necessary precondition of prolonged grief, I think this is neither the case nor intended by the authors.

3. Since the focus of this article is explicitly a global one with implications for beyond specific psychiatric settings, it is probably preferable to use terms such as mental disorders/mental health conditions instead of psychiatric conditions as recommended by both the WHO and the DSM.

4. I found it not entirely logical that after the authors introduce PGD in ICD-11 first, detailed criteria are then described for the DSM-5-TR, but not for ICD. Maybe adding a table showing all criteria for both classificatory systems and discussing differences would suffice.

5. How can ICD and DSM show “only moderate overlap” if they only “slightly differ”. Are the authors referring to overlap in diagnostic criteria or overlap in cases?

6. When talking about cultural differences, it might be helpful to differentiate expressions from symptoms (i.e. the pathological expression). At times (e.g. in paragraph 1.1) these two aspects get mixed or are used interchangeably.

7. It could makes sense to move the paragraph of prevalences (and differences in prevalences) (paragraph 3) to the beginning of the manuscript (maybe following paragraph 1.1.1) because most of the discussion of cultural differences is used to explain differences in prevalence.

8. Since PGD has only recently been introduced in the classificatory systems, it has not been part of the major international epidemiological initiatives, such as World Mental Health Surveys or Burden of Disease Studies. Also, many assessments rely on questionnaire data instead of diagnostic interviews. I somewhat missed a critical assessment of the current state of available data when presenting epidemiological data for PGD.

9. I found it somewhat difficult to understand the direct conclusions from the findings that have been presented. The authors mentioned various aspects from cultural differences in normative grief reactions to differences in risk factors. I believe the discussion could be sharpened by explaining in greater detail what follows from all these findings. Moreover, the discussion of cultural differences mainly focuses on the difference between Western and Non-western cultures, which is only a very broad distinction of potential cultural differences. Does the available data allow for a more fine-grained distinction of cultural backgrounds? And what are the main dimensions of cultural differences that are relevant for PGD? And what can we learn from these differences about GPD? Or is it just important to acknowledge them in measurement and treatment?

Glob Ment Health (Camb). doi: 10.1017/gmh.2023.28.pr4

Recommendation: Bereavement issues and prolonged grief disorder: A global perspective — R0/PR4

Editor: Petr Winkler1

No accompanying comment.

Glob Ment Health (Camb). doi: 10.1017/gmh.2023.28.pr5

Decision: Bereavement issues and prolonged grief disorder: A global perspective — R0/PR5

Editor: Judith Bass1

No accompanying comment.

Glob Ment Health (Camb). doi: 10.1017/gmh.2023.28.pr6

Author comment: Bereavement issues and prolonged grief disorder: A global perspective — R1/PR6

Charlotte Hilberdink 1

No accompanying comment.

Glob Ment Health (Camb). doi: 10.1017/gmh.2023.28.pr7

Review: Bereavement issues and prolonged grief disorder: A global perspective — R1/PR7

Reviewed by: Sebastian Trautmann

The authors have been very responsive to the reviewers' comments and provided a thoughtful revision. I have nothing to add.

Glob Ment Health (Camb). doi: 10.1017/gmh.2023.28.pr8

Review: Bereavement issues and prolonged grief disorder: A global perspective — R1/PR8

Reviewed by: Clare Killikelly1

I thank the authors for revising the manuscript according to my recommendations.

Glob Ment Health (Camb). doi: 10.1017/gmh.2023.28.pr9

Recommendation: Bereavement issues and prolonged grief disorder: A global perspective — R1/PR9

Editor: Petr Winkler1

No accompanying comment.

Glob Ment Health (Camb). doi: 10.1017/gmh.2023.28.pr10

Decision: Bereavement issues and prolonged grief disorder: A global perspective — R1/PR10

Editor: Judith Bass1

No accompanying comment.

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Data Availability Statement

    N/A for a review of the literature.

    Articles from Cambridge Prisms: Global Mental Health are provided here courtesy of Cambridge University Press

    RESOURCES