A prevalence assessment of prolonged grief disorder in Syrian refugees
Authors: Richard A. Bryant, Ahmad Bawaneh, Luana Giardinelli, Manar Awwad, Hadeel Al‐Hayek, Aemal Akhtar
Journal: World Psychiatry (2021)

Although many studies indicate the elevated rates of mental disorders in refugees1, relatively little attention has been given to prolonged grief. This is surprising, considering that refugees commonly experience bereavement arising from war, torture, detention, or in the process of fleeing persecution2. There has been an increasing focus on problematic grief reactions in recent years, culminating in the new diagnosis of prolonged grief disorder (PGD) being introduced into the ICD-113. PGD is defined as persistent yearning for the deceased, and associated emotional pain, difficulty in accepting the death, a sense of meaninglessness, bitterness about the death, and difficulty in engaging in new activities, persisting beyond six months after the death. The disorder is estimated to occur in 7% of bereaved people4, but one population-based study of re-settled refugees reported an incidence of 15.8%5. There are no large-scale representative sampling studies of PGD in refugees directly affected by war. This is a serious omission in the evidence, because there are millions of refugees directly affected by war, conflict and persecution, and understanding the rates of PGD in this group would help shape better mental health policies to assist those experiencing bereavement. To fill this gap in current knowledge, this study aimed to determine the rate of PGD in a representative sample of adult Syrian refugee parents residing in a camp in Jordan. Participants were recruited in the process of screening for eligibility for a trial testing the effectiveness of a psychological intervention (ACTRN12619001386123). The screening assessments included adult (>18 years) Syrian refugees who had at least one child residing in two villages in the Azraq Refugee Camp, which hosts approximately 35,000 Syrian refugees. Arabic-speaking interviewers approached each consecutive caravan in two villages in the camp between January 2019 and February 2020, and interviewed one randomly selected adult in the household. The interview included experience and timing of bereavement, cause of death, and relation to the deceased. PGD was assessed using a 5-item interview that has been used in a previous survey following a major disaster6, and is consistent with the ICD-11 definition. PGD was operationalized as satisfying the following criteria over the past month for a bereavement that had occurred at least six months earlier: a) yearning for the deceased at least “once a day”; b) at least two of the following three symptoms occurring “quite a lot”: bitterness about the loss, difficulty accepting the loss, or feeling that life is meaningless; and c) endorsing functional impairment as a result of the grief. Additionally, psychological distress was assessed with the Kessler Psychological Distress Scale (K10), on which severe mental disorder was categorized as scores ≥30. Disability was evaluated using the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), on which disability was defined as scores ≥17. The study was approved by the Institutional Review Board of the King Hussein Cancer Centre, Jordan. We assessed 955 participants (67.3% females). Of these, 564 (59.1%) reported bereavement, with cause of death including war (26.5%), accident (8.3%), natural causes (64.6%) or other causes (2.6%). The deceased was a parent (32.2%), spouse (4.2%), child (5.7%) or relative/friend (57.9%). Among those experiencing bereavement, 85 (15.1%) met criteria for PGD, which comprised 8.9% of the entire sample. In terms of the specific symptoms of PGD, 478 (84.8% of the bereaved sample) reported persistent yearning, 447 (79.3%) bitterness about the loss, 251 (44.5%) feeling meaningless, 167 (29.6%) difficulty accepting the death, and 149 (26.4%) impairment resulting from their grief. There was no relationship between marital status, educational level, cause of death or relationship to the deceased and the likelihood of developing PGD. In terms of the association between PGD and ongoing problems, after controlling for cause of death, refugees with PGD were more likely to have a serious mental disorder (68.2% vs. 56.3%: OR=1.6, 95% CI: 1.0-2.6). PGD was not associated with greater disability. These findings are significant as this is the first study reporting on the prevalence of PGD, by representative sampling, in a population of refugees directly affected by war. The percentage of 15.1% of bereaved refugees experiencing PGD is markedly higher than those reported in other population-based studies, although it is commensurate with one prior population-based study of refugees5. The finding that 8.9% of the screened refugees had PGD highlights the importance of bereavement-related mental health issues affecting refugees exposed to war. This is arguably because a large proportion of Syrian refugees are exposed to events that can cause traumatic or unexpected death, and the nature of the deaths increases the risk for PGD. It was somewhat surprising that bereavement caused by deaths incurred by war or accident was not more predictive of PGD, as violent and accidental deaths have previously been shown to be associated with a higher risk for PGD7. This lack of association may be explained by extreme conditions due to war and forced displacement, potentially causing many natural deaths. These deaths, which are nonetheless unexpected, potentially predispose refugees to PGD. The observation that refugees with PGD are more likely to have a serious mental disorder underscores the psychological costs associated with this condition. The rate of PGD in war-affected refugees points to the need for greater attention to managing the disorder in this population. Considering that there are millions of refugees similarly affected worldwide, it is important to develop and evaluate programs that can address PGD. Although there are proven treatments for PGD based on cognitive behavioral strategies8, these are lengthy, rely on mental health specialists, and are costly for health systems, which limits the capacity for poorly resourced countries to implement them on a large scale. Recent initiatives that rely on task-shifting, in which non-specialists are trained to deliver mental health programs9, can be implemented to reduce common mental disorders. However, these have yet to address the clinical needs of people with PGD. The increasing evidence of the widespread psychological problems caused by bereavement in refugees highlights the need to develop scalable interventions that can address PGD.