Addressing mental health care for the bereaved during the COVID-19 pandemic.

Abstract

As of 5 May 2020, COVID-19 has swept into over 200 countries with over 3 million cases and more than 239 604 deaths.1 The mortality rate is around 5.4% globally. With an increasing number of deaths occurring, we need to address the mental health care of the bereaved in order to prevent these individuals from having psychological issues. COVID-19 is transmitted through personal contact and respiratory droplets; thus, family members are often separated from their relatives with COVID-19 and are unable to be with them as they suffer or die. To avoid transmission after death, decedents’ bodies have to be transferred and buried by trained burial teams. Being unable to comfort or care for family members and not having the chance to be with dying loved ones can dramatically increase feelings of grief, distress, and guilt. Although most individuals ultimately successfully adjust to the loss, some bereaved individuals fall into a state of unremitting and disabling mourning and suffer from physical and psychological effects, such as depression, post-traumatic stress disorder, and complicated grief.2 Relatives who do not have the opportunity to say good-bye to loved ones have a higher risk of these morbidities.3 Bereaved individuals may be treated in hospitals or mobile clinics or be isolated as suspected cases because of the high rate of familial clusters of cases, therefore they experience fear and worry about themselves while grieving the loss of family members.4 Risk factors that impact bereavement outcomes include situational, intrapersonal, interpersonal, and coping factors. For example, traumatic or sudden loss during public health emergencies or disasters can be more detrimental and harder to resolve than natural or less sudden losses.5 Other factors, such as low self-esteem, previous mental health problems, low socioeconomic status, a lack of social support, and a lack of economic resources can also increase vulnerability of the bereaved. With high risks of incident mental disorders among the bereaved, more intervention strategies need to be implemented to address the psychological needs of bereaved individuals to identify their mental status, provide timely psychological interventions, and prevent the development of mental disorders. During the COVID-19 outbreak, acute grief combined with depression and anxiety should be considered among the bereaved. Under strict infection measures, non-essential personnel, such as psychiatrists and psychologists, are strongly discouraged from entering isolation wards for those in hospital with confirmed infection. However, we can utilize existing health-care resources to screen for mental health issues and address psychosocial interventions. For example, frontline health workers in hospitals can quickly learn specific mental health competencies from psychiatrists through face-to-face meetings or long-distance guidance via the Internet. Additionally, community workers and social workers can be well trained for dealing with grief among the isolated cases, along with the provision of telephone hotlines and online counseling. For bereaved individuals with acute grief, psychotherapy (e.g., complicated grief treatment) has been shown to have better efficacy than grief-focused interpersonal psychotherapy and can be adopted as a first-line treatment.6 For individuals who are diagnosed with complicated grief, antidepressants (e.g., citalopram) can be used to optimize the efficacy.7 Bereavement follow-up visits and consultations with mental health professionals and social workers should be available to identify people who are having a particularly difficult time adjusting to the loss of loved ones. Therapy can help reduce the risk of mental health disorders by providing psychoeducation and cognitive restructuring of grief and focusing on behavioral approaches to socializing and forming new interpersonal attachments.8 In any epidemic or pandemic, there are a great number of deaths. However, the psychological condition of bereavement is often ignored or misdiagnosed; indeed, few evidence-based bereavement support services are currently available.9 During recovery from a pandemic and the reconstruction period, evidence-based psychological interventions for the bereaved are needed. The current lack of mental health care for the bereaved may due to a lack of mental health awareness, stigma and discrimination, or the lack of mental health-care resources. Therefore, for better preparation for dealing with mental health issues among the bereaved, we should first emphasize the promotion of mental health literacy of the general public in order to improve coping skills and awareness of psychological issues. Second, concerted action is needed to strengthen and modify the evidence base for interventions under specific cultural concepts and practices. Third, the availability of mental health resources will need to be increased for successful implementation of these interventions to ensure that such services are sustainable and of sufficient quality.10 Finally, further research needs to confirm whether evidence-based interventions can be safely and sustainably implemented in low-resource settings where the bereaved are exposed to high ongoing risks. The authors declare no conflicts of interest.