Experiencing grief after the loss of a loved one is a natural reaction – an inevitable part of life. But for a small proportion of bereaved people, the grief is so overwhelming that it can lead to illness.

Previous studies have shown that many people request more healthcare services in the period after bereavement and that an increased short-term mortality rate is seen among the bereaved.

This is supported by a new study, where Danish researchers show that people in persistent intense grief, who experience strong grief symptoms that do not subside over time, have more contacts with the healthcare system and a higher mortality rate for up to 10 years after the loss. The results have just been published in Frontiers in Public Health.

”Our study is the first to examine the long-term use of healthcare services and mortality in a large cohort of bereaved individuals over ten years”, says the lead author of the study, Mette Kjærgaard Nielsen, who is a postdoctoral researcher at the Research Unit for General Practice in Aarhus.

A large cohort of bereaved

Since 2012, she and her colleagues have been following a cohort of 1,735 bereaved adults. A total of 66% lost their partner, 27% a parent and 7% another close relative.

The researchers used the Danish National Prescription Registry to identify patients who had recently been diagnosed with terminal illness. This enabled them to contact the patients and invite them, along with their closest relative, to participate in the study.

Categorisation of grief trajectories

The research group has previously identified five typical grief trajectories in the cohort. These trajectories are based on changes in the intensity of the bereaved person's grief symptoms measured at three points in time: before the death, six months after, and three years after. This was measured with the Prolonged Grief-13 (PG-13) questionnaire, using the average score of its 11 symptom items combined.

The previous study showed that 38% exhibited persistently low levels of grief symptoms, while 6% had persistently high levels. Three other categories fell between these two extremes: 18% followed a high, but declining curve, 29% followed a moderate, but declining curve, whereas 9% followed a late onset curve, with symptoms peaking approximately six months after bereavement.

Follow-up over 10 years

In the new study, the researchers extended the follow-up of participants to 10 years (until 2022). Using registry data, they examined the extent of four health services in the cohort: contacts with general practice, use of mental health services, use of psychotropic drugs and mortality.

The group with persistently high grief symptom levels had a higher number of contacts with their general practitioner (GP) for up to eight years after the bereavement. Hereafter, the differences in general practice contacts were no longer statistically significant between the five trajectories.

Participants with persistently high levels also generally received more health services for more than three years after the bereavement. For example, they were more likely to receive talk therapy in general practice, from a private psychologist or psychiatrist. They were also more likely to be prescribed antidepressants, sedatives or anxiolytic drugs.

In addition, the results showed that the risk of dying within 10 years was significantly higher in participants with persistently high levels of grief symptoms compared to those with low levels. However, the reason for the increased mortality is unknown.

‘Previous studies show a link between grief and a higher incidence of cardiovascular disease, mental health problems and even suicide. But the link with mortality needs to be investigated further,’ says Mette Kjærgaard Nielsen.

Important to detect warning signs

The authors point out that individuals at risk of developing persistent high levels of grief symptoms can be identified early for intervention, as a previous study has shown that these patients had more contacts with general practice even before the bereavement and were more likely to be prescribed psychotropic drugs.

"In general practice, we often have contact with the relatives of a deceased patient. If they show signs of severe stress, depression or another mental disorder, they can be offered follow-up in general practice, such as a series of consultations. Earlier this year, we found that approximately three consultations with the staff or the GP are meaningful. The GP can also suggest a follow-up appointment after the bereavement, with a focus on mental health in the bereaved," concludes Mette Kjærgaard Nielsen.

About the study

• The study cohort comprises 1,735 bereaved adults.
• The study was approved the Danish Data Protection Agency and the Research Ethics Committee in the Central Denmark Region.
• The study was funded by the Novo Nordisk Foundation and the Danish Cancer Society.
• Read the research paper “Grief trajectories and long-term health effects in bereaved relatives: a prospective, population-based cohort study with ten-year follow-up” in Frontiers in Public Health.

Contact information

Postdoc, general practitioner Mette Kjærgaard Nielsen
Research Unit for General Practice, Aarhus
Phone: +45 4257 7929
E-mail: mette.k.nielsen@ph.au.dk