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Managing Bereavement within the Health Care System. Kara Z. McDaniel, NCC, LPC, Ph.D. Department of Family and Preventive Medicine-PA Program Behavioral Medicine Course.

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Managing bereavement within the health care system

ManagingBereavement within the Health Care System

Kara Z. McDaniel, NCC, LPC, Ph.D.

Department of Family and Preventive Medicine-PA Program

Behavioral Medicine Course


Managing bereavement within the health care system

Life is a series of experiences, each one of which makes us bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and griefs which we endure help us in our marching onward.

-Henry Ford


Objectives
OBJECTIVES bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Participants will learn the definition of bereavement and grief in addition to the basic tasks/phases of grieving

  • Participants will learn the psychological, social, and physiological effects of bereavement and factors that influence the process of grief

  • Participants will learn the importance of their role in identifying and treating bereaved patients


What is bereavement
WHAT IS BEREAVEMENT? bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • “To be deprived by death” (NMHA, p.1)

  • “The state of having suffered a loss” (Rando, p. 16).

  • Feelings of grief experienced following the death of loved one


What is grief
WHAT IS GRIEF? bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • The process in which one reacts, psychologically, socially, and somatically, to the perception of loss

  • Develops continuously and involves many changes

  • Reaction that is natural and expected

  • Reaction to many types of loss, not just death

  • Loss does not need to be recognized or validated by others in order for person to experience grief (Rando, 1984).


Types of losses
TYPES OF LOSSES bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Physical (tangible)

    • Loss of possession or death of loved one

    • House fire

    • Pet loss

    • ??????


Types of losses cont
TYPES OF LOSSES, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Symbolic (psychosocial)

    • usually not identified as a loss

      • persons may not realize that time is needed to grieve

    • Some losses are clearly recognized

      • e.g. death or theft

    • Other losses may not be recognized as clearly and may not result in negative events.

    • Response to normal change and growth

      • e.g. having a baby

    • Some are competency-based

      • e.g. terminating therapy, graduating from college

        • Why am I feeling sad during a time that is supposed to bring happiness?


Types of losses cont1
TYPES OF LOSSES , cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Physical loss may also result in symbolic loss

    • e.g. mastectomy associated with breast cancer (Rando, 1984).

  • Additional types of symbolic losses

    • divorce

    • Loss of job

    • Demotion

    • Move

    • Empty nest

      • children leaving home to go to college, get married, etc.


Basic tasks of grief
BASIC TASKS OF GRIEF bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Must understand the basic tasks of grief in order to fully understand what one experiences during the grief process

  • Conceptualized by pioneer in grief investigation, Erich Lindemann, in 1944

  • Three tasks constitute what Lindemann termed “grief work” (Rando, 1984, p. 18).

  • Can be applied to both symbolic and physical losses

  • Basic Tasks of Grief

    • Emancipation

    • Readjustment

    • Formation

      • (See Tasks/Phases of Grief handout on Blackboard)


Process of grief
PROCESS OF GRIEF bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • There exists numerous conceptualizations describing the process of grief

    • may have different names and focus on different topics but all entail loss

      • e.g. Elisabeth Kubler-Ross’ work with death and dying (Kubler-Ross, 1969)

  • Theory was developed by Bowlby in 1961; included last three phases (Bowlby, 1980)

  • In 1974, Parkes revealed that Bowlby omitted one important phase, numbness (Parkes & Weiss, 1983).


Phases of grief
PHASES OF GRIEF bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Numbness

  • Yearning and searching

  • Disorganization and despair

  • Reorganization

    • See Tasks/Phases of Grief handout on Blackboard


Expression of loss
EXPRESSION OF LOSS bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Utilize conceptualization to explain loss in terms of reactions, not stages

  • Reactions do not form rigid phases

  • Person grieving may move back and forth; not sequential

  • Person may not experience all the reactions presented

  • Respond to those grieving based on needs at that time, not in terms of what stage

  • Duration may last from months to years and may experience ups and downs during this time


Expression of loss cont
EXPRESSION OF LOSS, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Psychological

    • View within three categories

      • Avoidance Phase

      • Confrontation Phase

      • Reestablishment Phase

  • Social

  • Physiological


Expression of loss cont1
EXPRESSION OF LOSS, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Psychological

    • Avoidance

      • avoid the acknowledgement of loss

      • shocked

        • physically and psychologically

      • confused, dazed, unable to comprehend, numbness

      • denial once shock wears off and one begins to recognize the loss


Expression of loss cont2
EXPRESSION OF LOSS, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Psychological

    • Confrontation

      • Intense grief

      • Shock wears off although denial may still exist

      • Emotional extremes

      • New reactions may prompt fear and anxiety

        • Panic or generalized anxiety

          • (e.g. unknown and unfamiliar)

      • Angry

        • (e.g. may be displaced onto other persons)

      • Guilt

        • (e.g. may remember just the negative about relationship; feeling guilty because loved one died and he/she didn’t )


Expression of loss cont3
EXPRESSION OF LOSS, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Psychological

    • Confrontation, cont.

      • Depression

      • Inability to concentrate

      • Feeling of “mutilation”

        • (expressing loss in physical terms) (Rando, 1984, p. 33)

      • Preoccupation with deceased

        • (e.g. obsessive rumination; dreaming)

      • Yearning

  • Psychological

    • Reestablishment

      • Grief gradually declines

      • One begins to reinvest in other things and relationships

      • Feelings of guilt and betrayal are possible as one moves forward in spite of loss


Expression of loss cont4
EXPRESSION OF LOSS, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Social reactions to loss

    • Restlessness

    • Social withdrawal


Expression of loss cont5
EXPRESSION OF LOSS, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Physiological reactions to loss

    • Anorexia

    • GI distress

    • Insomnia

    • Crying

    • Weight loss

    • Physical exhaustion

    • Symptoms of anxiety

      • e.g. heart palpitations; shortness of breath

    • Lack of energy

    • Loss in sexual desire


Factors influencing reactions to grief
FACTORS INFLUENCING REACTIONS TO GRIEF bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Psychological

  • Social

  • Physiological


Factors influencing reactions to grief cont
FACTORS INFLUENCING REACTIONS TO GRIEF, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Psychological

    • nature and meaning of loss to person grieving

      • e.g. pet loss vs. loss of parent

    • quality of relationship

      • e.g. conflicted

        • Role-loss and object-loss

    • role of deceased lost

    • coping behaviors, personality, and mental health

    • maturity and intelligence

    • background, socially, culturally, religiously

    • sex role

    • characteristics of deceased


Factors influencing reactions to grief cont1
FACTORS INFLUENCING REACTIONS TO GRIEF, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Psychological, cont.

    • unfinished business

    • sudden vs. expected death

    • fulfillment in life

    • issues surrounding death

    • timeliness

      • e.g. death of child vs. death of aging person

    • preventability

    • length of illness; anticipatory grief and involvement with dying loved-one

    • concurrent stresses (Rando, 1984)


Factors influencing reactions to grief cont2
FACTORS INFLUENCING REACTIONS TO GRIEF, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Social

    • social support system

    • religious/cultural/and ethnic background

    • educational, economic and occupational status


Factors influencing reactions to grief cont3
FACTORS INFLUENCING REACTIONS TO GRIEF, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Physiological

    • Drugs and sedatives

      • Need to be able to vent during crucial time when support available

      • Heavy vs. mild sedation

    • Nutrition

      • Anorexia; taste altered; GI distress

      • Encourage to maintain good eating habits to maintain strength

    • Rest and sleep

      • Some sleep distress is normal

      • May result in further problems if insomnia exists

    • Physical health

      • Some physical distress is normal

      • Attend to any physical symptoms to prevent further complications

    • Exercise

      • Not only keeps body healthy but serves as a good emotional outlet


Is it bereavement or depression
IS IT BEREAVEMENT OR DEPRESSION? bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Grieving individual may present symptoms that are similar to Major Depressive Episode (e.g. sadness, insomnia, poor appetite, weight loss) depressive symptoms usually transient and not many (Prigerson et al, 2001).

  • Many bereaved persons meet criteria for MDD during first few months after loss (Bruce et al., 1990; Clayton et al., 1972; Prigerson et al., 1997)

  • Diagnosis of MDD is usually not given until symptoms are still present 2 months following loss

  • Differentiating between normal grief reaction and depression

  • Morbidity and Mortality


Is it bereavement or depression cont
IS IT BEREAVEMENT OR DEPRESSION?, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Minority experience depressive syndromes beyond one year

    • 1 month-42%

    • 1 year-16% (Clayton et al., 1972)

  • Bereaved individual may view depressed mood as normal but seeks treatment for alleviation of associated symptoms


Is it bereavement or depression cont1
IS IT BEREAVEMENT OR DEPRESSION?, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • There are specific symptoms that are not characteristic of a normal reaction to grief

    • Assist in differentiating between MDD and bereavement

      • “guilt about things other than actions taken or not taken by the survivor at the time of the death”

      • “thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person”

      • “morbid preoccupation with worthlessness”

      • “marked psychomotor retardation”

      • “prolonged and marked functional impairment”

      • “hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person”

        (DSM-IV-TR, p. 741)


Bereavement
BEREAVEMENT bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Bereavement

    • Morbidity

      • studies have shown that bereavement has a negative impact on health (Rogers & Reich, 1988).

      • associated with

        • high blood pressure (Prigerson et al., 1997)

        • heart disease, and depressive and anxiety disorders (Chen et al., 1999; Devries et al., 1997).

      • Heightens risk for

        • sleep disruption (McDermott et al., 1997)

        • increase in consumption of alcohol, tranquilizers, and tobacco (Maddison & Viola, 1968; Glass et al., 1995)

        • suicide attempts (Birtchnell, 1970; Gregory, 1994)

        • mortality (Schaefer et al., 1995 & Kaprio et al., 1987).


Bereavement1
BEREAVEMENT bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Bereavement

    • Mortality

      • studies dating back to 1959 suggest a strong mortality risk to bereavement

      • Heart disease

        • 1996 study conducted by Martikainen and Valkonen

          • 1.5 million adults between ages 35 to 84

          • showed a 20%-35% excess mortality from ischemic heart disease within five years from spouse’s death

        • adverse and long-term bereavement effects from sudden or traumatic death of loved one (Rynearson & McCreery, 1993; Lehman, et al., 1987).

          • Showed a higher mortality and psychiatric morbidity among bereaved parents and spouses compared to nonbereaved control group 4-7 years after automobile accident that took loved one’s life (Lehman, et al., 1987)


Bereavement care
BEREAVEMENT CARE bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Physicians’ perception of bereavement care

    • Exploratory study of physicians’ perceptions of bereavement care conducted by Lemkau et al., 2000

      • showed that physicians generally believed that bereavement

        presented significant health risks to patients and that their role in identifying and treating bereavement was important

  • Role of physician in bereavement care

    • An extremely important role

    • Physicians care for many patients who may be experiencing grief, ailments, and distress (Prigerson et al., 2001).

    • As stated previously, bereavement increases one’s risk for health problems.

    • Persons are living longer

    • According to study above, how physicians responded and treated bereavement varied


Bereavement care cont
BEREAVEMENT CARE, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Contact with bereaved patients

    • When bereaved is not your patient

      • telephone call, letter of condolence, or visit after death (Main, 2000; Bedell et al., 1998)

        • According to Bedell et al. (1998), physician has one final responsibility to the patient who died which is to help care for bereaved family members.

      • Acknowledge loss, express sympathy, and allow family to clarify unanswered questions (Prigerson, 2001)

    • When bereaved is your patient

      • offer condolences

      • evaluate and monitor health care needs (Main, 2000)

      • office visits may shift to education and support through process of grief (Prigerson, 2001)

    • What to and what not to say

      • Refer to list provided on Blackboard


What not to say
WHAT NOT TO SAY bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Call me.

  • Casually ask, “How are you?

  • I know exactly how you feel.

  • It was probably for the best.

  • He/she is happy now.

  • It is God’s will.

  • It was time to go.

  • I’m sorry I brought up the subject.

  • Let’s change the subject.

  • You should be getting over this by now


What not to say cont
WHAT NOT TO SAY …cont bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • I have had other patients with the same illness and they suffered for a long time.

  • You should be glad your loved-one passed away so quickly.

  • You’re strong enough to cope with the loss.

  • Be thankful you have your other children.

  • You can always have more children.

  • I lost my loved one…

  • I understand, my loved-one was very sick too.

  • Be happy he/she was only 6 months old and not six years.

Holly, Jacobs, & Selby, 2001;

http://www.rollanet.org/~reb/docs/ThingsNotToSay.html


What to say
WHAT TO SAY bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • I’m sorry for your loss.

  • I can’t imagine the pain you are going through.

  • What do you remember about [the deceased’s name] today?

  • Say [deceased’s] name.

  • Talk about deceased.

  • Do you have any questions about the illness and treatment provided?

  • How are you feeling?

  • How has loss affected you?

Holly, Jacobs, & Selby, 2001


Bereavement care cont1
BEREAVEMENT CARE, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Facilitating healing

    • Develop new routines and skills

      • For women, financial strain links widowhood to symptoms of depression; for men, strains of household management are linked to depressive symptoms (Umberson et al., 1992)

      • encourage attempts to minimize strains

    • Maintain active routine on daily basis

      • Two studies involving elderly patients found that those who are bereaved and maintained a daily/busy routine slept better (Brown et al., 1996) and fewer symptoms of depression in comparison to those with less structure (Prigerson et al., 1994)

    • Written or verbal disclosure

      • e.g. journal

        • associated with an improvement in physical/mental health (Pennebaker et al., 2001; Esterling et al., 1994)

        • positive influence on one’s immune function (Esterling et al., 1994).


Bereavement care cont2
BEREAVEMENT CARE, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Treatment

    • When to intervene and/or make referral

      • barriers to treatment with grieving patients

      • if suspect psychiatric complications, health care provider needs to diagnose and treat and/or make referral to mental health professional

        • e.g. psychologist, psychiatrist

      • if suicidality exists at any time, refer to mental health professional (Prigerson, 2001)


Bereavement care cont3
BEREAVEMENT CARE, cont. bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

  • Treatment of psychiatric complications related to bereavement

    • treatment chosen is dependent upon diagnosis

    • Bereaved patients diagnosed with MDD

      • SSRIs and TCAs

        • randomized, placebo-controlled clinical trial of bereaved patients with MDD

          • nortriptyline alone-56% remission rate

          • nortriptyline with psychotherapy-69% remission rate

          • psychotherapy alone-29% remission rate (Reynolds et al., 1999)

      • open-label trial of paroxetine, SSRI, administered weekly for 4 weeks

        • showed 54% decline in MDD symptoms although study is needed to confirm efficacy of SSRI for MDD secondary to bereavement, MDD following the death of loved one has been shown to not be different than MDD manifested in other ways (Reynolds et al., 1993)


Managing bereavement within the health care system

bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and Physicians who aid grief-stricken patients are afforded the rewarding, quintessentially human opportunity of transforming a personal sorrow they inevitably will experience into sympathetic and supportive aftercare”-George Eliot


Managing bereavement within the health care system

Questions bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

or

Comments?


Resources
RESOURCES bigger, even though it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental

Disorders (DSM-IV). Washington, DC.: American Psychiatric Association.

Bedell, S.E., Cadenhead, K. Graboys, T.B. (2001). The doctor’s letter of condolence.

National vital statistics reports final data. New England Journal of Medicine, 344, 1161-

1162.

Birtchnell, J. (1970).The relationship between attempted suicide, depression, and

parent death. British Journal of Psychiatry, 116, 307-313.

Bowlby, J. (1980). Attachment and loss: Loss, sadness and depression (Vol. III). New

York: Basic Books.

Brown, L.F, Reynolds, C.F., Monk, T.H., et al. (1996). Social rhythm stability following

late-life spousal bereavement: Associations with depression and sleep impairment.

Psychiatry Res., 62, 161-169.


Managing bereavement within the health care system

Bruce, M. L., Kim, K., Leaf, P. J., & Jacobs, S. (1990).Depressive episodes and

dysphoria resulting from conjugal bereavement in a prospective community sample.

AmericanJournal of Psychiatry, 147, 608-611.

Chen, J. H., Bierhals, A. J., Prigerson, H. G., Kasl, S. V., Mazure, C. M., & Jacobs, S.

(1999). Gender differences in the effects of bereavement-related psychological distress in

health outcomes. Psychol Med., 29, 367-380.

Clayton, P.J., Halikas, J.A., Maurice, W.L. (1972). The depression of widowhood.

British Journal of Psychiatry, 120, 71-77.

DeVries, B., Davis, C. G., Wortman, C. B., & Lehman, D. R. (1997). Long-term

psychological and somatic consequences of later life parental bereavement, OMEGA

Journal of Death and Dying, 35, 97-117.

Esterling, B.A., Antoni, M.H., Fletcher, M.A., Margulies, S., Schneiderman, N. (1994).

Emotional disclosure through writing or speaking modulates latent Epstein-Barr virus

antibody titers. Journal of Consulting and Clinical Psychology, 62, 130-140.


Managing bereavement within the health care system

Glass, T.A., Prigerson, H.G., Kasl, S.V., Mendes de Leon, C.F. (1995). The effects of

negative life events on alcohol consumption among older men and women. J Gerontol B

Psychol Sci Soc Sci, 50, S205-S216.

Gregory, R.J. (1994). Grief and loss among Eskimos attempting suicide in western

Alaska. American Journal of Psychiatry, 151, 1815-1816.

Kaprio, J., Koskenvuo, M., Rita, H. (1987). Mortality after bereavement: A prospective

study of 95,647 widowed persons. American Journal of Public Health, 77, 283-287.

Kubler-Ross, E. (1969). On death and dying. New York: Simon and Schuster.

Lehman, D. R., Wortman, C. B., & Williams, A. F. (1987). Long-term effects of losing

a spouse or child in a motor vehicle crash. Journal of Pers. Soc. Psychology, 52, 218-231.

Lemkau, J.P., Mann, B., Little, D., Whitecar, P., Hershberger, P. & Schumm, J.A.

(2000). Questionnaire survey of family practice physicians’ perceptions of bereavement

care. Arch. Family Medicine, 9, 822-829.

Lindemann, E. (1944). Symptomatology and management of acute grief. American

Journal of Psychiatry, 101, 141-148.


Managing bereavement within the health care system

Maddison, D.C. & Viola, A. (1968). The health of widows in the year following

bereavement. J Psychosom Res., 12, 297-330.

Main, J. (2000). Improving management of bereavement in general practice based

on a survey of recently bereaved subjects in a single general practice. British Journal of

General Practice, 50, 863-866.

Martikainen, P. & Valkonen, T. (1996). Mortality after the death of a spouse: Rates

and causes of death in a large Finnish cohort. American Journal of Public Health, 86,

1087-1093).

McDermott, O.D., Prigerson, H.G., Reynolds, C.F.III, et al. (1997). Sleep in the wake

of complicated grief symptoms: An exploratory study. Biol Psychiatry, 41, 710-716.

National Mental Health Association (2004). General mental health issues: Coping with

loss-bereavement and grief. Retrieved from world wide web,

http://www.nmha.org/infoctr/factsheets/42.cfm.

Parkes, C. M. (1972). Bereavement: Studies of grief in adult life. New York:

International Universities Press.

Parkes, C. M., & Weiss, R. S. (1983). Recovery from bereavement. New York: Basic

Books.


Managing bereavement within the health care system

Pennebaker, J.W., Zech, E., & Rime, B. (2001). Disclosing and sharing emotion:

Psychological, social and health consequences. In M.S. Stroebe, R.O. Hansson, W.

Stroebe, & H. Schut, eds. Handbook of Bereavement Research: Consequences, coping,

and care. Washington, DC: American Psychological Association.

Prigerson, H.G. & Jacobs, S.C. (2001). Caring for bereaved patients: “All the

doctors just suddenly go.” Journal of American Medical Association, 286, 1369-1376.

Prigerson, H. G., Bierhals, A. J., Kasl, S. V., et al. (1997). Traumatic grief as a risk

factor for mental and physical morbidity. American Journal of Psychiatry, 154, 616-623.

Prigerson, H.G., Reynolds, C.F. III, Frank, E., Kupfer, D.J., George, C.J., & Houck,

P.R. (1994). Stressful life events, social rhythms, and depressive symptoms among the

elderly: An examination of hypothesized causal linkages. Psychol Res., 51, 33-49.

Rando, T. A. (1984). Grief, dying, and death: Clinical interventions for caregivers.

Illinois: Research Press.

Reynolds, C.F. III, Hoch, C.C., Buysse, D.J., et al. (1993). Sleep after spousal

bereavement: A study of recovery from stress. Biol Psychiatry, 34, 791-797.


Managing bereavement within the health care system

Reynolds, C.F. III, Miller, M.D., Pasternak, R.E., et al. (1999). Treatment of

bereavement-related major depressive episodes in later life: A controlled study

of acute and continuation treatment with nortriptyline and interpersonal

psychotherapy. American Journal of Psychiatry, 156, 202-208.

Rogers, M. P. & Reich, P. (1988). On the health consequences of

bereavement. New England Journal of Medicine, 319, 510-511.

Rynearson, E. K. & McCreery, J. M. (1993). Bereavement after homicide: A synergism

of trauma and loss. American Journal of Psychiatry, 150, 258-261.

Schaefer, C., Quesenberry, C.P. Jr., & Wi, S. (1995). Mortality following conjugal

bereavement and the effects of a shared environment. Am J Epidemiol, 141, 1142-1152.

Umberson, D. Wortman, C.B., & Kessler, R.C. (1992). Widowhood and depression:

Explaining long-term gender differences in vulnerability. J Health Soc Behav., 33, 10-24.