DEATH STUDIES

https://doi.org/10.1080/07481187.2022.2039326

Are deaths from COVID-19 associated with higher rates of prolonged grief
disorder (PGD) than deaths from other causes?
James Gang
, Francesca Falzarano
, Wan Jou She, Hillary Winoker, and Holly G. Prigerson
Center for Research on End-of Life Care, Weill Cornell Medicine, New York, New York, USA

ABSTRACT
With the COVID-19 pandemic prompting predictions of a “grief pandemic,” rates and risks
for Prolonged Grief Disorder (PGD) warrant further investigation. Data were collected online
from 1470 respondents between October 2020 and July 2021. Shorter time since death,
deaths of siblings and “others,” and deaths from accidents and homicides were positively
associated with potential risk of probable PGD; deaths of extended family and from demen-
tia were negatively associated with probable PGD. When compared directly to deaths from
COVID-19, natural causes of death were associated with lower potential risk of probable
PGD, while deaths from unnatural causes were associated with higher potential risk.

Introduction Research that has examined psychological conse-

An unfortunate consequence of the COVID-19 pan-
demic, and the more than 5 million deaths worldwide
(World Health Organization, 2021) that occurred as a
result, is the grief experienced by bereaved survivors.
Recent meta-analyses report a prevalence rate of 10%
of prolonged grief disorder (PGD)1 in bereaved sam-
ples that lost a loved one due to natural (i.e., non-vio-
lent) causes (Lundorff et al., 2017) and 49% in
bereaved samples that lost a loved one to unnatural
(i.e., violent) causes (Djelantik et al., 2020). PGD, a
new mental disorder recently added to the ICD-11
and approved for inclusion in the DSM-5-TR
(Prigerson et al., 2021), is characterized by persistent
yearning for and/or preoccupation with thoughts of
the deceased and associated distressing and disabling
grief symptoms (Prigerson et al., 2021). However, the
characteristics associated with COVID-19 (e.g., the
patient’s rapid demise and increased likelihood of
death in the intensive care unit (ICU) which is associ-
ated with heightened risk of psychiatric morbidity for
the bereaved (Wright et al., 2010) and the circumstan-
ces surrounding the pandemic (e.g., social isolation
and inability to be present at the time of death or
have proper funerals) may exacerbate levels of psycho-
logical distress among mourners, promoting a setting
ripe for development of PGD (Eisma et al., 2020;
Lichtenthal et al., 2020).
quences of natural disasters, which share similarities
to pandemics including high death toll and disrup-
tions to daily life, suggests that PGD prevalence may
rise dramatically as a result of the pandemic (Eisma
et al., 2020). Despite these predictions, there has been
little empirical investigation in the context of the pan-
demic to substantiate these claims. In the Netherlands,
it has been shown that being recently bereaved during
the pandemic elicited more severe acute grief (a sig-
nificant predictor of PGD) than before the pandemic
(Eisma & Tamminga, 2020). When comparing indi-
viduals bereaved specifically by deaths from COVID-
19 versus other causes of death, those who have lost
loved ones to COVID-19 exhibited greater grief sever-
ity when compared to those bereaved due to natural,
but not unnatural, causes (Eisma et al., 2021). In both
these studies, however, the amount of time that had
elapsed since the death was insufficient to meet the
time-criterion of PGD (i.e., 12 months) and, thus, pre-
cluded conclusions on the development of PGD
(Eisma et al., 2021; Eisma & Tamminga, 2020). A
recent study in China found elevated rates of PGD
(27–38%) among those bereaved due to COVID-19
or a COVID-19 related complications as well as differ-
ences by kinship relationship to the deceased, but no
significant differences in prevalence before and after
six months post-loss (Tang & Xiang, 2021).

CONTACT Holly G. Prigerson hgp2001@med.cornell.edu Center for Research on End-of Life Care, Weill Cornell Medicine, 420 East 70th Street,
Suite 3B, Room 321 Lasdon House, New York, NY 10021, USA.

These authors contributed equally and should be considered as co-first authors.
ß 2022 Taylor & Francis Group, LLC
2 J. GANG ET AL.
Determining those at risk for PGD is an important
public health priority given the association of PGD
with both physical and mental health problems (e.g.,
suicidal thoughts, impaired quality of life; Prigerson
et al., 1997, 2021). This need may be particularly severe
in the context of the pandemic, as the risk for and
severity of adverse outcomes associated with PGD may
themselves be elevated due to the pandemic. Given the
limited research on this topic, further research is
needed to confirm results of the few early studies in
this area (e.g., Eisma et al., 2021; Tang & Xiang, 2021).
In addition, while past studies have used measures
based upon the DSM-5 criteria for persistent complex
bereavement disorder (PCBD) or the ICD-11 criteria
for PGD, there is a need for findings based upon the
new DSM-5-TR criteria for PGD, which has replaced
PCBD. The present study aims to fill these research
gaps by using data from a self-reported online survey
to determine the rates of (probable) PGD associated
with COVID-19 versus other causes of death (e.g.,
other natural and unnatural causes of death), both with
and without adjustment for time since loss and
respondents’ relationship to the deceased.
Materials and methods
Participants and procedure
Data were collected from 2,040 participants between
October 2020 and July 2021. Participants were eligible
to participate in the study if they were 18 years or
older, experienced the death of a person they consid-
ered a significant other, and were able to access and
complete an online survey. The online survey was
hosted on the Cornell Center for Research on End-of-
Life Care website. Participants were not actively
recruited to complete the survey; instead, participants
found and voluntarily completed our survey online.
This study was deemed exempt by the local ethics
committee (record number #21-02023366), which
necessitated de-identification of study participants. As
a result, sociodemographic information and other
identifying characteristics were not obtained from
study participants. In addition, participants (n ¼ 570)
were excluded from the analytic sample if data were
missing on key analytic variables. No significant dif-
ferences in study variables emerged between partici-
pants who did and those who did not have missing
data (i.e., participants and those excluded from the
analysis). The final analytic sample consisted of 1,470
participants.
Measures
In addition to completing measures of grief intensity
(described below), participants were also asked to
report on the length of time (in months) since the
death, the respondent’s relationship to the deceased,
the deceased’s cause of death, and whether grief-
related symptoms caused significant impairment in
participant functioning. Respondents’ relationship to
the deceased was coded as parent, offspring, sibling,
extended family (a composite variable formed from
grandparent, aunt, uncle, cousin, and friend
responses), and “other” which served as the refer-
ence group.
Grief intensity scale
The Grief Intensity Scale (GIS) was created to serve as
an online version of the PG-13-R, a self-rated scale
consisting of 10 Likert-scale questions pertaining to
symptoms of grief (Prigerson et al., 2021). The GIS
uses the same 5-point Likert response format to evalu-
ate the intensity and severity of the assessed PGD
symptoms. The PG-13-R has demonstrated good reli-
ability in three independent bereaved study samples
(Cronbach’s a ¼ .83–.93; Prigerson et al., 2021). In
the current study, the GIS exhibited excellent reliabil-
ity, with Cronbach’s a ¼ .93. A symptom threshold
score of 30 or greater was shown to correspond well
to a probable diagnosis of PGD using the DSM crite-
ria set (kappa 0.70 across the datasets; Prigerson
et al., 2021). We acknowledge that scores of this
online assessment are not equivalent to clinical diag-
nosis made by a trained mental health professional.
Furthermore, the DSM-5-TR diagnosis requires
12 months or more to have elapsed since the death,
and therefore diagnoses consistent with the DSM-5-
TR criteria cannot be made prior to a year after the
death. For these reasons, we refer to the primary out-
come variable as “probable PGD.” Throughout the
survey, participants were instructed to seek evaluation
and support from a mental health professional if they
met criteria for probable PGD.
Statistical analyses
Prior to conducting data analyses, all variables were
examined for normality and homogeneity. Descriptive
statistics (means, standard deviations, frequency distri-
butions) were examined to characterize the sample
based on the limited background data available in this
IRB exempt study. These variables included cause of
death, the respondent’s relationship to the deceased,
and length of time since the death.
 DEATH STUDIES 3

Chi-square tests were conducted to examine differ-

Probable PGD Prevalenceⱡ

ences in participant characteristics for categorical vari-
ables, and independent samples t-tests were used to

61.4%
63.5%
72.5%
46.2%
59.4%
70.0%

59.5%
60.1%
64.1%
38.0%
71.7%
73.0%
66.1%
75.0%
61.6%
examine differences in continuous variables. Variables
that exhibited significant differences (i.e., type of
respondent’s relationship to the deceased and time
since loss) at p < .10 were retained for subsequent
“adjusted” analyses that included these variables.
Although diagnostic criteria for a PGD diagnosis
.021
<.001

.490
.815
.034
<.001
.476
<.001

.118
.483
.766
<.001
.007
.312
.447
.079
.705
p

requires symptoms to persist for one year, we include

those bereaved for less than 12 months to examine
correlates of meeting symptom threshold for probable
20.5 (85.7)
39.3 (6.03)

PGD because acute grief has been shown to be a

M (SD)

strong predictor for development of PGD (Boelen &

Probable PGD (n ¼ 922)

Lenferink, 2020). Using the DSM-5-TR symptom

threshold of 30 for meeting diagnostic criteria for
probable PGD, a dichotomous GIS variable was cre-
8.00
9.30
7.20

8.30

2.10
9.40
31.8
14.0

29.7

23.4
13.4

2.1
13.3

4.3
23.8
%

ated in which GIS scores 30 were coded as

1 ¼ probable PGD, and GIS scores <30 were coded as
0 ¼ no probable PGD. We also calculated relative risk
293
129
74
86
66
274

215
123
76
19
122
19
86
39
218
n

(RR) ratios with 95% confidence intervals using the

Mantal-Haenszel formula for variance.
To assess whether length of time since the loss
31.1 (81.9)
21.5 (5.73)
M (SD)

and/or respondents’ relationship to the deceased were

Adjusted for time since loss and respondent’s relationship (Sibling, Extended Family, and ‘Other’) to the deceased.

associated with probable PGD, we calculated RR ratios

No PGD (n ¼ 548)

with 95% CIs and crude and adjusted odds ratios

Note: Sample included participants bereaved 12-months and thus do not meet the time criterion for PGD.

(ORs). Further, to assess whether cause of death

5.10

8.20

7.70
5.30
8.60
1.30
8.10
2.40
33.6
13.5

18.2

21.4

27.1
14.8

24.7
Table 1. Descriptive Statistics for Study Sample Examining Probable PGDa (n ¼ 1470).

(COVID-19 versus each cause of death) was associated

%

with probable PGD scores independent of respond-

ents’ relationship to the deceased and time since loss,

Uses v2 for categorical variables and independent samples t-tests for continuous variables.
184
74
28
100
45
117

148
81
42
29
47
7
44
13
135
n

we used binary logistic regression models to calculate

adjusted ORs. Finally, we replicated the above analyses
and calculated RR ratios with 95% CIs and crude and
24.5 (84.4)
25.1 (16.4)
M (SD)

adjusted ORs to assess the relationships among cause

of death and probable PGD scores in a subsample of
Sample (n ¼ 1470)

participants (n ¼ 599) bereaved 12 months, consist-

ent with the DSM’s time criterion for PGD. A signifi-
6.90

7.60

8.10
3.30

1.80
8.90
3.50
32.4
13.8

12.7

26.6

24.8
13.9

11.6

24.1

cance value of p < .05 was used for all analyses.

%

For both sets of analyses, G
Power Software version

3.1 was used to conduct post-hoc power analyses to cal-
477
203
102
186
111
391

363
204
118
48
169
26
130
52
353
n

culate achieved power for our sample. Power was calcu-

lated in two ways: Cohen’s x (0.1 ¼ small; 0.3 ¼ medium)
was used for the unadjusted analysis and f2 for adjusted
Respondent’s Relationship to Deceased

analyses (f2: 0.1 ¼ small; 0.3 ¼ medium). Statistical analy-

ses were conducted using SPSS Version 25.
Natural/Man-Made Disaster
Heart Attack/Heart Failure
Time Since Death (Months)

Results
Extended Family

Cause of Death

Overall, the prevalence rate of probable PGD in this

Dementia
COVID-19

Homicide
Offspring

Accident

self-selected sample was 66.53% (978/1470). Table 1

Suicide
GIS Score

Sibling

Cancer
Parent

Friend
Other

Other
Variable

presents descriptive statistics for the full study sample

and subgroup comparisons based on PGD status
ⱡ
a
4 J. GANG ET AL.

Table 2. Analyses of Cause of Death and Kinship to the Deceased as Associations with Probable PGDa (n ¼ 1470).
Unadjusted Adjustedⱡ
COVID-19 versus Other Causes of Death No. Scoring  30 on GIS % RR 95% CI OR OR 95% CI
COVID-19 versus Dementia 1.63
1.12 to 2.37 2.76 2.52
1.19 to 5.31
Dementia 19 39.6
COVID 76 64.4
COVID-19 versus Cancer 1.09 .928 to 1.28 1.25 1.41 .898 to 2.21
Cancer 215 59.2
COVID 76 64.4
COVID-19 versus Heart Attack/Heart Failure 1.07 .897 to 1.27 1.19 1.09 .667 to 1.80
Heart Attack/Heart Failure 123 60.3
COVID-19 76 64.4
COVID-19 versus Accident 0.89 .758 to 1.05 0.697 0.724 .409 to 1.28
Accident 122 72.2
COVID-19 76 64.4
COVID-19 versus Natural/Man-Made Disaster 0.88 .673 to 1.15 0.667 0.525 .181 to 1.53
Natural/Man-Made Disaster 19 73.1
COVID-19 76 64.4
COVID-19 versus Suicide 0.97 .812 to 1.17 0.926 1.08 .607 to 1.91
Suicide 86 66.2
COVID-19 76 64.4
COVID-19 versus Homicide 0.86 .699 to 1.06 0.603 0.276
.104 to .736
Homicide 39 75.0
COVID-19 76 64.4
COVID-19 versus Other 1.04 .891 to 1.22 1.12 0.964 .611 to 1.52
Other 218 61.8
COVID-19 76 64.2
a
Note: Sample included participants bereaved  12-months and thus do not meet the time criterion for PGD. RR ¼ Relative Risk; OR =: Odds Ratio.
ⱡ
Adjusted for time since loss and respondent’s relationship (Sibling, Extended Family, and ‘Other’) to the deceased.

Statistically significant results p < .05.

(i.e., meets criteria for probable PGD by scoring 30
on the GIS [n ¼ 922] versus not [i.e., GIS scores <30;
n ¼ 548]). Independent samples t-tests indicate that
those in the probable PGD group reported a signifi-
cantly shorter amount of time since the death
(t[1468] ¼ 2.31, p ¼ .021). Chi-square tests were then
performed to examine the associations between
respondents’ relationship to the deceased, cause of
death, and meeting criteria for probable PGD. Results
(Table 1) indicate that those who were siblings (v2
[1, N ¼ 1470] ¼ 4.53, p ¼ .03), extended family mem-
bers (v2 [1, N ¼ 1470] ¼ 24.75, p < .001), and those
who reported their relationship to the deceased as
“other” (v2 [1, N ¼ 1470] ¼ 24.75, p < .001) were sig-
nificantly associated with probable PGD scores. When
examining differences in probable PGD by cause of
death, we found significant associations among demen-
tia (v2 [1, N ¼ 1470] ¼ 11.32, p < .001) and accidents
(v2 [1, N ¼ 1470] ¼ 7.39, p ¼ .007), while homicide
was trending significance (p ¼ .079). When examining
time since loss and each category of respondents’ rela-
tionship to the deceased as covariates, only variables
significantly associated with probable PGD (e.g., length
of time since death and the categories of sibling,
extended family, and “other” as respondents’ relation-
ship to the deceased) were included.
Table 2 summarizes unadjusted and adjusted asso-
ciations comparing COVID-19 versus other causes of
death as correlates of probable PGD in the full
sample. Each death cause category was used as the
reference group in each analysis. In general, when
comparing COVID-19 to dementia, those who
reported COVID-19 as cause of death were more
likely to score above the threshold for probable PGD.
When adjusting for time since loss and kinship to the
deceased, these findings remained significant (B ¼
.93, p ¼ .015). Additionally, although no significant
differences were identified in the unadjusted associa-
tions comparing COVID-19 to homicide as cause of
death, the adjusted model revealed that those who
reported COVID-19 as cause of death were less likely
to meet criteria for probable PGD compared to deaths
from homicide (B ¼ 1.29, p ¼ .010).
A post-hoc analysis using G
Power software ver-
sion 3.1 was conducted to calculate power for our
sample. In the full sample, power to detect small and
medium effects (Cohen’s x ¼ 0.1; 0.5 for small and
medium effects, respectively) at the p < .05 level for
the unadjusted analyses indicated that power ranged
from 22% to detect small effects when comparing
COVID-19 versus natural/manmade disasters to 59%
for COVID-19 versus cancer; while power to detect a
medium effect size was 94% and 99% for COVID-19
versus natural disasters and COVID-19 versus cancer,
respectively. While accounting for covariates in the
logistic regression model, the power to detect a small
effect (Cohen’s f2 ¼ 0.1) at p < .05 ranged from 28%
to detect a small effect comparing COVID-19 to

natural/manmade disasters, to 63.4% when comparing
COVID-19 versus cancer. When examining power to
detect a medium effect size, power was 87.6% and
99% for the comparisons of COVID-19 versus nat-
ural/manmade disaster and COVID-19 versus cancer,
respectively.
Subgroup analysis
Finally, we conducted a set of exploratory analyses in a sub-
sample of participants (n ¼ 599) who were bereaved  12-
months. When compared to the full sample, subsample par-
ticipants had significantly lower mean GIS scores compared
to those bereaved for fewer than 12 months t[1456] ¼ 3.54,
p < .001. Additionally, subsample participants were less
likely to report cancer (v2 [1, N ¼ 1470] ¼ 11.26, p < .001),
COVID-19 (v2 [1, N ¼ 1470] ¼ 42.29, p < .001), and
dementia (v2 [1, N ¼ 1470] ¼ 7.35, p ¼ .007) as death
causes compared to those bereaved for fewer than 12-
months. However, results also indicate that subsample par-
ticipants were more likely to report suicide (53.2%) as cause
of death compared to those bereaved for fewer than
12 months (46.8%); (v2 (1, N ¼ 1470) ¼ 8.19, p ¼ .006).
We then examined the unadjusted and adjusted
associations comparing COVID-19 versus other causes
of death as correlates of probable PGD among partici-
pants (n ¼ 599) bereaved 12 months (see Table 3).
Each cause of death category was used as the refer-
ence group in adjusted models. Results only showed a
significant association when comparing COVID-19
versus dementia in the unadjusted analysis, such that
those bereaved from COVID-19 were significantly
more likely to score above the threshold for probable
PGD. When adjusting for covariates, this association
was no longer significant. Further, although the com-
parison of COVID-19 versus cancer was not signifi-
cant in the unadjusted analysis, the adjusted model
was trending significance: those bereaved from
COVID-19 were more likely to score above the
threshold for probable PGD compared to those
bereaved from cancer (B ¼ 1.14, p ¼ .069).
A post-hoc analysis was conducted to calculate
achieved power for the subsample bereaved 12-
months, power to detect small and medium effects
(Cohen’s x ¼ 0.1; 0.5 for small and medium effects,
respectively) at the p < .05 level for the unadjusted
analyses indicated that power ranged from 7.5% to
detect small effects when comparing COVID-19 ver-
sus natural/manmade disasters to 28% for COVID-19
versus cancer; while power to detect a medium effect
size was 29% and 98% for COVID-19 versus natural
disasters and COVID-19 versus cancer, respectively.
DEATH STUDIES 5
When accounting for covariates in the logistic regres-
sion model, the power to detect a small effect
(Cohen’s f2 ¼ 0.1) at p < .05 ranged from 9.9% to
detect a small effect when comparing COVID-19 to
natural/manmade disasters, and 33.9% when compar-
ing COVID-19 versus cancer. When examining power
to detect a medium effect size, power was 24% and
94.5% for the comparisons of COVID-19 versus nat-
ural/manmade disasters and COVID-19 versus cancer,
respectively.
Discussion
This cross-sectional study uses the new DSM-5-TR
diagnostic criteria for PGD (Prigerson et al., 2021) to
determine rates and correlates of probable PGD in the
context of the COVID-19 pandemic. Comparing
COVID-19 versus other causes of death, we found
COVID-19 deaths to be associated with probable
PGD when compared to dementia and trended like-
wise with other natural causes of death. Compared to
unnatural causes of death such as deaths from homi-
cide, those who reported COVID-19 as cause of death
were less likely to meet criteria for PGD. Shorter time
since death, either a sibling or “other” relationship
with the deceased, and accidental deaths were posi-
tively associated with likelihood of meeting diagnostic
criteria for PGD, while extended family member dece-
dents and deaths attributed to dementia were nega-
tively associated with likelihood of meeting diagnostic
criteria for PGD.
Our results revealed a substantially higher probable
PGD prevalence rate of 66.5% compared to both the
9.8% reported in the Lundorff et al. (2017) meta-ana-
lysis of the naturally bereaved and the 49% reported
in the Djelantik et al. (2020) meta-analysis of the
unnaturally bereaved. It is important to acknowledge
our sample was self-selected; participants found our
Center for Research on End-of-Life Care website on
their own and voluntarily completed a survey about
their loss and reactions to it. Thus, respondents were
online users seeking information about grief which
would be expected to represent inflated rates com-
pared to more representative community-based sam-
ples (see 6.3%-16.6% in Prigerson et al., 2021). A
decade earlier, Lichtenthal et al. (2011) showed that
bereaved caregivers experiencing PGD did not readily
access mental health services, with the most common
reason being not having mental health concerns.
However, Google Analytics of the study website
revealed that 54.3% of our site traffic comes from
organic searches using keywords such as “grief
 6
J. GANG ET AL.

Table 3. Analyses examining cause of death and kinship to the deceased as associations with probable PGD in participants bereaved  12-Months (n ¼ 599).
Unadjusted Adjustedⱡ
COVID-19 versus Other Causes of Death N No. Scoring  30 on GIS % RR 95% CI OR OR 95% CI
COVID-19 versus Dementia 4.03
1.11 to 14.67 12.38 2.70 .195 to 37.16
Dementia 11 2 18.2
COVID-19 15 11 73.3


COVID-19 versus Cancer 1.37 .977 to 1.91 2.37 3.12I .917 to 10.60
Cancer 175 94 53.7
COVID-19 15 11 73.3
COVID-19 versus Heart Attack/Heart Failure 1.41 .974 to 2.05 2.55 2.21 .604 to 8.08
Heart Attack/Heart Failure 79 41 51.9
COVID-19 15 11 73.3
COVID-19 versus Accident 1.06 .753 to 1.49 1.22 1.96 .442 to 8.70
Accident 75 52 69.3
COVID-19 15 11 73.3
COVID-19 versus Natural/Man-Made Disaster 1.03 .587 to 1.80 1.10 1.28 .080 to 20.65
Natural/Man-Made Disaster 7 5 71.4
COVID-19 15 11 73.3
COVID-19 versus Suicide 1.07 .756 to 1.51 1.263 1.64 .417 to 6.45
Suicide 67 46 68.7
COVID-19 15 11 73.3
COVID-19 versus Homicide 1.05 .689 to 1.59 1.18 .164 .013 to 2.02
Homicide 20 14 70.0
COVID-19 15 11 73.3
COVID-19 versus Other 1.40 .995 to 1.97 2.50 2.12 .604 to 7.43
Other 147 77 52.4
COVID-19 15 11 73.3
Notes. RR ¼ Relative Risk. OR ¼ Odds Ratio.
ⱡ
Adjusted for time since loss and respondent’s relationship (Sibling, Extended Family, and ‘Other’) to the deceased.

Statistically significant results.

I
Trending significance at p ¼.069.

assessment,” “grief intensity scale,” or “grief scale” and
32.86% from a direct link suggesting referrals from
mental health professionals or recurrent use. This sug-
gests that most of our site visits are self-referrals from
bereaved people who want and seek information
about their grief, as well among those who express an
interest in and willingness to complete a voluntary
online survey about their grief intensity. Although cer-
tainly not conclusive, it does suggest an interest in
and receptivity to disordered grief and the use of
online bereavement resources.
Contrary to our expectations, our findings failed to
support the predictions that COVID-19 deaths would
be associated with a higher prevalence of PGD (Eisma
et al., 2020). In the context of disproportionate sam-
pling of unnaturally bereaved in our sample (Kersting
et al., 2011), this is consistent with Eisma et al. (2021)
finding that the COVID-19 bereaved do not experi-
ence greater grief than the unnaturally bereaved. One
explanation for this is that the 2-8 week period
between COVID-19 symptom onset to death (Baud
et al., 2020) perhaps allows mourners to prepare for
the loss of their loved one more than would be the
case in deaths due to accidents or homicides, but less
so than in deaths attributed to a protracted illness
such as dementia. This explanation is consistent with
a prior finding that the unexpectedness of the death
explains greater PGD symptom levels among the
COVID-19 bereaved compared to those bereaved by
deaths from natural causes (Eisma et al., 2021). We
here found that those bereaved by a COVID-19 death
were more likely to meet criteria for probable PGD
when directly compared to dementia as a cause of
death. Another explanation is that there may be some
comfort found in the high death toll, a sense of com-
munity among those affected fostering empathy and
support, and a reduced sense of guilt given that the
virus has indiscriminately infected people from all
walks of life (Mein, 2020). Further research is needed
on loss characteristics associated with COVID-19 and
coping strategies used during this pandemic (Breen
et al., 2022).
With regard to other causes of death, our findings
indicate accidents and homicides were positively asso-
ciated with likelihood of probable PGD overall, which
aligns with previous research on the propensity of
unnatural causes of death to precipitate mental health
disorders (Kristensen et al., 2012). Likewise, our
results suggest that dementia may be a negative cor-
relate of probable PGD, which also aligns with previ-
ous research demonstrating that the confrontation of
“serial losses” (e.g., as a result of cognitive and
DEATH STUDIES 7
physical declines of the person with dementia) (Chan
et al., 2013; Holley & Mast, 2009; Kiely et al., 2008;
Schulz et al., 2003; Singer & Papa, 2021) prior to the
death, and the stress reduction as a result from a
reduction in caregiving responsibilities after the death
(Ghesquiere et al., 2011), may alleviate grief severity
during bereavement and facilitate positive bereave-
ment adjustment. When considering these results by
death types, they are consistent with Eisma et al.
(2021) finding that only unnatural bereavement yields
higher grief levels than COVID-19 bereavement.
This study also found that being a sibling of the
deceased is positively correlated with probable PGD,
while being an extended family member of the
deceased is negatively correlated with probable PGD.
These findings are consistent with previous research
demonstrating that closer kinship to the deceased is
consistently related to higher grief intensity across dif-
ferent age and cultures (Glickman, 2020; He et al.,
2014; Stammel et al., 2013; Tang & Xiang, 2021).
“Other” being a positive correlate of probable PGD is
difficult to explain given the lack of specificity, but
one possible explanation is that this option may have
captured the loss of a spouse or pet, which have been
shown to precipitate PGD (Lee, 2020; Lundorff et al.,
2017), but was not explicitly measured in the current
study. Lastly, we found that less time elapsed since the
death was positively correlated with probable PGD.
This result may be explained by the phenomenon of
adjusting to the loss over time contributing to declin-
ing grief severity (Guldin et al., 2012; Latham &
Prigerson, 2004; Prigerson et al., 1997), which is sub-
stantiated by our finding of lower mean GIS scores
for subjects bereaved 12 months compared to those
bereaved <12 months. Given similarities in the risks
for PGD before and after 12 months post-loss, and
prior studies showing that a 6-month assessment pre-
dicts a 12-month assessment of PGD as well as other
forms of future morbidity (Prigerson et al., 2009;
2021), this suggests the need for more empirical work
to examine the harms and benefits of PGD diagnosis
before and after one year post-loss.
Although the current study provides timely insight
into potential risk factors and intensity of grief experi-
enced among those bereaved during the COVID-19
pandemic, the results should be considered in the
context of its limitations. First, while the DSM criteria
for PGD requires at least 12 months to have elapsed
since the death, our overall sample did not exclude
those who did not meet this temporal requirement,
which only further contributes to the caution that par-
ticipants in this study were not formally diagnosed; a
8 J. GANG ET AL.
subanalysis exploring only those bereaved 12 months
was performed to provide additional information about
differences in rates of probable PGD based on time
from loss. Second, the cross-sectional nature of our
survey does not allow us to examine changes in grief
over time nor make inferences of causality, which
restricts interpretation of the study variables as risk fac-
tors. It should also be noted that our analyses in those
bereaved greater than or equal to 12 months had a low
number of reported COVID-19 as cause of death
(n ¼ 15), thus these analyses are considered exploratory
and were not adequately powered to detect significant
effects. Relatedly, a third limitation is the correlational
nature of the study, and thus future research should
contribute to the sparse literature examining unas-
sessed variables, such as social support and relationship
quality with the deceased, that may influence grief
intensity following the death of a loved one due to
COVID-19 (Eisma et al., 2021; Eisma & Tamminga,
2020). Lastly, the use of an online survey limits formal
diagnosis of PGD, as well as the assessment of other
demographic factors (i.e., gender, race/ethnicity, eco-
nomic vulnerability) that we could examine for their
associations with the respondent’s grief intensity.
Future research should contribute to the sparse litera-
ture examining the impact of demographic and cultural
(i.e., importance and use of mourning rituals) factors
on bereavement adjustment (Eisma et al., 2021; Eisma
& Tamminga, 2020) and seek to replicate our current
findings in larger samples with more than a single
assessment time point to capture more granular
changes in grief intensity during bereavement in the
wake of the COVID-19 pandemic.
In conclusion, this cross-sectional study found that
probable PGD onset was associated with lower rates
than unnatural deaths (e.g., accidents, homicide) and
higher rates than natural deaths (e.g., dementia) com-
pared to deaths from COVID-19. Less time since
death, closeness of the respondent’s relationship to the
deceased, and violent causes of death were positively
associated with probable PGD, while extended family
kinship and dementia was negatively associated. More
focused research on the prevalence of PGD among the
COVID-19 bereaved is needed in light of the number
of grieving individuals, availability of a new psychi-
atric diagnosis, and online tools and resources to
identify and minimize the public health risks posed
by PGD.
Disclosure statement
No potential conflict of interest was reported
the authors.
Note
1. References to PGD throughout this study refer to the
psychometrically validated diagnostic criteria for PGD
that will appear in DSM-5-TR. However, the citations
in this introduction may refer to/have investigated PGD
predecessors such as complicated grief and traumatic
grief. For the purposes of this introduction, these can
all be assumed to be roughly equivalent.
Acknowledgements
All sponsors had no direct input into the design or conduct
of the study; collection, management, analysis, or interpret-
ation of the data; or preparation, review, or approval of
the manuscript.
Funding
This work was supported by grants from the National Cancer
Institute [CA197730; Prigerson; CA218313; Prigerson/Lichtenthal],
the National Institute of Minority Health and Health Disparities
[MD007652; Maciejewski/Prigerson], the National Institute of
Nursing Research [NR018693; Prigerson/Epstein]; the National
Institute on Aging [AG049666; Reid/Prigerson; K99 AG073509:
Falzarano; T32 AG049666; Prigerson/Falzarano], the National
Institute of Mental Health [MH121886; Maciejewski/Prigerson].
ORCID
Francesca Falzarano http://orcid.org/0000-0003-
1090-3337
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