Farewell, grief and depression of individuals who lost close relatives during social isolation: A mixed methods study

Abstract

Objective

To compare grief outcomes between individuals who were able to say goodbye to a dying relative and those who were not, and to explore the lived experiences of grief and bereavement.

Design

Observational, descriptive, cross-sectional survey study.

Site

Conducted in Mexico through an online survey administered to the general population after the COVID-19 pandemic.

Participants

Adults aged 18 years or older who had lost a close family member since November 2020. 261 participants were included, with a median age of 28 years (IQR 23–41).

Interventions

Not applicable.

Main measurements

Sociodemographic characteristics were recorded, prolonged grief disorder was assessed using the PGD-13-R, and depressive symptoms were evaluated with the Beck Depression Inventory (BDI). Chi-square and Fisher's exact tests were used for quantitative analysis, and qualitative responses were analyzed using thematic analysis.

Results

Eight participants met criteria for prolonged grief disorder. No statistically significant differences were found in the prevalence of prolonged grief between participants who were able to say goodbye and those who were not (p = 0.493). Qualitative analysis identified seven major themes: COVID-19-related restrictions, emotional impact and coping strategies, memories and legacy, presence and participation in the grieving process, spirituality, social support and family dynamics, and sudden loss.

Conclusions

In this Mexican sample, the opportunity to say goodbye was not associated with differences in the risk of prolonged grief disorder or depressive symptoms. However, qualitative findings underscore the importance of farewell rituals in meaning-making, coping processes, and perceived social support during bereavement.

Resumen

Objetivo

Comparar los desenlaces del duelo entre personas que pudieron despedirse de un familiar en proceso de muerte y aquellas que no lo hicieron, así como explorar las experiencias vividas de duelo y pérdida.

Diseño

Estudio observacional, descriptivo, transversal, de tipo encuesta.

Emplazamiento

Realizado en México mediante una encuesta en línea aplicada a la población general posterior a la pandemia por COVID-19.

Participantes

Adultos de 18 años o más que habían perdido a un familiar cercano desde noviembre de 2020. Se incluyeron 261 participantes, con una edad mediana de 28 años (RIC 23–41).

Intervenciones

No aplica.

Mediciones principales

Se recopilaron datos sociodemográficos. El trastorno de duelo prolongado se evaluó mediante el PGD-13-R y los síntomas depresivos con el Inventario de Depresión de Beck (BDI). Se emplearon pruebas de chi cuadrada y exacta de Fisher para el análisis cuantitativo, y análisis temático para las respuestas cualitativas.

Resultados

Ocho participantes cumplieron criterios para trastorno de duelo prolongado. No se identificaron diferencias estadísticamente significativas en la prevalencia de duelo prolongado entre quienes pudieron despedirse y quienes no (p = 0.493). El análisis cualitativo identificó siete temas principales, entre ellos restricciones por COVID-19, impacto emocional, afrontamiento, espiritualidad, apoyo familiar y pérdida súbita.

Conclusiones

En esta muestra mexicana, la oportunidad de despedirse no se asoció con diferencias en el riesgo de duelo prolongado ni de síntomas depresivos; sin embargo, los hallazgos cualitativos resaltan la relevancia de los rituales de despedida en el afrontamiento y la percepción de apoyo social durante el duelo.

Introduction

The experience of grief is an inherent human phenomenon characterized by emotional, physical, and behavioral responses following the loss of a loved one.¹ In most cases, this process unfolds without causing significant medical or psychological impairment and represents a common and adaptive response to loss.

Grief may take on a more complex and prolonged form, known as complicated grief, characterized by persistence beyond culturally and socially expected norms and impairment in overall functioning.² Its prevalence is estimated at 2–3% in the general population and is higher among individuals experiencing sudden, violent, or critical losses, reaching up to 52% in intensive care settings.³ Due to its clinical relevance, prolonged grief disorder was included in the DSM-5-TR in March 2022.⁴

The COVID-19 pandemic introduced unique challenges to the grieving process, increasing vulnerability through losses such as economic security, physical connection, and freedom of movement. It also disrupted customary grieving experiences, particularly in hospital settings, where infection-control restrictions led to the separation of families from hospitalized loved ones, limiting emotional preparation for potential loss.⁵ Additionally, funeral rituals were substantially altered, often occurring remotely and reducing access to traditional family support and comfort.⁶

Therefore, this study aimed to identify the difference in the grieving process between individuals who had the opportunity to say goodbye and those who did not, as well as to further explore participants lived experiences of grief and bereavement to better understand key aspects of this universal human experience.

Methodology

This observational, descriptive, cross-sectional survey included adults who experienced the loss of a close family member due to any illness from November 2020 onward. Close family members were defined as parents, siblings, children, or a spouse/partner. The study protocol was approved by the local ethics committee (PS21-00015) and conducted in accordance with the Declaration of Helsinki and applicable regulations. Electronic informed consent was obtained from all participants.

Participants included men and women aged 18 years or older who had experienced the death of a family member since November 2020 and agreed to participate voluntarily. Individuals with a pre-existing psychiatric diagnosis prior to bereavement or a diagnosis of hypothyroidism were excluded. Incomplete or incorrectly completed surveys were also excluded from the analysis.

Sample size

Using a formula for the difference of two proportions, with an estimated prevalence of complicated grief of 3% and 52% in special cases,³ considering a significance level of 95% for a one-tailed hypothesis and a power of 80%, a minimum required sample size of 10 participants per groups was obtained. Even so, the total amount of complete surveys was added and analyzed.

Procedure

Data were collected through electronic surveys in Google Forms and distributed via social media platforms (Facebook, Twitter, Instagram, and WhatsApp) and flyers with QR codes. Each invitation included a brief description of the study and contact information for the primary researcher. The survey comprised a sociodemographic questionnaire and two validated instruments: the Prolonged Grief Disorder-13 Revised (PGD-13-R), a 13-item Likert-scale instrument (score range 13–65; cutoff ≥30) assessing five grief-related domains,⁷ and the Beck Depression Inventory (BDI),⁸ a 21-item self-report scale classifying depressive symptoms as minimal, mild, moderate, or severe.⁹

Data analysis

Data were summarized using descriptive statistics, with means and dispersion for numerical variables and frequencies for categorical ones. Group comparisons employed Chi-square or Fisher's exact test. Open-ended responses were analyzed thematically to identify grief-related patterns. Data was managed in Excel and analyzed in SPSS v.23, with significance set at p < 0.05.

Thematic analysis

Thematic analysis was conducted following the six-phase framework proposed by Braun and Clarke.¹⁰ After familiarization with the data, codes were generated by one researcher and independently reviewed by two authors. Final codes were then grouped into themes and reviewed by the research team for reporting.

Results

A total of 525 individuals participated in the study, of whom 261 (49.71%) had experienced the loss of an immediate family member. The median age of bereaved participants was 28 years (IQR 23–41), and most identified as women (77.01%), heterosexual (84.29%), single (59%), and religious (82.76%) (Table 1). Overall, 129 participants (49.42%) were able to say goodbye to their relative, while 132 (50.57%) were not; among the latter, 77.27% reported that COVID-19-related preventive measures were the main reason.

Table 1.

Sociodemographic characteristics of the included participants.

Variable	Total (N = 261)	Farewell		p-Value
		Yes(n = 129)	No(n = 132)
Age, median (IQR)	28 (23–41)	28 (23–41)	29 (23–41)	0.362
Gender, n (%)
Woman	201 (77.01)	99 (76.74)	102 (77.27)	0.41
Man	54 (20.69)	28 (21.70)	26 (19.69)
Prefer not to say	5 (1.91)	1 (0.77)	4 (3.03)
Pet	1 (0.38)	1 (0.77)	0 (0)
Sexual preference, n (%)
Heterosexual	220 (84.29)	112 (86.82)	108 (81.81)	0.374
Homosexual	11 (4.21)	4 (3.10)	7 (5.30)
Bisexual	26 (9.96)	10 (7.75)	16 (12.12)
Asexual	1 (0.38)	1 (0.77)	0 (0)
Pet	1 (0.38)	1 (0.77)	0 (0)
Religion, n (%)
Atheist/Agnosticism	39 (14.94)	20 (15.50)	19 (14.39)	0.888
Christian catholic	175 (67.05)	87 (67.42)	88 (66.66)
Non-Catholic Christian	36 (13.79)	18 (13.95)	18 (13.63)
Other	7 (2.68)	3 (2.32)	4 (3.03)
None	4 (1.53)	1 (0.77)	3 (2.27)
Religion adherence, n (%)	105 (40.2)	54 (41.86)	51 (38.63)	0.595
Education level, n (%)
Middle school	10 (3.83)	2 (1.55)	8 (6.06)	0.214
High school	103 (36.46)	55 (42.63)	48 (36.36)
Bachelor‘s degree	102 (39.08)	48 (37.02)	54 (40.90)
Posgraduate	46 (17.62)	24 (18.06)	22 (16.66)
Economic class, n (%)
Low	5 (1.91)	3 (2.32)	2 (1.51)	0.329
Lower middle	42 (16.09)	21 (16.27)	21 (15.90)
Middle	149 (57.08)	69 (53.48)	80 (60.60)
Upper middle	58 (22.22)	30 (23.25)	28 (21.21)
Prefer not to answer	7 (2.68)	6 (4.65)	1 (0.75)
Marital status, n (%)
Married	73 (27.96)	33 (25.58)	40 (30.30)	0.052
Divorced	11 (4.21)	2 (1.55)	9 (6.81)
Single	154 (59.00)	86 (66.66)	68 (51.51)
Common-law/co-habiting	18 (6.89)	6 (4.65)	12 (9.09)
Widowed	5 (1.91)	2 (1.55)	3 (2.27)

IQR: interquartilic range.

p-Values obtained with Chi-square or Mann–Whitney's U.

Percentages might not add to 100 due to rounding.

Prolonged grief

Among participants who experienced the loss of a close relative, eight (3.06%) met criteria for prolonged grief, five of whom were unable to say goodbye. No significant differences were observed in prolonged grief between those who could not say goodbye and those who could (p = 0.493). The median number of criteria met was 1.0 (IQR 0.0–1.0) and 0.0 (IQR 0.0–1.0), respectively, with no significant differences (p = 0.47) (Table 2).

Table 2.

Frequencies and percentages of answers to the domains of the PDG-13-R.

	Farewell		Overall	p
	Yesn = 129	Non = 132
Separation distress
Yes	35 (27.1)	30 (22.7)	65 (24.9)	0.47
No	94 (72.9)	102 (77.3)	196 (75.1)
Duration criterion
Yes	51 (39.5)	63 (47.7)	114 (43.7)	0.21
No	78 (60.5)	69 (52.3)	147 (56.3)
Cognitive emotional and behavioral symptoms
Yes	4 (3.1)	7 (5.3)	11 (4.2)	0.54
No	125 (96.9)	125 (94.7)	250 (95.8)
Have you experienced a significant reduction in social, occupational, or other important areas of functioning?
Yes	48 (37.2)	46 (34.8)	94 (36)	0.7
No	81 (62.8)	86 (65.2)	167 (64)

All participants experienced bereavement (event criterion domain).

Depression and substance abuse

BDI total scores showed a median of 11.0 (IQR 3.5–20.5) among participants who were able to say goodbye and 13.0 (IQR 2.2–21.0) among those who were not, with no significant difference (p = 0.41). Similarly, no significant differences were observed when comparing categorized BDI scores between groups (p = 0.108). No statistically significant differences were found in the consumption of drugs, tobacco, alcohol, sedatives, or analgesics between groups.

Thematic analysis

Thematic analysis identified seven main themes: COVID-19-related challenges, emotional impact and coping mechanisms, memories and legacy, presence and participation, spiritual and religious practices, support systems and family dynamics, and sudden or unanticipated loss. Selected participant excerpts are presented in Table 3.

Table 3.

Identified themes and quotes from direct answers.

Theme	Quotes
COVID-19 related challenges	“I only could say goodbye via phone call, since I wasn’t allowed to enter his room. No chance for a funeral, it was everything so hard and frustrating”.“It was really hard to watch him die. In our house we did not have the infrastructure to provide the amount of oxygen he needed, furthermore, every day it passed it was harder and harder to get a handle on an oxygen tank due to COVID-19. I still feel guilty remembering his suffering.”
Emotional impact and coping mechanisms	“It is a process, which is even harder since you don’t have the opportunity to say goodbye as you would like (…) during the pandemic, funerals have become an insufferable pain.”“I don’t remember much about those days; I feel like it zoned it out”.
Memories and legacy	“My father was the most loving man there is. Now I don’t have that kind of love anymore. I still cry for him, but I carry beautiful memories inside of me”
Presence and participation	“I could say goodbye to my grandma before she was admitted, although I did not say goodbye with her death in mind, still I am grateful to have done it.”“I was at her bedside, hugging her and kissing her, talking to her until the silence was all there was”
Spiritual and religious practices	“Yes, I was with my grandparents surrounded by family. We had a funeral filled with tradition and mariachi in a community in Guanajuato^a”“We had the chance to mourn during a mass and a novena^b”
Support systems and family dynamics	“The process was painful, even though we did have a funeral it was with a limited number of attendings, I missed the support of family and friends”“All the family was with him, taking care of him and hugging him until the end”
Unanticipated loss and sudden death	“I don’t usually care for death, I used to see her all so natural up until he died…I still cry from time to time.”“I went to see her just out of casualty, I felt the need to go to her house that day, I told her I loved her and three days later she passed away.”

a

Guanajuato is a Mexican state known for its attachment to Mexican culture.

b

Novenaries include Christian rites consisting of praying for nine successive days, as an act of goodbye.

COVID-19 pandemic introduced challenges to the grieving process, including coping with the loss of relatives under restrictive conditions. Saying goodbye through text messages, phone calls, or video calls became common, while health protocols generated feelings of frustration, helplessness, and powerlessness, further exacerbated by limited access to medical resources.

Emotional impact and coping mechanisms

A recurrent theme was the emotional impact of grief, characterized by mixed feelings. While pain and sadness were described as natural responses, participants emphasized the need for acceptance and meaning making to achieve a healthy grieving process. Some viewed grief as a necessary, albeit painful, process for moving forward, whereas others reported difficulty processing the loss, including emotional numbness and detachment from events.

Memories and legacy

Remembering the dead is a huge deal in Mexican culture, with positive memories being a huge comfort. Participants mourned their loved ones and expressed feelings of loss but positively remembered their legacy.

Presence and participation

Being physically present at the time of death was frequently highlighted by participants, emphasizing the importance of the last encounter, even if it occurred days before death. For many, expressing farewell, either, before death or during funeral rituals, played a meaningful role in their grieving process.

Spiritual and religious practices

Religion and spirituality are a very important part of Mexican culture. From catholic processions and mass to a very traditional mariachi funeral, participants found solace in various ways, with the most prevalent being related to a form of Catholicism and God.

Support systems and family dynamics

Family was identified as a central source of support and unity during the grieving process. While many participants described family as a key support system, others highlighted the absence of familial support as a significant unmet need during bereavement, underscoring its importance in coping with loss.

Unanticipated loss and sudden death

Experiencing the death of a loved one is never an easy task and experiencing an unexpected loss was particularly traumatic for respondents. Coming to terms with an unanticipated loss and the shock and difficulty it carried with it were frequently mentioned by participants.

Discussion

Funerals and mourning rituals play a fundamental role in cultural and religious systems by providing psychological and social support to the bereaved and an opportunity to express love and respect for the deceased.¹¹ The COVID-19 pandemic profoundly altered these practices, including the grieving process. Previous reports suggest that the inability to say goodbye is associated with increased psychological distress,^12–14 a finding that contrasts with the results of this study. Grief responses are highly heterogeneous, and identifying a single universal effect may not adequately reflect the complexity of bereavement.

Quantitative analyses showed no significant differences between groups; however, participants’ narratives revealed notable emotional changes, often described as distress. Although the inability to say goodbye was not associated with prolonged grief, qualitative findings suggest that farewell holds an important place in the subjective experience of grief, even when not reflected in statistical outcomes. Similarly, the absence of differences in depression scores and substances use contrasts with the emotional depth described in themes related to emotional impact and coping.

Participants reported diverse coping processes, with some integrating loss as part of an adaptive process, while others described emotional disengagement and difficulty processing events. These findings suggest that quantitative measures may capture symptom intensity but not the qualitative dimensions or narrative trajectories of grief.

Qualitative findings identified farewell as an important coping mechanism, consistent with previous thematic analyses and related studies.^15,16 Final conversations, whether in person or via phone or video call, appear to play a meaningful role in coping with loss. However, in this study, the ability to say goodbye was not associated with significant quantitative differences.

The COVID-19 pandemic substantially altered traditional farewell practices by limiting physical contact and post-funeral gatherings, potentially resulting in unsatisfactory or incomplete farewells.¹⁷ Previous studies examining restricted funeral attendance under different circumstances also found no association with prolonged grief.^18,19 Despite the associated distress, saying goodbye before or at the time of death remains an important component of the healing process and may facilitate emotional closure.^20,21

Speaking of spirituality, our results align with the findings of Braam et al., indicating that religiosity predicts a decrease in depression over time, especially in individuals with psychiatric symptoms.²² There have been several other papers that study the relationship between religion/spirituality and grief. A study done in the United States found no significant differences in the intensity of grief between those who did and did not attend a funeral in Latino and Anglo-American samples.²³ Specifically in the Latino sample, no difference was found in grief intensity between those who had and had not participated in a novena. Even so, the difference between quantitative and qualitative studies is still present. In qualitative studies, participants perceived funeral participation positively as a chance to say goodbye, and those unable to participate due to geographical distance reported distress.^24,25 Although this might not be considered as enough evidence to promote change in public policies and healthcare interventions, perhaps aiming to foster spirituality and/or religiousness might help people during their mourning process.

Activating patient resources plays a big role in day-to-day medical practice, especially in patients going through normative events such as the loss of a family member. Among the resources that one as a medical provider can foster, social support is one to note. Greater levels of social support may be expected to correlate with better grief outcomes.^26,27 It is worth noting that social support during the pandemic was reduced due to social distancing, or in-person support for most cases. In this study, patients stated what were difficulties during the pandemic resulted in difficulty in processing their loss, which aligns with what Wallace et al. published, with sudden or unexpected deaths being more difficult to accept.^28,29

The results of this study highlight a complexity of factors influencing mental health after the loss of a loved one and underscore the importance of considering various contextual and demographic elements in future research on this delicate topic. Furthermore, these results suggest that bidding farewell or not bidding farewell before the death of a loved one, as well as the opportunity to practice corresponding farewell rituals, do not pose a qualitative greater risk for developing major depressive disorder and/or complicated grief.

Thematic analysis helps with contextualizing why farewell does not emerge as a strong statistical predictor of prolonged grief in this sample, that to say, Mexican culture is characterized by rituals of remembrance, religious practices, and the central piece that family plays as a network of support. Even so, narratives of unexpected losses and sudden deaths indicate that, in certain cases, the absence of a farewell intertwines with shock and lack of emotional preparedness, shaping more complex grief experiences. Taking both the integration of quantitative and qualitative findings suggests that farewell behaves less as an isolated risk factor and more as a phenomenon embedded within a cultural, relational, and symbolic framework that modulates the experience of grief and its potential development into something chronic.

Nevertheless, this study has some limitations. The use of a self-administered questionnaire to determine depressive episodes conducted electronically limited to a structural in-person assessment. Furthermore, the way sampling was done, administering the questionnaire via social media, has an implicit selection bias which could cause underrepresentation of some age groups and people that aren’t’ online frequently. Another limitation is that the perceived relationship between participants and the family member they lost was not explored. Likewise, using a single open-ended question might not be enough to get a full phenomenological picture to deeply dive into the experience of grief of the participants. Similar results in the qualitative and quantitative sections of this study were expected but not obtained. These further highlight the differences between both methodological approaches as well as their focus. More studies with more rigorous qualitative and quantitative methodologies are warranted.

It is important to note that assuming that a COVID-19 death is inherently worse than a “typical” death may further increase anxiety and feelings of distress in mourning people or participants who have experienced the loss of a family member.³⁰ The usual stages of grief (denial, anger; negotiation or bargaining, depression, and, acceptance) were considered as standard during all mourning processes,³¹ nevertheless, the changes imposed by the COVID-19 pandemic have affected this established process. The grief process has no stepwise linear timeline, and changes according to the mourners’ culture and beliefs. During the pandemic, people were found coping with losses in different creative ways by posting obituaries through Facebook, Instagram, Twitter, YouTube, and Zoom.³² These new creative ways of mourning, along with new technological platforms, offer new opportunities for the public expression of grief, structures for the containment of grief against disorientation and chaos, the pronouncement of continuity of the bereaved person's life without the deceased's presence, and human connection and support from members in the social group.³³

Conclusion

This study provides insight into the grieving process and depressive tendencies in the Mexican population, identifying the themes of COVID-19-related challenges, emotional impact and coping mechanisms, memories and legacy, presence and participation, spiritual and religious practices, support systems and family dynamics, and unanticipated loss and sudden death. There was no statistically significant difference in the risk of developing major depressive disorder, contrary to our initial hypothesis. Similarly, we could not demonstrate a higher risk of experiencing complicated grief among relatives who did not have the chance to say goodbye or engage in farewell rituals, differing from the qualitative outcome.

What is known about the topic?

• •

  Grief is a normal human response, although in some cases it may evolve into prolonged grief disorder, particularly after sudden losses or in critical contexts.

• •

  The COVID-19 pandemic significantly disrupted traditional farewell practices and mourning rituals, which previous studies have associated with increased psychological distress.

• •

  Existing literature suggests that the inability to say goodbye may increase the risk of complicated grief and depressive symptoms.

What does this study contribute?

• •

  In this Mexican sample, the inability to say goodbye was not associated with a higher risk of prolonged grief disorder or depressive symptoms.

• •

  Qualitative findings highlight that farewell holds an important symbolic and emotional value in the subjective experience of grief, even when not reflected in statistical differences.

• •

  The results emphasize the role of cultural context, rituals, spirituality, and family support in shaping the grieving process.

Ethical considerations

The study was reviewed and approved by the Research and Ethics Committees of the Hospital Universitario “Dr. José Eleuterio González” (protocol PS21-00015). All procedures complied with the Declaration of Helsinki and applicable regulations. Written informed consent was obtained electronically from all participants.

Funding

This study did not receive external funding.

Conflict of interests

The authors declare no financial or non-financial conflicts of interest during the preparation of this study for publication in a medical scientific journal.