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Report to Congress: An Overview of Bereavement and Grief Services in the United States

Nov 12, 2024 | Advocacy, Appropriations, Federal Government, Grief

With Evermore’s support and encouragement, Congress passed the Consolidated Appropriations Act of 2023, directing the U.S. Department of Health and Human Services to produce a report on the need for bereavement and grief services in the United States. Last week, just prior to the national election, the report was released to the public. To our knowledge, it is the first report by the U.S. and a direct result of Evermore’s leadership.

The report examined the scope of need for quality grief services, assessed the demand for such services, and provided a holistic evaluation of affected populations. This included identifying necessary interventions for specific groups, such as healthcare workers and other impacted demographics, and assessing the prevalence of conditions like post-traumatic stress disorder (PTSD) and complicated grief (CG). Additionally, the role of hospice programs in offering community bereavement support was underscored as essential to addressing these growing needs.

Findings from an environmental scan and interviews with experts, including researchers, advocates, and clinicians, reveal that grief responses are complex and vary widely. Approximately 10% of bereaved adults develop prolonged grief disorder (PGD) or CG, though contributors suggest these figures might be underestimated due to diagnostic complexities and overlapping mental health issues. PGD frequently co-occurs with PTSD, depression, and substance use disorder, posing challenges for treatment. Children, caregivers, veterans, and individuals who experience traumatic loss are among those most affected by PGD. Effective support services span from traditional therapy to music therapy, emphasizing trauma-informed care, while schools and mental health settings serve as critical sites for identifying those in need.

The report highlights hospice as a crucial service in promoting healthy bereavement by offering anticipatory support and post-loss coping mechanisms. However, concerns about access inequities and the shift toward for-profit hospice models were noted. Systemic factors like race and socioeconomic status also influence access to bereavement services, with disparities particularly prominent for communities of color. Although the COVID-19 pandemic has increased awareness around grief and reduced stigma, it has also amplified service demands, especially in underserved communities. Many contributors support a more comprehensive approach to grief that goes beyond medicalization, advocating for a nuanced understanding of grief’s social and cultural dimensions.

The report suggests that current bereavement services are fragmented and inequitable, with a need for a more comprehensive, less medicalized approach to grief support. Recommendations include enhancing healthcare systems, improving access to services, and addressing the inequities in bereavement support.

Resources:

Read the full Report to Congress: An Overview of Bereavement and Grief Services in the United States here.

Got Questions? National Call To Discuss the U.S. Government’s First Report on Grief & Bereavement

Jun 19, 2024 | Advocacy, Federal Government

Got Questions? National Call to Discuss the U.S. Government’s First Report on Grief & Bereavement

We’re Here to Answer Your Questions:

Join Us!

]In May, the Agency for Healthcare Research and Quality (AHRQ), a little-known government agency, released its draft report, “Interventions to Improve Care of Bereaved People.” This is the U.S. government’s first report on grief and bereavement, and AHRQ is accepting public comments until Friday, June 28, 2024.

  • You can submit your comments via this link.
  • Additional context for the report can be found here.

If you have questions, consider joining Evermore’s national call this Friday at 1 p.m. Eastern Time.

Reviewers found that “important gaps in our knowledge of various aspects of bereavement care” remain. This report is a first step toward advancing bereavement care for all bereaved people, but a lot more work needs to be done.

Your voice, questions, and concerns are important. Please consider submitting them today.

Advancing Bereavement Leave for All Students in Higher Education

May 14, 2024 | Advocacy, Community, Grief

Advancing Bereavement Leave for All Students in Higher Education

Each year, over 4 million students in higher education
are socially and academically impacted by bereavement

Losing a loved one at any juncture can alter the course of a life; navigating grief is a fraught and difficult process in the best of times. But for students in higher education—from trade schools to elite universities—it can be particularly overwhelming and cause them to abandon their studies.

According to some experts, nearly a third of college students who lose a friend or loved one while enrolled in higher education will fail to obtain their degree.

 

Douglas with his family.

Beyond the emotional ramifications, failing to get a degree has lifelong effects, and many grief experts argue that institutions should offer students bereavement leave and grief support. Sydney Rains and Red Douglas were two students who would have benefited from bereavement leave and grief support: Both lost their fathers when they were undergraduates, and now they are working to ensure future generations of students receive the critical support they did not. 

 

Collaborating with Evermore and members from public and private institutions from across the country, Rains and Douglas are leading Evermore’s Higher Education Leave Policy (HELP) campaign. Their goal is to bring awareness that students, from trade schools to universities, are being severely impacted by grief and more can be done to support them.

 

Rains with her father.

Rains was finishing up her junior year at Gonzaga University when her father died, and she struggled to complete assignments when she returned to school. Amidst her grief, she successfully led a student-specific bereavement policy campaign at Gonzaga, and she’s now working with the Evermore HELP campaign to advise colleges interested in implementing similar plans at their own institutions.

 

The HELP campaign was developed after Dr. Heather Servaty-Seib, who played a critical role in establishing the Grief Absence Policy for Students (GAPS) for students at Purdue University in 2011, connected Douglas with Evermore. He’s a Ph.D. candidate at Oakland University in Rochester, Michigan, studying ways higher education administrators can provide support for bereaved students, and said he was “frequently citing Servaty-Seib’s findings… so I reached out and she quickly replied, connecting me with Evermore,” Douglas said. Evermore “embraced my work and proposed the idea of developing a nexus for higher education professionals advocating for students on this topic.”

Douglas’ dad reading the sports page, which includes Red’s statistics.

 

One of the primary issues facing advocates and experts creating these policies is a straightforward data question. According to research conducted by various scholars over the past two decades, the prevalence of grief among higher education students is dramatically underestimated. Reports indicate that 20 to 35% of undergraduate students are within 12 months of losing a loved one; upwards of 40% are within two years of a significant loss.

 

Despite this reality, as of 2019 only 44 institutions of higher education in the United States had student-specific bereavement policies. Sevaty-Seib argues this is surprising when considering such policies exist at the K-12 level, and are also extended as workplace benefits to faculty, staff, and administrators at most colleges and universities.

 

Such policies address the risks that are specific to students in higher education, which boil down to these major factors:

 

Disruption of Academic Performance

The death of a loved one can significantly disrupt a college student’s academic performance. Grieving individuals may struggle to concentrate, meet deadlines, or attend classes regularly. Symptoms can manifest as lethargy, changes in appetite, insomnia, loss of interest in hobbies, and social isolation, all of which negatively impact grades and may result in dropping out. It’s essential for students to communicate with professors and academic advisors about their situation to explore possible accommodations and support systems.

 

Emotional Turmoil

Grief is a complex and intense emotional experience. Students mourning the loss of a loved one may feel overwhelmed by a range of emotions, including sadness, jealousy, anger, guilt, and confusion. These emotions can affect every aspect of their lives, from relationships with friends and family to their sense of self and purpose. Douglas said that felt “a strange jealousy toward my friends who still had both parents.” Seeking support from campus counseling services, support groups, or trusted individuals can provide a safe space to express and process these emotions.

 

Social Isolation

While research indicates social support is key, in the midst of grief, students often withdraw from social activities and isolate themselves from their peers. “When I lost my father, it was a very isolating experience,” Douglas said. “I never wanted to bring it up, so I had no idea how many other students were going through something similar.” Higher ed administrators can help grieving students by facilitating connections with their peers in similar situations.

 

Financial Stress

The death of a loved one can also bring financial burdens, such as funeral expenses, medical bills, or loss of financial support from parents. Students may find themselves grappling with these financial stressors on top of their grief, leading to heightened anxiety and uncertainty about their future. However, data on exactly how dire these situations become for grieving students is hard to find. Indiana University graduate and HELP contributor Malhar Pagay sought to find the number of bereaved students who dropped out due to financial stress, but discovered “the data is nearly impossible to find.” Colleges and universities are not keeping data on whether leaving is related to grief or bereavement. But if they did ask these questions, Pagay said, it would help them “make data-informed decisions about policies related to student grief and bereavement.”

5 Things You Didn’t Know About the Funeral Industry

Apr 17, 2024 | Advocacy, Federal Government

When someone close to us dies, we’re hardly in the right frame of mind to handle logistics and practical matters. Yet, often, this is the first thing we’re forced to confront.

There’s the matter of the deceased’s body and how it will be handled, but also funeral arrangements and ceremonial planning to honor the life of the person we’re grieving.

Funeral planning requires people to make multiple decisions while experiencing difficult and intense emotions. Making matters even more challenging, funeral arrangements are financially taxing.

In America, the funeral industry is essentially unavoidable after someone close to us dies. Because the funeral industry is ubiquitous and homogenous — offering the same services, same processes and procedures for after-death care — we rarely question it. But there’s a lot about the funeral industry you may not know.

 

Here are five facts about the funeral industry that will probably surprise you:

1. The funeral industry pulls in big dollars.

In the U.S., funeral homes are a $20 billion dollar annual industry. Most funeral homes are privately owned, and increasingly, more funeral homes are owned by large corporations.

Service Corporation International, the largest death-care corporation in the country, owns and operates more than 1,400 locations in North America and brought in more than $4 billion in revenue in 2023.

“Families are hurting. They are not only losing someone meaningful in their lives, their losses are compounded by the soaring costs in burials and cremations,” says Evermore founder Joyal Mulheron. “The funeral industry is well-funded, made only more profitable by our nation’s concurrent mortality epidemics — just look at their revenue statements.”

According to Statista, there are nearly 19,000 funeral homes in the U.S., yet there remains a surprising lack of competition in the industry. In the past several decades, larger funeral service companies, and in some cases, private equity firms, have bought up smaller, family-run businesses that were well-known and trusted in their communities.

The result has been a growing monopoly on the industry by fewer wealthy — and powerful — businesses. The industry’s consolidation was the central storyline for the 2023 hit The Burial, starring Tommy Lee Jones and Jamie Foxx and directed by Maggie Betts.

 

2. The funeral industry is poorly regulated.

The funeral industry is primarily regulated by the Funeral Rule. Introduced in 1984 by the Federal Trade Commission (FTC), the Funeral Rule was established to prevent vulnerable families from being exploited by licensed funeral homes after the FTC found widespread deceptive practices that limited consumers’ ability to make informed decisions. Today, if funeral homes violate the Rule, they may be subject to penalties of more than $51,000 per violation.

While this seems like a strong deterrent, the FTC granted the funeral industry a “sweetheart deal” more than 25 years, according to the Wall Street Journal (WSJ). When funeral homes are found to be in violation of the Funeral Rule, they can opt to participate in the Funeral Rule Offenders Program (FROP), a training program run by the National Funeral Directors Association (NFDA), which is the industry’s largest trade association and lobbying group. The offending funeral homes who enroll in the program become members of the association.

Essentially, the organization that lobbies lawmakers for fewer industry regulations is the same entity responsible for “policing” and penalizing offending businesses. NFDA conceals violations from American consumers and according to some experts, “it’s essentially a hush-money business.” However, the WSJ secured a list of 538 funeral homes that violated the Funeral Rule and publicly reported them earlier this year.

 

3. With no price transparency requirements for the funeral industry, consumers are highly vulnerable to overpaying.

In October 2022, the FTC revealed that more than 60 percent of funeral homes have little to no pricing information on their websites. This leaves consumers in a particularly vulnerable position.

“Imagine losing your child and then having to negotiate where their body goes and how much you’ll pay for it, all within hours,” says Mulheron. “When our own daughter was terminally ill, I called several funeral homes in hopes of identifying one where she could be taken once she died. Several told me they would ‘cut me a deal’ if she died soon. One facility, more than an hour away from our home, said, ‘We charge our flat rate for children of $400.’ We need more people like this leading the industry, not private equity brokers.”

Funeral costs for a single death event are significant, especially for families who struggle to cover the ongoing costs of housing, food, and medical care. According to a 2023 NFDA survey, the average cost of a funeral with a viewing and burial is nearly $8,300. A funeral with cremation costs only about $2,000 less.

These costs don’t take into account the costs of the cemetery, monument, marker, or other miscellaneous expenses, such as flowers. According to the Funeral Alliance Association, these added expenses often increase the total cost of full funeral services by $2,000 or $3,000.

 

4. Plan your funeral, but don’t prepay!

Following the WSJ’s release of the 538 funeral homes that violated federal law, a second WSJ article featured several stories of individuals who tried to act responsibly by paying for their own funerals in advance of dying. In some cases, their families ended up paying twice or more than the initial contracted amount. Whether it is lost paperwork, industry consolidation, “the fine print,” or something else entirely, it’s best to plan for the funeral but not pre-pay, then share your desires widely with family and friends.

 

5. Rather than regulate, your hard-working tax dollars are being used to reimburse funeral expenses.

In 2020, Congress passed a bill reimbursing some families for funeral expenses and only if they lost a loved one to COVID-19 (i.e., if your loved one died from overdose, homicide, or suicide, for example, you do not qualify for reimbursement). As of today, the Federal Emergency Management Agency (or FEMA), responsible for managing taxpayer reimbursement dollars for funeral expenses, has distributed $2.8 billion to 438,000 approved applications, with an average award of $6,400.

Fortunately, the federal government is beginning to act. The FTC has initiated a regulatory process indicating it will reissue the Funeral Rule. Evermore submitted comments to the FTC and is continuing to follow along. However, this process can take years and there is no indication on when the FTC might act. There is reason to believe that the industry will sue the FTC when it does act, further delaying price transparency.

 

It’s time for the funeral industry to join the digital age by sharing prices online. If we, as a nation, focus on closing down children’s lemonade stands for operating without permits, we can easily protect consumers from the funeral industry’s bad actors. After all, as Benjamin Franklin said, “nothing is certain except death and taxes.”

—

We welcome readers to share their experiences working with funeral homes — positive or negative, confusing, frustrating, or supportive. If you have a story to share, email us at hello@stagingevermore.dbdodev.com.

 

Evermore’s Comments on Interventions to Improve Care of Bereaved Persons

Jan 11, 2024 | Advocacy, Federal Government

Evermore Submits Comments to AHRQ on Interventions to Improve Care of Bereaved Persons

Bereavement’s long-standing absence from public policy debates and national health priorities, along with its newfound urgency, requires sound leadership and an aggressive agenda to address the substantial challenges confronting our nation’s grieving population. Today, America lacks a comprehensive, coordinated, and evidence-based bereavement care system that is protective and mitigates bereavement’s harmful effects across time and place. As a result, bereavement has major spillover effects at every stage of the life course, especially in the first two decades of life (for children and youth) and in mid-life (when family formation, child-rearing, and employment peak).

However, bereavement as a public concern is in its nascent stages and thus offers an unparalleled opportunity to leverage existing public and private healthcare initiatives to go “upstream” by delivering effective preventive services to stem the onset of chronic or debilitating health conditions associated with bereavement. 

For example, in one 2020 register-based study examining the entire Norwegian population from 1986 to 2014, researchers found evidence of elevated alcohol-induced mortality among bereaved parents. Based on this evidence, healthcare providers should invoke existing quality alcohol misuse screening tools for bereaved parents to stem the short- and long-term ramifications of alcohol misuse following the death of a child. According to the U.S. Preventive Services Task Force (USPSTF), unhealthy alcohol use screening among adults aged 18 presently receives a B rating. Healthcare providers attending to newly bereaved parents can identify the patient’s risk for developing alcohol misuse while also preventing the onset of addiction and reducing premature mortality. Evidence-based tools for grief and bereavement may be lacking, but alcohol misuse evidence-based resources are not. 

Read the full letter..

Federal Government Requests Public Comments on Interventions to Improve Care of Bereaved Persons

Dec 10, 2023 | Advocacy, Data Collection, Federal Government

Federal Government Requests Comments on Interventions to Improve Care of Bereaved Persons

In 2023, and as a result of your hard work, Congress directed The Agency for Healthcare Research and Quality (AHRQ) to establish an evidence base for what constitutes high-quality bereavement and grief care. This systematic review will inform an independent subject matter expert panel that will assess the feasibility of developing consensus-based quality standards for high-quality bereavement and grief care.

AHRQ is seeking comments from the public for a limited time. Outlined below are AHRQ’s initial findings and how you may submit your comments directly. The deadline for public comment is January 11, 2024!

Background & Objectives

Bereavement – the state of having lost someone – and grief – the emotional response to the loss – are fundamental aspects of the life course and most individuals will experience the loss of someone during their lifetime.1 In recent years, a growing number of individuals report experiencing grief and bereavement, due to both better identification of grief and grief-related needs, as well as a large aging population, the COVID-19 pandemic, and more frequent mass trauma events. Emotions related to grief can include feelings of deep sadness, longing, and shock.2 There are a range of interventions to support individuals through their grieving process, ranging from informal supports (e.g., online resources, pamphlets, bereavement support groups) to formal supports such as individual and group therapy. Most individuals experience acute grief without formal intervention, yet a small subset of individuals develop complicated grief or grief with a high level of distress that extends 6 to 12 months following the death.3-5 This type of grief was named prolonged grief disorder by the WHO and included in the ICD-11 in 20186 and classified as a formal disorder in the DSM-V TR in 2022.7 Symptoms of prolonged grief disorder include persistent longing for the deceased person, difficulty accepting the death, emotional pain, and feelings of bitterness.8, 9 In addition, recently bereaved individuals face higher medical risks as well, including increased risk of morbidity and mortality,10-13 suicide,14, 15 and lower functional status and quality of life.10, 16

There are a range of decisional dilemmas related to the screening, intervention, and follow-up of bereaved individuals for grief and grief-related needs over time. Broadly, there is ongoing debate about the “medicalization” of grief and its characterization as a disorder. Potential consequences of this medicalization of grief include the overdiagnosis,  overtreatment, and the loss of traditional and cultural methods of adapting to the loss of a loved one.17 Then there are important questions related to the appropriate screening of bereaved individuals, or those who may become bereaved, to identify and intervene on maladaptive grief responses, such as prolonged grief disorder. In general, mental health services for bereaved individuals, especially bereaved individuals who are caregivers to individuals at the end of life, are considered to be underutilized.18 The public health model for bereaved individuals focuses on identifying and supporting three groups: a) the bereaved population as a whole (universal approach), b) individuals who may be at risk for prolonged grief disorder (selected approach), and c) individuals who have signs or symptoms of a grief disorder (indicated approach).19 Some argue that a universal approach to screening may overlook some individuals who need more tailored support, while engaging other individuals who may not need intervention.20 In contrast, a selected or indicated approach may overlook the opportunity to support and intervene a wider group of bereaved individuals who could benefit.

Related to approaches to identifying and supporting bereaved individuals is the timing of screening and intervention. A variety of factors are related to the grieving processes that make it challenging to determine the most appropriate time to conduct screening. Bereavement processes are unique to each bereaved individual and the trajectory is cyclical, rather than staged.21, 22 The type and circumstances of death (e.g., expected vs unexpected), preparation for the death, awareness of prognosis, acceptance of death, and readiness to engage in bereavement can all play a role in grief processes and timing. While proactive and early screening provides an opportunity for early intervention during the normal bereavement process, screening that comes too early in an individual’s bereavement process may at best be ineffective, and at worst, create undue distress and anxiety. In contrast, screening that happens later in the course of bereavement may miss a window of opportunity for intervention.

In general, clinicians feel that bereavement screening could be useful yet there are various contextual barriers to implementation in health care settings.23 Many bereaved individuals have time-limited contact with the healthcare system in the context of their loss and typically only if their loved one dies in a healthcare setting such as in a hospital, intensive care unit, emergency room, nursing home, or hospice. This limits opportunity for screening and intervention as well as consistent follow-up, with potential for wide variation in how screening is conducted and by whom. Numerous tools exist, but with little consensus or standardization regarding what to use when, and inconsistent implementation.24-27

There are several decisional dilemmas pertaining to appropriate interventions for grief. Given the cyclical and non-linear trajectory of grief, identifying the optimal time for intervention is a persistent challenge for the field. For example, could bereaved individuals experiencing “normal” or typical grief still benefit from formal interventions, and if so, what types of interventions might be most useful? When does normal grief cross a threshold into prolonged grief, and when is formal intervention likely to be most effective? And who is best suited to deliver grief interventions (e.g., health care providers such as a psychologist or psychiatrist for therapy/pharmacotherapy vs community-based practitioners such as a grief counselor or spiritual counselor)? 28-30

There are also outstanding questions regarding the effectiveness of treatment for bereaved individuals who have been identified as having a grief disorder. Interventions to treat prolonged grief disorder include interpersonal psychotherapy, cognitive behavioral therapy, bereavement programs, peer support and group therapy. Most studies on interventions to treat bereaved individuals, however, are small pilot studies.29 There are conflicting results related to the effectiveness of preventive interventions prior to the death, while interventions after the death have resulted in short and long-term improvements.31 Information on their implementation and use in practice is varied, and there are inconsistencies in the extent to which current practice is substantiated by grief and loss theory. This in turn may diminish their credibility and further limit their use in practice. Innovative interventions such as narrative storytelling32 have recently been developed to address averse emotional outcomes of grieving, but little is known about their effectiveness in clinical practice.

We know little still about how contextual factors might impact the effectiveness and even appropriateness of grief interventions.33 The same factors that might influence the timing and appropriateness of screening likely impact the adoption and effectiveness of grief interventions such as circumstances of the death (e.g., traumatic death, anticipated death, overdose, suicide), and place of death such as the ICU, relationship to the deceased person (e.g., child, spouse, estranged relationship), and social isolation and loneliness.34 Comorbid mental health conditions – both pre-existing as well as new onset – may play a particularly influential role, for example the interaction between grief and comorbid depression, and how this should be integrated into intervention. Cultural preferences may influence whether a bereaved individual engages in the intervention, and what types of interventions are likely to be useful and effectives.

Finally, questions remain regarding feasible and appropriate follow-up of bereaved individuals identified as grieving and with grief-related needs. Because grief and bereavement are cyclical non-linear processes unique to each individual,22 follow-up screening may be particularly useful to capture any new, maladaptive (or otherwise benefitting from intervention) responses to grieving. However, follow-up and longer-term screening and intervention is complicated by the various settings in which bereaved individuals may interact. For example, bereavement support might be available in the hospital following an inpatient death, but service is often discontinued once the bereaved individual returns home. Community bereavement support may be available but is often only accessed if the bereaved individual proactively seeks it out, and even then, systematic follow-up in the community is likely highly limited. Some emergency departments report bereaved family members commonly requested referral to community bereavement resources, but found that consistent follow-up was resource intensive and difficult to implement.35 This gap between intervention and follow-up risks overlooking the potential for maladaptive grief response over the longer-term, when it may actually be more likely to develop.

Key Questions

The key questions proposed for the systematic review, addressing screening approach (Key Question 1), screening tools (Key Question 2), bereavement interventions (Key Question 3), and maladaptive grief-related disorder interventions (Key Question 4) were generally supported by key informants, and slightly refined following their input. We sought input from six key informants; including a patient advocate, a caregiver representative, a supportive medicine physician, a clinical psychologist, an expert in spiritual grief, and a social work representative focusing on policy. Key informants emphasized that grief is nonlinear and differs by individual person, and noted that the lack of guidance around grief and bereavement care reinforces the need for a systematic review. Major considerations or revisions recommended by key informants included 1) the importance of extending the screening and follow-up period to more than 1-year following the loss; 2) the need for clinical interview or qualitative assessment in addition to standardized screening and diagnostic tools; 3) the importance of taking spiritual, religious, and cultural differences into account when screening, assessing, and diagnosing; and 4) the importance of considering different bereavement contexts including the type of death (e.g., illness), nature of the death (e.g., sudden death), setting of death (e.g., hospital), relationship to the deceased person (e.g., spouse), and age of the deceased person (e.g., child). Finally, key informants also noted that screening and intervention can take place in the community beyond healthcare settings; for example, facilitated through religious institutions, support groups, and online organizations.

Following the described input, the key questions are as follows:

Key Question 1: What is the effectiveness and harms of universally screening people for bereavement and response to loss?

  1. Timing: predeath, acute, or 6-12 months post loss, and more than 1 year post loss?
  2. Does effectiveness vary by patient characteristic or setting?

Key Question 2: How accurate are tools to identify bereaved persons at risk for or with grief disorders?

Key Question 3: What are the effectiveness, comparative effectiveness, and harms of interventions for people at risk for grief disorders related to bereavement?

  1. Timing: predeath, acute, or 6-12 months post loss, and more than 1 year post loss?
  2. Does effectiveness vary by patient characteristic or setting?

Key Question 4: What are the effectiveness, comparative effectiveness and harms of interventions for people diagnosed with grief-related disorders?

  1. Does effectiveness vary by patient characteristic or setting?

Logic Model

The analytic framework depicts the patient population, the interventions, and the outcomes that will be addressed in the evidence synthesis

References

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  3. Simon NM, Pollack MH, Fischmann D, et al. Complicated grief and its correlates in patients with bipolar disorder. J Clin Psychiatry. 2005 Sep;66(9):1105-10. doi: 10.4088/jcp.v66n0903. PMID: 16187766.
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  16. Chen JH, Gill TM, Prigerson HG. Health behaviors associated with better quality of life for older bereaved persons. J Palliat Med. 2005 Feb;8(1):96-106. doi: 10.1089/jpm.2005.8.96. PMID: 15662178.
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