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Cited by 50Grief, Bereavement, and Mental HealthMigration, Health and TraumaPosttraumatic Stress Disorder Research

A prevalence assessment of prolonged grief disorder in Syrian refugees

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Bryant, Richard A., Bawaneh, Ahmad, Giardinelli, Luana, Awwad, Manar, Al‐Hayek, Hadeel, Akhtar, Aemal·2021·World Psychiatry
DOI 10.1002/wps.20876PMC PMC8129832
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Abstract

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 b

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Authors
Bryant, R. A., Bawaneh, A., Giardinelli, L., Awwad, M., Al‐Hayek, H., & Akhtar, A.
Affiliations
  • UNSW Sydney (AU)
  • Jordan Country Office International Medical Corps Amman Jordan
ORCID
Venue
World Psychiatry
Publisher
Wiley
Published
2021-05-18
Volume
20
Issue
2
Pages
302-303
ISSN
  • 1723-8617 (ISSN-L)
  • 2051-5545
DOI
10.1002/wps.20876
PMC
PMC8129832
OpenAlex
W3160773090
Cited by
50
References
9
Citations by year
2026: 2 · 2025: 6 · 2024: 11 · 2023: 9 · 2022: 20 · 2021: 2
FWCI
7.16
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • World Psychiatry (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • VU Research Portal (submittedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
  • Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
  • Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
Keywords
prolonged grief disorder, Syrian refugees, bereavement, prevalence, ICD-11, refugee mental health, functional disability, resettled refugees

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