Doi:10.1016/s0140-6736(07)61816-9

Health outcomes of bereavement
Margaret Stroebe, Henk Schut, Wolfgang Stroebe Lancet 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.
[email protected]
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.com Vol 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
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(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.com Vol 370 December 8, 2007
Physical ill health
rence of pain in older widowed individuals, focus ing on General patterns
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 not undertaken 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). Conclusions
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 reduced use 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.com Vol 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 Aﬀ ective
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 Cognitive
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 Behavioural
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 Physiological–somatic
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.com Vol 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 5th edition*96
the diagnosis of major depressive disorder. Although Criterion A
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 Criterion B
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 Psychiatric disorders
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 symptoms in bereaved Criterion C
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 Criterion D
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 chronic and 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.com Vol 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.com Vol 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 Risk factors
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 Restoration-
listed under situation and circumstances of death orientated
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
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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 Secondary
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 Tertiary
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.com Vol 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 Conclusions
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
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Curso de Inglés Irlanda-Agosto 2013 “4 to 1” Intensivo Dirigidos por: COLEGIO CLARET Organización Técnica: AVANTYA in Education Avda. Padre Claret, 3 C/ Santa Bernardita 3 40003 Segovia - Tel.: 921 420 300 28023 Madrid - Tel.: 91 435 25 22 CENTRO DE ENSEÑANZA CENTRE FOR ENGLISH STUDIES Mercy College St. Brendan’s Drive Tel. 00-353 1 8480

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Optimal Parity Edge-Coloring of Complete GraphsDavid P. Bunde∗, Kevin Milans†, Douglas B. West‡, Hehui Wu§A parity walk in an edge-coloring of a graph is a walk along which each color is usedan even number of times. Let p(G) be the least number of colors in an edge-coloring ofG having no parity path (a parity edge-coloring). Let p(G) be the least number of colorsin an edge-coloring of