Positive mental health indirectly buffers prolonged grief among refugees, study finds

Refugees who have lost someone close to them face one of the highest known risks of prolonged grief disorder, a condition in which acute, dysfunctional mourning persists well beyond the six to twelve months that grief reactions are normally expected to last. A new longitudinal study published in Current Psychology by Nesreen Dababneh, Jürgen Margraf and Julia Brailovskaia of Ruhr University Bochum now offers a detailed picture of how one protective factor, positive mental health, may shape the course of this disorder over time. Tracking Arabic-speaking refugees across six months, the researchers found that positive mental health did not act on prolonged grief directly. Instead, its apparent protective influence traveled through two negative states that frequently accompany grief: depression and anxiety.

The study recruited 196 adult Arabic-speaking refugees who reported persistent grief symptoms at least six months after the death of a close person. Participants completed an online self-report survey in Arabic at baseline, at a three-month follow-up and at a six-month follow-up. The sample was predominantly female, with 78.6 percent women, and had a mean age of 36.1 years with a standard deviation of 11.03. On average, participants had held refugee status for 8.25 years, with a standard deviation of 3.8. For 61.4 percent of the sample, the deceased was a close family member, and for 44.2 percent the death was caused by factors related to the refugee experience and violent contexts; for the remainder, the cause was sickness or undetermined, and the deceased was a significant figure but not a family member.

Data collection ran from February 2022 to December 2022, with participation voluntary and uncompensated. Participants reached the survey through flyers, QR codes or contact information distributed via refugee organization centers, and received reminder messages by email or SMS at each time point. Of the 196 participants who completed the baseline survey, 131 returned at the three-month follow-up and 117 at the six-month follow-up. Missing data were handled with the maximum likelihood method. Because attrition was substantial, the team ran logistic regressions on baseline predictors including gender, age, relation to the deceased, cause of death, positive mental health, prolonged grief, anxiety and depression, and found no significant differences in baseline characteristics between those who completed all three surveys and those who dropped out.

Prolonged grief disorder is formally recognized in recent diagnostic frameworks of the American Psychiatric Association and the World Health Organization. Its symptoms center on preoccupation with and longing for the deceased, alongside emotional discomfort such as sorrow or anger, identity disturbance, loss of life purpose, intense loneliness and relationship difficulties. The disorder is particularly prevalent among refugees, with reported prevalence reaching up to 54 percent, a burden attributed to the death context itself and to comorbid conditions, with the highest co-occurrence observed alongside posttraumatic stress disorder. In forced migration settings, grief carries specific characteristics when the death is directly caused by displacement or occurs alongside it, and ongoing losses of homeland, lack of social networks, ambiguous losses and multiple bereavements intensify the psychological response.

To measure the key constructs, the researchers used three validated instruments translated into Arabic through a translation-backtranslation procedure. Prolonged grief symptoms were assessed with the Traumatic Grief Inventory-Self Report Plus, a unidimensional 22-item scale rated on a five-point range from never to always, in which scores above 71 suggest potential prolonged grief disorder; its reliability ranged from Cronbach’s alpha of 0.90 at baseline to 0.92 at both follow-ups. Depression and anxiety were measured with the corresponding subscales of the Depression Anxiety Stress Scales 21, each with seven items rated from zero to three, showing reliabilities between 0.81 and 0.86. Positive mental health was assessed with the nine-item Positive Mental Health Scale, which captures psychological, emotional and social well-being, with an alpha of 0.79 at baseline.

The statistical architecture of the study relied on two mediation models estimated with the PROCESS macro. Model 80, a parallel-serial model, tested whether positive mental health at baseline related to prolonged grief at six months through prolonged grief, depression and anxiety measured at baseline and at three months, including eleven specific indirect paths. Model 6, a serial mediation model, tested a sequential chain in which baseline positive mental health first related to depression at three months, which in turn related to anxiety at three months, which then related to prolonged grief at six months. Confidence intervals of 95 percent were computed from 10,000 bootstrap samples, and a mediation effect was considered present when the interval excluded zero. Years of refugee status, relation to the deceased and cause of death were controlled as covariates.

The results were nuanced. In the parallel-serial model, the total indirect effect of baseline positive mental health on six-month prolonged grief was significant, with a coefficient of minus 0.139, a standard error of 0.069 and a 95 percent confidence interval from minus 0.287 to minus 0.018. Of the eleven specific paths, two were significant: one running through anxiety at three months and prolonged grief at three months, with a coefficient of minus 0.020, and one through depression at three months and prolonged grief at three months, with a coefficient of minus 0.019. Yet neither the total effect nor the direct effect of positive mental health on later grief reached significance, indicating that the protective association operated entirely through the intermediate variables.

The serial mediation model sharpened this picture further. After controlling for cause of death, years of refugee status and relation to the deceased, the total indirect effect was again significant, at minus 0.097 with a standard error of 0.050 and a confidence interval from minus 0.208 to minus 0.013. Crucially, the only significant specific path was the sequential one, in which depression at three months and then anxiety at three months jointly carried the association from baseline positive mental health to six-month prolonged grief, with a coefficient of minus 0.047. The single-mediator paths through depression alone or anxiety alone were not significant. The direct and total effects were likewise nonsignificant, meaning that positive mental health predicted lower prolonged grief symptoms only through the collective, sequential mediation of depression and anxiety.

The authors interpret these findings through the network theory of grief, which frames grief reactions as interconnected relationships rather than a separate core of symptoms, and through the dual-factor model of mental health, which holds that positive and negative dimensions interact rather than operating independently. Depression and anxiety are tightly linked: previous research cited in the paper found that 45.7 percent of lifetime major depressive disorder was accompanied by one or more lifetime anxiety symptoms, and such comorbidities have a particularly strong impact on prolonged grief. Higher depression is linked to maladaptive interpretations of life events, while anxiety traits influence how individuals perceive social support during grief, and both affect how people appraise and cope with adverse events, including loss.

The study carries clear limitations that the authors themselves enumerate. The sample size constrains generalizability, the six-month follow-up is relatively short, and continuous multiple losses in the refugee context may have interfered with the follow-up assessments. All data were self-reported and may include response bias, and the high attrition, though statistically addressed, may have reduced statistical power. The authors also note that the temporal direction of the associations could be reversed, and that bidirectional rather than unidirectional pathways need further longitudinal investigation. Within those constraints, the findings suggest that in challenging contexts such as forced displacement, shifting focus from reducing distress alone toward integrating protective factors such as positive mental health, while simultaneously addressing depression and anxiety, may help prevent mental health deterioration among the bereaved.

Subject of Research: Longitudinal mediation pathways between positive mental health, depression, anxiety and prolonged grief disorder among bereaved refugees

Article Title: The longitudinal mediation pathways between positive mental health and prolonged grief disorder among refugees

Article References: Dababneh, N., Margraf, J., & Brailovskaia, J. (2026). The longitudinal mediation pathways between positive mental health and prolonged grief disorder among refugees. Current Psychology, 45(21), Article 1651. https://doi.org/10.1007/s12144-026-10164-y

Image Credits: AI Generated

DOI: 10.1007/s12144-026-10164-y

Keywords: prolonged grief disorder, positive mental health, refugees, depression, anxiety, longitudinal study, mediation analysis, bereavement, mental health, forced migration, Current Psychology, protective factors