Underscoring the Significance of Memorial Attendance in Reducing Future Psychological Distress in Bereaved Older Women

There have been few periods in human history when bereavement and grief were as globally relevant as they were during the peak of the COVID-19 pandemic. Early estimates indicated that each COVID-19 death in the United States left approximately nine close relatives bereaved.¹ These data revealed a higher proportion of the bereaved from COVID-19-related excess mortality, deviating from the usual levels. Similar generational patterns of kin loss were also observed in other countries, with older adults experiencing increased bereavement during the periods of COVID-19 excess mortality.² Given the staggering death toll during the pandemic, compounded by the sudden and unanticipated losses, physical distancing policies, social support system disruptions, and cascading life stressors faced by the bereaved, experts warned about the anticipated surge in grief-related mental health complications in the years ahead. It is in this context that the article by Denckla et al.³ published in this issue of the American Journal of Geriatric Psychiatry holds great relevance.

Denckla and colleagues³ leveraged a large sample of older women (n = 39,564; mean age: 65.2 years) from the COVID-19 substudy in the Nurses’ Health Study II. They examined the association between bereavement during the early pandemic months and future psychological distress. They also explored how memorial attendance after a loss is related to subsequent psychological distress. Participants answered bereavement questions between March and October 2020, providing information whether they had experienced the death of a loved one during the pandemic. Those who answered affirmatively were asked the type of relationship with the deceased, cause of death, and memorial attendance. Psychological distress was self-reported between January and October 2021 using the Patient Health Questionnaire-4, which included anxiety and depressive symptom items. The study revealed that older women who experienced bereavement during the early pandemic months had higher subsequent psychological distress than their non-bereaved counterparts, even after accounting for sociodemographic factors and prepandemic depressive symptoms. This association was seen in older women who lost their spouse/partner, child, friend, neighbor, or other relative, but not in those who lost their parent, grandparent, or sibling. Interestingly, COVID-19 deaths were associated with higher levels of anxiety, but not depressive symptoms, among the bereaved compared to non-COVID deaths. Notably, attending a memorial service in-person or online was associated with lower distress among the bereaved, irrespective of the cause of death.

Denckla et al.’s study is among the more comprehensive longitudinal investigations to date highlighting the positive association between bereavement and future depressive and anxiety symptoms in the context of the COVID-19 pandemic. Previous meta-analytic studies have shown a higher prevalence of psychological distress and mental health adversities during the COVID-19 pandemic compared to prepandemic periods, akin to other epidemics, major disasters, and wars.⁴ Bereavement during the pandemic also show similar patterns, including more intense acute grief symptoms, particularly in the COVID-19 bereaved.^5,6 However, there are discrepancies in these findings,⁷ potentially attributed to multiple factors, including cross-sectional study designs and the omission of relevant influencing factors, further emphasizing the novelty of this study.

The finding of higher levels of future anxiety, but not depressive symptoms, in the COVID bereaved opens promising avenues for future research. Factors related to the circumstances, context, and consequences of COVID-19 deaths offer plausible explanations.⁸ The COVID-19-related deterioration in health and subsequent deaths were often swift and unanticipated. Restrictions in hospital visitations during the early pandemic months meant that loved ones could not be physically present during the last moments, and even when visits were allowed, physical contact with the dying was prohibited. These protective measures were strictly enforced in COVID-related hospitalizations to minimize virus spread and extended to funeral practices and memorial services. Media coverage highlighting the rising number of COVID deaths may have served as a constant reminder of personal losses. The COVID bereaved may have faced other unique stressors, such as personal exposure to and infection with the virus, heightened worries about their own vulnerability to succumbing to the virus, and social deprivation. Survivor guilt, feeling responsible for transmitting the virus to the deceased, and perceiving COVID-19 deaths as preventable also may have heightened subsequent anxiety symptoms. Additionally, they may have encountered higher restoration-oriented stressors (e.g., financial strain, changes in living arrangements, adapting to new roles). Anticipatory worrying about further deaths, unemployment, and financial insecurities may have intensified anxiety symptoms. The traumatic nature of COVID deaths could also have increased the risk of anxiety and trauma-related disorders, like patterns seen after major disasters and violent deaths. If so, later anxiety can be an indirect manifestation of higher incidence of these psychiatric disorders among the COVID-19 bereaved.

The suggestion that memorial attendance is associated with lower future psychological distress during the pandemic may seem straightforward. The immediate practices and rituals following a loss can be unique to each culture and faith, reflecting diverse perspectives on death, community, and the afterlife. Traditional memorial services offer a venue to observe these diverse culturally and religiously rooted mourning practices, allowing the bereaved bid proper farewells to the deceased. Attending a memorial service allows individuals to acknowledge the passing, offer condolences, and honor and celebrate the deceased’s life. They create a safe space for the bereaved to confront and publicly express their grief and navigate the stressful aspects of the loss experience. They bring together caring family members and friends, bridging the internal world of personal grief with external social connections and support. Memorial services may thus universalize and normalize the grieving process, aiding successful adaptation to the loss. However, prior evidence on the effects of memorial services on psychological distress and mental health is inconclusive.^9,10 The number of attendees, the format of attendance and faith-based practices at these services may hold less significance for the bereaved than previously thought. Instead, the protective effects may stem from how personal and meaningful they are in fostering emotional connections, building a sense of community, and promoting collective grief expression. These services may also aid in developing and strengthening social networks, mobilizing social support and resources, and reducing loneliness and social isolation, thereby facilitating integrated grief.

Nurses’ Health Study II was established in 1989 to examine the long-term effects of oral contraceptives, diet, and lifestyle risk factors in women nurses aged 25 and 42 years. Consequently, the COVID substudy sample primarily consisted of white and middle-aged to youngest-old women, with a significant number from middle to higher socioeconomic backgrounds. However, COVID-19 disproportionately affected the historically marginalized, including the racial and ethnic minorities and socioeconomically disadvantaged older adults.^11,12 They faced greater health disparities, including lower vaccination rates and access to quality healthcare. Additionally, these marginalized groups and the oldest old conferred a higher risk for severe symptoms and death from the virus. Bereavement likely had a more pronounced impact on these vulnerable subgroups, leading to greater secondary losses (e.g., income loss, homelessness, food insecurity), widened health inequities, disrupted social support, heightened loneliness, and poorer mental health. Their limited digital literacy may have also hindered access to virtual memorial services and social connectedness, further exacerbating their risk for adverse outcomes. The associations between bereavement, memorial attendance, and psychological distress may have varied throughout the pandemic depending on the strictness of restrictions, COVID surges, and the availability of vaccines and treatments. While Denckla et al. provide valuable insights into deaths during the pandemic and future psychological distress, additional research is warranted before generalizing their findings to the entire older population.

Nevertheless, the novel findings in this paper have potential public health and clinical implications for the mental health of grieving older adults even in the postpandemic world. It is crucial to train healthcare providers and staff on grief and its complications, factors impacting adaptive coping, and strategies to reduce psychological distress and prevent complications. They should also receive education on delivering competent care that respects cultural, social, and religious practices. Community-level efforts to promote bereavement and grief literacy of the lay public should be undertaken, to facilitate integrated grief and improve early recognition of complications. Holding funeral and memorial services, whether virtual or in-person, which are tailored and meaningful to the bereaved, incorporate cultural- and faith-based practices, and nurture emotional connection among the attendees may be an important facet of the early grieving process.

Given the enormous death toll during the pandemic and concerns about mental health risks for bereaved older adults, there is an urgent need for conducting state-of-the-art research to unveil the risk and protective architecture of grief-related complications. It is critical to study both in-person and remotely delivered psychological interventions to support the older bereaved during acute grief and alleviate their mental health suffering in the postpandemic period.¹³ Bereavement and grief researchers are taking ambitious steps to tackle the mental health crises from deaths during the pandemic. They recognize the urgent need to develop and disseminate best practice guidelines for diagnosing, assessing, and treating grief-related complications, including prolonged grief disorder. For instance, the Bereavement Network Europe¹⁴ was recently established, proposing strategies to raise public and professional awareness of prolonged grief disorder, and a three-tiered model for evidence-based, accessible, and high-quality bereavement care that can be personalized to individual needs and target groups. The feasibility, long-term sustainability, and the impact of these initiatives on the care and outcomes of grieving older adults are yet to be determined.

DATA STATEMENT

The data has not been previously presented orally or by poster at scientific meetings.