Health outcomes of bereavement Margaret Stroebe, Henk Schut, Wolfgang StroebeLancet 2007; 370: 1960–73 In this Review, we look at the relation between bereavement and physical and mental health. Although grief is not a Research Institute for disease and most people adjust without professional psychological intervention, bereavement is associated with Psychology and Health, excess risk of mortality, particularly in the early weeks and months after loss. It is related to decrements in physical Utrecht University, Utrecht, health, indicated by presence of symptoms and illnesses, and use of medical services. Furthermore, bereaved Netherlands (M Stroebe PhD, individuals report diverse psychological reactions. For a few people, mental disorders or complications in the grieving process ensue. We summarise research on risk factors that increase vulnerability of some bereaved individuals. Diverse factors (circumstances of death, intrapersonal and interpersonal variables, ways of coping) are likely to co-determine excesses in ill-health. We also assess the eﬀ ectiveness of psychological intervention programmes. Intervention should be targeted at high-risk people and those with complicated grief or bereavement-related depression and stress disorders. M.S.Stroebe@UU.NL Introduction
physical eﬀ ects does loss of a loved person have on
Research on stressful life-events has progressed during survivors? Is the risk of succumbing to health disorders the past three decades, from study of the cumulative eﬀ ect greater in bereaved than non-bereaved counterparts?We of life-events (measured with scales such as the social try to establish prevalence of health outcomes, identifying readjustment rating scale [SRRS])8 to a focus on speciﬁ c subgroups that are especially vulnerable. Furthermore, life-events, such as bereavement. Death of a spouse ranks
we review studies on the eﬀ ectiveness of psychological
as the life-event needing the most intense readjustment intervention programmes in reducing the risk of negative on the SRRS, conﬁ rming the status of bereavement as a health issues in bereaved individuals, asking a third highly stressful event. Much research has been undertaken
question: Can counsellors and therapists help to reduce
on bereavement, deﬁ ned as the situation of having the health problems of bereaved people? recently lost a signiﬁ cant person through death.3 Although comparatively rare in childhood, bereavement is a The mortality of bereavement life-event that, sooner or later, becomes part of nearly Overall patterns everyone’s experience. Of children younger than 18 years,
For several decades, researchers have examined whether
3·4% have experienced the death of a parent,9 whereas in
the death of a loved one increases the mortality risk of
elderly populations, spousal bereavement is most the bereaved person—understood popularly as dying of frequent, with about 45% of women and 15% of men a broken heart. The most valid and reliable information older than 65 years becoming widowed.10 As such, is provided in longitudinal investigations comparing bereavement can be viewed as a normal, natural human bereaved with non-bereaved counterparts, controlling experience, one which most people manage to come to for several confounders12 such as socioeconomic and terms with over the course of time. Nevertheless, it is lifestyle factors the bereaved spouse would have shared associated with a period of intense suﬀ ering for most with their deceased partner, which could aﬀ ect the individuals, with an increased risk of developing mental bereaved spouse’s health as well. Other potential and physical health problems. Adjustment can take confounders include cases of deaths from accidents months or even years and is subject to substantial involving both spouses (where one outlives the other variation between individuals and across cultures. For a and becomes categorised as widowed—thereby few people, mental and physical ill-health is extreme and
increasing the number of deaths of widows that are
persistent. For this reason, bereavement is a concern not
unrelated to the bereavement) and selection into
only for preventive care but also for clinical practice.
remarriage of the healthiest widowed individuals
Grief is deﬁ ned as the mainly emotional reaction to
bereavement, incorporating diverse psychological and physical reactions.3 Over the past few decades, scientiﬁ c
Search strategy and selection criteria
study of the symptoms, mental and physical health
We searched PubMed, Medline, and PsycINFO with the terms
outcomes, and ways of coping with grief has expanded
“bereavement” and “grief” for reports published after 1997.
rapidly.3,11 This research seeks to develop ways to identify
When selecting reports for inclusion, we gave priority to:
and provide preventive care for individuals at risk for
recent studies; those meeting quality criteria (sample size,
bereavement-related health problems. The current state
response rate, use of standardised measurements, analytical
of knowledge with respect to the consequences of
techniques, etc); those that included a control group of non-
bereavement and care of bereaved people is the focus of
bereaved individuals (where appropriate); prospective studies
this Review. We review scientiﬁ c published work on the
(before or after a death); and longitudinal studies. We also
mental and physical health outcomes of bereavement. We
referred to our previous publications.1–7
address two basic questions. What psychological and
www.thelancet.comVol 370 December 8, 2007 Reference/location Sample characteristics Follow-up Findings (years)
Men who had lost partner by suicide had relative risk of suicide of 46·2
Relatives of n=9011 who committed suicide,
(95% CI 1·3–116·4) and risk of mortality by other causes of 10·1 (6·5–15·8)
Women’s risks were 15·8 (6·6–37·4) and 3·3 (1·5–7·2), respectively
Child bereavement by suicide or other causes imposed about a two-fold increased risk in parents
Early excess mortality for widowers older than 74 years, no other
Widows of men aged >64 years, widowers of women
Spouses whose partners spent time in hospital before death
Hazard ratio for widowers=1·21 (95% CI 1·19–1·22), for widows=1·17
Widows=252 557, widowers=156 004 aged >65 years
(115–1·19) compared with people with a living spouseVery high increased risk in ﬁ rst 30 days after bereavement
Excess mortality seen in white but not black widowers and widows
86 323 widowers, 176 671 widows aged older than 65 years
(similar in both sexes), especially in the ﬁ rst month, but remaining raised over many years
n=2323 (deaths from suicides, widowed vs other marital
Signiﬁ cant increase in suicide risk during ﬁ rst year of bereavement,
In absolute terms, oldest men had highest increase in suicide risk immediately after loss (15-fold > than middle-aged still-married men)
Being widowed had no signiﬁ cant eﬀ ect on suicide risk
Longitudinal survey of 50 000 households, 545 suicidesMales and females, age 15 years and older
Suicide risk for widowers was 3·3 times as high as for married men
Parents of children who died at age <18 years
Overall increased mortality from natural and unnatural causes in
Early increased mortality from unnatural causes in fathers
Bereavement was a mortality risk factor for both men and women,
n=1993 pairs of twins, one widowed, the other still married
higher for the “young-old”(age <70 years) and for those recently widowedDecrease in risk of death after 4 years of bereavement in “young-old” widows (age <70 years) compared with married women
Risk of dying for widowed individuals was signiﬁ cantly higher than for
married people (among both blacks and whites), but this risk was
accounted for by deaths among widowersWidows’ risks were similar to those of married women
Excess mortality for both bereaved men and women, especially with
n=4420 bereaved men, n=11 114 bereaved women; n=49 566
short duration of bereavement (during ﬁ rst 6 months, during which
time excess mortality was 40% for men, 50% for women)
Excess mortality was 17% in men, 6% in women
n=22 294 men, n=61 686 women, from n=1 580 000 married
Higher risk for shorter than longer durations of bereavement
Increase of about 75–100% in risk of mortality in ﬁ rst 6 months in
n=237 widowed from a cohort of 1046 married
elderly widowers, but results not statistically signiﬁ cant due to limited
power of the study Higher risk in widows than widowers (age 65–74 years)
Parents completing suicide n=18 611, controls n=372 220
Both fathers and mothers (similar excess rates) had raised suicide risk
(greater than other causes) after death of a child, especially after younger child loss and in ﬁ rst month of bereavement
Raised relative risk in both sexes, particularly during second half of ﬁ rst
n=1453 men, n=3294 women bereaved in cohort of n=12 522
In men, risk decreased after 24 months but remained high over years
after bereavementIn women, eﬀ ects were restricted mostly to ﬁ rst year
Younger (<65 years old) widowers’ rates were raised when wife died
n=141 men, n=351 women, n=1782 married controls
suddenly (at 6 months or less onset of disease)
Older (>64 years old) widows’ rates were lower when husband died of long-term illness
Cross-sectional surveys, including national or other large-scale ones, are omitted from table 1 because even if they introduce controls for confounding factors, they do not have information on the duration of bereavement at death. Compared with individuals who have not been bereaved, cross-sectional surveys typically ﬁ nd patterns of high mortality in widowed people. They also ﬁ nd higher mortality in widowers compared with widows, and in younger compared with old widowed individuals (likewise, when the ratios are compared with non-bereaved individuals). Table 1: Mortality of bereavement
www.thelancet.comVol 370 December 8, 2007
(therefore the individuals left in the widow group tend to
duration of bereavement. Excess mortality in widowed
be the least healthy and more vulnerable to mortality).
populations is highest in the early months, and
Table 1 presents an overview of ﬁ ndings of longitudinal
decreases with increasing duration of bereavement.24
studies published since our 1993 review12 on the Martikainen and Valkonen24 reported higher rates for mortality of bereavement. Nearly all reports have been widows and widowers compared with married people: of spousal bereavement, partly because these statistics mortality was very high for accidental and violent causes are somewhat easier for researchers to access than and alcohol-related diseases, moderate for chronic other data but also because this type of bereavement is ischaemic heart disease and lung cancer, and small for fairly common (compared with child loss) and has a other causes of death. Of bereaved parents, excess risk great personal eﬀ ect (compared with parental loss in of mortality for mothers has been seen to extend for adulthood). Most of the ﬁ ndings indicate an early ex-
18 years in one study, with deaths attributable to natural
cess risk of mortality,21,23–25,27 although some researchers and unnatural causes, whereas for fathers, greater risk have also noted risks persisting for longer than 6 months
was noted early on in bereavement from unnatural
As seen in table 1, several longitudinal studies have
Subgroup diﬀ erences
focused speciﬁ cally on the risk that bereaved people will
Importantly, in some studies, researchers have take their own lives, with most investigations ﬁ nd ing examined subgroup diﬀ erences—eg, sex and age excess mortality.13,17,20,28,32,33 Kaprio and col
patterns, education and ethnic origin, household size example, noted large excess mortality in the ﬁ rst week and number of children. For example, a controlled, of bereavement: 66-fold for widowers and 9·6-fold for large-scale study16 reported a greater risk of widows. In some of the other studies included in table 1, bereavement-related mortality in white people than in analyses by suicide were also reported.20 In general, black people. Sex and age patterns have been recorded these ﬁ ndings conﬁ rmed the pattern of excess mortality most frequently. Generally most, though not all,15
seen in the suicide-speciﬁ c studies listed. In some cases,
ﬁ ndings conﬁ rm that there are sex diﬀ erences in the studies have included analysis of the person whose mortality of spousal bereavement (table 1):4 widowers death had been the cause of bereavement.13 Agerbo13 (compared with married same-sex counterparts) are at noted that death by suicide increased the suicide risk for relatively more excessive risk of mortality than widows bereaved widowers and parents even more than other (compared with married same-sex counterparts). That causes. widowers with poor health tend not to remarry does not account for the diﬀ
erences in mortality. That Conclusions
sex-diﬀ erence patterns can vary across types of loss (eg,
Bereavement is associated with an increased risk of
spousal, child, parent) is noteworthy. Death of a child mortality from many causes, including suicide. In has been reported to have an even greater eﬀ ect on published studies, confounders have been well-controlled, mothers than fathers.19 Furthermore, patterns of and patterns are quite consistent, enabling the conclusion mortality by sex in bereaved people could be altering that the mortality of bereavement is attributable in large with changing sex roles in recent decades.
part to a so-called broken heart (ie, psychological distress
With respect to age, ﬁ ndings of studies have also in di-
due to the loss, such as loneliness34 and secondary
cated a greater mortality risk for younger than for older
consequences of the loss, such as changes in social ties,
be reaved people who have lost their spouse,24,29 conﬁ rm-
living arrangements, eating habits and economic
ing earlier reported patterns.12 This eﬀ ect might be support35). For widowers, the increased risk will probably more pronounced for widowers than for widows.23,30
be associated with alcohol consumption and the loss of
However, caution must be used in interpretation of age
their sole conﬁ dante, who would have overseen her
diﬀ erences in the mortality of bereavement.10 For husband’s health status.4 Some evidence is available that example, institutionalised individuals (ie, those in excess mortality rates extend beyond spousal loss, to prisons, nursing homes, juvenile detention facilities, or
include parents (and possibly others too, such as
residential mental hospitals) are sometimes excluded children). Individuals who have been bereaved for a short purposely from large-scale samples18 and rates for time are at greater risk of mortality than are those residential relocation increase on the death of a partner.31
bereaved for longer, although raised risk might persist
Thus, those people who are very frail and whose (particularly from certain causes such as alcohol-related mortality risk is therefore high could be excluded from
samples, thereby boosting the relative survival rates of
Although mortality is a drastic outcome of losing a
elderly populations compared with young people.
loved one, it must be assessed in terms of the absolute number of bereaved people who die. Baseline rates
Causes of death
are low, with, for instance, about 5% of widowers
Bereaved people die excessively from various causes, versus 3% of married men in the 55 years and older age which are, not surprisingly, diﬀ erentially related to the category dying in the ﬁ rst 6 months of bereavement.4
www.thelancet.comVol 370 December 8, 2007 Physical ill health
rence of pain in older widowed individuals, focus ing on
particular aspects (activity-limiting pain, strength of most
Some investigators have reported a greater occurrence of
severe pain, and current pain). Those bereaved for short
physical health complaints in bereaved people (compared
with matched controls), ranging from physical symptoms
pain and moderate-to-severe current pain. In general,
(eg, headaches, dizziness, indigestion, and chest pain) to
compared with non-bereaved controls, widowed people
high rates of disability and illness, greater use of medical
were three times more likely to report having current
services (in some studies), and drug use.1,35 Many surveys
strong pain. The current level of mood disturbance
have been undertaken cross-sectionally, thus researchers
mediated the relation between widowhood and pain.
have not identiﬁ ed recently bereaved people. Most studies
Bereavement has also been associated with weight
have been done with bereaved partners, although a few loss.35,41 Schulz and colleagues42 reported that, in general, have been undertaken for other types of loss. For example,
individuals who had notundertaken caregiving of their
Murphy and colleagues36 compared the health of mothers
spouse before their death were more likely to have weight
and fathers after the violent death of a child. They loss in bereavement. These people were also more likely recorded poorer physical health in mothers than in to be using non-tricyclic antidepressants. The researchers fathers, but unlike mothers, the health of fathers suggested that these patterns might be attributable to the deteriorated rather than improved over time (14% of unpredictable nature of the death. fathers rated their health as poor at 4 months after bereavement and 24% did so at 24 months).
Some studies have included ﬁ ndings across the wide People who have been bereaved are more likely to have
range of physical ailments and illnesses, speciﬁ cally for physical health problems, particularly those who have been recently bereaved spouses, comparing rates with longer bereaved recently. Bereaved individuals also have higher term bereaved and non-bereaved counterparts. In a rates of disability, medication use, and hospitalisation than classic study, Thompson and co-workers37 reported odds non-bereaved counterparts. Although widowed people in of a new or worsened illness in older bereaved spouses at
general consult with doctors more frequently, most likely
2 months after their loss, estimating these odds to be because of symptoms of anxiety and tension,35 ﬁ ndings 1·40 times the risk of non-bereaved people. Similarly, suggest that many of those with intense grief might fail to self-reported medication use was higher among bereaved
consult with doctors when they need to.
individuals (1·73 times greater), as were perceived current ill health and ratings on illness severity. Visits to
Psychological symptoms and ill health
doctors were not increased in this elderly sample. By Psychological symptoms 6 months, most of these diﬀ erences had declined.
Bereavement is also associated with various psychological
The ﬁ nding that visits to doctors were not increased in
symptoms and illnesses;1,35 panel 1 provides an overview
bereaved populations in the Thompson study37 is of common reactions.1,7 Neimeyer and Hogan have noteworthy. In a study of women who had been bereaved
reviewed grief assessment methods.43 Psychological
for about 4 months, Prigerson and colleagues38 noted that
reactions are, generally speaking, most intense in early
women who reported high intensities of grief had bereavement.35,44 Studies of individual psychological reduceduse of health services for physical health reactions to bereavement, such as those listed in panel 1, disorders despite the fact that they had a signiﬁ cantly have been undertaken by many researchers, including increased likelihood of high blood pressure and investigation of suicidal ideation,34,44–48 loneliness,49,50 and functional impairment compared with widows reporting
insomnia.51 Other workers have identiﬁ ed relations
between grief-speciﬁ c symptoms and depression, anxiety,
The results suggest that bereaved individuals who are distress, somatic symptoms, insomnia, and social
most in need of health care might not be obtaining such
dysfunction at 6 months’ bereavement duration.39,44
help. The ﬁ ndings of this investigation are particularly
Researchers have also studied the similarities and
worrisome in view of results of a pre-post bereavement diﬀ erences between depression and grief,43,52–56 even at a investigation of hospital patients’ spouses.39 High physiological level.57 Growing evidence suggests that intensities of grief at an earlier point in the investigation
depression and grief might represent distinct, though
predicted severe physical health disorders (eg, cancer, related, clusters of reactions to bereavement.52,56heart attack) in bereaved individuals more than a year
Bereavement is a harrowing experience for most
people, one that causes considerable upset and disruption of everyday life. For most people the experience, though
Speciﬁ c debilitating aspects
cult, is tolerable and abates with time. For some,
Other research groups have identiﬁ ed additional however, the suﬀ ering is intense and prolonged. debilitating aspects of physical ill health in bereaved
Psychological reactions to bereavement are diverse,49,58
populations. For example, in a cross-sectional in
varying between individuals as well as between cultures
tigation, Bradbeer and colleagues40 examined the occur-
and ethnic groups.59–61 Few well-controlled studies of
www.thelancet.comVol 370 December 8, 2007
cultural diﬀ erences in bereavement have been done. A tisation of grief in non-western cultures.63 However, later study60 of qualitative interviews with bereaved studies do not support this notion. In a large-scale African-American individuals described unique international study, Simon and colleagues64 noted that characteristics of grief in that population, undermining cognitive and somatic symptoms were alike across general assumptions made about grief based on studies
diverse cultures. Although patients’ experience of
of white Americans. Generally, clinical experience and depression seemed to diﬀ er little across cultures, accounts of grieving in speciﬁ c societal and ethnic variation was evident in presenting symptoms. For groups suggest there are diﬀ erences in cultural patterns
example, at centres where depressed patients did not
of grief and grieving, with some diﬀ erences attributable have an ongoing relationship with a primary-care to religious beliefs. For example, Egyptian Muslims physician, a situation that is more common in express intense overt grief, but the Muslim community non-western settings, patients were more likely to in Bali does not; they avoid any display of grief such as present with somatic symptoms than were those who crying.62
had a personal physician. These results suggest that the
Some studies of depression suggested the possibility diﬀ erences in diﬀ erent countries’ health care systems
of cultural diﬀ erences, speciﬁ cally, increased soma-
may play a role in how patients present as well as patients’ beliefs about the best way to seek help and have one’s troubles recognised. Nevertheless, it is likely that
Panel 1: Reactions to bereavement
the fundamental manifestations of grief are universal.65
Reactions vary in nature and intensity according to the
type of lost relationship. Scientiﬁ c investigation has
recorded speciﬁ c reaction patterns to various diﬀ erent
types of bereavements. For example, uniquely, in the case
of a child’s death, many bereaved grandparents feel
enormous sadness and pain for their grieving adult child
and a sense of generational survivor guilt.66 Studies have
been done looking at a wide variety of bereavements,
including loss of a parent in childhood or adolescence67–69 and in adulthood,70 the death of a child,71–73 perinatal loss,74,75
loss of a grandchild,66 or death of a friend.76 AIDS-related
Preoccupation with thoughts of deceased, intrusive
grief and coping—with a focus on gay communities—has
also been a concern of scientiﬁ c investigation in recent
Changes during bereavement
Changes in symptoms of bereavement over time were
originally described in terms of stages or phases of
shock, yearning and protest, despair, and recovery,80 and
lately in terms of tasks.81 This so-called task model is
used in guiding counselling and therapy. The four tasks
of grieving are: accepting reality of loss; experiencing
the pain of grief; adjusting to the environment without
the deceased; and relocating the deceased emotionally
and moving on. We should note, however, that not all
grieving individuals undertake these tasks, nor, if they
do, do they undertake them in a ﬁ xed order. Both
individual and cultural diﬀ erences may play a role. In addition, bereaved individuals are far from uniform in
their emotional reactions over time, leading some
investigators to suggest that there are diﬀ erent
Energy loss, exhaustionSomatic complaints
Resilience versus vulnerability
Researchers have reported that over the long-term,
Immunological and endocrine changes
most bereaved people are resilient, recovering from
Susceptibility to illness, disease, mortality
their loss, emotionally and physically, with time.58,83 These claims are in line with general scientiﬁ c opinion
Adapted from references 1 and 7, with permission.
that bereavement is a normal life event to which most
www.thelancet.comVol 370 December 8, 2007
people adjust.1,3,84 Depression is thought to be such a normal response to bereavement that the Diagnostic
Panel 2: Criteria for complicated grief proposed for
and Statistical Manual of Mental Disorders, 4th edition85
Diagnostic and Statistical Manual of Mental Disorders,
excludes people bereaved for less than 2 months from
the diagnosis of major depressive disorder. Although
identifying what makes people susceptible to Chronic and disruptive yearning, pining, longing for the psychological disorders has a long research tradition,
the problem of bereavement can also be approached by studying the factors that make people resilient. For
example, researchers have focused on positive growth86
The individual must have four of the following eight
or, more speciﬁ cally (albeit with limited empirical
remaining symptoms at least several times a day or to a
evidence so far), on creativity that might come about as
degree intense enough to be distressing and disruptive:
a result of (early-life) bereavement.87 Thus some people
gain from their bereavement experience.
3 Excessive bitterness or anger related to the death
In general, most people have acute suﬀ ering, particularly
early on in bereavement.3,35,84 And for a few, symptoms for
6 Feeling life is empty or meaningless without deceased
reactions listed in panel 1, such as depression or anxiety,
can become clinically important.88 Many studies report
an increase in depressive symptomsin bereaved
populations.35 For a few people depression reaches
The above symptom disturbance causes marked and
clinical importance,88 with ﬁ ndings of studies suggesting
persistent dysfunction in social, occupational, or other
that 25–45% have mild levels of depressive symptoms
In some cases, especially when the loss of life has been
massive or the nature of the deaths horriﬁ c, the bereaved
The above symptom disturbance must last at least
develop post-traumatic stress disorder.88,89 In a sample of
bereaved parents 5 years after the death of their child,
*For a diagnosis of complicated grief, A, B, C, and D criteria must be met. Reprinted
27·7% of mothers and 12·5% of fathers met diagnostic
criteria for post-traumatic stress disorder compared with 9·5% women and 6·3% men in normative samples.90
inhibited grief. Prigerson and colleagues have used their
Psychiatric morbidity increases after widowhood91 and analysis to develop diagnostic criteria for complicated bereaved parents have higher rates of psychiatric (prolonged) grief (panel 2). An alternative diagnostic morbidity than non-bereaved individuals.92 In a study by system in terms of a stress response model is presented Li and colleagues,92 mothers especially had high rates of by Horowitz and coworkers.99 Complicated grief has not ﬁ rst psychiatric admission, particularly during the ﬁ rst yet been classiﬁ ed as a category of mental disorder in the year of bereavement. Of course, bereaved individuals can
Diagnostic and Statistical Manual of Mental Disorders,
have a combination of disorders, developing, for example,
4th edition,85 although eﬀ orts are being made to have it
both post-traumatic stress disorder and major depressive
included as a separate category in forthcoming editions.100
disorder, further complicating their grief reaction.88,93
Estimates of the occurrence of complicated forms of
grief vary across investigations and diagnostic criteria.
Complications in the grieving process
For example, chronic grief has been reported to occur in
In some cases, the grieving process can become complicated
about 9% of a population of adults experiencing
or disturbed, perhaps because of other mental-health bereavement,88 whereas 20% prevalence for complicated diﬃ
culties.38,94–96 Complicated grief has been deﬁ ned as a grief was recorded in another investigation.93 In a study of
deviation from the normal (in cultural and societal terms) parents who had lost a child 18 months previously,101 as grief experience in either time course, intensity, or both, many as 78% of those bereaved by suicide or accidents entailing a chronicand more intense emotional experience
and 58% by sudden infant death syndrome scored above
or an inhibited response, which either lacks the usual a suggested cutoﬀ level, using the Prigerson and Jacobs93 symptoms or in which onset of symptoms is delayed.3,35,97,98
criteria for complicated grief reactions. Such large
Prigerson and Jacobs93 have suggested criteria for numbers might indicate high intensity of grief in parents
complicated grief in terms of separation distress (eg, but, given the nature of the parent-child relationship, they preoccupation with thoughts of the deceased) and may not necessarily indicate pathological processes. This traumatic distress (eg, feelings of disbelief about the raises the question whether this cut-oﬀ point is a good death). Their construct of complicated (long-term) grief marker of chronic grief or whether norm scores for bears similarity to chronic grief while omitting delayed or
www.thelancet.comVol 370 December 8, 2007 Speciﬁ c risk factor Main ﬁ ndings
Cause of death (including Inconsistent results for sudden vs expected deaths;111,112 traumatic deaths: worse outcomes;89,113 note also parents’ reactions to traumatic
deaths.36,90 Sudden death likely to have the most eﬀ ect on vulnerable people (eg, those with low self-esteem) and those who are personally less
well-prepared114,115Few diﬀ erences in eﬀ ect of suicide or non-suicide deaths in some studies, but longer adaptation and some aspects (eg, stigmatisation, shame) more of an issue after suicide deaths than after other deaths.116 Excessive risk of mortality (including suicide) after suicide death.13 Suicide-bereaved children might be vulnerable117
Multiple (concurrent) losses;2 witnessing extreme distress in terminal illness increases eﬀ ect of loss,118 but a so-called good death (eg,
appropriate medical care, reducing distress for dying and bereaved) ameliorates the eﬀ ect7,119
Rituals can help, particularly for children120Deaths with hospice care are sometimes (not always121) associated with better outcomes than deaths in hospital in bereaved people. Some evidence suggests that deaths in hospice care are associated with lower mortality rates in the bereaved.122 Death of a child in hospital is associated with more symptoms for parents than the death of a child at home123
Strain aﬀ ects health of caregiver before and after bereavement, 7,42,124–126 although successful caregiving can be helpful, caregiving beneﬁ ts
might also be associated with high amounts of grief127 Health consequences not only owing to burden and responsibilities but also to personal neglect of one’s own health, nutrition, physical and emotional needs42 Death might on occasion be judged a relief for patient and bereaved128
Findings of a few studies show that kinship relationship moderates type of eﬀ ect on health.129,130 Loss of a child (adult) associated with more
intense and persistent grief and depression than loss of spouse131,132
Earlier claims that poor relationships (eg, ambivalence, dependency) lead to diﬃ
culties in bereavement, some beneﬁ ts from good
relationships,95 but ﬁ ndings not consistent concerning positive or negative outcomes and marital quality with respect to dependency, closeness, harmony, etc133–135
Concurrent stressors aﬀ ect bereavement outcome, eg, ﬁ nancial hardship that compounds diﬃ
culties in adjustment. If bereavement is
concurrent work and legal accompanied by a drop in economic resources, or insuﬃ
cient income, eﬀ ects of bereavement might be exacerbated.7,26,136 Poor eating habits
and loss of weight compared with married people41
Intrapersonal risk or Personality or attachment Some protective factors identiﬁ ed (eg, optimism,132,137 perceived control over daily activities,115 high self-esteem,115.138 secure attachment style in protective factors
Pre-bereavement depression probably associated with high risk of intensiﬁ cation of depression in bereavement88
Findings of most studies show early (childhood or adolescent) bereavement to be a risk for later (adulthood) mental and physical health issues;141–144 also noted are: cortisol concentration diﬀ erences,142,143 information processing biases;145 diﬀ erent sibling relationships.146 Adequacy of remaining parent care and personal characteristics of child are important141
Findings of some, but by no means all, studies show religion helps132,147–149
Socioeconomic status: ﬁ ndings of some studies suggest that health outcomes of bereavement are not related to socioeconomic status (see
also economic resources below).2,7 Some reports of poorer health in lower socioeconomic groups probably indicate non-bereavement-speciﬁ c patterns.2 Relative mortality is similar across education and income groups but absolute diﬀ erences compared with married people are greater in lower social strata25 Gender: widowers are relatively more vulnerable than widows;4,150,151 mothers are aﬀ ected more than fathers19,152Age: young people are reported to be more vulnerable in some studies,7,84 curvilinear relations also noted153 Ethnic group: similarities in grieving recorded between black and white people; however, anger and despair are lower in black populations,134 and high rates of psychiatric disorders154 and mortality are seen in both black and white bereaved people (patterns of comparative sex diﬀ erences are less clear).22 Diﬀ ering ethnic groups also have unique features of grief60
Social support helps bereaved and non-bereaved individuals alike, but bereaved people with higher support are not comparatively better-
adjusted than are those with low support, compared with non-bereaved counterparts5
Cultural and social embedding probably aﬀ ects bereavement outcome60
Material resources (money; services) might buﬀ er against extra stresses, but in general, eﬀ ects of bereavement are broadly similar across income groups7,26
Grief work, sharing, and disclosure are not as predictive of outcome as has been previously claimed. Avoidance is not necessarily so detrimental,
but rumination is associated with poor outcomes, whereas positive (re)appraisal is associated with good outcomes.5,52,77,137,155–159 Meaning making is regarded as beneﬁ cial157,158
Regulation (confrontation or avoidance; positive and negative appraisals) in the grieving process is likely to be beneﬁ cial52,59,160
Table 2: Potential risk or protective factors in bereavement Conclusions
to extreme and long-lasting over the months or even years
A wide range of psychological reactions are associated of bereavement. with bereavement, causing researchers to regard grief as a complex emotional syndrome.102 Although some responses
Additional medical implications
can be more symptomatic of grief than others, no one Bereavement can have an even broader range of response is essential to the syndrome. Furthermore, consequences than those already discussed. Bereavement reactions range from mild and comparatively short-lived has been shown to be associated with impaired memory
www.thelancet.comVol 370 December 8, 2007
performance,103 nutritional problems,104 work and relationships (eg, over-dependency vs typical dependency; relationship diﬃ
culties concentrating; and lack of harmony vs autonomy) might shed light on apparent
decreases in social participation.105,106 And health-care costs
inconsistencies.133 Research on attachment strongly
for bereaved individuals have been shown to be higher.11
supports the view that the quality or nature of the lost
These health eﬀ ects are likely to be associated with relationship has much eﬀ ect on outcome.80,95,139,140changes in diﬀ erent underlying physiological mechanisms.
Intrapersonal resources and protective factors refer to
A full discussion of these mechanisms is beyond the scope
characteristics intrinsic to the bereaved individual.
of this Review, however, research has begun to show Remarkably little research has been undertaken on these biological links between bereavement and increased risks
aspects of personality, despite the fact that clinicians
of physical illnesses. For example, research has been done
assume that people with well-adjusted personalities would
looking at how bereavement aﬀ ects the immune system, be better able to deal with loss than those who are less leads to changes in the endocrine, autonomic nervous, well-adjusted.88 Findings of available studies support the and cardiovascular systems, and helps to account for view that robust individuals adjust to bereavement better increased vulnerability to external agents;2,3,107 how MRI than people who are fragile. These patterns are probably scans can be used to study the neuroanatomy of grief,108
related to attributional52 and emotional regulation
and how autonomic and emotion regulation indicators processes.52,59,160 Atributions refer to the interpretations can been used to identify physiological diﬀ erences with which people make sense of what is happening to between bereaved, depressed, and control individuals.109
them; emotion regulation processes refer to the strategies people use to modify aspects of their emotions. Research
into such risk factors and the associated underlying
Much research eﬀ ort has been directed at identiﬁ cation cognitive processes is incomplete. Further research is also of risk factors to understand why people are aﬀ ected by needed on other predisposing vulnerabilities (eg, previous bereavement in diﬀ erent ways; why some people have mental-health disorders, medical or physical health issues, extreme or lasting outcomes and others do not.110
age-related frailty, substance abuse), but childhood loss of
Bereavement researchers use the term risk factor to a parent has been better researched, indicating various signify the situational and intrapersonal and interpersonal
long-term eﬀ ects. Importantly, evidence suggests that the
characteristics associated with increased vulnerability to adequacy of remaining parental care (eg, warmth and the range of bereavement outcomes.110,111 Some researchers
discipline) after the death of one parent, and personal
have integrated into their analyses protective factors that
characteristics of the child (ie, factors contributing to
appear to promote resilience and to lower risk of adverse
resilience) are more powerful predictors of later
health outcomes.83 Indeed, research should incorporate adjustment than the loss of the parent per se.141,142 analyses of the coping process, which can impede or
Of interpersonal factors, social support from others
facilitate adjustment, to determine whether there are would generally be regarded as a major variable, buﬀ ering healthy and unhealthy ways of going about grieving.
individuals against the negative health outcomes of
Table 2 categorises risk factors into four categories, bereavement. However, this assumption has not been
indicating the scope of empirical research and providing
well-founded empirically.5,161 Inadequate social support is
some key ﬁ ndings and references. Although some of the
a general risk factor, one that aﬀ ects the health and
listed factors have been investigated empirically, others well-being of non-bereaved people as much as those who are suggested in clinical or qualitative published work and need further quantitative investigation. Furthermore, in some studies non-bereaved controls are omitted. Thus, whether the speciﬁ c risk factor is general (present in
Everyday life experience
non-bereaved people too) or bereavement-speciﬁ c remains unclear.
There is considerable evidence that many of the variables
listed under situation and circumstances of deathorientated orientated
contribute to diﬀ erences in adjustment (although some
work has yielded inconclusive or contradictory results). It
is important, then, to take the broader circumstances of
death, including cause of death and caregiver strain, into
account and to realise the complex combination of personal
and situational factors that account for the eﬀ ect of variables such as these. We noted in table 2 discrepancies in ﬁ ndings on quality of relationship to the deceased (placed in this category since it bears on circumstances and situation of death, but it is relevant to other categories too). Further investigation of the various features of Figure: Dual process model of coping with bereavement160
www.thelancet.comVol 370 December 8, 2007 Comments
Absence of eﬀ ects possibly because nearly all studies used outreaching
recruitment procedures (help oﬀ ered rather than asked for)171
More positive results than previous studies.78,79,173,174 Suggestions of better results seen in
Positive results possibly because three of four studies were inreaching studies
females (adults and young girls) than in young males.78,79,174 Better results in people with
cacy for those with higher levels of mental-health
mental-health problems at baseline, for both adults175 and children174,176
problems before intervention suggests rationale for secondary intervention
Generally, though not unequivocally, more eﬀ ective than primary intervention, though eﬀ ects Eﬀ ectiveness associated with strict use of risk criteria, showing need to diﬀ erentiate
were modest and improvements were temporary
more within groups and tailor intervention to the subgroup (eg, by gender181)
Improvements in children bereaved by suicide in group intervention (compared with
community care).177 Families at high-risk showed slightly more improvement after family-focused grief therapy178,179 in terms of general distress (not family functioning). Those with worst symptoms had most improvement. No eﬀ ects of a highly-speciﬁ c (body touching) therapy180 on bereaved mothers. Emotion-focused interventions most eﬀ ective for distressed widowers; problem-focused for distressed widows.181 Fathers in general, and mothers with low baseline values of distress and grief did not beneﬁ t from group intervention focused on problems and emotions; highly distressed or grieving mothers improved most through intervention182
Modest but lasting positive eﬀ ects on symptoms of pathology and grief (individual and group Therapy for complicated grief or bereavement-related depression and stress
interventions; from analytically oriented dynamic psychotherapy to cognitive and behaviour
disorders has led to substantial and lasting results. 3 additional studies were
cult to interpret (no non-intervention control group) but were interesting for
future research.52,165,185,186 For example, gender diﬀ erences in eﬀ ects of time-limited
Substantiate earlier ﬁ ndings: strong eﬀ ects in terms of intrusion, avoidance, grief, depression
supportive and interpretative group therapy in bereaved people with major
& anxiety.183,184 Assessed nortriptyline and interpersonal psychotherapy (alone and in
depression: women improved more than men in depression, anxiety, avoidance
combination) for people with bereavement-related major depressive episodes examined.184
and general distress; men reported less grief than women after interpretive group
Nortriptyline led to less remission than placebo and psychotherapy. Indication that
therapy.185 A speciﬁ c individual treatment module for complicated grief was more
combination of medication and psychotherapy gave best results
eﬀ ective than standard interpersonal psychotherapy165
Table 3: Eﬀ ectiveness of bereavement intervention programmes: psychosocial and psychological counselling and therapy105,170
are bereaved, but others cannot easily take the place of directly with the loss, such as going over death events the deceased individual. Use of professional support can
(loss orientation) versus sources of secondary stress,
also be regarded as an interpersonal resource factor, such as dealing with ﬁ nances (restoration orientation). encompassing the more formal level of social support Following this model, adaptive grieving entails both than that provided within the family, friendship, and confrontation and avoidance of the two types of stressor. neighbourhood networks.
Researchers are currently testing variables of the model
The way that an individual goes about coping with and using the model as a guideline for designing
bereavement is important because, unlike many other intervention programmes.164,165 variables, it can be changed—eg, it may be amenable to brief interventions.77 In recent decades, researchers have Conclusions been critical of the generally accepted notion that so-called
We have noted that situational, intrapersonal, inter-
grief work (confronting the reality of loss and personal, and coping factors aﬀ ect bereavement outcome. relinquishing the bond to the deceased individual)162 is They do so in complex ways and there could be essential for overcoming bereavement.5 Empirical interactions between factors (eg, between personality and research has shown that people who do not work through
circumstances of death) that operate to aﬀ ect outcome.
their grief frequently recover as well as, if not better than,
Many potential risk factors have been under-researched.
those who do so.155,163 Findings of studies on beneﬁ ts of The ways that risk factors relate precisely to the diﬀ erent emotional disclosure or social sharing,5,156 or on negative health outcomes also remain to be seen—eg, why one eﬀ ects of avoidance or repression,59,155 also provided little person can succumb to mental-health disorders while support for the grief-work notion.
another might die prematurely after bereavement.
By contrast, ﬁ ner-grained examinations of maladaptive
processes have provided useful leads. Findings of such Intervention eﬃ
studies suggest the importance of positive and negative Since bereavement increases the risk of negative health cognitions and the regulation of emotion in the grieving
outcomes for some individuals, research needs to establish
process,52 both of which have been integrated in the dual
whether intervention is to be recommended and whether
process model of coping with loss.160 This model (ﬁ gure) intervention is actually eﬀ ective. The focus here is on addresses shortcomings of the grief work model and psychological and not medical or pharmacological posits an oscillation process, whereby the bereaved intervention: we restrict the discussion to eﬀ ectiveness individuals would confront and avoid stressors to do studies of psychosocial and psychological counselling and
www.thelancet.comVol 370 December 8, 2007
therapy programmes (to our knowledge, very little research
Australia) countries. At the same time, we have noted
exists on the eﬀ ectiveness of pharmacological and medical
that grief is a normal natural process after bereavement.
interventions for bereaved people, but Alexopoulos166 and Most reactions are not complicated and for most Raphael and colleagues88 provide relevant information. bereaved people, family and friends, religious and The Center for the Advancement of Health addresses the community groups, and various societal resources will role of health-care professionals and health systems provide the necessary support. Professional psychological issues11). A few previous reviews have been published.6,11,167–170
intervention is generally neither justiﬁ ed nor eﬀ ective
Our own narrative review published in 20016 was based on
strict methodological selection criteria (presence of control
Much is now known about typical manifestations of
groups, non-systematic assignment to the experimental grief and grieving, and there is growing understanding and control condition, an appropriate design with valid about factors that either complicate the course of grief and reliable assessment instruments, correct statistical over time, raise the risk of other mental and physical analyses, etc) and excluded studies that were not primarily
disabilities, or both. Progress has also been made in the
aimed at bereaved people. Table 3 summarises and updates
design and provision of psychological intervention for
the conclusions arrived at in 2001 and 2005.
those who need it. Nevertheless, although the quality of
Grief interventions can be divided into primary, studies in the various areas reviewed above is better
secondary, and tertiary preventive interventions.6 Primary
than in previous research, methodological shortcomings
preventive interventions are those in which professional still are present in some investigations (eg, selection help is available to all bereaved individuals irrespective of
biases, small samples, poor response, and high dropout
whether intervention is indicated. Secondary preventive rates). interventions are designed for bereaved individuals who,
Furthermore, even though we were able to make
through screening or assessment, can be regarded as statements about general occurrences and manifesta-more vulnerable to the risks of bereavement (eg, high tions associated with bereavement, considerable gaps in levels of distress, traumatic circumstances of loss, etc). knowledge remain. For example, some of the most recent Tertiary preventive interventions denote those providing studies of the mortality of bereavement are still of spousal therapy for complicated grief, grief-related depression, or
loss: the eﬀ ect of other types of bereavement on mortality
post-traumatic disorders, usually evident longer after has received too little research attention. Likewise, we bereavement (since pathological processes usually take need to learn more about codeterminants of the poorer time to develop).
outcomes of bereavement, to understand how the circumstances of bereavement interact with
pre-bereavement experience, personal factors, and ways
As Parkes,187 the leading expert on bereavement, stated, of coping with grief to cause diﬃ
there is “no evidence that all bereaved people will beneﬁ t scope for improvement in the design of intervention from counselling and research has shown no beneﬁ ts to studies and for strict assessment of their eﬀ ectiveness arise from the routine referral to counselling for no other
following evidence-based treatment criteria.
reason than that they have suﬀ ered a bereavement”. Conﬂ ict of interest statement Primary prevention can, however, be helpful when the We declare that we have no conﬂ ict of interest. initiative is left with the bereaved individual. Both in Acknowledgments terms of suﬀ ering and ﬁ nances, this strategy is to be We thank Dora Black, Colin Murray Parkes, and Beverley Raphael for recommended. This approach needs an accessible their comments on parts of this Review. infrastructure of grief counselling organisations. References Interventions for risk groups are an important provision,
Stroebe MS, Hansson RO, Schut H, Stroebe W. Handbook of bereavement research and practice: advances in theory and
but improvements in assessment of empirically based
intervention. Washington, DC: American Psychological Association,
risk factors are essential for better results to be achieved.
A reasonably wide variety of treatment modalities for 2
Stroebe MS, Stroebe W, Hansson RO. Handbook of bereavement: Theory, research, and intervention. New York: Cambridge University
complicated grief is available and these are generally
quite eﬀ ective.6 Systematic comparison of the relative 3
Stroebe MS, Hansson RO, Stroebe W, Schut HAW. Handbook of
eﬀ ectiveness of diﬀ erent therapeutic approaches is
bereavement research: consequences, coping and care. Washington DC: American Psychological Association, 2001.
needed to understand what works for whom. A ﬁ rst step 4 Stroebe MS, Stroebe W, Schut H. Gender diﬀ erences in adjustment
in this direction would be to address closely gender
to bereavement: an empirical and theoretical review. Rev Gen Psychol
diﬀ erences in the eﬀ ectiveness of intervention.181
2001; 5: 62–83.
Stroebe W, Schut H, Stroebe MS. Grief work, disclosure and counseling: do they help the bereaved? Clin Psychol Rev 2005;
Final comments 25: 395–414.
We have recorded negative health issues across various 6
Schut H, Stroebe M, van den Bout J, Terheggen M. The eﬃ
mental and physical outcomes and for some diﬀ erent
bereavement interventions: Who beneﬁ ts? In: Stroebe MS, Hansson RO, Stroebe W, Schut H, eds. Handbook of bereavement
types of bereavement, ﬁ nding quite consistent patterns
research: consequences, coping, and care. Washington, DC:
in research from various (mostly the USA, Europe, and
American Psychological Association, 2001: 705–737.
www.thelancet.comVol 370 December 8, 2007
Hansson RO, Stroebe, MS Bereavement in late life: development,
35 Parkes CM. Bereavement: Studies of grief in adult life (3rd edn).
coping, and adaptation.Washington, DC: American Psychological
36 Murphy SA, Lohan J, Braun T, et al. Parents’ health, health care
Holmes TH, Rahe RH. The social readjustment rating scale.
utilization, and health behaviors following the violent deaths of
J Psychosom Res 1967; 11: 213–18.
their 12-to 28-year-old children: a prospective longitudinal
Christ GH, Siegel, K, Christ AE. Adolescent grief “It never really hit
analysis. Death Stud 1999; 23: 589–616.
me until it actually happened”. JAMA 2005; 288: 1269–79.
37 Thompson LW, Breckenridge JN, Gallagher D, Peterson JA.
10 Hansson RO, Stroebe MS. Grief, older adulthood. In: Gullotta TP,
Eﬀ ects of bereavement on self-perceptions of physical health in
Bloom M, eds. The encyclopedia of primary prevention and health
elderly widows and widowers. J Gerontol 1984; 39: 309–14.
promotion. Boston: Kluwer, 2003: 515–21.
38 Prigerson H, Silverman GK, Jacobs S, Maciejewski P, Kasl SV,
11 Center for the Advancement of Health. Report on bereavement and
Rosenheck R. Traumatic grief, disability and the underutilization
grief research. Death Stud 2004; 28: 491–575.
of health services: a preliminary look. Prim Psychiatry 2001; 8:
12 Stroebe MS, Stroebe W. The mortality of bereavement: a review. In:
Stroebe MS, Stroebe W, Hansson RO, eds. Handbook of
39 Chen JH, Bierhals AJ, Prigerson HG, Kasl SV, Mazure CM,
bereavement: theory, research, and intervention. New York:
Jacobs S. Gender diﬀ erences in the eﬀ ects of bereavement-related
Cambridge University Press, 1993: 175–95.
psychological distress in health outcomes. Psychol Med 1999; 29:
13 Agerbo E. Midlife suicide risk, partner’s psychiatric illness, spouse
and child bereavement by suicide or other modes of death: a gender
40 Bradbeer M, Helme RD, Yong HH, Kendig HL, Gibson SJ.
speciﬁ c study. J Epidemiol Community Health 2005; 59: 407–12.
Widowhood and other demographic associations of pain in
14 Bowling A. Mortality after bereavement: an analysis of mortality
independent older people. Clin J Pain 2003; 19: 247–54.
rates and associations with mortality 13 years after bereavement.
41 Shahar D, Schultz R, Shahar A, Wing R. The eﬀ ect of widowhood
Int J Geriatr Psychiatry 1994; 9: 445–59.
on weight change, dietary intake, and eating behavior in the
15 Christakis N, Allison P. Mortality after the hospitalization of a
elderly population. J Aging Health 2001; 13: 186–99.
spouse. N Engl J Med 2006; 354: 719–30.
42 Schulz R, Beach SR, Lind B, et al. Involvement in caregiving and
16 Elwert F, Christakis N. Widowhood and race. Am Sociol Rev 2006; 71:
adjustment to the death of a spouse. JAMA 2001; 285: 3123–29.
43 Neimeyer RA, Hogan NS. Quantitative or qualitative?
17 Erlangsen A, Jeune B, Bille-Brahe U, Vaupel JW. Loss of partner and
Measurement issues in the study of grief. In: Stroebe MS,
suicide risks among oldest old: a population-based register study.
Hansson RO, Stroebe W, Schut H, eds. Handbook of
Age Ageing 2004; 33: 378–383.
bereavement research: Consequences, coping, and care. Washington DC: American Psychological Association, 2001:
18 Kposowa A. Marital status and suicide in the National Longitudinal
Mortality Study. J Epidemiol Community Health 2000; 54: 254–61.
44 Byrne GJ, Raphael B. The psychological symptoms of conjugal
19 Li G. The interaction eﬀ ect of bereavement and sex on the risk of
bereavement in elderly men over the ﬁ rst 13 months.
suicide in the elderly: an historical cohort study. Soc Sci Med 1995;
Int J Geriatr Psychiatry 1997; 12: 241–51. 40: 825–28.
45 Rosengard C, Folkman S. Suicidal ideation, bereavement, HIV
20 Li J, Precht DH, Mortensen PB, Olsen J. Mortality in parents after
serostatus and psychosocial variables in partners of men with AIDS.
death of a child in Denmark: a nationwide follow-up study. LancetAIDS Care 1997; 9: 373–84.
2003; 361: 363–67.
46 Latham AE, Prigerson, H. Suicidality and bereavement: Complicated
21 Lichtenstein P, Gatz M, Berg S. A twin study of mortality after
grief as psychiatric disorder presenting greatest risk for suicide.
spousal bereavement. Psychol Med 1998; 28: 635–43. Suicide Life Threat Behav 2004; 34: 350–62.
22 Lillard LA, Waite LJ. Till death do us part—marital disruption and
47 Segal NL, Roy, A. Suicidal attempts and ideation in twins whose
mortality. Am J Sociol 1995; 100: 1131–56.
co-twins’ deaths were non-suicides: replication and elaboration.
23 Manor O, Eisenbach Z. Mortality after spousal loss: are there
Pers Individ Diﬀ 2001; 31: 445-452.
socio-demographic diﬀ erences? Soc Sci Med 2003; 56: 405–13.
48 Range LM, Knott EC. Twenty suicide assessment instruments:
24 Martikainen P, Valkonen T. Mortality after death of spouse in
Evaluation and recommendations. Death Stud 1997; 21: 25–58.
relation to duration of bereavement in Finland.
49 Lund DA, Caserta MS, Dimond MF. The course of spousal
J Epidemiol Community Health 1996; 50: 264–68.
bereavement in later life. In: Stroebe MS, Stroebe W, Hansson RO,
25 Martikainen P, Valkonen T. Mortality after the death of a spouse:
eds. Handbook of bereavement: Theory, research, and intervention.
Rates and causes of death in a large Finnish cohort. Am J Pub Health
New York: Cambridge University Press, 1993: 240–54.
1996; 86: 1087–93.
50 van Baarsen B, van Duijn MA, Smit JH, Snijders TA,
26 Martikainen P, Valkonen T. Do education and income buﬀ er the
Knipscheer KP. Patterns of adjustment to partner loss in old age: the
eﬀ ects of death of spouse on mortality? Epidemiology 1998; 9: 530–34.
widowhood adaptation longitudinal study. Omega 2001–02; 44: 4–36.
27 Mendes de Leon C, Kasl S V, Jacobs S. Widowhood and mortality
51 Hardison HG, Neimeyer RA, Lichstein KL. Insomnia and
risk in a community sample of the elderly: a prospective study.
complicated grief symptoms in bereaved college students.
J Clin Epidemiol 1993; 46: 519–27. Behav Sleep Med 2005; 3: 99–111.
28 Qin P, Mortensen PB. The impact of parental status on the risk
52 Boelen PA. Complicated grief: Assessment, theory, and treatment.
of completed suicide. Arch Gen Psychiatry 2003; 60: 797–802.
29 Schaefer C, Quesenberry CP, Wi S. Mortality following conjugal
53 Ogrodniczuk JS, Piper WE, Joyce AS, et al. Diﬀ erentiating
bereavement and the eﬀ ects of a shared environment.
symptoms of complicated grief and depression among psychiatric
Am J Epidemiol 1995; 141: 1142–52.
outpatients. Can J Psychiatry 2003; 48: 87–93.
30 Smith KR, Zick CD. Risk of mortality following widowhood: Age
54 Prigerson HG, Jacobs SC. Perspectives on care at the close of life.
and sex diﬀ erences by mode of death. Soc Biol 1996; 43: 59–71.
Caring for bereaved patients: “all the doctors just suddenly go”.
31 Bradsher JE, Longino CF Jr, Jackson DJ, Zimmerman RS. Health
JAMA 2001; 286: 1369–76.
and geographic mobility among the recently widowed. J Gerontol
55 Prigerson HG, Frank E, Kasl SV, et al. Complicated grief and
1992; 47: S261–68.
bereavement-related depression as distinct disorders: preliminary
32 Duberstein PR, Conwell Y, Cox C. Suicide in widowed persons: A
empirical validation in elderly bereaved spouses. Am J Psychiatry
psychological autopsy comparison of recently and remotely
1995; 152: 22–30.
bereaved older subjects. Am J Geriatr Psychiatry 1998; 6: 328–34.
56 Wijngaards-de Meij L, Stroebe M, Schut H, et al. Couples at risk
33 Kaprio J, Koskenvuo M, Rita H. Mortality after bereavement: a
following the death of their child: predictors of grief versus
prospective study of 95,647 widowed persons. Am J Public Health
depression. J Consult Clin Psychol 2005; 73: 617–23.
1987; 77: 283–87.
57 O’Connor MF, Allen J, Kaszniak AW. Autonomic and emotion
34 Stroebe M, Stroebe W, Abakoumkin G. The broken heart:
regulation in bereavement and depression. J Psychosom Res 2002;
Suicidal ideation in bereavement. Am J Psychiatry 2005; 162: 52: 183–85.
www.thelancet.comVol 370 December 8, 2007
58 Boerner K, Wortman CB, Bonanno GA. Resilient or at risk? A
82 Bisconti TL, Bergeman CS, Boker SM. Emotional well-being in
4-year study of older adults who initially showed high or low
recently bereaved widows: a dynamical systems approach.
distress following conjugal loss. J Gerontol 2005; 60: P67–73. J Gerontol B Psychol Sci Soc Sci 2004; 59: 158–67.
59 Bonanno GA, Papa A, Lalande K, Zhang N, Noll JG. Grief
83 McCrae RR, Costa PT. Psychological resilience among widowed
processing and deliberate grief avoidance: a prospective
men and women: a 10-year follow-up of a national sample. In:
comparison of bereaved spouses and parents in the United States
Stroebe MS, Stroebe W, Hansson RO, eds. Handbook of
and the People’s Republic of China. J Consult Clin Psychol 2005; 73:
bereavement: Theory, research, and intervention. New York:
Cambridge University Press, 1993: 196–207.
60 Rosenblatt PC, Wallace BR. African American grief. New York:
84 Archer J. The nature of grief: The evolution and psychology of
reactions to grief. London: Routledge,1999.
61 Rubin SS, Yasien-Esmael H. Loss and bereavement among Israeli’s
85 American Psychiatric Association. Diagnostic and statistical
Muslims: acceptance of God’s will, grief, and the relationship to the
manual of disorders (4th edn). Washington DC: American
deceased. Omega 2004; 49: 149–62.
62 Wikan U. Bereavement and loss in two Muslin communities: Egypt
86 Schaefer JA, Moos RH. Bereavement experiences and personal
and Bali. Soc Sci Med 1988; 27: 451–60.
growth. In: Stroebe MS, Hansson RO, Stroebe W, Schut H, eds.
63 Kleinman A, Good B. Culture and depression: Studies in the
Handbook of bereavement research: consequences, coping, and
anthropology and cross-cultural psychiatry of aﬀ ect and disorder.
care. Washington DC: American Psychological Association, 2001:
Berkeley: University of California Press, 1985.
64 Simon G, VonKorﬀ M, Piccinelli M, Fullerton C, Ormel J. An
87 Simonton D. Great psychologists and their times. Washington, DC:
international study of the relation between somatic symptoms and
American Psychological Association, 1988.
depression. N Engl J Med 1999; 341: 1329–34.
88 Raphael B, Minkov C, Dobson M. Psychotherapeutic and
65 Parkes CM, Laungani P, Young, B. Death and bereavement across
pharmacological intervention for bereaved persons. In: Stroebe MS,
Hansson RO, Stroebe W, Schut H, eds. Handbook of bereavement
66 Fry PS. Grandparents’ reactions to the death of a grandchild: an
research: Consequences, coping, and care. Washington, DC:
exploratory factor analytic study. Omega 1997; 35: 119–40.
American Psychological Association, 2001: 587–612.
67 Lin KK, Sandler IN, Ayers TS, Wolchik SA, Luecken LJ. Resilience
89 Kaltman S, Bonanno GA. Trauma and bereavement: examining the
in parentally bereaved children and adolescents seeking preventive
impact of sudden and violent deaths. J Anxiety Disord 2003;
services. J Clin Child Adolesc Psychol 2004; 33: 673–83. 17: 131–47.
68 Kirwin KM, Hamrin V. Decreasing the risk of complicated
90 Murphy SA, Johnson LC, Chung I, Beaton RD. The prevalence of
bereavement and future psychiatric disorders in children.
PTSD following the violent death of a child and predictors of change
J Child Adolesc Psychiatr Nurs 2005; 18: 62–78.
5 years later. J Traumatic Stress 2003; 16: 17–25.
69 Rotherham-Borus MJ, Weiss R, Alber S, Lester P. Adolescent
91 Surtees PG. In the shadow of adversity: The evolution and resolution
adjustment before and after HIV-related parental death.
of anxiety and depressive disorder. Br J Psychiatry 1995; 166: 583–94. J Consult Clin Psychol 2005; 73: 221–28.
92 Li J, Laursen TM, Precht DH, Olsen J, Mortensen PB.
70 Scharlach AE. Factors associated with ﬁ lial grief following the death
Hospitalization for mental illness among parents after the death of a
of an elderly parent. Am J Orthopsychiatry 1991; 61: 307–13.
child. N Engl J Med 2005; 352: 1190–96.
71 Murphy SA, Das Gupta A, Cain KC, et al. Changes in parents’
93 Prigerson H, Jacobs, S. Traumatic grief as a distinct disorder: a
mental distress after the violent death of an adolescent or young
rationale, consensus criteria, and a preliminary empirical test. In:
adult child: a longitudinal prospective analysis. Death Stud 1999;
Stroebe MS, Hansson RO, Stroebe W, Schut H, eds. Handbook of
bereavement research: consequences, coping, and care. Washington, DC: American Psychological Association, 2001: 613–45.
72 Murphy SA, Johnson LC, Wu L, Fan JJ, Lohan J. Bereaved parents’
outcomes 4 to 60 months after their children’s deaths by accident,
94 Jacobs S. Pathologic grief: Maladaptation to loss. Washington, DC:
suicide, or homicide: a comparative study demonstrating
diﬀ erences. Death Stud 2003; 27: 39–61.
95 Parkes CM, Weiss RS. Recovery from bereavement. New York:
73 Rubin SS, Malkinson R. Parental response to child loss across the
life cycle: clinical and research perspectives. In: Stroebe MS,
96 Prigerson H, Maciejeski, P. A call for sound empirical testing and
Hansson RO, Stroebe W, Schut H, eds. Handbook of bereavement
evaluation of criteria for complicated grief proposed for DSM-V.
research: consequences, coping, and care. Washington DC:
Omega 2005; 52: 9–19.
American Psychological Association, 2001: 219–40.
97 Averill JR. Grief: its nature and signiﬁ cance. Psychol Bull 1968;
74 Barr P. Guilt- and shame-proneness and the grief of perinatal
bereavement. Psychol Psychother 2004; 77: 493–510.
98 Middleton W, Burnett P, Raphael B, Martinek N. The bereavement
75 Vance JC, Boyle FM, Najman JM, Thearle MJ. Couple distress after
response: a cluster analysis. Br J Psychiatry 1996; 169: 167–71.
sudden infant or perinatal death: a 30-month follow-up.
99 Horowitz MJ, Siegel B, Holen A, Bonanno GA, Milbrath C,
J Paediatr Child Health 2002; 38: 368–72.
Stinson CH. Diagnostic criteria for complicated grief disorder.
76 Sklar FHS. Close friends as survivors: Bereavement patterns in a
Am J Psychiatry 1997; 154: 904–10.
“hidden” population. Omega 1991; 21: 103–12.
100 Parkes CM. Complicated grief: a symposium. Omega 2005;
77 Folkman S. Revised coping theory and the process of bereavement.
52: whole issue.
In: Stroebe MS Hansson RO, Stroebe W, Schut H, eds. Handbook
101 Dyregrov K, Nordanger D, Dyregrov A. Predictors of psychosocial
of bereavement research: consequences, coping, and care.
distress after suicide, SIDS and accidents. Death Stud 2003; 27:
Washington DC: American Psychological Association, 2001: 563–84.
78 Sikkema KJ, Hansen NB, Kochman A, Tate DC, Difranceisco W.
102 Averill J. The functions of grief. In: Izard C, ed. Emotions in
Outcomes from a randomized controlled trial of a group
personality and psychopathology. New York, 1979: 339–68.
intervention for HIV positive men and women coping with
103 Aartsen MJ, van Tilburg T, Smits CH, Comijs HC,
AIDS-related loss and bereavement. Death Stud 2004; 28: 187–209.
Knipscheer KC. Does widowhood aﬀ ect memory performance of
79 Sikkema KJ, Hansen NB, Meade CS, Kochman A, Lee RS.
older people? Psychol Med 2004; 34: 1–10.
Improvements in health-related quality of life following a group
104 Rosenbloom CA, Whittington FJ. The eﬀ ects of bereavement on
intervention for coping with AIDS-bereavement among
eating behaviors and nutrient intakes in elderly widowed persons.
HIV-infected men and women. Qual Life Res 2005; 14: 991–1005. J Gerontol; 48: S223–29.
80 Bowlby J. Attachment and loss, vol 3: Loss: sadness and
105 Carr D, Nesse RM, Wortman C. Late life widowhood in the United
depression. London: Hogarth Press, 1980.
States. New York: Springer Publishing Co, 2005.
81 Worden JW. Grief counseling and grief therapy: A handbook for
106 Utz RL, Carr D, Nesse R, Wortman CB. The eﬀ ect of widowhood
the mental health practitioner, 3rd Edn. New York: Springer
on older adults’ social participation: An evaluation of activity,
disengagement, and continuity theories. Gerontologist; 42: 522–33.
www.thelancet.comVol 370 December 8, 2007
107 Gerra G, Monti D, Panerai AE, et al. Long-term
129 Bernard LL, Guarnaccia CA. Two models of caregiver strain and
immune-endocrine eﬀ ects of bereavement: Relationships with
bereavement adjustment: a comparison of husband and daughter
anxiety levels and mood. Psychiatry Res 2003; 121: 145–58.
caregivers of breast cancer hospice patients. Gerontologist 2003;
108 Gündel H, O’Connor M-F, Littrell L, Fort C, Lane R. Functional
neuroanatomy of grief: an MRI study. Am J Psychiatry 2003; 160:
130 Seltzer MM, Lee LW. The dynamics of caregiving: transitions during
a three-year prospective study. Gerontologist 2000; 40: 165–78.
109 O’Connor M, Allen J, Kaszniak A. Autonomic and emotion
131 Cleiren MH. Bereavement and adaptation: a comparative study of
regulation in bereavement and depression. J Psychosom Res 2002;
the aftermath of death. Washington, DC: Hemisphere, 1993. 52: 183–85.
132 Nolen-Hoeksema SL J. Coping with loss. Mahwah, NJ: Mahwah,
110 Stroebe M, Folkman S, Hansson RO, Schut H. The prediction of
bereavement outcome: development of an integrative risk factor
133 Carr D, House JS, Kessler RC, Nesse RM, Sonnega J, Wortman C.
framework. Soc Sci Med 2006; 63: 2446–51.
Marital quality and psychological adjustment to widowhood
111 Stroebe W, Schut H. Risk factors in bereavement outcome: a
among older adults: a longitudinal analysis.
methodological and empirical review. In: Stroebe MS, Stroebe W,
J Gerontol B Psychol Sci Soc Sci 2000; 55: S197–207.
Hansson RO, Schut H, eds. Handbook of bereavement research:
134 Carr D. Black/White diﬀ erences in psychological adjustment to
consequences, coping, and care. Washington, DC: American
spousal loss among older adults. Res Aging 2004; 26: 591–622.
Psychological Association, 2001: 349–71.
135 Prigerson H, Maciejewski P, Rosenheck R. Preliminary
112 Carr D, House JS, Wortman C, Nesse R, Kessler RC. Psychological
explorations of the harmful interactive eﬀ ects of widowhood and
adjustment to sudden and anticipated spousal loss among older
marital harmony on health, health service use, and health care
widowed persons. J Gerontol B Psychol Sci Soc Sci 2001; 56:
costs. Gerontologist 2000; 40: 349–57.
136 Murdoch ME, Guarnaccia CA, Hayslip B Jr, McKibbin CL. The
113 Raphael B, Martinek N. Assessing traumatic bereavements and
contribution of small life events to the psychological distress of
PTSD. In: Wilson JP, Keane TM, eds. Assessing psychological
married and widowed older women. J Women Aging 1998; 10:
trauma and PTSD. New York: Guilford, 1997: 373–95.
114 Barry LC, Kasl SV, Prigerson HG. Psychiatric disorders among
137 Moskowitz JT, Folkman S, Acree M. Do positive psychological
bereaved persons: the role of perceived circumstances of death
states shed light on recovery from bereavement? Findings from a
and preparedness for death. Am J GeriatrPsychiatry 2002; 10:
3-year longitudinal study. Death Stud 2003; 27: 471–500.
138 Haine RA, Ayers TS, Sandler IN, Wolchik SA, Weyer JL. Locus of
115 Ong AD, Bergeman, CS, Bisconti, TL. Unique eﬀ ects of daily
control and self-esteem as stress-moderators or stress-mediators
perceived control on anxiety symptomatology during conjugal
in parentally bereaved children. Death Stud 2003; 27: 619–40.
bereavement. Pers Individ Diﬀ 2005; 38: 1057–67.
139 Stroebe M, Schut H, Stroebe W. Attachment in coping with
116 Harwood D, Hawton K, Hope T, Jacoby R. The grief experiences
bereavement: a theoretical integration. Rev Gen Psychol 2005; 9:
and needs of bereaved relatives and friends of older people dying
through suicide: a descriptive and case-control study. J Aﬀ ect Disord
140 Parkes CM. Love and loss: the roots of grief and its complications.
2002; 72: 185–94.
117 Cerel J, Fristad MA, Weller EB, Weller RA. Suicide-bereaved
141 Luecken LJ. Attachment and loss experiences during childhood are
children and adolescents: a controlled longitudinal examination.
associated with adult hostility, depression, and social support.J Am Acad Child Adolesc Psychiatry 1999; 38: 672–79. J Psychosom Res 2000; 49: 85–91.
118 Prigerson HG, Cherlin E, Chen JH, Kasl SV, Hurzeler R, Bradley
142 Luecken LJ, Appelhaus. Early parental loss and salivary cortisol in
EH. The Stressful Caregiving Adult Reactions to Experiences of
young adulthood: The moderating role of family environment.
Dying (SCARED) scale: a measure for assessing caregiver exposure
Dev Psychopathol 2006; 18: 295–308.
to distress in terminal care. Am J Geriatr Psychiatry 2003; 11: 309–19.
143 Nicolson NA. Childhood parental loss and cortisol levels in adult
119 Carr D. A ‘good death’ for whom? Quality of spouse’s death and
men. Psychoneuroendocrinol 2004; 29: 1012–18.
psychological distress among older persons. J Health Soc Behav
144 Tsuchiya KJ, Agerbo E, Mortensen PB. Parental death and bipolar
2003; 44: 215–32.
disorder: A robust association was found in early maternal suicide.
120 Fristad MA, Cerel J, Goldman M, Weller EB, Weller RA. The role of
J Aﬀ ect Disord 2005; 86: 151–59.
ritual in children’s bereavement. Omega 2001; 42: 321–39.
145 Mikulincer M, Shaver P. An attachment perspective on
121 Ringdal GI, Jordhoy MS, Ringdal K, Kaasa S. Factors aﬀ ecting grief
bereavement. In Stroebe M, Hansson RO, Schut H, Stroebe W, eds.
reactions in close family members to individuals who have died of
Handbook of bereavement research and practice: advances in
cancer. J Pain Symptom Manage 2001; 22: 1016–26.
theory and intervention. Washington, DC: American Psychological
122 Christakis NA, Iwashyna TJ. The health impact of health care on
families: a matched cohort study of hospice use by decedents and
146 Mack KY. The eﬀ ects of early parental death on sibling relationships
mortality outcomes in surviving, widowed spouses. Soc Sci Med
in later life. Omega 2004; 49: 131–48.
2003; 57: 465–75.
147 Benore ER, Park CL. Death-speciﬁ c religious beliefs and
123 Goodenough B, Drew D, Higgins S, Trethewie S. Bereavement
bereavement: belief in an afterlife and continued attachment.
outcomes for parents who lose a child to cancer: are place of
Int J Psychol Relig 2004; 14: 1–22.
death and sex of parent associated with diﬀ erences in
148 Stroebe M. The role of religion in bereavement: courage of
psychological functioning? Psychooncology 2004; 13: 779–91.
convictions or scientiﬁ c scrutiny. Int J Psychol Relig 2004; 14: 23–36.
124 Aneshensel CS, Botticello AL, Yamamoto-Mitani N. When
149 Brown SL, Nesse RM, House JS, Utz RL. Religion and emotional
caregiving ends: the course of depressive symptoms after
compensation: results from a prospective study of widowhood.
bereavement. J Health Soc Behav 2004; 45: 422–40. Pers Soc Psychol Bull 2004; 30: 1165–74.
125 Ferrario SR, Cardillo V, Vicario F, Balzarini E, Zotti AM.
150 van Grootheest DS, Beekman AT, Broese van Groenou MI, Deeg DJ.
Advanced cancer at home: caregiving and bereavement.
Sex diﬀ erences in depression after widowhood. Do men suﬀ er more?
Palliat Med 2004; 18: 129–36. Soc Psychiatry Psychiatr Epidemiol 1999; 34: 391–98.
126 Ringdal GI, Ringdal K, Jordhoy MS, Ahlner-Elmqvist M,
151 Lee GR, DeMaris A, Bavin S, Sullivan R. Gender diﬀ erences in the
Jannert M, Kassa S. Health-related quality of life (HRQOL) in
depressive eﬀ ect of widowhood in later life. J Gerontol 2001; 56B:
family members of cancer victims: results from a longitudinal
intervention study in Norway and Sweden. Palliat Med 2004; 18: 108–20.
152 Kreicbergs U, Valdimarsdóttir U, Onelöv E, Henter J, Steineck G.
Anxiety and depression in parents 4-9 years after the loss of a child
127 Boerner K, Schulz R, Horowitz A. Positive aspects of caregiving
owing to a malignancy: a population-based follow-up. Psychol Med
and adaptation to bereavement. Psychol Aging 2004; 19: 668–75.
2004; 34: 1431–41.
128 Schulz R, Mendelsohn AB, Haley W, et al. End-of-life care and the
153 Perkins HW, Harris LB. Familial bereavement and health in adult life
eﬀ ects of bereavement on family caregivers of persons with
course perspective. J Marriage Fam 1990; 52: 233–41.
dementia. N Engl J Med 2003; 349: 1936–42.
www.thelancet.comVol 370 December 8, 2007
154 Williams DR, Takeuchi DT, Adair RK. Marital status and psychiatric
172 Morrison Tonkins SA, Lambert MJ. A treatment outcome study of
disorders among blacks and whites. J Health Soc Behav 1992; 33:
bereaved groups for children. Child Adolesc Soc Work J 1996; 13: 3–21.
173 Goodkin K, Blaney NT, Feaster DJ, Baldewicz T, Burkhalter JE,
155 Bonanno GA. Grief and emotion: a social-functional perspective. In:
Leeds B. A randomized controlled clinical trial of a bereavement
Stroebe MS, Hansson RO, Stroebe W, Schut H, eds. Handbook of
support group intervention in human immunodeﬁ ciency virus type
bereavement research: consequences, coping, and care. Washington
1-seropositive and -seronegative homosexual men.
DC: American Psychological Association, 2001: 493–515. Arch Gen Psychiatry 1999; 56: 52–59.
156 Pennebaker J, Zech E, Rimé, B. Disclosing and sharing emotion:
174 Sandler IN, Ayers TS, Wolchik SA, et al. The family bereavement
psychological, social, and health consequences. In: Stroebe MS,
cacy evaluation of a theory-based prevention program for
Hansson RO, Stroebe W, Schut H, ed. Handbook of bereavement
parentally bereaved children and adolescents. J Consult Clin Psychol
research: Consequences, coping, and care. Washington, DC:
2003; 71: 587–600.
American Psychological Association, 2001: 517–43.
175 Vachon ML, Lyall WA, Rogers J, Freedman-Letofsky K, Freeman SJ. A
157 Nolen-Hoeksema S. Ruminative coping and adjustment to
controlled study of self-help intervention for widows. Am J Psychiatry
bereavement. In: Stroebe MS, Hansson RO, Stroebe W, Schut H,
1980; 137: 1380–84.
eds. Handbook of bereavement research: consequences, coping, and
176 Murray JA, Terry DJ, Vance JC, Battistutta D, Connolly Y. Eﬀ ects of a
care. Washington, DC: American Psychological Association, 2001:
program of intervention on parental distress following infant death.
Death Stud 2000; 24: 275–305.
158 Bower JE, Kemeny, ME, Taylor SE, Fahey JL. Cognitive processing,
177 Pfeﬀ er CR, Jiang H, Kakuma T, Hwang J, Metsch M. Group
discovery of meaning, CD4 decline, and AIDS-related mortality
intervention for children bereaved by the suicide of a relative.
among bereaved HIV-seropositive men. J Consult Clin Psychol 1998;
J Am Acad Child Adolesc Psychiatry 2002; 41: 505–13. 66: 979–86.
178 Kissane DW, McKenzie M, Bloch S, Moskowitz C, McKenzie DP,
159 Davis C, Nolen-Hoeksema S, Larson J. Making sense of loss and
O’Neill I. Family focused grief therapy: a randomized controlled trial
beneﬁ ting from the experience: two construals of meaning.
in palliative care and bereavement. Am J Psychiatry 2006; 163: 1208–18. J Pers Soc Psychol 1998; 75: 561–74.
179 Kissane DW, McKenzie M, McKenzie DP, Forbes A, O’Neill I, Bloch S.
160 Stroebe M, Schut H. The dual process model of coping with
Psychosocial morbidity associated with patterns of family functioning
bereavement: rationale and description. Death Stud 1999; 23: 197–224.
in palliative care: baseline data from the Family Focused Grief Therapy
161 Zettel LA, Rook KS. Substitution and compensation in the social
controlled trial. Palliat Med 2003; 17: 527–37.
networks of older widowed women. Psychol Aging 2004; 19: 433–43.
180 Kempson DA. Eﬀ ects of intentional touch on complicated grief of
162 Freud S. Mourning and melancholia. In: Strachey J, ed. Standard
bereaved mothers. Omega 2001; 42: 341–53.
edition of the complete works of Sigmund Freud. London: Hogarth,
181 Schut HA, Stroebe MS, van den Bout J, de Keijser J. Intervention for
the bereaved: gender diﬀ erences in the eﬃ
163 Wortman C, Silver R. The myths of coping with loss revisited. In:
programmes. Br J Clin Psychol 1997; 36: 63–72.
Stroebe MS, Hansson RO, Stroebe W, Schut H, ed. Handbook of
182 Murphy SA, Johnson C, Cain KC, Das Gupta A, Dimond M, Lohan J.
bereavement research: consequences, coping, and care. Washington,
Broad-spectrum group treatment for parents bereaved by the violent
DC: American Psychological Association, 2001: 405–29.
deaths of their 12- to 28-year-old children: A randomized controlled
164 Lund DA, Caserta MS, deVries B, Wright S. Restoration after
trial. Death Stud 1998; 22: 209–35.
bereavement. Generations review: Br Soc Gerontol 2004; 14: 9–15.
183 Wagner B, Knaevelsrud C, Maercker A. Internet-based
165 Shear K, Frank E, Houck PR, Reynolds CF 3rd. Treatment of
cognitive-behavioral therapy (INTERAPY) for complicated grief: A
complicated grief: a randomized controlled trial. JAMA 2005; 293:
randomized controlled trial. Death Stud 2006; 30: 429–53.
184 Reynolds CF, Miller MD, Pasternak RE, et al. Treatment of
166 Alexopoulos GS. Depression in the elderly. Lancet 2005; 365: 1961–70.
bereavement-related major depressive episodes in later life: A
167 Kato PM, Mann T. A synthesis of psychological interventions for the
controlled study of acute and continuation treatment with
bereaved. Clin Psychol Rev 1999; 19: 275–96.
nortriptyline and interpersonal psychotherapy. Am J Psychiatry 1999;
168 Litterer Allumbaugh D, Hoyt WT. Eﬀ ectiveness of grief therapy: a
meta-analysis. J Counsel Psychol 1999; 46: 370–80.
185 Ogrodniczuk JS, Piper WE, Joyce AS. Diﬀ erences in men’s and
169 Jordan JR, Neimeyer RA. Does grief counseling work? Death Stud
women’s responses to short-term group psychotherapy. Psychother Res
2003; 27: 765–86.
2004; 14: 231–43.
170 Schut H, Stroebe M. Interventions to enhance adaptation to
186 Piper WE, McCallum M, Joyce AS, Rosie JS, Ogrodniczuk JS. Patient
bereavement. J Palliat Med 2005; 8: S140–47.
personality and time-limited group psychotherapy for complicated grief. Int J Group Psychother 2001; 51: 525–52.
171 Black D, Urbanowicz MA. Family intervention with bereaved
children. J Child Psychol Psychiatry 1987; 28: 467–76.
187 Parkes CM. Editorial comments. Bereavement Care 1998; 17: 18.
www.thelancet.comVol 370 December 8, 2007
China Biotech In Review: Chindex Buys Israeli Laser Company For $240 Million Shanghai Fosun Pharma (SH: 600196; HK: 02196), Chindex (NSDQ: CHDX) and a private equity partner willspend up to $240 million to buy 95.6% of an Israeli medical device company, Alma Lasers (see story). Alma,which had revenues of about $100 million last year, makes lasers and other products, primarily for aestheticp
Wolfgang Hofmann Coordinator Jean-Paul-Str. 14 D 40470 DüsseldorfFon: +49 (0)211 612087 Fax: +49 (0)211 612089Mobile: +49 (0)173 2569881 Mail: firstname.lastname@example.org SAHARAULTRAMARATHON2007 WESTSAHARA The Race in brief UltraMarathon 160,9344 kilometres non stop race from Bir Lehlu to Tifariti. The start will be. 21 kilometer in front of Bir Lehlu Only desert region on a track road