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Bereavement care interventions: a systematic review

BMC Palliative Care20043:3

DOI: 10.1186/1472-684X-3-3

Received: 20 February 2004

Accepted: 26 July 2004

Published: 26 July 2004

Abstract

Background

Despite abundant bereavement care options, consensus is lacking regarding optimal care for bereaved persons.

Methods

We conducted a systematic review, searching MEDLINE, PsychINFO, CINAHL, EBMR, and other databases using the terms (bereaved or bereavement) and (grief) combined with (intervention or support or counselling or therapy) and (controlled or trial or design). We also searched citations in published reports for additional pertinent studies. Eligible studies had to evaluate whether the treatment of bereaved individuals reduced bereavement-related symptoms. Data from the studies was abstracted independently by two reviewers.

Results

74 eligible studies evaluated diverse treatments designed to ameliorate a variety of outcomes associated with bereavement. Among studies utilizing a structured therapeutic relationship, eight featured pharmacotherapy (4 included an untreated control group), 39 featured support groups or counselling (23 included a control group), and 25 studies featured cognitive-behavioural, psychodynamic, psychoanalytical, or interpersonal therapies (17 included a control group). Seven studies employed systems-oriented interventions (all had control groups). Other than efficacy for pharmacological treatment of bereavement-related depression, we could identify no consistent pattern of treatment benefit among the other forms of interventions.

Conclusions

Due to a paucity of reports on controlled clinical trails, no rigorous evidence-based recommendation regarding the treatment of bereaved persons is currently possible except for the pharmacologic treatment of depression. We postulate the following five factors as impeding scientific progress regarding bereavement care interventions: 1) excessive theoretical heterogeneity, 2) stultifying between-study variation, 3) inadequate reporting of intervention procedures, 4) few published replication studies, and 5) methodological flaws of study design.

Keywords

Bereavement intervention systematic review

Background

Give sorrow words; the grief that does not speak

Whispers the o'er fraught heart and bids it break.

Shakespeare, Macbeth IV, iii, 209

Grieving the death of a loved one has an ancient history: from time immemorial, cultures have provided the bereaved with advice and rituals to address – and express – the experience of grief [1]. Over the past several decades, efforts to aid the bereaved have increasingly focused on the physical and psychological morbidity, and the spiritual suffering and social isolation associated with bereavement. The resulting plethora of intervention options, ranging from mutual-help support groups to prescribed pharmacotherapy and professionally led psychotherapy, is striking, as is the panoply of settings in which bereavement care can be found: hospitals, hospices, churches, palliative care units, community-based services, and bereavement-specific foundations all provide an array of bereavement care interventions. This welter of activity testifies to the broadly valued goal of decreasing the severity of bereavement-related symptoms.

Given the abundance of care options, what is the best way to care for a bereaved person? Numerous studies measuring the impact of bereavement interventions have been published in diverse journals, yet no consensus has emerged in the medical, mental health, or social work communities regarding whether one form of treatment is preferable to another [25]. We therefore have conducted a systematic review of bereavement care interventions. Our goal is to present a comprehensive yet coherent synthesis of the current literature that will promote the advancement in the quality of care and research on behalf of bereaved individuals.

Methods

Data sources

To identify studies in the traditional medical literature as well as the complementary and alternative medicine literature, we searched the following databases: MEDLINE; PsychINFO; Cumulative Index to Nursing and Allied Health (CINAHL); BIOSIS Previews; ISI Science Citation Index Expanded and Social Sciences Index; Evidence Based Medicine Reviews (EBMR), including the Cochrane Database of Systematic Reviews (DSR), the Cochrane Controlled Trial Registry (CCTR), Database of Abstracts of Reviews of Effectiveness (DARE), and the American College of Physicians' (ACP) Journal Club Review; Sociological Abstracts; Alt HealthWatch; and Wilson Web from 1966 to 2003. We identified all relevant articles on bereavement care interventions by using the primary search terms of "bereaved or bereavement" and "grief", combined with secondary descriptors of "intervention or support or counselling or therapy" and "controlled or trial or design".

Study selection

Our inclusion criteria specified that each study: 1) addressed the treatment of bereaved individuals, and 2) included an evaluation of a selected method of therapy aimed at reducing the grief reaction due to bereavement. We considered only articles written in the English language. We then reviewed the titles and abstracts of all articles we retrieved through our initial database search, and obtained the full texts of all applicable studies. We also reviewed the references in all applicable studies for additional pertinent studies.

Data extraction

The full articles of all studies that met inclusion criteria and passed subsequent title and abstract reviews were retrieved and examined independently by two of the authors. Each article was reviewed for measured outcomes, patient and decedent characteristics, and intervention characteristics. These measures included sample size, type of intervention, length of intervention, patient's relationship to the deceased, time since the bereaved death, and patient demographics. Data was extracted and any disagreements were resolved through discussion, clarification, and consensus within the research team.

Characteristics of reviewed studies

The initial literature search generated 737 citations. Elimination of duplicate citations yielded 340 references. 2 studies, written in Chinese and Spanish, were excluded. Reviewing the titles culled the sample to 243 citations, and a review of the abstracts found 87 of these to be potentially relevant. Of these, 9 were dissertations, 2 were irretrievable, 2 were duplicate publications of the same study, and 15 were ineligible because they did not meet our inclusion criteria. The resulting set of 74 articles was subject to review for data extraction. A list of all citations found, including those excluded from this analysis, is available [see Additional file 1].

Of the 74 studies that met inclusion criteria, almost 6,000 participants within these studies experienced a multitude of losses – of parents, spouses, children, and other loved ones who had died from a wide range of causes, both sudden and protracted. The therapies utilized and outcomes evaluated varied widely. Heterogeneity among both the outcomes and the measures used to assess similar outcomes precluded an effort to summarize data across studies, even in the form of generic effect-size measures. Furthermore, for a significant portion of the studies, concerns regarding the internal or external validity of the reported results cautioned against making quantitative summary statements regarding treatment effects.

Results

The 74 studies selected for detailed review evaluated diverse types of interventions designed to ameliorate the adverse physical and psychological outcomes associated with bereavement. These interventions can be classified according to various schemes, including their underlying theoretical framework (ranging from Freudian psychoanalysis to neurotransmitter imbalances), the format of the intervention (individual, group, family, marital), the timing of the intervention (acute, intermittent crisis, chronic), the tasks assigned to the bereaved (ranging from verbalizing feelings to taking medication), or the population targeted for the intervention (children, adults, seniors). We chose to organize this review on the basis of the social framework used to implement the intervention (that is, either personalized structured therapeutic relationships or less personal systems-level interventions), as this attribute of the interventions emerged as the most verifiable and salient measure.

Structured therapeutic relationship

Eight studies feature pharmacotherapy, but only four compared active therapy to non-pharmacotherapy controls, and only one study clearly reported their random allocation method (Table 1) [613]. These studies targeted adults and seniors, ranged in sample size from 10–80 subjects, and used a variety of drugs, including tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRI), buprioion, and benzodiazepines. Overall, these studies demonstrated a statistically significant beneficial effect of pharmacotherapy on ameliorating symptoms of depression and improving subjective sleep quality [611, 13]. These benefits persisted only as long as the subjects continued to receive pharmacotherapy. Pharmacotherapy was found, however, to have a mixed effect on bereavement intensity as measured by symptoms of grief (i.e., Texas Revised Inventory of Grief, Inventory of Complicated Grief). For example, Warner and colleagues (2001) did not find evidence of an effect of benzodiazepines (diazepam) on bereavement-related grief intensity[12]. One study combined pharmacotherapy with psychotherapy in a 16-week double-blinded factorial design trial of nortriptyline (NT) and interpersonal psychotherapy [6]. The 80 patients were randomly assigned to one of four treatment conditions: NT plus interpersonal psychotherapy, NT plus medication clinic (i.e., no interpersonal psychotherapy), placebo pill plus interpersonal psychotherapy, and placebo pill plus medication clinic (i.e., no interpersonal psychotherapy conditions). Details of the psychotherapy were not described. While the results displayed a statistically significant benefit of nortriptyline over placebo regarding remission of depression, none of the treatment conditions were associated with diminishment of grief.
Table 1

Pharmacotherapy Interventions

Medication

Pop

CG

RA

Num*

TSL (days)

Dose

DT (days)

Key Outcome Measures

Article

Nortriptyline

Senior

Y

Y-NE

80/66

216–279

Steady-state plasma level: 50–120 ng/mL

112

Depression (HAM-D); Grief (TRIG)

Reynolds, Miller, et al, 1999**

 

Senior

Y

Y-NE

27/27

210 (mean)

Steady-state plasma level: 79.9+/-28.3 ng/mL

Daily dose: 70.8+/-22.2 mg

<180

Sleep (PSQI); Depression (HAM-D, BDI)

Taylor, Reynolds, et al, 1999

 

Senior

Y

NR

30/24

276

Steady-state plasma level: 72.7 ng/mL

Daily dose: 53.0 mg

112

Sleep (PSQI)

Pasternak, Reynolds, et al, 1994

 

Senior

N

NA

13/13

150–750

Daily dose: 49.2 mg

9–184

Depression (HAM-D, BDI, BSI); Grief (TRIG, JGI); Sleep (PSQI)

Pasternak, Reynolds, et al, 1991

Nortriptyline and Paroxetine

Adult

N

NA

21/15

183–4158

PT Daily dose: 20–50 mg

NT Daily dose: 50–160 mg

120

Depression (HAM-D); Grief (ICG); Sleep (PSQI)

Zygmont, Prigerson, et al, 1998

Desipramine

Adult

N

NA

10/9

NR

Daily dose: 75–150 mg

28

Depression (HDRS, CGI, Raskin DS); Grief (Separation Distress)

Jacobs, Nelson, et al, 1987

Bupropion

Adult

N

NA

22/14

42–56

Daily dose: 150–300 mg

56

Grief (TRIG, ICG); Depression (HAM-D)

Zisook, Schuchter, et al, 2001

Diazepam

Senior

Y

Y

35/30

<14

2 mg/pill, self-administered

<42

Bereavement (BPQ)

Warner, Metcalfe, et al, 2001

Notes: * All Ns are reported as (starting population of bereaved individuals/bereaved population completing all follow-ups), unless only study included only one assessment. ** Study also included psychotherapy condition. Legend: Pop, Target Population; CG, Control Group; RA, Random Assignment; Num, Number of subjects; TSL, Time Since Loss; DT, Duration of Trial; NA, Not Applicable; NR, Not Reported; UC, Unclear; Y, Yes; N, No; Y-NE, Randomization mentioned, but allocation method not explicitly stated; RS, Randomization Subverted.

Support groups or counsellingconstituted the intervention in 39 studies, of which 23 had control groups and 15 claimed random allocation, yet only three of these included clearly described allocation methods (Table 2) [1452]. Ten of these were mutual/self-help, with the majority taking the form of informal group therapy. The remaining 29 studies were professionally led support groups targeting select subgroups including parentally bereaved children, college students, and seniors, as well as many specific adult populations. Program implementation across studies varied even further. This variation was found in terms of number of sessions (one to 25), whether the sessions proceeded with full-fledged patient-driven discussion or highly structured protocols, whether attendance was mandatory or individually motivated, as well as in the nature of the group leadership and the format (individual, group, or marital). Perhaps due to these or other differences in the interventions, some studies documented study treatment effects [22, 26, 2931, 33, 34, 52] while other studies showed no effect [15, 17, 27, 37, 46, 51].
Table 2

Support/Counselling Interventions

Type

Format

Pop

CG

RA

Num

TSL (days)

DT

Key Outcome Measures

Article

Mutual/Self-help

Individual

Adult

Y

Y-NE

162/62

~30

NR

Psychiatric Functioning (GHQ); Social Support/psychological and psychophysiological variables (author-created)

Vachon, Lyall, et al, 1980

Mutual/Self-help (included professionally-lead groups)

Group

Senior

Y

RS

339/295

30–60

56, 365 days

Self-Esteem (Rosenberg's Self-Esteem Scale); Life Satisfaction (LSI-A); Depression (GDS); Grief (TRIG)

Caserta & Lund, 1983

Mutual/Self-help

Group

Senior

Y

N

23

34–474

21 days; 7 sessions

Domain Specific State Locus of Control (Zeigler-Reid State Locus of Control Measure); Trait Locus of Control (I-E); Distress (BSI, GSI)

McKibbin, Guarnaccia, et al, 1997

Mutual/Self-Help

Group

Adult

Y

Y

113/67

90–365

63 days; 9 sessions

Depression (GHQ, BDI); Anxiety (STAI); Social Functioning (SAS); Social Support (SSQ)

Tudiver, Hilditch, et al, 1992

Mutual/Self-help

Group

Adult

Y

Y-NE

113/112

90–365

63 days

Healthcare visit rates (Family Physician, Specialist, Psychiatrist)

Tudiver, Permaul-Woods, et al, 1995

Mutual/Self-help

Group

Adult

Y

N

38/21

90–750

70 days; 10 sessions

Treatment Expectancy (Expectancy Scale); Depression (BDI); Avoidance, Anxiety (Social Anxiety and Distress Scale); Enjoyability (Pleasant Events Scale); Life Satisfaction (Life Satisfaction Scale)

Walls & Meyers, 1985

Mutual/Self-help

Group

Adult

Y

N

721/502

~1290

365 days; >3 sessions

Depression, Anxiety, Somatization (Hopkins Symptom Checklist); Self Esteem, Well-being, Mastery (Not reported)

Lieberman & Videka-Sherman, 1986

Mutual/Self-help

Group

Adult

Y

N

667/391

365–1095

365 days

Depression, Anxiety, Somatization (Not reported); Self Esteem (Rosenberg 1965); Life Satisfaction, Mastery, Medication (Not reported); Social Functioning Parental Functioning Attitudes (BPQ)

Videka-Sherman & Lieberman, 1985

Mutual/Self-help

Group

Adult

N

Y-NE

61/55

120–1095

84 days; 12 sessions

Avoidance/Intrusion (IES); Stress Symptoms (SRRS); Depression (BDI); Mental Distress (BPRS, SCL-90); Social Functioning (SAS-SR); Overall Functioning (GAS)

Marmar, Horowitz, et al, 1988**

Mutual/Self-help

Group

Adult

N

NA

53/33

<730

8 sessions, optional 4

Psychosomatic Symptoms (SCL-90 subscales: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism, GSI)

Rogers, Sheldon, et al, 1982

Professionally Lead

Individual

Adult

Y

NR

493/225

120

1 day; 1 session

Grief (HGRC)

Kaunonen, Tarkka, et al, 2000

Professionally Lead

Family

Adult

Y

Y-NE

50/30

1–2

1–120 days; up to 8 sessions

General Health Questionnaire (self-rated); Anxiety, Depression (Leeds Scale)

Forrest, Standish, & Baum, 1982

Professionally Lead

Family

Adult

Y

UC

334/161*

<1–180

7–70 days; up to 10 sessions

Medical Illness (CMI, MMPI); Psychiatric Illness (Boston Bereavement, Mood Inventory); Family Functioning (Ferriera-Winter, Bodin Drawing); Crisis Coping (Intrapersonal, Family, Job/Financial, Social); Social Cost (Gross Income, Living Expenses, Absenteeism, Economic Loss)

Williams, Lee, & Polak, 1976 Polak, Egan, et al, 1975

Professionally Lead

Family

Adult

Y

UC

176/86*

<1–180

7–70 days; up to 10 sessions

Neurotic Symptoms Scale; Bodin Family Closeness; Crisis Coping Scale; Religious helping of others; Authoritarian Family Functioning; Depression; Monthly Income; Monthly Expenses; Social Costs; Bereavement Adjustment

Williams & Polak, 1979

Professionally Lead

Family

Adult

N

NA

77/37*

<1

>360 days

Personal and social phenomena of death (structured interview)

Oliver, Sturtevant, et al, 2001

Professionally Lead

Family

Child

Y

Y-NE

72/55

<730

15 sessions

Depression (CDI, CBCL, PERI Demoralization Scale); Parental Warmth (CRPBI); Family Cohesion (Family Environment Scale); Parent perception of support (author-created scale); Family Coping (F-COPES)

Sandler, West, et al, 1992

Professionally Lead

Group

Senior

N

NR

28/11

90–7300

<140 days; up to 20 sessions

Social Support (ASSIS); Affect/Mood (PANAS); Emotional/Social Loneliness (ESLI)

Stewart, Craig, et al, 2001

Professionally Lead

Group

Adult

Y

Y

197/166

<180

70 days; 10 sessions

Grief (TRIG, GRI); Distress (POMS); Depression and Anxiety (SIGH-AD)

Goodkin, Blaney, et al, 1999

Professionally Lead

Group

Adult

Y

Y-NE

242/185

0–35

77 days; 3 sessions

Distress (POMS-TMD, Anxiety-tension, Depression-dejection, Anger-hostility, Confusion-bewilderment, Overall emotional disturbance); Self-Esteem (Rosenberg 1965 scale)

Swanson, 1999

Professionally Lead

Group

Adult

Y

Y-NE

150/120

30–240

270 days

Depression (CES-D, BDI); Anxiety (A-Sta); Somatic Symptoms (SOM); Emotional Symptoms (EMOT); Life Satisfaction (Lsat, SelfAnch)

Kay, Guernsey de Zapien, et al, 1993

Professionally Lead

Group

Adult

Y

Y-NE

119/119

<180

70 days; up to 10 sessions

Immunological measures (CD3+CD4+ cell count, CD3+CD8+ cell count, CD4/CD8 ratio, CD3+ cell count, CD4 cell count, Lymphocyte count, T-lymphocyte count); Neuroendocrine measure (Plasma cortisol level)

Goodkin, Feaster, et al, 1998

Professionally Lead

Group

Adult

Y

Y-NE

110/80

~730

28 days; 8 sessions

Coping and Adaptation (TAT)

Balk, Lampe, et al, 1998

Professionally Lead

Group

Adult

Y

Y-NE

36/36

<180

70 days; up to 10 sessions

Plasma Viral Load (HIV-1 RNA copy number)

Goodkin, Baldewicz, et al, 2001

Professionally Lead

Group

Adult

Y

N

159/127

42–140

Up to 25 sessions

Social Support (SSES); Group Involvement (Liberman & Videka-Sherman, 1986); Depression (CES-D, POMS-D); Anger (POMS-A); Anxiety (POMS-T); Stress (IES)

Levy, Derby, et al, 1993

Professionally Lead

Group

Adult

Y

N

121

30–4745

30–365 days

Grief (HGRC subscales: Despair, Panic behavior, Personal growth, Blame and Anger, Detachment, Disorganization)

DiMarco, Menke, & McNamara, 2001

Professionally Lead

Group

Adult

N

Y

139/107

90–17155

84 days; 12 sessions

Avoidance/Intrusion (IES); Grief (TRIG); Interpersonal Distress (IIP); Social Functioning (SAS-SR); Depression (BDI); Anxiety (STAI); Mental Distress (BSI, GSI); Self-Esteem (SES); Physical Functioning (SF-36); Symptomatic Distress (SCL-90)

Piper, McCallum, et al, 2001**

Professionally Lead

Group

Adult

N

N

83/70

<30–8030

49 days; 7 sessions

Physical, Emotional, and Social Functioning (author created measures); Self Esteem (Rosenberg, 1962); Locus of Control (I-E); Life satisfaction (Neugarten, Havighurdt, & Tobin, 1961); Attitude Toward Women (Spence & Helmreich, 1972, Gump 1972)

Barrett, 1978

Professionally Lead

Group

Adult

N

NA

392/77

NR

56 days

Distress (BSI); Group Process and Satisfaction (author created questionnaire)

Glajchen & Magen, 1995

Professionally Lead

Group

Adult

N

NA

174/138

780

730 days

Motives for joining (Lieberman 1979); Interpersonal relations (Porat 1987); Group leadership style (Porat 1987); Perceived contribution of treatment on recovery

Geron, Ginsberg, & Solomon, 2003

Professionally Lead

Group

Adult

N

NA

21/21

NR

70 days; up to 10 sessions

Perceived Social Support (PRQ); Perceived Stress (PSS)

Davis, Hoshiko, et al, 1992

Professionally Lead

Group

Adult

N

NA

21/21

365–3650

52 days; up to 8 sessions

Depression (CDI); Anxiety (HSC-25); Knowledge of Death and Bereavement (KDBQ)

Stoddart, Burke, & Temple, 2002

Professionally Lead

Group

Adult

N

NA

20

90–1095

<1095 days; unlimited sessions

Grief (TRIG); Social Network (SNM, SNG)

Forte, Barrett, & Campbell, 1996

Professionally Lead

Group

Adult

N

NA

12/5

60–780

28 days; 8 sessions

Emotional Distress (EPI); Family Adjustment (FACES-III); Social Adjustment (SAS-SR)

Heiney, Ruffin, & Goon-Johnson, 1995

Professionally Lead

Group

Child

Y

Y-NE

17/17

>730

42 days; 6 sessions

Self-Esteem (PH); Depression (CDI); Behavior (CBCL-TRF, CBCL-YSR)

Huss & Ritchie, 1999

Professionally Lead

Group

Child

N

NA

38/29

<900

300 days; 12 sessions

Depression (BID); Attitude/ Conception of Death (ATCD)

Shilling, Koh, et al, 1992

Professionally Lead

Group

Child

N

NA

18/18

<730

52 days; 8 sessions

Bereavement Survey (author created); Loss Resolution (LRS-Modified); Distress and Somatic Complaints (ALAC)

Opie, Goodwin, Finke, et al, 1992

Professionally Lead

Group

Child

N

NA

6/6

240–1020

42 days; 6 sessions

Psychological measures (Lewis Counselling Inventory, IPAT)

Quarmby, 1993

Professionally Lead

Group

Child

N

NA

4/4

<90

77 days; 11 sessions

Self-Esteem (Piers-Harris Self-Concept Scale); Descriptive (Risk Impact, Negative Chain Events, Opening Up Opportunities)

Zambelli & DeRosa, 1992

Professionally Lead

Couple/ Marital

Adult

Y

Y-NE

57/31

NR

Mean of 6 sessions

Grief (TRIG); Irritability, Depression, Anger (IDA)

Lilford, Stratton, et al, 1994

Notes: * Families, not individuals. ** Study also included psychotherapy condition. Legend: Type, Type of Intervention; Format, Format of Intervention; Pop, Target Population; CG, Control Group; RA, Random Assignment; Num, Number of subjects; TSL, Time Since Loss; DT, Duration of Trial; NA, Not Applicable; NR, Not Reported; UC, Unclear; Y, Yes; N, No; Y-NE, Randomization mentioned, but allocation method not explicitly stated; RS, Randomization Subverted.

Several studies documented substantial spontaneous improvements in bereavement symptomology in the control groups. Kay and others (1993) report a bereavement intervention for Mexican-American widows [33]. They found that all widows improved on all depression scales, state anxiety, life satisfaction, and emotional and somatic symptom scales over the course of two years. However, those widows in the experimental support group exhibit significantly improved changes in these scores. Tudiver and colleagues (1992) conducted a mutual-help support group for recently bereaved widowers [17] that can be compared to Vachon and colleagues' (1980) and Barrett's (1978) widow studies [14, 39]. Tudiver and others found significant improvement over time (baseline to eight months) for all widowers, but found no significant differences between those who received treatment and a comparison group of windowers who were on the wait list to receive treatment but had not.

Psychotherapy-based treatments, another form of psychological interventions, can be done in different formats (family, group, or individual), and via different approaches. Of the 25 studies that use psychotherapy as an intervention, approaches included cognitive-behavioral, psychodynamic, psychoanalytical, and interpersonal approaches, as well as combinations of these and modality and social support (Table 3)[6, 19, 22, 35, 38, 5372]. Seventeen of these studies utilized control groups, only 13 claimed randomization, and only five of these clearly stated their method of allocation.
Table 3

Psychotherapy Interventions

Type

Format

Pop

CG

RA

Num

TSL (days)

DT

Key Outcome Measures

Article

Cognitive-behavioral

Individual

Senior

Y

N

58/NR

120–180

70 days; 4 sessions

Mastery (Personal Mastery Scale); Well-being (MHI subscales, ABS Subscale, PERI self-esteem); Distress (PERI Demoralization Scales, MHI subscales)

Reich & Zautra, 1989

 

Individual

Senior

N

NA

4/4

540–730

98 days; 14–18 sessions

Distress (SUDS); Grief (ICG); Depression (BDI); Anxiety (BAI)

Harkness, Shear, et al, 2002**

 

Individual

Adult

Y

Y

30/25

>90

35 days; 10 sessions

Avoidance/Intrusion (IES); Anxiety (SCL-90); Depression (SCL-90); Mood (POMS)

Lange, van de Ven, et al, 2001

 

Individual

Adult

Y

Y-NE

26/14

180–7300

70 days; 6 sessions

Depression (Wakefield, BDI); Physical Symptoms (Mawson et al, 1981); Fear (FQ); Grief (TRIG); Avoidance (Bereavement Avoidance Tasks)

Sireling, Cohen, & Marks, 1988

 

Group

Adult

Y

Y-NE

261/147

46–229

84 days; 8 sessions

Mental Distress (BSI, GSI); PTS Symptoms (TES); Grief (GES); Physical Health (HHB); Marital Strain (DAS)

Murphy, Johnson, et al, 1998 Murphy, 1997

 

Group

Adult

Y

Y-NE

110/80

~730

28 days; 8 sessions

Coping and Adaptation (TAT)

Balk, Lampe, et al, 1998

 

Group

Adult

Y

N

38/21

90–750

70 days; 10 sessions

Treatment Expectancy (Expectancy Scale); Depression (BDI); Avoidance, Anxiety (Social Anxiety and Distress Scale); Enjoyability (Pleasant Events Scale); Life Satisfaction (Life Satisfaction Scale)

Walls & Meyers, 1985

 

Group

Adult

N

NA

8/8

>30

56 days; 8 sessions

Avoidance/Intrusion (IES); Depression (BDI, SCL-90-R); Anxiety (SCL-90-R, STAI); Grief (GRI); Distress (PERI Demoralization)

Sikkema, Kalichman, et al, 1995****

 

Group

Child

Y

UC

19/18

<730

NR

Behavior (BRIC-S, BRIC-H); Depression (DSRS); Grief (BP)

Hilliard, 2001

Psycho-dynamic

Individual

Senior

Y

Y

228

~60

<180 days; Unlimited sessions

Number of Office Visits, Types of Illnesses

Gerber, Wiener, Battin, et al, 1975

 

Individual

Senior

Y

Y-NE

33/30

90–1170

14 days; 4 sessions

Mental Distress (BSI); Depression (GDS); Hopelessness (GHS); Avoidance/Intrusion (IES); Mood (PANAS)

Segal, Bogaards, et al, 1999

 

Individual

Adult

Y

Y

66/56

<49

90 days; up to 9 sessions

General Health(general health questionnaire)

Raphael, 1977

 

Individual

Adult

Y

N

72/63

60–462

12–20 sessions

Avoidance/Intrusion (IES-A, IES-I); Depression (SCL-90); Anxiety (SCL-90); Total Pathology (SCL-90); Stress-Intrusion (SRRS); Neurotic Symptoms (BPRS)

Horowitz, Weiss, et al, 1984

 

Individual

Adult

N

Y-NE

12/6

365–3650

196 days

Depression (Wakefield); Grief (TRIG) Phobic Avoidance (FQ); Hostility/Anger/Guilt (HAG); Attitude to self and deceased (author-created scales); Avoidance (Bereavement Avoidance Tasks); Physical Symptoms (Maddison & Viola, 1968); Compulsive Behavior (Compulsive Activity Checklist); Social Adjustment (Watson & Marks, 1971)

Mawson, Marks, et al, 1981

 

Individual

Adult

N

NA

1/1

<180

112 days; 10 sessions

Grief (Grief Scale); Coping (CRI)

Orton, 1994

 

Group

Senior

Y

Y

150/117

<365–7300

540 days; 6 sessions

Depression (BDI); Socialization (RSAS)

Constantino, 1988*****

Psycho-dynamic

Group

Adult

Y

Y-NE

56/53

120–330

8 sessions

Depression, Anxiety, Somatization (Hopkins Symptom Checklist); Grief Intensity, Preoccupation, Guilt, Anger (Lieberman & Videka-Sherman, 1986); Psychological Distress (Bradburn Affect Balance Scale); Locus of Control (Pearlman et al, 1981); Self-Esteem (Rosenberg scale, 1965); Social Adjustment (Pearlman et al, 1981, Lieberman & Videka-Sherman, 1986)

Lieberman & Yalom, 1992

 

Group

Adult

Y

N

50/50

NR

90 days; 14 sessions

Grief (TRIG)

Sabatini, 1988–89

 

Group

Adult

N

Y

139/107

90–17155

84 days; 12 sessions

Avoidance/Intrusion (IES); Grief (TRIG); Interpersonal Distress (IIP); Social Functioning (SAS-SR); Depression (BDI); Anxiety (STAI); Mental Distress (BSI, GSI); Self-Esteem (SES); Physical Functioning (SF-36); Symptomatic Distress (SCL-90)

Piper, McCallum, et al, 2001*

 

Group

Adult

N

Y-NE

61/55

120–1095

84 days; 12 sessions

Avoidance/Intrusion (IES); Stress Symptoms (SRRS); Depression (BDI); Mental Distress (BPRS, SCL-90); Social Functioning (SAS-SR); Overall Functioning (GAS)

Marmar, Horowitz, et al, 1988**

 

Group

Child

Y

N

16/16

30–365

56 days

Depression (CDI); Behavior (AP, AT); Grief (BP); Family alliance (TP); Grief, family relationship (TC)

Tonkins & Lambert, 1996

 

Group

Child

N

NA

45/37

30–3650

70 days

Trauma (CPTSRI)

Salloum, Avery, & McClain, 2001

Psycho-analytic

Group

Adult

N

N

154/59

NR

84 days; 12 sessions

Affect (author created); Psychodynamic Work (PWORS); Severity of objectives (author created)

McCallum, Piper, & Morin, 1993

Inter-personal

Individual

Senior

Y

Y-NE

80/66

216–279

112 days; up to 16 sessions

Grief (TRIG)

Reynolds, Miller, et al, 1999***

Behavioral and Psycho-dynamic

Individual

Adult

Y

N

83/83

<1825

15–20 sessions

Anger (State Trait Anger Inventory); Anxiety (STAI); Avoidance/Intrusion (IES); Somatic/psychoneurotic symptoms (SCL-90); (Locus of Control Scale)

Kleber & Brom, 1987

Notes: * Study also included support/counselling condition. ** Treatment also included aspects of interpersonal psychotherapy. *** Study also included pharmacotherapy condition. **** Treatment also included aspects of social support. ***** Study also included social activities condition. Legend: Type, Type of Intervention; Format, Format of Intervention; Pop, Target Population; CG, Control Group; RA, Random Assignment; Num, Number of subjects; TSL, Time Since Loss; DT, Duration of Trial; NA, Not Applicable; NR, Not Reported; UC, Unclear; Y, Yes; N, No; Y-NE Randomization mentioned, but allocation method not explicitly stated.

Cognitive-behavioral therapywas employed in nine trials, four of which used individual sessions while five studies used group sessions. Murphy and colleagues (1998) studied an intervention for parents bereaved by the violent death of their children [57]. The results show no treatment effect between intervention and control groups over the five main tested outcome variables. The authors then proceeded with a post-hoc subgroup analysis, which identified mothers with high Global Severity Index scores and grief at baseline as potentially benefiting from intervention during the period, while fathers who received the intervention appeared to have more posttraumatic stress disorder (PTSD) symptoms at six-month follow-up.

Kleber and Brom (1987) conducted a comparative outcome study of three forms of short-term psychotherapy [69]. They compared the results of 83 patients suffering from a major loss who had been randomized into hypnotherapy (behavioral), trauma desensitization (behavioral), psychodynamic therapy, and a delayed-treatment control group. They found all three therapies successful in improving patients' conditions, but did not find any particular therapy to be significantly more effective than another. While the control group showed slight recovery, over time the three therapies were more effective in reducing symptoms of the bereavement response.

Studies of psychodynamictherapy, which strives for the patient to understand and cope better with feelings by re-experiencing them and talking them through with the aid of the therapist, was found to be quite prevalent in the bereavement care literature. Overall, the results are mixed, with more support found in the group format of psychodynamic therapy than in individual therapy. Of the studies we evaluated as psychodynamic therapy, six were individual in format, seven had a group format, and eight employed control groups; five of these claimed random allocation (one additional study randomly assigned subjects to two experimental conditions but lacked a control group).

Psychoanalysis, as exemplified by Freud, proceeds with an inward investigation of unconscious mental processes and childhood experiences as the principal therapeutic procedure. Problematic measurement methodology beset the one study that utilized a group format to provide a psychoanalytic-based intervention (with no details regarding the tasks assigned to the patients)[68]. This study focused primarily on the relationship between the patient's personal affect (measured by an unvalidated affect assessment scale) and a favorable treatment outcome (measured again by an ad-hoc unvalidated measure).

Behavioral therapyuses learning principles (such as behavior modification, systematic desensitization, and aversion) to eliminate or reduce unwanted reactions to either external situations, one's thoughts and feelings, and bodily sensations or functions. Behavioral therapy was used in only one study, which compared traumatic desensitization to hypnotherapy and psychodynamic therapies [69]. As described in the section on cognitive-behavioral therapies above, all three therapies resulted in significant improvements from pre- to post-treatment as compared to controls, and no one therapy was found to be more effective than the others in treating bereavement-related symptoms.

Interpersonal therapyaims to improve communication skills and increase self-esteem during a short time period by focusing on a patient's behaviors and social interactions with family and friends, directly teaching how better to relate to others. Only one study used interpersonal therapy as a bereavement care intervention, and this study found no effect on grief as the only measured outcome [6].

Systems-oriented interventions

Seven studies featured interventions that altered the manner in which the healthcare system interacted with patients, family, and friends prior to death, guided by an underlying (yet not fully explicated) notion that interactions experienced by loved ones prior to death can influence the subsequent bereavement process (Table 4) [7379]. Six of the seven interventions provided enhanced or augmented care, in the form of palliative care, hospice care, or care coordination. One intervention gave family members the option of witnessing resuscitation efforts [79]. Overall, the studies that reported systems-oriented interventions produced mixed results of efficacy, with only three of the seven studies showing any treatment effect, mostly in long-term follow-up ranging from 60–365 days post-death. In fact, no study found significant treatment effects when measured during the intervention.
Table 4

Systems-Oriented Interventions

Intervention

Pop

CG

RA

Num

Time of Evaluation

Key Outcome Measures

Article

Care Coordination

Relative of cancer death

Y

Y

94

365 days pre-death

56 days post-death

Anxiety (HADA, Leeds Depression and Anxiety Scale); Depression (HADD, Leeds Depression and Anxiety Scale); Social Support (Family Apgar Scale)

Addington, MacDonald, et al, 1992

Emergency Room

Relative of Emergency Room Death

Y

N

100/66

180–365 days post-death

Changes in satisfaction of care, information received (author-created questionnaire)

Adamowski, Dickinson, et al, 1993

Hospice Care

Relative of cancer death

Y

Y-NE

96

42 days post-death

540 days post-death

Depression (CES-D); Anxiety (Rand Health Insurance Study); General Health (Rand Health Insurance Study); Social Functioning

Kane, Klein, et al, 1986

Palliative Care

Relative of cancer death

Y

Y

183

60–270 days pre-death

390 days post-death

Grief (TRIG2)

Ringdal, Jordhoy, et al, 2001

 

Relative of cancer death

Y

NR

119/49

0–60 days post-death

Anxiety, Depression, Mental Exhaustion ("observations and ratings")

Haggmark & Theorell, 1988

 

Relative of cancer death

Y

N

49/37

365 days post-death

Health, Anger, Mental State, Depression (Holland & Segroi's instrument)

Haggmark, Bachner, & Theorell, 1991

Witnessed Resuscitation

Relative of unsuccessful resuscitation

Y

Y

18

30 days post-death 90 days post-death

Grief (TRIG1, TRIG2); Avoidance/Intrusion (IESA, IESI); Depression (BDI, HADD); Anxiety (HADA, BAI)

Robinson, Makenzie-Ross, et al, 1998

Legend: Pop, Target Population; CG, Control Group; RA, Random Assignment; Num, Number of subjects; NR, Not Reported; Y, Yes; N, No; Y-NE Randomization mentioned, but allocation method not explicitly stated.

Ringdal and colleagues (2001) found no significant differences between those family members whose relative received palliative care and those who received traditional care [76]. This intervention, however, was not directed to the bereaved relatives, but rather to their terminally ill relatives. The bereaved relatives did show an overall significant decline in TRIG grief scores over one year post-bereavement for both palliative and traditional care groups.

Robinson (1998) examined the psychological effect of witnessing resuscitation efforts of patients in the emergency room on bereaved relatives [79]. They found no psychological differences between the control group who did not witness the resuscitation attempt and the experimental group who had the option of viewing the resuscitation effort. In fact, at the three- and nine-month follow up, the experimental group exhibited median scores lower (that is, better) than the controls on five of the eight measured scales. At nine months, the authors found the difference in TRIG2 scores approaching the 5% significance level with a reported p = 0.08. These findings provide no evidence to support the popular belief that relatives should be excluded from the resuscitation room, and provide only weak evidence of possible psychological benefit of witnessed resuscitation; they do not, however, suggest that having witnessed an unsuccessful resuscitation attempt alleviates the grief reaction of the bereaved.

Discussion

When reviewed systematically, the current bereavement intervention literature – notwithstanding the existence of many intriguing reports – yields few reliable conclusions to guide treatment. Good evidence supports the pharmacological treatment of depression occurring in the context of bereavement. For all other forms of intervention, however, and for all attempts to diminish grief per se, no consistent pattern of treatment benefit has been established across well-designed experimental studies.

Why – despite prevalence of bereavement, the intense dedication on the part of the bereavement research community, and the multitude of peer-reviewed published bereavement studies – does the field of bereavement care lack a formidable evidence base? In order to improve the effectiveness and quality of bereavement care, this question begs to be addressed. On the basis of our systematic review of the literature, we postulate the following five factors as hindering methodical scientific progress regarding bereavement care interventions.

Excessive theoretical heterogeneity

As the history of science and medicine suggests, successful scientific inquiry into a topic is typically a cumulative process undertaken by a community of investigators working within a shared scientific paradigm [80, 81]. The field of bereavement care intervention studies does not appear to be organized in such a manner, but instead consists of distinct groups of investigators working within disparate theoretical frameworks: pharmacologic, psychodynamic, psychoanalytic, behavioral, cognitive-behavioral, interpersonal, and social supportive theories each vie for attention. Indeed, although specification of an underlying treatment-theory conceptual model may improve causal inference [82], the bereavement care literature may be too invested in and reliant on theoretical justifications of treatments. Consequently, the compiled published reports demonstrate a cumulative 'Tower of Babel' phenomenon, with the different theory-dominated perspectives failing to engage each other meaningfully: the sum is no greater than the parts, and perhaps less.

Stultifying between-study variation

Treatments featured in published studies vary almost as much as the authors who tested them. One can observe substantial variation across studies regarding the type of intervention generally or regarding the specific implementation of a specific type of intervention (such as different doses of pharmaceuticals); regarding characteristics of targeted patient populations; regarding outcome measurements and study design methodology. Scrutinizing the key outcome measures listed in the accompanying tables illustrates this remarkable heterogeneity. Although these differences have been due in part to diverse treatment-theory paradigms, even studies conducted within the same theoretical paradigm often differed markedly in terms of what potential benefit was being tested, and how it was being measured. Such substantial variation between studies stymies comparison or confirmation of treatment effects.

Inadequate reporting of intervention procedures and implementation

Aside from the pharmacological studies, which reported the dosing of the intervention medication, very few reported studies describe the intervention procedures in sufficient detail for readers to envision clearly what tasks or activities intervention subjects were asked to perform. This under-specification prevents sensible analysis, within a class of treatments (such as cognitive-behavioral therapy), of observed differences in treatment effects (since the implementation of cognitive-behavioral therapy, for instance, may have been quite different in seemingly similar intervention studies).

Few published "replication" studies

Inadequate specification of intervention procedures, combined with other factors at work within the community of bereavement care investigators, may have resulted in the dearth of published replication studies. This lack of replication prevents the accumulation of a body of evidence that would confirm, refute, or refine prior estimates of treatment effects.

Methodological study-design and data-analysis flaws

A final factor inhibiting research progress in the realm of bereavement care interventions encompasses a number of recurring methodological flaws that greatly limit inferences regarding treatment effects. First and foremost is the omission of control groups. Control groups are essential for the valid evaluation of a bereavement intervention, particularly because of the typically self-limited course of grief: even absent any treatment, most bereaved people show "diminished pathological symptoms and fewer signs of disturbance within two years of the loss"[65]. Purported beneficial treatment effects observed in an intervention group without a suitable control group therefore may in fact be simply the natural grief remission process. A second common study design feature is the non-random assignment of study subjects into treatment and control groups, which again limits the strength of inference regarding observed 'treatment' effects, as these differences between treatment and control groups may be due to selection or assignment bias. Third, many studies measured subject outcomes using untried assessment tools that had been created on an ad hoc basis, and which may therefore have compromised measurement accuracy and inference validity. Lastly, studies that failed to demonstrate a statistically-significant difference for the main outcome measure often performed numerous post hoc subgroup analyses, a practice that negates the rigor of statistical hypothesis testing.

If these five factors are indeed hampering progress towards improving bereavement care interventions and quality of care for bereaved individuals, then concrete actions could facilitate progress within the field of bereavement care, specifically: 1) Convening a consensus-building conference among key stakeholders and investigators to define a specific research agenda that would draw on a limited number of theoretical paradigms and delineate key elements of treatment theory [82]; 2) Focusing on interventions to improve key outcomes that are valued by bereaved individuals; 3) Targeting well-defined patient populations at well-defined phases of bereavement; 4) Conducting high-quality randomized controlled trial research designs, employing rigorous tests of hypotheses defined prior to the conduct of the study, and eschewing unplanned subgroup analyses; 5) Weighing the ethical arguments for and against the use of randomized control subjects in such research; 6) Increasing incentive to conduct and publish highly-comparable replication studies; and 7) Enforcing the adoption of uniform standards regarding clinical trial study reporting (such as outlined in the CONSORT statement [83]) by journal editors and the bereavement research community.

Abbreviations

CG: 

Control group

NT: 

Nortriptyline

SSRI: 

Selective serotonin reuptake inhibitors

TCA: 

Tricyclic antidepressants

TRIG: 

Texas Revised Inventory of Grief

Declarations

Acknowledgements

The conduct of this review was supported in part by funds from The Children's Hospital of Philadelphia and by grant KO8 HS00002 from the Agency for Health Care Research and Quality.

Authors’ Affiliations

(1)
Pediatric Advanced Care Team and Pediatric Generalist Research Group, Division of General Pediatrics, The Children's Hospital of Philadelphia
(2)
Department of Social Work and Family Services, The Children's Hospital of Philadelphia
(3)
The Leonard Davis Institute of Health Economics, University of Pennsylvania
(4)
Center for Bioethics, University of Pennsylvania

References

  1. Aries P: The Hour of Our Death. 1981, Oxford, Oxford University Press, 614.Google Scholar
  2. Parkes CM: Bereavement counselling: does it work?. Br Med J. 1980, 281: 3-6.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Schneiderman G, Winders P, Tallett S, Feldman W: Do child and/or parent bereavement programs work?. Can J Psychiatry. 1994, 39: 215-218.PubMedGoogle Scholar
  4. Chambers HM, Chan FY: Support for women/families after perinatal death. Cochrane Database Syst Rev. 2000, CD000452.Google Scholar
  5. Rowa-Dewar N: Do interventions make a difference to bereaved parents? A systematic review of controlled studies. Int J Palliative Nurs. 2002, 8: 452-457.View ArticleGoogle Scholar
  6. Reynolds CF, 3rd, Miller MD, Pasternak RE, Frank E, Perel JM, Cornes C, Houck PR, Mazumdar S, Dew MA, Kupfer DJ: Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. Am J Psychiatry. 1999, 156: 202-208.PubMedGoogle Scholar
  7. Taylor MP, Reynolds CF, 3rd, Frank E, Dew MA, Mazumdar S, Houck PR, Kupfer DJ: EEG sleep measures in later-life bereavement depression. A randomized, double-blind, placebo-controlled evaluation of nortriptyline. Am J Geriatr Psychiatry. 1999, 7: 41-47.PubMedGoogle Scholar
  8. Pasternak RE, Reynolds CF, Houck PR, Schlernitzauer M, Buysse DJ, Hoch CC, Kupfer DJ: Sleep in Bereavement-Related Depression During and after Pharmacotherapy with Nortriptyline. J Geriatr Psychiatry Neurol. 1994, 7: 69.View ArticlePubMedGoogle Scholar
  9. Pasternak RE, Reynolds C. F., 3rd, Schlernitzauer M, Hoch CC, Buysse DJ, Houck PR, Perel JM: Acute open-trial nortriptyline therapy of bereavement-related depression in late life. J Clin Psychiatry. 1991, 52: 307-310.PubMedGoogle Scholar
  10. Zygmont M, Prigerson HG, Houck PR, Miller MD, Shear MK, Jacobs S, Reynolds CFIII: A post hoc comparison of paroxetine and nortriptyline for symptoms of traumatic grief. J Clin Psychiatry. 1998, 59: 241-245.View ArticlePubMedGoogle Scholar
  11. Zisook S, Schuchter SR, Pedrelli P, Sable J, Deaciuc SC: Bupropion sustained release for bereavement: Results of an open trial. J Clin Psychiatry. 2001, 64: 227-230.View ArticleGoogle Scholar
  12. Warner J, Metcalfe C, King M: Evaluating the use of benzodiazepines following recent bereavement. Br J Psychiatry. 2001, 178: 36-41. 10.1192/bjp.178.1.36.View ArticlePubMedGoogle Scholar
  13. Jacobs SC, Nelson JC, Zisook S: Treating depressions of bereavement with antidepressants: a pilot study. Psychiatr Clin North Am. 1987, 10: 501-510.PubMedGoogle Scholar
  14. Vachon ML, Lyall WA, Rogers J, Freedman-Letofsky K, Freeman SJ: A controlled study of self-help intervention for widows. Am J Psychiatry. 1980, 137: 1380-1384.View ArticlePubMedGoogle Scholar
  15. Caserta MS, Lund DA: Intrapersonal Resources and the Effectiveness of Self-Help Groups for Bereaved Older Adults. Gerontologist. 1993, 33: 619.View ArticlePubMedGoogle Scholar
  16. McKibbin CL, Guarnaccia CA, Hayslip B., Jr., Murdock ME: Locus of control perceptions among conjugally bereaved older adults: a pilot study. Int J Aging Hum Dev. 1997, 44: 37-45.View ArticlePubMedGoogle Scholar
  17. Tudiver F, Hilditch J, Permaul JA, McKendree DJ: Does mutual help facilitate newly bereaved widowers? Report of a randomized controlled trial. Eval Health Prof. 1992, 15: 147-162.View ArticleGoogle Scholar
  18. Tudiver F, Permaul-Woods JA, Hilditch J, Harmina J, Saini S: Do widowers use the health care system differently? Does intervention make a difference?. Can Fam Physician. 1995, 41: 392-400.PubMedPubMed CentralGoogle Scholar
  19. Walls N, Meyers AW: Outcome in group treatments for bereavement: experimental results and recommendations for clinical practice. Int J Ment Health. 1985, 13: 126-147.View ArticleGoogle Scholar
  20. Lieberman MA, Videka-Sherman L: The impact of self-help groups on the mental health of widows and widowers. Am J Orthopsychiatry. 1986, 56: 435-449.View ArticlePubMedGoogle Scholar
  21. Videka-Sherman L, Lieberman M: The effects of self-help and psychotherapy intervention on child loss: the limits of recovery. Am J Orthopsychiatry. 1985, 55: 70-82.View ArticlePubMedGoogle Scholar
  22. Marmar CR, Horowitz MJ, Weiss DS, Wilner NR, Kaltreider NB: A controlled trial of brief psychotherapy and mutual-help group treatment of conjugal bereavement. Am J Psychiatry. 1988, 145: 203-209.View ArticlePubMedGoogle Scholar
  23. Rogers J, Sheldon A, Barwick C, Letofsky K, Lancee W: Help for families of suicide: survivors support program. Can J Psychiatry. 1982, 27: 444-449.PubMedGoogle Scholar
  24. Kaunonen M, Tarkka M, Laippala P, Paunonen-Ilmonen M: The impact of supportive telephone call intervention on grief after the death of a family member. Cancer Nurs. 2000, 23: 483-491. 10.1097/00002820-200012000-00012.View ArticlePubMedGoogle Scholar
  25. Forrest GC, Standish E, Baum JD: Support after perinatal death: a study of support and counselling after perinatal bereavement. Br Med J (Clin Res Ed). 1982, 285: 1475-1479.View ArticleGoogle Scholar
  26. Williams WV, Lee J, Polak PR: Crisis intervention: effects of crisis intervention on family survivors of sudden death situations. Community Ment Health J. 1976, 12: 128-136.View ArticlePubMedGoogle Scholar
  27. Williams WV, Polak PR: Follow-up research in primary prevention: a model of adjustment in acute grief. J Clin Psychol. 1979, 35: 35-45.View ArticlePubMedGoogle Scholar
  28. Oliver RC, Sturtevant JP, Scheetz JP, Fallat ME: Beneficial effects of a hospital bereavement intervention program after traumatic childhood death. J Trauma. 2001, 50: 440-6; discussion 447-8.View ArticlePubMedGoogle Scholar
  29. Sandler IN, West SG, Baca L, Pillow DR, Gersten JC, Rogosch F, Virdin L, Beals J, Reynolds KD, Kallgren C, Tein JY, Kriege G, Cole E, Ramirez R: Linking empirically based theory and evaluation: the Family Bereavement Program. Am J Community Psychol. 1992, 20: 491-521.View ArticlePubMedGoogle Scholar
  30. Stewart M, Craig D, MacPherson K, Alexander S: Promoting positive affect and diminishing loneliness of widowed seniors through a support intervention. Public Health Nurs. 2001, 18: 54-63. 10.1046/j.1525-1446.2001.00054.x.View ArticlePubMedGoogle Scholar
  31. Goodkin K, Blaney NT, Feaster DJ, Baldewicz T, Burkhalter JE, Leeds B: A randomized controlled clinical trial of a bereavement support group intervention in human immunodeficiency virus type 1-seropositive and -seronegative homosexual men. Arch Gen Psychiatry. 1999, 56: 52-59. 10.1001/archpsyc.56.1.52.View ArticlePubMedGoogle Scholar
  32. Swanson KM: Effects of caring, measurement, and time on miscarriage impact and women's well-being. Nurs Res. 1999, 48: 288-10.1097/00006199-199911000-00004.View ArticlePubMedGoogle Scholar
  33. Kay M, Guernsey de Zapien J, Wilson CA, Yoder M: Evaluating treatment efficacy by triangulation. Soc Sci Med. 1993, 36: 1545-1554. 10.1016/0277-9536(93)90343-3.View ArticlePubMedGoogle Scholar
  34. Goodkin Karl, Feaster Daniel J., Asthana Deshratn, Blaney Nancy T., Kumar Mahendra, Baldewicz Teri, Tuttle Raymond S., Maher Kevin J., Baum Marianna K., Shapshak Paul, Fletcher Mary Ann: A bereavement support group intervention is longitudinally associated with salutary effects on the CD4 cell count and number of physician visits. Clin Diagn Lab Immunology. 1998, 5: 382-391.Google Scholar
  35. Balk DE, Lampe S, Sharpe B, Schwinn S, Holen K, Cook L, Dubois R., 3rd: TAT results in a longitudinal study of bereaved college students. Death Stud. 1998, 22: 3-21. 10.1080/074811898201704.View ArticlePubMedGoogle Scholar
  36. Levy LH, Derby JF, Martinkowski KS: Effects of membership in bereavement support groups on adaptation to conjuga bereavement. Am J Community Psychol. 1993, 21: 361-381.View ArticlePubMedGoogle Scholar
  37. DiMarco MA, Menke EM, McNamara T: Evaluating a support group for perinatal loss. MCN, Am J Matern Child Nurs. 2001, 26: 135-140. 10.1097/00005721-200105000-00008.View ArticleGoogle Scholar
  38. Piper WE,, McCallum M, Joyce AS, Rosie JS, Ogrodniczuk J: Patient personality and time-limited group psychotherapy for complicated grief. Int J Group Psychoth. 2001, 51: 525-552.View ArticleGoogle Scholar
  39. Barrett AV: Effectiveness of widows' groups in facilitating change. J Consult Clin Psych. 1978, 46: 20-31. 10.1037//0022-006X.46.1.20.View ArticleGoogle Scholar
  40. Glajchen M, Magen R: Evaluating process, outcome, and satisfaction in community-based cancer support groups. Support Groups: Current Perspective on Theory and Practice. 1995, 18: 27-40.Google Scholar
  41. Geron Y, Ginzburg K, Solomon Z: Predictors of bereaved parents' satisfaction with group support: An Israeli perspective. Death Stud. 2003, 27: 405-10.1080/07481180302876.View ArticlePubMedGoogle Scholar
  42. Davis JM, Hoshiko BR, Jones S, Gosnell D: The effect of a support group on grieving individuals' levels of perceived support and stress. Arch Psychiatric Nurs. 1992, 6: 35-39. 10.1016/0883-9417(92)90052-K.View ArticleGoogle Scholar
  43. Stoddart KP, Burke L, Temple V: Outcome evaluation of bereavement groups for adults with intellectual disabilities. J Appl Res Intellect Disabilities. 2002, 15: 28-35. 10.1046/j.1468-3148.2002.00084.x.View ArticleGoogle Scholar
  44. Forte JA, Barrett AV, Campbell MH: Patterns of social connectedness and shared work: a symbolic interactionist perspective. Soc Work Groups. 1996, 19: 29-51.View ArticleGoogle Scholar
  45. Heiney SP, Ruffin J, Goon-Johnson K: The effects of a support group on selected psychosocial outcomes of bereaved parents whose child died from cancer. J Pediatr Onc Nurs. 1995, 12: 51-8; discussion 59-61. 10.1016/1043-4542(95)90014-4.Google Scholar
  46. Huss Susan Norris, Ritchie Martin: Effectiveness of a group for parentally bereaved children. J Specialists Group Work. 1999, 24: 186-196.View ArticleGoogle Scholar
  47. Schilling RF, Koh N, Abramovitz R, Gilbert L: Bereavement Groups for Inner-City Children. Res Social Work Prac. 1992, 2: 405.Google Scholar
  48. Opie ND, Goodwin T, Finke LM, Beattey JM, Lee B, van Epps J: The effect of a bereavement group experience on bereaved children's and adolescents' affective and somatic distress. J Child Adoles Psychiatric Ment Health Nurs. 1992, 5: 20-26.View ArticleGoogle Scholar
  49. Quarmby D: Peer group counselling with bereaved adolescents. Br J Guid Couns. 1993, 21: 196-211.View ArticleGoogle Scholar
  50. Zambelli GC, DeRosa AP: Bereavement support groups for school-age children: theory, intervention, and case example. Am J Orthopsychiatry. 1992, 62: 484-493.View ArticlePubMedGoogle Scholar
  51. Lilford RJ, Stratton P, Godsil S, Prasad A: A randomised trial of routine versus selective counselling in perinatal bereavement from congenital disease. Br J Obstet Gynaecol. 1994, 101: 291-296.View ArticlePubMedGoogle Scholar
  52. Goodkin K, Baldewicz TT, Asthana D, Khamis I, Blaney NT, Kumar M, Burkhalter JE, Leeds B, Shapshak P: A bereavement support group intervention affects plasma burden of human immunodeficiency virus type 1:report of a randomized controlled trial. J Human Virol. 2001, 4: 44-54.Google Scholar
  53. Reich JW, Zautra AJ: A perceived control intervention for at-risk older adults. Psychol Aging. 1989, 4: 415-424. 10.1037//0882-7974.4.4.415.View ArticlePubMedGoogle Scholar
  54. Harkness KL, Shear MK, Frank E, Silberman RA: Traumatic grief treatment: case histories of 4 patients. J Clin Psychiatry. 2002, 63: 1113-1120.View ArticlePubMedGoogle Scholar
  55. Lange A, van de Ven JP, Schrieken B, Emmelkamp PM: Interapy, treatment of posttraumatic stress through the Internet: a controlled trial. J Behav Ther Exp Psychiatry. 2001, 32: 73-90. 10.1016/S0005-7916(01)00023-4.View ArticlePubMedGoogle Scholar
  56. Sireling L Cohen D., Marks I: Guided mourning for morbid grief: A controlled replication. Behav Ther. 1988, 19: 121-132.View ArticleGoogle Scholar
  57. Murphy SA, Johnson C, Cain KC, Das Gupta A, Dimond M, Lohan J, Baugher R: Broad-spectrum group treatment for parents bereaved by the violent deaths of their 12- to 28-year-old children: a randomized controlled trial. Death Stud. 1998, 22: 209-235. 10.1080/074811898201560.View ArticlePubMedGoogle Scholar
  58. Sikkema KJ, Kalichman SC, Kelly JA, Koob JJ: Group intervention to improve coping with AIDS-related bereavement: model development and an illustrative clinical example. AIDS Care. 1995, 7: 463-475. 10.1080/09540129550126416.View ArticlePubMedGoogle Scholar
  59. Hilliard RE: The effects of music therapy-based bereavement groups on mood and behavior of grieving children: a pilot study. J Music Ther. 2001, 38: 291-306.View ArticlePubMedGoogle Scholar
  60. Segal Dl, Bogaards JA, Becker LA, Chatman C: Effects of emotional expression on adjustment to spousal loss among older adults. J Ment Health Aging. 1999, 5: 297-310.Google Scholar
  61. Raphael B: Preventive intervention with the recently bereaved. Arch Gen Psychiatry. 1977, 34: 1450-1454.View ArticlePubMedGoogle Scholar
  62. Horowitz MJ, Weiss DS, Kaltreider N, Krupnick J, Marmar C, Wilner N, DeWitt K: Reactions to the death of a parent. Results from patients and field subjects. J Nerv Ment Dis. 1984, 172: 383-392.View ArticlePubMedGoogle Scholar
  63. Mawson D Marks I. M. Ramm L. Stern R. S.: Guided mourning for morbid grief: a controlled study. British Journal of Psychiatry. 1981, 138: 185-193.View ArticlePubMedGoogle Scholar
  64. Orton M: A Case-Study of an Adolescent Mother Grieving the Death of Her Child Due to Sudden-Infant-Death-Syndrome. Am J Art Ther. 1994, 33: 37.Google Scholar
  65. Lieberman MA, Yalom I: Brief group psychotherapy for the spousally bereaved: a controlled study. Int J Group Psychoth. 1992, 42: 117-132.Google Scholar
  66. Tonkins SA, Lambert MJ: A treatment outcome study of bereavement groups for children. Child Adolesc Social Work J. 1996, 13: 3-21.View ArticleGoogle Scholar
  67. Salloum A, Avery L, McClain RP: Group psychotherapy for adolescent survivors of homicide victims: a pilot study. J Am Acad Child Adolesc Psychiatry. 2001, 40: 1261-1267. 10.1097/00004583-200111000-00005.View ArticlePubMedGoogle Scholar
  68. McCallum M, Piper WE, Morin H: Affect and outcome in short-term group therapy for loss. Int J Group Psychoth. 1993, 43: 303-319.Google Scholar
  69. Kleber Rolf J., Brom Daniel: Psychotherapy and pathological grief controlled outcome study. Israel J Psychiatry Relat Sci. 1987, 24: 99-109.Google Scholar
  70. Gerber I, Wiener A, Battin D, Arkin AM: Brief therapy for the bereaved. Bereavement: Its psychosocial aspects. Edited by: Shoenberg B and Gerber I. 1975, New York, Columbia University Press, 310-333.Google Scholar
  71. Constantino RE: Comparison of two group interventions for the bereaved. Image - J Nurs Scholarship. 1988, 20: 83-87.View ArticleGoogle Scholar
  72. Sabatini L: Evaluating a treatment program for newly widowed people. Omega. 1988, 19: 229-237.Google Scholar
  73. Addington-Hall JM, MacDonald LD, Anderson HR, Chamberlain J, Freeling P, Bland JM, Raftery J: Randomised controlled trial of effects of coordinating care for terminally ill cancer patients. BMJ. 1992, 305: 1317-1322.View ArticlePubMedPubMed CentralGoogle Scholar
  74. Adamowski K, Dickinson G, Weitzman B, Roessler C, Carter-Snell C: Sudden unexpected death in the emergency department: caring for the survivors. CMAJ. 1993, 149: 1445-1451.PubMedPubMed CentralGoogle Scholar
  75. Kane Rl, Klein SJ, Bernstein L, Rothenberg R: The role of hospice in reducing the impact of bereavement. J Chronic Dis. 1986, 39: 735-742. 10.1016/0021-9681(86)90156-6.View ArticlePubMedGoogle Scholar
  76. Ringdal GI, Jordhoy MS, Ringdal K, Kaasa S: The first year of grief and bereavement in close family members to individuals who have died of cancer. Palliat Med. 2001, 15: 91-105. 10.1191/026921601674021869.View ArticlePubMedGoogle Scholar
  77. Haggmark C, Bachner M, Theorell T: A follow-up of psychological state in relatives of cancer patients one year after the patient's death: effects of an activation program. Acta Oncol. 1991, 30: 677.View ArticlePubMedGoogle Scholar
  78. Haggmark C, Theorell T: Evaluation of an activation programme: repeated observations of mental exhaustion, anxiety and depression in relatives of cancer patients. Scand J Caring Sci. 1988, 2: 129-141.View ArticleGoogle Scholar
  79. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, Egleston CV, Prevost AT: Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998, 352: 614-617. 10.1016/S0140-6736(97)12179-1.View ArticlePubMedGoogle Scholar
  80. Fleck L: Genesis and development of a scientific fact. Edited by: Thaddeus J Trenn and Robert K Merton. 1979, Chicago, University Press, 203.Google Scholar
  81. Kuhn TS: The structure of scientific revolutions. 1970, Chicago, University of Chicago Press, 210-2ndGoogle Scholar
  82. Lipsey MW: Theory as method: small theories of treatment. New Directions for Program Evaluation. 1993, 5-38.Google Scholar
  83. CONSORT Statement, accessed 1 July 2004. [http://www.consort-statement.org]
  84. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-684X/3/3/prepub

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