Grief after the loss of a loved one is a natural response – an inevitable part of living and loving. But in a minority of the bereaved, grief is so overwhelming that it can lead to physical and mental illnes, even if they don’t necessarily qualify for a diagnosis with the mental health condition ‘prolonged grief disorder’. For example, studies have shown that people who recently lost a loved one use healthcare services more often, and have an increased mortality rate, over the short term.

Now, researchers from Denmark have shown that bereaved people with persistent high levels of intense grief used more healthcare services and were more likely to die within 10 years. The results are published in Frontiers in Public Health.

“This is the first study to investigate the long-term use of healthcare and patterns of mortality over a decade after bereavement in a large-scale cohort,” said Dr Mette Kjærgaard Nielsen, a postdoctoral researcher at the Research Unit for General Practice in Aarhus, Denmark, and the study’s corresponding author.

Starting in 2012, Nielsen and colleagues followed a cohort of 1,735 bereaved women and men living in Denmark with a mean age of 62 years on enrollment. Among them, 66% had recently lost their partner, 27% a parent, and 7% another kind of loved relation. Through the national register of drug prescriptions, the researchers knew which patients had recently been prescribed treatment for a terminal condition. They were thus able to contact those dying patients to invite them and their loved ones to participate in the study. The protocol had been approved by the Health Research Ethics of the Central Denmark Region and the Danish Data Protection Agency.

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‘Grief trajectories’

Previously, Nielsen et al. had identified five common ‘trajectories’ among this cohort, based on changes in the intensity of grief symptoms over the first three years after losing a loved one. They measured this with the tried-and-tested ‘Prolonged Grief-13’ (PG-13) questionnaire, which assesses symptoms through 13 questions.

People on the ‘low’ trajectory (38%) displayed persistently low levels of grief symptoms, while 6% followed a ‘high’ trajectory with persistently elevated levels. Three other categories lay between these extremes: 18% and 29% followed a ‘high but decreasing’ and a ‘moderate but decreasing’ trajectory, respectively, and 9% a ‘late onset’ trajectory with a peak of symptoms around six month after bereavement.

In the present study, the researchers extended their follow-up of the participants for a total of 10 years until 2022, except for those who died or emigrated earlier. To do so, Nielsen et al. used data from the Danish National Health Service Register to assess how often each participant received ‘talk therapy’ from a GP or specialist, or were prescribed any psychotropic medication. Records from the Danish Registry of Causes of Deaths gave information on deaths from any cause.

The results showed that for participants on the ‘high’ trajectory, the hazard rate (ie, instantaneous event rate) of dying within 10 years was 88% higher than for participants on a ‘low’ trajectory. They also showed that participants on the ‘high’ trajectory were most likely to receive additional health care services beyond three years after bereavement. For example, these had 186% higher odds of receiving talk therapy or other mental health services, 463% higher odds of being prescribed antidepressants, and 160% higher odds of being prescribed sedatives or anxiety drugs.

Catching the warning signs

Differences in the frequency of use of these healthcare services between the five trajectories were no longer significant after the first eight years, but the excess mortality of participants on the ‘high’ trajectory remained pronounced over the full 10 years of follow-up.

What might be the physiological cause of the excess mortality? The researchers aren’t sure yet.

“We have previously found a connection between high grief symptom levels and higher rates of cardiovascular disease, mental health problems, and even suicide. But the association with mortality should be further investigated,” said Nielsen.

The authors point out that people at risk for a ‘high’ grief trajectory may be recognizable for intervention early, since the data showed that these patients were prescribed psychotropic medication more often even before their loss.

“The ‘high grief’ group had lower education on average, and their more frequent use of medication before bereavement suggested that they had signs of mental vulnerability, which may cause greater distress on bereavement,” said Nielsen.

“A GP could look for previous signs of depression and other severe mental health conditions. They can then offer these patients tailored follow-up in general practice, or refer them to a private-practice psychologist or secondary care. The GP may also suggest a bereavement follow-up appointment focusing on mental health,” suggested Nielsen.

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