Hostname: page-component-cd9895bd7-dzt6s Total loading time: 0 Render date: 2024-12-26T05:55:31.524Z Has data issue: false hasContentIssue false
  • English
  • Français

Pre-loss personal factors and prolonged grief disorder in bereaved mothers

Published online by Cambridge University Press:  09 November 2018

Richard D. Goldstein Open the ORCID record for Richard D. Goldstein [Opens in a new window] ,
Carter R. Petty ,
Sue E. Morris ,
Melanie Human ,
Hein Odendaal ,
Amy Elliott ,
Deb Tobacco ,
Jyoti Angal ,
Lucy Brink  and
Hannah C. Kinney
...Show all authors
Richard D. Goldstein*
Affiliation:
Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA
Carter R. Petty
Affiliation:
Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
Sue E. Morris
Affiliation:
Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
Melanie Human
Affiliation:
Faculty of Medicine and Health Science, Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg, Cape Town, South Africa
Hein Odendaal
Affiliation:
Faculty of Medicine and Health Science, Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg, Cape Town, South Africa
Amy Elliott
Affiliation:
Center for Pediatric and Community Research, Avera McKennan Hospital & University Health Center Sioux Falls, Sioux Falls, SD, USA
Deb Tobacco
Affiliation:
Center for Pediatric and Community Research, Avera McKennan Hospital & University Health Center Sioux Falls, Sioux Falls, SD, USA
Jyoti Angal
Affiliation:
Center for Pediatric and Community Research, Avera McKennan Hospital & University Health Center Sioux Falls, Sioux Falls, SD, USA
Lucy Brink
Affiliation:
Faculty of Medicine and Health Science, Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg, Cape Town, South Africa
Hannah C. Kinney
Affiliation:
Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
Holly G. Prigerson
Affiliation:
Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY, USA
for the PASS Network
Affiliation:
Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, MA, USA Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA Faculty of Medicine and Health Science, Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg, Cape Town, South Africa Center for Pediatric and Community Research, Avera McKennan Hospital & University Health Center Sioux Falls, Sioux Falls, SD, USA Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY, USA
*
Author for correspondence: Richard D. Goldstein, E-mail: Richard.goldstein@childrens.harvard.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Identifying characteristics of individuals at greatest risk for prolonged grief disorder (PGD) can improve its detection and elucidate the etiology of the disorder. The Safe Passage Study, a study of women at high risk for sudden infant death syndrome (SIDS), prospectively examined the psychosocial functioning of women while monitoring their healthy pregnancies. Mothers whose infants died of SIDS were followed in bereavement.

Methods

Pre-loss data were collected from 12 000 pregnant mothers and analyzed for their associations with grief symptoms and PGD in 50 mothers whose infants died from SIDS, from 2 to 48 months after their infant's death, focusing on pre-loss risk factors of anxiety, depression, alcohol use, maternal age, the presence of other living children in the home, and previous child loss.

Results

The presence of any four risk factors significantly predicted PGD for 24 months post-loss (p < 0.003); 2–3 risk factors predicted PGD for 12 months (p = 0.02). PGD rates increased in the second post-loss year, converging in all groups to approximately 40% by 3 years. Pre-loss depressive symptoms were significantly associated with PGD. Higher alcohol intake and older maternal age were consistently positively associated with PGD. Predicted risk scores showed good discrimination between PGD and no PGD 6–24 months after loss (C-statistic = 0.83).

Conclusions

A combination of personal risk factors predicted PGD in 2 years of bereavement. There is a convergence of risk groups to high rates at 2–3 years, marked by increased PGD rates in mothers at low risk. The risk factors showed different effects on PGD.

Keywords

Bereavementmaternalprolonged grief disorderprospectiverisk factorssudden infant death syndrome
Type
Original Articles
Information
Psychological Medicine , Volume 49 , Issue 14 , October 2019 , pp. 2370 - 2378
Copyright
Copyright © Cambridge University Press 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Affonso, DD, De, AK, Horowitz, JA and Mayberry, LJ (2000) An international study exploring levels of postpartum depressive symptomatology. Journal of Psychosomatic Research 49, 207–216.Google Scholar
Barry, LC, Kasl, SV and Prigerson, HG (2002) Psychiatric disorders among bereaved persons: the role of perceived circumstances of death and preparedness for death. American Journal of Geriatric Psychiatry 10, 447–457.Google Scholar
Bergink, V, Kooistra, L, Lambregtse-van den Berg, MP, Wijnen, H, Bunevicius, R, van Baar, A and Pop, V (2011) Validation of the Edinburgh Depression Scale during pregnancy. Journal of Psychosomatic Research 70, 385–389.Google Scholar
Boelen, PA (2009) The centrality of a loss and its role in emotional problems among bereaved people. Behaviour Research and Therapy 47, 616–622.Google Scholar
Boelen, PA and Prigerson, HG (2007) The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life among bereaved adults: a prospective study. European Archives of Psychiatry and Clinical Neuroscience 257, 444–452.Google Scholar
Boelen, PA, van de Schoot, R, van den Hout, MA, de Keijser, J and van den Bout, J (2010) Prolonged grief disorder, depression, and posttraumatic stress disorder are distinguishable syndromes. Journal of Affective Disorders 125, 374–378.Google Scholar
Bonanno, GA and Kaltman, S (1999) Toward an integrative perspective on bereavement. Psychological Bulletin 125, 760–776.Google Scholar
Bonanno, GA, Wortman, CB, Lehman, DR, Tweed, RG, Haring, M, Sonnega, J, Carr, D and Nesse, RM (2002) Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss. Journal of Personality and Social Psychology 83, 1150–1164.Google Scholar
Bonanno, GA, Wortman, CB and Nesse, RM (2004) Prospective patterns of resilience and maladjustment during widowhood. Psychology and Aging 19, 260–271.Google Scholar
Bowlby, J (1980) Loss: Sadness and Depression. New York: Basic Books, vol.3, pp. 242–243.Google Scholar
Brick, J (2006) Standardization of alcohol calculations in research. Alcoholism, Clinical and Experimental Research 30, 1276–1287.Google Scholar
Cattell, RB (1966) Anxiety and motivation: theory and crucial experiments. In Spielberger, CB (ed.) Anxiety and Behavior. New York: Academic Press, pp. 12–19.Google Scholar
Centers for Disease Control and Prevention (2016) Compressed Mortality File 1999–2015 on CDC WONDER Online Database. In Series 20 No. 2U, 2016, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program, ICD-10 codes R95 (Sudden infant death syndrome-SIDS), R96.0 (Instantaneous death), R98 (Unattended death), R99 (Other ill-defined and unspecified causes of mortality), W75 (Accidental suffocation and strangulation in bed). National Center for Health Statistics.Google Scholar
Centers for Disease Control and Prevention (2017) Underlying Cause of Death 1999–2016 on CDC Wonder Online Database [December, 2017]. Data are from the Multiple Cause of Death Files, 1999–2016, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. National Center for Health Statistics.Google Scholar
Cleiren, M, Diekstra, RF, Kerkhof, AJ and van der Wal, J (1994) Mode of death and kinship in bereavement: focusing on ‘who’ rather than ‘how’. Crisis 15, 22–36.Google Scholar
Coelho, A, Silva, C and Barbosa, A (2017) Portuguese validation of the Prolonged Grief Disorder Questionnaire-Predeath (PG-12): psychometric properties and correlates. Palliative and Supportive Care 15, 544–553.Google Scholar
Cox, JL, Chapman, G, Murray, D and Jones, P (1996) Validation of the Edinburgh Postnatal Depression Scale (EPDS) in non-postnatal women. Journal of Affective Disorders 39, 185–189.Google Scholar
Dukes, KA, Burd, L, Elliott, AJ, Fifer, WP, Folkerth, RD, Hankins, GD, Hereld, D, Hoffman, HJ, Myers, MM, Odendaal, HJ, Signore, C, Sullivan, LM, Willinger, M, Wright, C, Kinney, HC and Network, PR (2014) The safe passage study: design, methods, recruitment, and follow-up approach. Paediatric and Perinatal Epidemiology 28, 455–465.Google Scholar
Dyregrov, A and Dyregrov, K (1999) Long-term impact of sudden infant death: a 12- to 15-year follow-up. Death Studies 23, 635–661.Google Scholar
Dyregrov, K, Nordanger, D and Dyregrov, A (2003) Predictors of psychosocial distress after suicide, SIDS and accidents. Death Studies 27, 143–165.Google Scholar
Field, NP, Strasser, J, Taing, S, Horiuchi, S, Chhim, S and Packman, W (2014) Prolonged grief following the recent death of a daughter among mothers who experienced distal losses during the Khmer Rouge era: validity of the prolonged grief construct in Cambodia. Psychiatry Research 219, 183–190.Google Scholar
Givens, JL, Prigerson, HG, Kiely, DK, Shaffer, ML and Mitchell, SL (2011) Grief among family members of nursing home residents with advanced dementia. American Journal of Geriatric Psychiatry 19, 543–550.Google Scholar
Goldsmith, B, Morrison, RS, Vanderwerker, LC and Prigerson, HG (2008) Elevated rates of prolonged grief disorder in African Americans. Death Studies 32, 352–365.Google Scholar
Goldstein, R and Rimer, KP (2013) Parents’ views of their child's end-of-life care: subanalysis of primary care involvement. Journal of Palliative Medicine 16, 198–202.Google Scholar
Goldstein, RD, Lederman, RI, Lichtenthal, WG, Morris, SE, Human, M, Elliott, AJ, Tobacco, D, Angal, J, Odendaal, H, Kinney, HC, Prigerson, HG and Network, P (2018) The grief of mothers after the sudden unexpected death of their infants. Pediatrics 141, e20173651.Google Scholar
Goodenough, B, Drew, D, Higgins, S and Trethewie, S (2004) Bereavement outcomes for parents who lose a child to cancer: are place of death and sex of parent associated with differences in psychological functioning? Psycho-Oncology 13, 779–791.Google Scholar
Heeke, C, Stammel, N and Knaevelsrud, C (2015) When hope and grief intersect: rates and risks of prolonged grief disorder among bereaved individuals and relatives of disappeared persons in Colombia. Journal of Affective Disorders 173, 59–64.Google Scholar
Janssen, HJ, Cuisinier, MC, de Graauw, KP and Hoogduin, KA (1997) A prospective study of risk factors predicting grief intensity following pregnancy loss. Archives of General Psychiatry 54, 56–61.Google Scholar
Kendler, KS, Karkowski, LM and Prescott, CA (1998) Stressful life events and major depression: risk period, long-term contextual threat, and diagnostic specificity. Journal of Nervous and Mental Disease 186, 661–669.Google Scholar
Kendler, KS, Hettema, JM, Butera, F, Gardner, CO and Prescott, CA (2003) Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of onsets of major depression and generalized anxiety. Archives of General Psychiatry 60, 789–796.Google Scholar
Kersting, A, Brahler, E, Glaesmer, H and Wagner, B (2011) Prevalence of complicated grief in a representative population-based sample. Journal of Affective Disorders 131, 339–343.Google Scholar
Keyes, KM, Pratt, C, Galea, S, McLaughlin, KA, Koenen, KC and Shear, MK (2014) The burden of loss: unexpected death of a loved one and psychiatric disorders across the life course in a national study. American Journal of Psychiatry 171, 864–871.Google Scholar
Kozinszky, Z and Dudas, RB (2015) Validation studies of the Edinburgh Postnatal Depression Scale for the antenatal period. Journal of Affective Disorders 176, 95–105.Google Scholar
Li, J, Precht, DH, Mortensen, PB and Olsen, J (2003) Mortality in parents after death of a child in Denmark: a nationwide follow-up study. Lancet 361, 363–367.Google Scholar
Li, J, Laursen, TM, Precht, DH, Olsen, J and Mortensen, PB (2005) Hospitalization for mental illness among parents after the death of a child. New England Journal of Medicine 352, 1190–1196.Google Scholar
Littleton, HL, Breitkopf, CR and Berenson, AB (2007) Correlates of anxiety symptoms during pregnancy and association with perinatal outcomes: a meta-analysis. American Journal of Obstetrics and Gynecology 196, 424–432.Google Scholar
Lotterman, JH, Bonanno, GA and Galatzer-Levy, I (2014) The heterogeneity of long-term grief reactions. Journal of Affective Disorders 167, 12–19.Google Scholar
Lundorff, M, Holmgren, H, Zachariae, R, Farver-Vestergaard, I and O'Connor, M (2017) Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis. Journal of Affective Disorders 212, 138–149.Google Scholar
Maciejewski, PK, Maercker, A, Boelen, PA and Prigerson, HG (2016). “Prolonged grief disorder” and “persistent complex bereavement disorder”, but not “complicated grief”, are one and the same diagnostic entity: an analysis of data from the Yale Bereavement Study. World Psychiatry 15, 266–275.Google Scholar
Maciejewski, PK, Zhang, B, Block, SD and Prigerson, HG (2007) An empirical examination of the stage theory of grief. JAMA 297, 716–723.Google Scholar
Maercker, A, Brewin, CR, Bryant, RA, Cloitre, M, Reed, GM, van Ommeren, M, Humayun, A, Jones, LM, Kagee, A, Llosa, AE, Rousseau, C, Somasundaram, DJ, Souza, R, Suzuki, Y, Weissbecker, I, Wessely, SC, First, MB and Saxena, S (2013) Proposals for mental disorders specifically associated with stress in the International Classification of Diseases-11. Lancet 381, 1683–1685.Google Scholar
Mancini, AD, Griffin, P and Bonanno, GA (2012) Recent trends in the treatment of prolonged grief. Current Opinion in Psychiatry 25, 46–51.Google Scholar
McCarthy, MC, Clarke, NE, Ting, CL, Conroy, R, Anderson, VA and Heath, JA (2010) Prevalence and predictors of parental grief and depression after the death of a child from cancer. Journal of Palliative Medicine 13, 1321–1326.Google Scholar
Michon, B, Balkou, S, Hivon, R and Cyr, C (2003) Death of a child: parental perception of grief intensity – end-of-life and bereavement care. Paediatrics & Child Health 8, 363–366.Google Scholar
Neugebauer, R, Kline, J, Shrout, P, Skodol, A, O'Connor, P, Geller, PA, Stein, Z and Susser, M (1997) Major depressive disorder in the 6 months after miscarriage. Journal of the American Medical Association 277, 383–388.Google Scholar
Nielsen, MK, Neergaard, MA, Jensen, AB, Bro, F and Guldin, MB (2016) Do we need to change our understanding of anticipatory grief in caregivers? A systematic review of caregiver studies during end-of-life caregiving and bereavement. Clinical Psychology Review 44, 75–93.Google Scholar
Nielsen, MK, Neergaard, MA, Jensen, AB, Vedsted, P, Bro, F and Guldin, MB (2017) Predictors of complicated grief and depression in bereaved caregivers: a nationwide prospective cohort study. Journal of Pain and Symptom Management 53, 540–550.Google Scholar
Ostfeld, BM, Ryan, T, Hiatt, M and Hegyi, T (1993) Maternal grief after sudden infant death syndrome. Journal of Developmental and Behavioral Pediatrics 14, 156–162.Google Scholar
Papa, A, Lancaster, NG and Kahler, J (2014) Commonalities in grief responding across bereavement and non-bereavement losses. Journal of Affective Disorders 161, 136–143.Google Scholar
Parkes, CM and Weiss, RS (1983) Recovery From Bereavement. New York: Basic Books, Inc, pp. 216–226.Google Scholar
Pohlkamp, L, Kreicbergs, U, Prigerson, HG and Sveen, J (2018) Psychometric properties of the Prolonged Grief Disorder-13 (PG-13) in bereaved Swedish parents. Psychiatry Research 267, 560–565.Google Scholar
Prigerson, HG, Frank, E, Kasl, SV, Reynolds, CF III, Anderson, B, Zubenko, GS, Houck, PR, George, CJ and Kupfer, DJ (1995) Complicated grief and bereavement-related depression as distinct disorders: preliminary empirical validation in elderly bereaved spouses. American Journal of Psychiatry 152, 22–30.Google Scholar
Prigerson, HG, Bierhals, AJ, Kasl, SV, Reynolds, CF III, Shear, MK, Newsom, JT and Jacobs, S (1996 a) Complicated grief as a disorder distinct from bereavement-related depression and anxiety: a replication study. American Journal of Psychiatry 153, 1484–1486.Google Scholar
Prigerson, HG, Bierhals, AJ, Kasl, SV, Reynolds, CF, Shear, MK, Newson, JT and Jacobs, S (1996 b) Complicated grief as a disorder distinct from bereavement-related depression and anxiety: a replication study. American Journal of Psychiatry 153, 1484–1486.Google Scholar
Prigerson, HG, Bierhals, AJ, Kasl, SV, Reynolds, CF III, Shear, MK, Day, N, Beery, LC, Newsom, JT and Jacobs, S (1997) Traumatic grief as a risk factor for mental and physical morbidity. American Journal of Psychiatry 154, 616–623.Google Scholar
Prigerson, HG, Bridge, J, Maciejewski, PK, Beery, LC, Rosenheck, RA, Jacobs, SC, Bierhals, AJ, Kupfer, DJ and Brent, DA (1999) Influence of traumatic grief on suicidal ideation among young adults. American Journal of Psychiatry 156, 1994–1995.Google Scholar
Prigerson, HG, Vanderwerker, LC and Maciejewski, PK (2008) A Case for Inclusion of Prolonged Grief Disorder in DSM-V. Washington, DC, US: American Psychological Association.Google Scholar
Prigerson, HG, Horowitz, MJ, Jacobs, SC, Parkes, CM, Aslan, M, Goodkin, K, Raphael, B, Marwit, SJ, Wortman, C, Neimeyer, RA, Bonanno, GA, Block, SD, Kissane, D, Boelen, P, Maercker, A, Litz, BT, Johnson, JG, First, MB and Maciejewski, PK (2009) Prolonged grief disorder: psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine 6, e1000121.Google Scholar
Rando, TA (1986) Parental Loss of a Child. Champaign, IL: Research Press.Google Scholar
Roberts, K, Holland, J, Prigerson, HG, Sweeney, C, Corner, G, Breitbart, W and Lichtenthal, WG (2017) Development of the Bereavement Risk Inventory and Screening Questionnaire (BRISQ): item generation and expert panel feedback. Palliative and Supportive Care 15, 57–66.Google Scholar
Rogers, CH, Floyd, FJ, Seltzer, MM, Greenberg, J and Hong, J (2008) Long-term effects of the death of a child on parents’ adjustment in midlife. Journal of Family Psychology 22, 203–211.Google Scholar
Schaal, S, Jacob, N, Dusingizemungu, JP and Elbert, T (2010) Rates and risks for prolonged grief disorder in a sample of orphaned and widowed genocide survivors. BMC Psychiatry 10, 55.Google Scholar
Schulz, R, Mendelsohn, AB, Haley, WE, Mahoney, D, Allen, RS, Zhang, S, Thompson, L, Belle, SH and Resources for Enhancing Alzheimer's Caregiver Health I (2003) End-of-life care and the effects of bereavement on family caregivers of persons with dementia. New England Journal of Medicine 349, 1936–1942.Google Scholar
Schut, H, Stroebe, MS, van den Bout, J and Terheggen, M (2001) The efficacy of bereavement interventions: determining who benefits. In Stroebe, MS, Hansson, RO, Stroebe, W and Schut, H (eds) Handbook of Bereavement Research: Consequences, Coping, and Care. Washington, DC: American Psychological Association, pp. 705–737.Google Scholar
Sobell, LC and Sobell, MB (1992) Timeline Followback: A Technique for Assessing Self Reported Ethanol Consumption. Totowa, NJ: Humana Press.Google Scholar
Spielberger, CD (1983) Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press.Google Scholar
Statistics South Africa (2015) Methodological Report on Rebasing of National Poverty Lines and Development of Pilot Provincial Poverty Lines. Pretoria, South Africa: Statistics SA.Google Scholar
Stroebe, W and Schut, H (2001) Risk factors in bereavement outcome: a methodological and empirical review. In Stroebe, MS, Hansson, RO, Stroebe, W and Schut, H (eds), Handbook of Bereavement Research. Washington, DC: American Psychological Association, pp. 349–372.Google Scholar
Stroebe, MS, Folkman, S, Hansson, RO and Schut, H (2006) The prediction of bereavement outcome: development of an integrative risk factor framework. Social Science and Medicine 63, 2440–2451.Google Scholar
Stroebe, M, Schut, H and Boerner, K (2017). Cautioning Health-Care Professionals. Omega (Westport) 74, 455–473.Google Scholar
Su, KP, Chiu, TH, Huang, CL, Ho, M, Lee, CC, Wu, PL, Lin, CY, Liau, CH, Liao, CC, Chiu, WC and Pariante, CM (2007) Different cutoff points for different trimesters? The use of Edinburgh Postnatal Depression Scale and Beck Depression Inventory to screen for depression in pregnant Taiwanese women. General Hospital Psychiatry 29, 436–441.Google Scholar
Toedter, LJ, Lasker, JN and Campbell, DT (1990) The comparison group problem in bereavement studies and the retrospective pretest. Evaluation Review 14, 75–90.Google Scholar
Toedter, LJ, Lasker, JN and Janssen, HJ (2001) International comparison of studies using the perinatal grief scale: a decade of research on pregnancy loss. Death Studies 25, 205–228.Google Scholar
United States Census Bureau (2017) QuickFacts. Available at https://www.census.gov/quickfacts/fact/table/oglalalakotacountysouthdakota/INC110216#viewtop.Google Scholar
Warland, J, O'Leary, J, McCutcheon, H and Williamson, V (2011) Parenting paradox: parenting after infant loss. Midwifery 27, e163–e169.Google Scholar
Wijngaards-de Meij, L, Stroebe, M, Stroebe, W, Schut, H, Van den Bout, J, Van Der Heijden, PG and Dijkstra, I (2008) The impact of circumstances surrounding the death of a child on parents’ grief. Death Studies 32, 237–252.Google Scholar
World Health Organization (2018) International Classification of Diseases for Mortality and Morbidity Statistics (ICD-11 MMS) Available at https://icd.who.ont/dev11/l-m/en#Google Scholar
Xiu, D, Maercker, A, Woynar, S, Geirhofer, B, Yang, Y and Jia, X (2016) Features of prolonged grief symptoms in Chinese and Swiss bereaved parents. Journal of Nervous and Mental Disease 204, 693–701.Google Scholar
Zetumer, S, Young, I, Shear, MK, Skritskaya, N, Lebowitz, B, Simon, N, Reynolds, C, Mauro, C and Zisook, S (2015) The impact of losing a child on the clinical presentation of complicated grief. Journal of Affective Disorders 170, 15–21.Google Scholar
Zisook, S, Devaul, RA and Click, MA Jr. (1982) Measuring symptoms of grief and bereavement. American Journal of Psychiatry 139, 1590–1593.Google Scholar
Zisook, S and Shuchter, SR (1985) Time course of spousal bereavement. General Hospital Psychiatry 7, 95–100.Google Scholar