An Unprecedented Review: 12,000+ Bereavement Studies to Improve the Quality of Future Healthcare for Bereaved Persons
By Joyal Mulheron
On Thursday, March 13, the Agency for Healthcare Research and Quality (AHRQ) released the nation’s first report on the quality of today’s psychosocial interventions used to attend to the needs of bereaved people. For me, it was a long time coming, as I approached Congressional appropriators in 2022 to direct AHRQ to conduct this review. Over the past few years, the nation’s most distinguished leaders have been engaged in the effort, including myself. It was an honor to serve as a “Key Informant” in supporting the team’s conceptualization of bereavement—and its subsequent care—now and in the future, particularly after thousands of everyday Americans trusted me with their stories and hardships. Three years later, the most comprehensive and rigorous review of bereavement literature is available for public consumption.
Within our field, one of the most passionate debates is the increasing medicalization of grief care. The review, conducted by the Southern California Evidence-based Practice Center, helps our field understand the quality of the evidence completed to date and where to head in the future.
More than 12,063 psychosocial research studies were identified, but only the texts of 5,228 studies were obtained, with only 219 meeting the eligibility criteria. Take a moment for that to absorb: a preponderance of the studies did not meet the necessary benchmarks.
Taken in the context with the objective of the report: “to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services,” we can definitively say that we have a long way to go in our field.
Six intervention types for bereaved persons were identified, with one category serving as a catch-all:
- Pharmacotherapy
- Psychotherapy
- Expert-facilitated support groups
- Peer support
- Non-psychotherapy / spiritual counseling
- Self-help interventions
- Other
Within each intervention type, the expert team further examined the scientific evidence for how each intervention impacts various facets of the bereavement experience, giving the evidence one of four grades: high, moderate, low, and insufficient (see Table 2 of the report). No study, and thereby intervention, met the “high” criteria.
For example, does pharmacotherapy help with loneliness or suicide ideation? There is insufficient evidence to conclude that. Does pharmacotherapy help with grief disorder symptoms and grief symptoms? Yes, they are moderately confident that the intervention helps grieving people. They go on to say, “The largest effects were found for a cognitive narrative intervention for widows, an intervention combining exposure therapy for memories of the death with cognitive behavioral therapy, and a study evaluating accelerated resolution therapy that focused on rescripting and processing of distressing memories.”
Conversely, do expert-facilitated support groups provide benefits to those who are grieving? Yes, there is moderate evidence to support this intervention.
As the field of bereavement develops, we must root programs and policies in well-evidenced science, ensuring that grieving people are well-cared for. I am looking forward to a future where interventions for bereaved people match those that we evoke for heart disease or diabetes, and they live in communities, not medical settings.
Bereavement care is the frontline medical care, and there are many care providers—some with MDs and many without—averting the catastrophic health outcomes associated with bereavement’s aftermath each day. We know, for example, that bereaved parents, children, siblings, and spouses are all at risk of premature death from their losses (as evidenced in large population studies). We also know that the unexpected or untimely death of a loved one is among the most common traumatic events Americans experience; many rate it as the worst event in their life. But, we need high-quality interventions to provide holistic care and support.
Today’s community care providers meet people when they are most vulnerable, most susceptible to cascading poor health, social, and economic outcomes. They do this without reimbursement, often relying on the generosity of donors in their communities to keep their doors open. Now is the time to invest in bereavement science in order to develop well-evidenced interventions that will serve millions each year, which will also be reimbursable by insurers because interventions are evidenced and of high quality.
This is an attainable future. Our fellow Americans deserve quality, consistent, and compassionate care in their communities. I hope you join us in making this a reality.
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Other Key Findings From the Expert Team
“Only a small body of evidence has evaluated the effects of screening approaches. There was insufficient evidence for evidence statements regarding participant experience, validity and diagnostic accuracy of the screening tool or approach, or adverse events associated with the screening process.
“A small body of evidence has addressed the identification of bereaved people at risk or with grief disorder; and reports positive diagnostic accuracy of the Inventory of Complicated Grief. None of the identified studies used the reference standard of the newly established clinical diagnosis of grief disorder to determine diagnostic accuracy.
“A substantial body of evidence addressed psychotherapy, pharmacotherapy, expert-facilitated support groups, peer support, self-help approaches, and other interventions (writing and music, comprehensive support, integrative medicine), but the strength of evidence was limited or insufficient for many interventions. No study evaluated spiritual counselling. We found moderate strength of evidence (SoE) for the beneficial effect of psychotherapy on severity of grief disorder, grief symptoms, and depression symptoms and expert-facilitated support groups on grief symptoms.
“There is a small body of evidence reporting on individuals diagnosed with grief disorders; with low SoE for the beneficial effect of psychotherapy on grief disorder and grief symptoms.”