Substance Use Disorder Among Bereaved Individuals: A Systematic ReviewAbstract
Substance use disorder (SUD) is related to several psychosocial factors, such as grief. This study aimed to find an association of SUD among bereaved individuals based on a systematic review. The research was registered in the PROSPERO platform and the following databases were used: MEDLINE, PsycNET, LILACS, PubMed, EMBASE, CINAHL, and SciELO. The Rayyan software tool was used and this study was performed under the guidelines of the PRISMA protocol. In total, 17 articles were eligible, of which more than 88% showed an association between SUD and the grieving process and almost 60% associated grief and drug use with depression and anxiety. Alcohol was the most used substance. These findings may contribute to future studies on grief and substance use and underlie the elaboration of preventive actions for drug use.
Keywords: grief; death and dying; suffering; drugs
Resumo
O Transtorno por Uso de Substâncias (TUS) relaciona-se a vários fatores psicossociais; como o luto. Este trabalho teve por objetivo identificar uma associação do TUS entre pessoas em processo de luto, a partir de uma revisão sistemática. A pesquisa foi registrada na plataforma PROSPERO e foram utilizadas as seguintes bases de dados: MEDLINE, PSYCNET, LILACS, PubMed, EMBASE, CINAHL e SciELO. Foi utilizado o software Rayyan e as etapas do protocolo PRISMA foram seguidas. Foram elegíveis 17 artigos, dos quais mais de 88% apresentaram uma associação entre o TUS e o processo de luto, e quase 60% associaram o luto e o consumo de drogas à depressão e à ansiedade. A substância mais consumida foi o álcool. Estes achados podem contribuir para futuras pesquisas na área de luto e uso de substâncias, bem como subsidiar a formulação de ações preventivas ao uso de drogas.
Palavras-chave: luto; morte; sofrimento; drogas
Resumen
El Trastorno por Uso de Sustancias (TUS) está relacionado con varios factores psicosociales, como el duelo. A partir de una revisión sistemática, este trabajo se propuso identificar una asociación del TUS en personas en proceso de duelo. La investigación se registró en la plataforma PROSPERO, y se utilizaron las siguientes bases de datos: MEDLINE, PSYCNET, LILACS, PubMed, EMBASE, CINAHL y SciELO. Se utilizó el software Rayyan, y se siguieron los pasos del protocolo PRISMA. Diecisiete artículos fueron elegibles, de los cuales más del 88% mostraron una asociación entre el TUS y el proceso de duelo, y casi el 60% asociaron el duelo y el consumo de drogas con la depresión y la ansiedad. La sustancia más consumida fue el alcohol. Estos resultados pueden contribuir a futuras investigaciones sobre el duelo y el consumo de sustancias, además de subvencionar la formulación de acciones preventivas para el consumo de drogas.
Palabras clave: luto; muerte; sufrimiento; drogas
The history of psychoactive substance use spans across various civilizations and dates back to ancient times. Often, individuals use these substances to cope with emotional challenges, external pressures, or in pursuit of pleasure (Sarvet & Hasin, 2016). The United Nations Office on Drugs and Crime (UNODC) reports that over 270 million individuals worldwide have used illicit drugs, with 35 million experiencing some form of mental disorder due to excessive consumption (UNODC, 2021). During the COVID-19 pandemic, for instance, 42% of health professionals across 77 countries reported using cannabis. The American Psychiatric Association (APA) characterizes substance use disorder (SUD) as a pattern of psychotropic substance use that can cause significant distress or impairment in various life aspects (APA, 2013). In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the acronym SUD replaced the previously used terms “abuse” and “dependence” (APA, 2013).
The death of friends or family members can create emotional vulnerabilities that predispose individuals to harmful substance use and dependence. These vulnerabilities have been exacerbated by the socioeconomic consequences of the pandemic, such as increased inequalities, reduced opportunities, and widespread losses and grief (Inchausti et al., 2020; UNODC, 2020, 2021). Studies suggest that complicated grief may intensify SUD, as this condition correlates with a higher occurrence of traumatic events and increased difficulty in coping emotionally (Lima, 2021; Parisi et al., 2019). Complicated grief is an intensified grieving process that results in psychosocial damage from psychological, physical, and social responses to a person’s loss, further impairing an individual’s quality of life (Masferrer et al., 2020).
Grief, however, manifests differently depending on context. The loss of a close person can elicit reactions such as disinterest in daily activities and sadness (Parisi et al., 2019). When confronting a disrupted bond, individuals may develop contextually coherent and expected reactions. Conversely, complicated grief may arise from difficulties in assimilating the loss, resulting in a prolonged period of clinically significant suffering and a high likelihood of adopting unhealthy behaviors, such as excessive, harmful, or risky use of psychoactive substances (Caparrós & Masferrer, 2021; Masferrer et al., 2020).
Researchers have explored the association between SUD and grief from various theoretical and methodological perspectives. Some authors, adopting a psychosocial viewpoint, regard increased substance use among bereaved individuals as a maladaptive coping strategy (Caparrós & Masferrer, 2021). For example, Pilling et al. (2012) found that men grieving for two years were twice as likely to engage in abusive alcohol use compared to non-bereaved men. Furthermore, psychiatric comorbidities may exacerbate this process. Individuals experiencing complicated grief and diagnosed with depression exhibited significantly higher levels of alcohol dependence than their non-depressed counterparts with complicated grief (Sung et al., 2011).
Systematizing the main findings from the literature on the potential association between grief and SUD through a systematic review can facilitate a more profound understanding of the phenomenon and generate scientific evidence to inform preventative actions against problematic substance use. Consequently, this study aimed to identify associations between SUD and bereaved individuals through a systematic review, describe the drug use profile of these individuals, and pinpoint their primary psychosocial characteristics.
Method
Study characteristics
This systematic literature review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under protocol number CRD 42020221617. This registration aimed to minimize the risk of publication bias, prevent duplication of systematic reviews with similar objectives, and ensure the study’s quality, consistency, and credibility.
Identification of the research question
The central question of this study, “Is there a relationship between SUD and the grieving process?”, was formulated based on the FINER criteria (Feasible, Interesting, Novel, Ethical, Relevant). Cummings et al. (2013) proposed these criteria, which have since been adopted in numerous systematic review protocols. The research question was considered feasible and ethical due to the many studies evaluating SUD among grieving individuals. Furthermore, it was deemed interesting and novel because the association between drug abuse and grief requires additional research. Finally, the question was relevant since systematizing the results on this topic can help enhance treatment methods for bereaved individuals with psychiatric comorbidities who engage in problematic use of psychoactive substances.
Definition of inclusion and exclusion criteria
This study utilized the PECOS criteria to define the profile of articles to be included: Population - Bereaved individuals of any gender, geographic region, or age; Exposure - Problematic use evaluated using various criteria in each article, including licit or illicit substances with depressant, stimulant, or central nervous system disturbing properties; Comparison - Bereaved individuals compared with their pre-grief state or non-bereaved participants; Outcomes - Emphasis on the relationship between harmful psychoactive substance use and the grieving process; Study Design - Cross-sectional (exploratory) and longitudinal (case control, cohort) studies that control for causal relationships.
Articles that did not directly correspond to the topic were excluded, such as those addressing grieving processes unrelated to death, qualitative studies, interventions, case studies, literature reviews of any kind, theses, and dissertations. These procedures aimed to enhance the systematic review’s quality and decrease the likelihood of encountering publications with the aforementioned characteristics.
Literature review
The search encompassed the EMBASE, CINAHL, SciELO, LILACS, MEDLINE, and PsycNET databases. Data collection occurred from December 2021 to May 2022. These databases were chosen because they feature studies specifically focused on psychology and health. The keywords used were consulted in advance using the Medical Subject Headings (MeSH) and/or Descriptors in Health Sciences (DeCS) indexes and were combined using Boolean operators to create strings for each database. Additional Boolean operators AND and/or OR were applied a posteriori to refine the search according to eligibility criteria. The initial stage did not impose filters, time frames, or language restrictions, following the PRISMA protocol (Page et al., 2022). The searches examined the presence of keywords in any reference field, such as title, abstract, or full text (Table 1).
Strings of the search for articles in the databases and number of studies exported in each one
Selection of articles and data extraction
Figure 1 displays the procedure from article collection to inclusion (PRISMA). Two independent judges conducted the screening and removed duplicates using the Rayyan® software tool (Ouzzani et al., 2016), designed explicitly for systematic reviews (https://www.rayyan.ai/). Concerning eligible articles (N = 38), the judges were uncertain about including five of them. As a result, specific meetings were convened, and a third judge determined whether to include these articles (casting vote).
Regarding the inclusion of articles (final step in Figure 1), two other judges critically read the full texts and were asked to include or exclude them based on previously discussed criteria in meetings. This process was conducted in a blinded manner, as recommended by specific systematic review guidelines (Page et al., 2022), also utilizing Ryyan® (Blind ON). In this approach, no judge had access to information from the others until the analyses were complete. A total of 17 articles were included in the final sample. Table 2 displays the excluded articles and the rationale for exclusion from each judge.
Evaluation of articles and risk of bias
The quality assessment of the articles was conducted using the Risk of Bias in Systematic Reviews (ROBIS) tool, following the guidelines of Whiting et al. (2016). This method comprises a three-step checklist: (i) relevance; (ii) review process; (iii) risk of bias assessment, which evaluates whether the methods employed in the systematic review minimize the likelihood of bias in the validity estimates and outcomes of the included studies. The review process (Step 2) encompasses four specific dimensions: (i) study eligibility; (ii) identification and selection of articles; (iii) analysis of results and evaluation of articles; (iv) summary of findings.
Results
The study included published articles with populations from the United States, Australia, Sweden, Denmark, Spain, Hungary, and the United Kingdom, amassing 15,810 bereaved individuals (Table 3). The United States had the highest prevalence of publications (47%), followed by Australia (11.7%) and Spain (11.7%). The publication period spanned from 1994 to 2020, but the highest concentration of studies was in 2016, with 17.6% of the articles. Table 3 provides the primary data on the authors, year and country of publication, methodological design, sample size, and age group of the participants.
Table 4 summarizes the profile of the bereaved population and its relationship with the context of grief, the presence of psychological symptoms resulting from it, and substance use disorder (SUD). Most studies (58.8%) established a relationship between grief and psychological variables such as depression and anxiety. Concerning the contexts of grief addressed by the publications, traumatic deaths and widowhood were the most common causes (52.9%) compared to other grief contexts. Over 88% of the analyzed articles indicated an association with the use of certain drugs, and nearly one-third of the authors asserted that this use is a risk factor among young people.
Discussion
This study aimed to assess the association between substance use disorders (SUD) and grief while examining the primary sociodemographic characteristics and psychological symptoms linked to this condition. The articles reviewed displayed significant methodological variations, particularly in relation to participants’ characteristics. These differences were not connected to the age range evaluated, as the study with fewer participants encompassed a broader age range than the one with a larger sample size. However, they might be attributed to the databases employed by each article and their predetermined inclusion criteria.
In terms of age groups, we noticed a substantial variation among participants, who ranged from seven to 75 years old. This broad spectrum enabled comparisons of grief’s effects and its relationship with SUD across various life stages. Furthermore, the collected data may facilitate SUD prevention measures by recognizing grief as a risk factor, given that over 29% of the articles indicated an increased predisposition to substance use among bereaved children and young people.
The data revealed that traumatic deaths constituted the most prevalent grief context in more than 36% of the articles. These articles also reported a rise in substance use by bereaved individuals attempting to cope with both the loss and the trauma. Other studies (McDevitt-Murphy et al., 2021; Pitman et al., 2020) not only investigated the repercussions of traumatic deaths on grieving individuals but also compared those affected by such deaths to bereaved individuals who had not encountered a similar situation. They found a higher propensity for substance use among individuals who had experienced a tragic and unexpected loss.
McDevitt-Murphy et al. (2021) further explored the implications of complicated grief in relation to increased substance use by examining the specific effects of this grief type as opposed to normal grief. The authors observed heightened substance use among individuals with complicated grief compared to other participants. In cases involving suicide attempt survivors, Young et al. (2012) noted an elevated risk of prolonged/complicated grief, along with the development of depressive disorders, post-traumatic stress disorder, and additional attempts. The authors suggested that the stigma surrounding suicide exacerbates the situation, acting as a barrier to accessing mental health support and necessary protective resources during times of loss.
Consequently, sudden and traumatic deaths may intensify substance use as a means of alleviating emotional symptoms of loss, particularly those tied to anxiety and depression (Carr, 2020). These findings correspond with evidence illustrating the connection between complicated grief, heightened risk of psychiatric morbidities, and increased symptoms across multiple forms of psychopathology (Keyes et al., 2014), predominantly in cases of unnatural deaths. A British study involving 243 adults aged 18 to 40 years, which assessed alcohol and drug use following the sudden unnatural death of family members or close friends, identified a pattern of age-related harmful substance use in response to grief-related challenges during childhood. The study also found that men tended to consume greater amounts of alcohol to facilitate emotional expression. As a result, motivations for substance use were linked to justifications such as embracing life, escaping reality, and managing emotions, among others (Drabwell et al., 2020).
Other authors have noted that, besides traumatic deaths causing significant negative effects on the grieving process, expected deaths, like the loss of an older spouse, exert a considerable influence on substance use (Byrne et al., 1999; Carr, 2020; Grimby & Johansson, 2009). Studies examining substance use problems among grieving older adults revealed increased substance use by older men and heightened resilience among widows during the grieving process (Carr, 2020; Liew, 2011). In other research involving bereaved older adults, higher frequency and intensity of depressive symptoms and elevated mortality rates were observed in this population following the loss of their spouses (Hung et al., 2021; Seifter et al., 2014).
In the case of bereaved young individuals, men displayed a higher predisposition to substance use (Hamdan et al., 2013). This finding supports the notion that men face greater difficulty expressing emotions in vulnerable situations compared to women. Conversely, Grimby and Johansson (2009) focused exclusively on widows, and their findings indicated increased substance use among widows while grieving. However, unlike the previously mentioned studies, their research did not involve a comparison between the sexes. Byrne et al. (1999) provided a counterpoint to these results, observing increased substance use among widowers but not attributing this increase directly to loss or grief. Along with the influence of sex, these authors examined another significant variable: the degree of kinship in the context of loss. Similar findings were presented in other studies (Brent et al., 2009; Høeg et al., 2017; Lysell et al., 2016), which assessed the impact of parental loss on children and its potential future implications. The primary results revealed an increased predisposition for young individuals and children to use substances throughout adulthood following the loss of their parents, particularly when the event was traumatic.
Meanwhile, McDevitt-Murphy et al. (2021) and Vance et al. (1994) employed samples of parents who had experienced the loss of a child, also emphasizing the degree of kinship. Both studies found that parents turned to substances after the loss, but they did not analyze expected losses, suggesting that the substance use might be trauma-related.
In contrast to earlier population samples, Masferrer et al. (2017) observed a surge or relapse in problematic substance use cases prior to the grieving process. The authors investigated the implications of significant loss in individuals who habitually used psychoactive drugs and exhibited signs of dependence. They discovered a substantial increase in the intensity of use in response to significant loss.
Regarding the types of substances mentioned in the reviewed articles, alcohol was the most prevalent among bereaved individuals, possibly because it is easily accessible, affordable, and legal. Additionally, there is a scarcity of studies that differentiate between licit and illicit substances and their prevalence among grieving individuals. Furthermore, as a central nervous system depressant, alcohol can alleviate symptoms associated with nervous system activation, including anxiety, stress, anguish, and depression (Testino, 2022). Although some studies identified other substances used by bereaved individuals, they did not classify them or present statistically significant results (Masferrer et al., 2017).
Our study presents several limitations. First, the majority of articles included small sample sizes, constraining the possibility of more robust analyses concerning SUD and grief. Second, the criteria for both grief and drug use exhibited substantial variation across the studies, which hindered our ability to make more precise interpretations of the findings. Third, we were unable to determine causal relationships between SUD and grief, as we did not employ specific methodologies tailored for this purpose, such as longitudinal studies, case-control studies, or cohort studies.
The data analyzed and discussed in this study indicate a higher likelihood of men developing SUD. Nonetheless, research should extend beyond the consideration of gender and take into account the substance being abused, contextual factors, and individual subjective characteristics. Additionally, it is important to examine the increased risk of individuals with dependency issues escalating their substance use or relapsing after experiencing a loss, as observed in some articles. These factors constitute risk elements for drug use and grief following traumatic or sudden losses, as well as the death of close family members. While establishing a direct relationship between the variables of grief and harmful drug use remains unfeasible, they do share strong connections with factors promoting continuous and detrimental substance use.
As such, further investigation into this topic is necessary, incorporating other variables like the duration of grief and the presence or absence of a support network, among others. This will aid in the development of preventive measures and health promotion strategies, as well as inform future research. Systematic reviews play a crucial role in collating evidence on the subject and its repercussions, offering accuracy and reliability. Through this process, health professionals gain valuable support for adopting more coherent and effective practices. The articles encompassed in this study hold significant importance; by utilizing diverse population samples, they facilitate the identification of potential risk factors associated with the correlated variables.
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Publication Dates
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Publication in this collection
17 July 2023 -
Date of issue
2023
History
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Received
22 Aug 2022 -
Reviewed
04 Nov 2022 -
Accepted
05 Dec 2022
