Complicated Grief

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Risk factors, interventions, and resources for oncology nurses
Cindy S. Tofthagen, PhD, ARNP, AOCNP®, FAANP, FAAN, Kevin Kip, PhD, FAHA, Ann Witt, MS, LMHC, NCC, and Susan C. McMillan, PhD, ARNP, FAAN

BACKGROUND: When a loved one dies of cancer, GRIEF IS PART OF THE HUMAN EXPERIENCE and a normal reaction to the death of
complicated grief (CG) may occur because of the a loved one. Although the pain of loss may never completely subside, most
trauma associated with family caregivers’ percep- individuals adjust to life without the deceased and develop a new sense
tions of their loved one’s suffering, either from of normalcy over time. For others, the grief process becomes prolonged.
advanced cancer or from side effects of cancer Individuals who have difficulty accepting the death and assimilating into life
treatment. without the deceased experience what is known as complicated grief (CG),
or prolonged grief disorder (Shear, 2010).
OBJECTIVES: This article provides an overview of CG may occur in as many as 40% of family caregivers who lose a close
CG and existing interventions for family caregivers family member to cancer (Guldin, Vedsted, Zachariae, Olesen, & Jensen,
who may be at risk for CG following the loss of a 2012). For some, symptoms of CG can occur before the patient dies when
loved one and the implications for oncology nurs- family members are struggling to accept the cancer diagnosis and impending
es who provide emotional support and guidance. death (Tomarken et al., 2008). CG disproportionately affects older adults,
with more than 25% of older adults experiencing CG, compared to only
METHODS: Current evidence related to the 5%–7% of the general population (Newson, Boelen, Hek, Hofman, & Tiemeier,
treatment of CG and information to assist with 2011; Shear, 2010). CG is associated with numerous psychological problems,
identification of individuals at risk for CG are pre- including loneliness, social isolation, anxiety, clinical depression, cognitive
sented, as well as resources for oncology nurses impairment, and post-traumatic stress disorder (PTSD) (Ghesquiere, Shear,
who encounter individuals who are at high risk for, & Duan, 2013; Shear, Ghesquiere, & Glickman, 2013). Compounded losses of
or who are experiencing, CG. multiple close family members and friends, increased likelihood that the de-
ceased will be a spouse or partner, and financial burdens associated with the
FINDINGS: Although therapy interventions for loss may lead to a higher incidence of CG among older adults (Ghesquiere et
CG have been shown to be effective forms of al., 2013; Newson et al., 2011).
treatment, these therapies are not widely available Oncology nurses often form close relationships with patients and their
and often require an extended treatment period family caregivers, both of whom depend on them for guidance and emotional
to yield results. Oncology nurses can provide support during cancer treatment (Guldin et al., 2012). Therefore, oncology
early interventions, such as referrals to supportive nurses are positioned to direct family caregivers to appropriate grief services,
care services and mental health professionals to as well as to deliver continued emotional support and guidance. This article
facilitate effective treatment. provides information to assist with identifying individuals at risk for CG, dis-
cusses current evidence related to treatment for CG, and provides resources
for oncology nurses who encounter individuals who are at high risk for, or
who are experiencing, CG.

Risk Factors
KEYWORDS Although anyone can experience CG, certain risk factors may elevate the like-
grief; family caregivers; patient education; lihood of CG occurring. Manifestations of CG include (a) intense longing;
end-of-life care; integrative therapies (b) loneliness, emptiness, or lack of meaning in life; (c) recurring thoughts
of wanting to join the deceased; and (d) intrusive thoughts about the de-
DIGITAL OBJECT IDENTIFIER ceased that interfere with functioning (Shear et al., 2011). Individual signs
10.1188/17.CJON.331-337 and symptoms of CG also may include feelings of guilt over the death; con-
stantly replaying the circumstances of the death in their mind; imagining

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that they could have somehow prevented the death if they had
done something differently; and feeling numb, shocked, or in
disbelief over the death. The nature of the relationship to the
“Grief is a culture-
deceased, personality traits, coping style, psychiatric history and
comorbidities, and socioeconomic factors all contribute to the
bound experience
risk of CG. that occurs within
Relational Factors
The closer the relationship to the deceased, the more likely it
an individual’s
is that the individual will experience CG. Spouses and parents
are particularly vulnerable to symptoms of CG. Spouses may be
social-cultural
highly inter-dependent on each other and share a close relation-
ship and a lifetime commitment. Widowed parents with young
environment.”
children may face additional stressors that can lead to depression
and increased psychological distress (Yopp, Park, Edwards, Deal,
& Rosenstein, 2015). Because parents normally do not expect a ment styles are also prone to prolonged emotional distress and
child to precede them in death, feelings of guilt and existential display maladaptive avoidant behavior, causing them to suppress
suffering may ensue. Older adults may experience multiple losses emotions that could result in psychosomatic symptoms (Mancini
in a short period of time that compound grief and delay recovery et al., 2015).
(Newson et al., 2011). The negative cognitions associated with the previously men-
tioned attachment styles create beliefs of not being able to live
Personality Traits and Coping Style without the deceased individual, feeling worthless without the
Personality plays a key role in how an individual grieves, in- presence of the deceased person, and feeling like life no longer
ternalizes the grief, and integrates understanding and mean- has meaning (Boelen et al., 2006). These negative cognitions
ing about the loss of a loved one (Piper, Ogrodniczuk, Joyce, & cause bereaved individuals to dwell on their loss rather than to
Weideman, 2011). An individual’s psychological adjustment pro- focus on problem- or emotion-specific solutions (Mancini et al.,
cess, combined with attachment style and coping capability, can 2015). Negative cognitions play a significant role in prolonging
help determine whether he or she is at a higher or lower risk emotional distress and serve as the target for therapeutic inter-
of experiencing symptoms of CG (Piper et al., 2011). Although ventions to help bereaved individuals dispute and restructure
more well-adjusted individuals would be expected to cope bet- their maladaptive thoughts and beliefs (Boelen et al., 2006;
ter with grief and loss, the literature does not clearly support Piper et al., 2011). Behavioral interventions that support the
this relationship (Mancini, Sinan, & Bonanno, 2015; Piper et al., lessening of negative cognitions and avoidant behaviors serve
2011). Personality traits identified as correlates for poorer coping as protective factors in resolving grief and loss (Mancini et al.,
strategies and prolonged emotional distress include anxiety, in- 2015).
security, lower levels of self-esteem, and higher levels of negative Individuals who experience CG during their bereavement
cognition (Boelen, van den Bout, & van den Hout, 2006; Piper et tend to exhibit greater dependency behaviors, focus primarily
al., 2011). on negative cognitions about the deceased, are highly emotion-
Despite inconclusive research regarding a causal relationship al, experience a greater degree of loneliness, and hold negative
between personality and severity of grief, personality does fac- perceptions about the support they will receive if they reach out
tor into the level of distress some individuals experience when to others for help (Boelen et al., 2006; Mancini et al., 2015; Piper
dealing with grief and the length of time required for the grief et al., 2011). Individuals who demonstrate greater levels of resil-
symptoms to resolve (Piper et al., 2011). The literature presents a ience during their bereavement hold a more favorable view of the
compelling argument that an individual’s level of worry and anx- support they can expect from others, rely more on their support
iety, along with his or her attachment style, plays a role in the systems, openly share their feelings, and worry less about avail-
ability to effectively adapt after a loss (Schenck, Eberle, & Rings, able support when needed (Mancini et al., 2015).
2015). For example, securely attached individuals tend to adapt Additional protective factors that lead to more adaptive be-
and resolve their grief more effectively than those with a more reavement include spiritual and religious practices or rituals,
anxious attachment style (Piper et al., 2011). Those with higher prior adaptive psychological well-being, personal and financial
anxiety-related attachment styles may experience difficulty mov- control, and no co-occurring losses (Mancini et al., 2015; Piper
ing through the grief process, managing emotions, and adjusting et al., 2011). These protective factors predict less negative cogni-
after a loss (Piper et al., 2011). Individuals with anxious attach- tion and higher rates of perceived wellness (Boelen et al., 2006).

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However, bereaved individuals with insecure attachment styles than reminders of the deceased. On the other hand, in CG, indi-
may demonstrate unwillingness or inability to engage with com- viduals may experience intrusive and involuntary thoughts about
munity and social support networks (Piper et al., 2011). diverse aspects of the relationship with the deceased, including
Studies conducted by Mancini et al. (2015) and Schenck et positive content that the bereaved longs for, and avoidance is
al. (2015) concluded that individuals with insecure attachment mostly limited to stimuli that serve as reminders of the reality or
styles remained more focused on negative cognitions about the permanence of the loss (Alexander & Litz, 2014). However, the
deceased than those with secure attachment styles. Findings also cardinal symptom of emotional numbness since the time of the
revealed a higher level of CG symptoms among bereaved individ- loss is shared by both CG and PTSD (Alexander & Litz, 2014).
uals with insecure attachment styles. Those bereaved individuals Common comorbidities and similar symptom overlap between
who displayed CG symptoms demonstrated greater levels of sep- CG and other mental health disorders add to the challenge of
aration distress (Piper et al., 2011; Schenck et al., 2015). Grief in- identifying optimal treatments.
tegration is necessary to find meaning in the loss and to find ways
of maintaining a sense of closeness with the deceased (Schenck et Psychotherapeutic Interventions
al., 2015), resulting in adaptive coping that strengthens resilience The normal grief process is a fluid process that most individuals
(Mancini et al., 2015). can resolve without the intervention of healthcare professionals
(Waller et al., 2016). Oncology nurses should consider referring
Psychiatric Comorbidities and Differentiation individuals experiencing normal grief to support groups, grief
As with many primary mental health disorders, comorbidities counseling, and spiritual care services (Ghesquiere et al., 2013),
are common among individuals suffering from CG. This includes which are offered through hospice and palliative care programs
when CG is considered the primary disorder, as well as when throughout the United States (Centers for Medicare and Medicaid
CG is secondary to mental health disorders that share symptom Services, n.d.). When grief is prolonged, and the grief-stricken in-
overlap. For example, individuals presenting for care with a pri- dividual is unable to reconcile the grief and adjust to life without
mary diagnosis of CG exhibit elevated rates of comorbid anxiety his or her deceased loved one, psychotherapeutic interventions
disorders, especially PTSD (48% current, 52% lifetime) and panic are warranted (Wittouck, Van Autreve, De Jaegere, Portzky, & van
disorder (14% current, 22% lifetime) (Simon, Shear, et al., 2007). Heeringen, 2011).
In nontreatment settings, approximately 15% of bereaved indi- Support groups and bereavement counseling offer psychoso-
viduals also meet the diagnostic criteria for PTSD (O’Connor, cial support throughout the grief process and educate participants
2010). Similarly, individuals with CG present with psychological about normal grieving patterns; however, little evidence suggests
characteristics often found in individuals with anxiety disorders,
such as experiential avoidance (Boelen, van den Bout, & van
den Hout, 2010) and intolerance of uncertainty (Boelen, 2010). FIGURE 1.
Considering reverse directionality, high rates of comorbid CG PSYCHOTHERAPY MODALITIES
have been documented in individuals with a primary diagnosis
of major depressive disorder (Kersting et al., 2009; Sung et al., COGNITIVE BEHAVIORAL THERAPY
2011). Consistent with this temporal relationship, a history of ɔɔ Form of psychotherapy that explores how thought patterns affect an
prior trauma or loss and a history of mood and anxiety disor- individual’s attitudes, feelings, and behaviors
ders also predict greater likelihood of developing CG (Lobb et COGNITIVE RESTRUCTURING
al., 2010). ɔɔ Form of cognitive behavioral therapy that focuses on identifying negative,
Although significant symptom overlap exists whether CG is ineffective, or disruptive thought patterns and replacing them with more
primary or secondary to PTSD, each disorder has its own unique positive ones to encourage behavioral change
features (O’Connor, 2010; O’Connor, Lasgaard, Shevlin, & Guldin, EXPOSURE THERAPY
2010). Whereas PTSD is characterized typically by fear, horror, ɔɔ Form of cognitive behavioral therapy in which individuals confront a
anger, guilt, or shame, combined with an anxious hyperarousal traumatic event through cognitive re-exposure and learn how to process
and exaggerated reactivity, the experience of CG is marked pri- emotions associated with the event
marily by yearning, loss, or emptiness (Alexander & Litz, 2014). INDIVIDUAL INTERPERSONAL THERAPY
CG symptoms include an intense longing for the deceased and ɔɔ Form of psychotherapy that focuses on interpersonal issues that can con-
distress over the loss of the relationship, which is not a central tribute to emotional distress to reduce symptoms, improve functioning,
component of PTSD (O’Connor et al., 2010). To further differ- and enhance social support
entiate, when experiencing PTSD after a loss, intrusive thoughts
Note. Based on information from Foa et al., 2008; Interpersonal Therapy Institute,
fixate on the death event itself, leading individuals to avoid inter-
2017; Mills et al., 2008; National Alliance on Mental Illness, 2017.
nal and external reminders of the death event specifically, rather

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COMPLICATED GRIEF

that psychosocial support is effective in preventing or treating CG A 2011 meta-analysis of interventions for CG, which pooled
(Ghesquiere et al., 2015). Because bereavement programs are wide- data from 14 randomized, controlled trials testing interventions
ly available and facilitated by mental health professionals, they may to prevent or treat CG, determined that treatment of CG sig-
be helpful in identifying individuals who require treatment for CG. nificantly improved grief-related symptoms, whereas preven-
Despite an abundance of hospice and palliative care programs tion interventions have not demonstrated consistent efficacy
offering support groups and counseling for grieving individuals, (Wittouck et al., 2011). The studies of CG interventions pre-
only a small percentage of people use these services (Steiner, sented in the meta-analysis were published from 1990–2007
2006). Online groups offer similar benefits, increased access, and included studies of cognitive behavioral therapy, individ-
and lower associated costs (Lubas & De Leo, 2014) which may ual interpersonal therapy, and a combination of the two (see
encourage usage. However, healthcare providers have expressed Figure 1). The interventions ranged in length from 12–20 weeks
concerns about the safety, oversight, and confidentiality of online and were conducted by trained mental health counselors and
programs (Lubas & De Leo, 2014; Wells, Mitchell, Finkelhor, & therapists.
Becker-Blease, 2007). Katherine Shear, MD, a faculty physician in the School of
Early palliative care interventions for family caregivers, deliv- Social Work at Columbia University, has been instrumental in
ered by advanced practice nurses via telephone while the patient moving the science of grief therapy forward. Shear and her re-
is in advanced stages of malignancy, may reduce depression and search team developed a 16-session psychotherapeutic interven-
CG, but require further study (Dionne-Odom et al., 2016). A writ- tion for individuals with CG that has demonstrated efficacy in
ing intervention, called Finding Balance, allows bereaved care- three large randomized, controlled trials involving more than
givers of patients with cancer to reflect, process emotions, and 600 participants (Shear et al., 2014, 2016; Shear, Frank, Houck,
find balance through specific writing activities (Holtslander et al., & Reynolds, 2005). The Complicated Grief Treatment interven-
2016). These promising new interventions, developed and evalu- tion is a structured psychotherapy program, designed to be im-
ated by nurse scientists, aim to guide nursing practice in specific plemented by licensed mental health professionals (Shear et al.,
interventions to alleviate grief; however, more research is needed 2014). Complicated Grief Treatment has also demonstrated effi-
to evaluate their effectiveness in CG. cacy in a group setting, which affords a more economical option
and higher access to treatment (Supiano & Luptak, 2014).

FIGURE 2. Pharmacologic Interventions

RESOURCES FOR GRIEF SUPPORT Depression and CG frequently co-occur, and preliminary ev-
idence suggests that antidepressants factor into treatment of
ONLINE RESOURCES CG (Bui, Nadal-Vicens, & Simon, 2012; Glickman, Shear, & Wall,
PsychCentral® Grief Quiz: A brief self-assessment to determine if a bereaved 2016; Hensley, Slonimski, Uhlenhuth, & Clayton, 2009; Simon
individual is experiencing complicated grief symptoms et al., 2008; Simon, Thompson, Pollack, & Shear, 2007; Zisook,
ɔɔ http://psychcentral.com/quizzes/grief-quiz.htm Shuchter, Pedrelli, Sable, & Deaciuc, 2001). Pilot studies have
HelpGuide.org: Coping with grief and loss demonstrated positive effects of selective serotonin reuptake in-
ɔɔ www.helpguide.org/articles/grief-loss/coping-with-grief-and-loss.htm hibitors on CG (Hensley et al., 2009; Simon, Thompson, et al.,
GoodTherapy.org’s top 10 websites for grief and loss 2007; Zygmont et al., 1998); however, a clinical trial involving
ɔɔ www.goodtherapy.org/blog/best-resources-2012-top-10-grief-loss 395 people with CG found that providing citalopram (Celexa®)
-0104137 and Complicated Grief Treatment in combination reduced
Mindfulness and Grief: Meditation and journaling for grief depression-related outcomes, but did not lead to specific im-
ɔɔ http://mindfulnessandgrief.com provements in CG when compared to Complicated Grief
The Grieving Heart: For hope and support after loss Treatment plus placebo (Shear et al., 2016).
ɔɔ http://thegrievingheart.info

The Center for Complicated Grief Implications for Nursing

ɔɔ https://complicatedgrief.columbia.edu Practice
BOOK RESOURCES In practice, except for hospices, family caregivers are not consid-
Mindfulness and Grief: With Guided Meditations to Calm Your Mind and ered targets of oncology nursing care, and healthcare providers
Restore Your Spirit by Heather Stang and hospitals are not reimbursed for administering care to family
ɔɔ http://mindfulnessandgrief.com/mindfulness-and-grief-book caregivers. Therefore, nurses may find providing support to them
Recommended grief-related books to provide support after loss after the death of the patient to be challenging. Nevertheless,
ɔɔ http://thegrievingheart.info/griefbooks.html oncology nurses are well positioned to identify family caregivers
who are at the greatest risk for CG and should remain alert to the

334   CLINICAL JOURNAL OF ONCOLOGY NURSING  VOLUME 21, NUMBER 3 CJON.ONS.ORG

 IMPLICATIONS FOR PRACTICE
ɔɔ Recognize the risk factors associated with complicated grief (CG) to
ensure that family caregivers receive prompt interventions.
ɔɔ Support family caregivers experiencing CG by offering condolences
possibility. Oncology nurses should stay abreast of available com- for their loss, providing referrals to grief counseling or supportive
munity resources so that family caregivers experiencing CG, or services, and allowing family caregivers to express their feelings
those at risk for CG, can be referred promptly to support groups, about the loss.
grief counseling, or spiritual support services. Nurses can provide ɔɔ Provide efficient palliative care, symptom management, and patient
direct support for those struggling with grief by offering condo- and family education during the cancer trajectory to help prevent
lences, demonstrating concern, and allowing family caregivers experiences of CG in family caregivers.
to express their feelings. Individuals may be open to discussing
feelings and concerns or they may be reluctant. If concerns about
the potential for self-harm arise, nurses have an ethical obligation constructs when developing intervention programs (Schenck et
to obtain immediate mental health services for that individual. al., 2015).
Figure 2 provides online resources that can help support individ-
uals experiencing CG. Many hospices provide free bereavement Conclusion
services regardless of whether the individual experiencing the Oncology nurses often encounter individuals who are suffering
loss was involved in that hospice. Often, pastors are trained in with, or who are at risk for, CG. Prompt recognition and referral
managing grief, so referring family caregivers to their local faith to supportive services and mental health experts can help facili-
community leader may be helpful. tate early and effective treatment. Current evidence suggests that
psychotherapy and pharmacologic treatments may be helpful
Education in alleviating CG symptoms. Providing effective palliative care,
Nursing education has very little focus on the issues of loss and symptom management, and patient and family education during
grief for family caregivers and even less focus on CG. Therefore, the cancer trajectory may help to prevent CG. Acknowledging the
nursing educators should incorporate assessment and manage- loss, engaging in active listening, and allowing family caregivers
ment of CG at all levels of the nursing curriculum and conduct to express their feelings and tell their story are important ways
educational research to measure the efficacy of adding CG-related that oncology nurses can intervene in CG.
content. Cancer centers and oncology units should offer continu-
ing education focusing on CG to keep practicing nurses up to date Cindy S. Tofthagen, PhD, ARNP, AOCNP®, FAANP, FAAN, is an associate professor
on the latest findings from research, as well as to provide educa- and director of oncology in the College of Nursing and Kevin Kip, PhD, FAHA, is
tion and support to assist nurses who might be experiencing grief a distinguished professor in the College of Public Health, both at the University of
themselves. South Florida; Ann Witt, MS, LMHC, NCC, is the president of and a licensed mental
health counselor at PieWiseLiving, LLC; and Susan C. McMillan, PhD, ARNP, FAAN,
Research is a distinguished professor in the College of Nursing at the University of South
Although Complicated Grief Treatment has been shown to be Florida, all in Tampa. Tofthagen can be reached at [email protected], with
an effective treatment for CG symptoms, it is not widely avail- copy to [email protected]. (Submitted August 2016. Accepted November 29,
able and typically requires a relatively lengthy treatment period 2016.)
(16 weeks) (Shear et al., 2014). Future studies should focus on
efficient ways of delivering treatment for CG and other effective The authors take full responsibility for this content and did not receive honoraria or disclose
forms of psychotherapy to more individuals. To date, few stud- any relevant financial relationships. The article has been reviewed by independent peer
ies have evaluated psychotherapeutic interventions specifically reviewers to ensure that it is objective and free from bias. Mention of specific products and
for CG in loved ones of patients who have died from cancer. The opinions related to those products do not indicate or imply endorsement by the Oncology
experience of family caregivers and close family or friends during Nursing Society.
diagnosis and treatment, as well as near the end of life, may influ-
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Supiano, K.P., & Luptak, M. (2014). Complicated grief in older adults: A randomized controlled
trial of complicated grief group therapy. Gerontologist, 54, 840–856. doi:10.1093/geront CNE ACTIVITY
/gnt076 EARN 0.5 CONTACT HOURS
Tomarken, A., Holland, J., Schachter, S., Vanderwerker, L., Zuckerman, E., Nelson, C., . . . Priger-
son, H. (2008). Factors of complicated grief pre-death in caregivers of cancer patients. ONS members can earn free CNE for reading this article and completing
Psycho-Oncology, 17, 105–111. doi:10.1002/pon.1188 an evaluation online. To do so, visit cjon.ons.org/cne to link to this article’s
Waller, A., Turon, H., Mansfield, E., Clark, K., Hobden, B., & Sanson-Fisher, R. (2016). Assisting evaluation and to access a current list of all available activities.
the bereaved: A systematic review of the evidence for grief counselling. Palliative Medicine,
30, 132–148. doi:10.1177/0269216315588728 QUESTIONS FOR DISCUSSION
Wells, M., Mitchell, K.J., Finkelhor, D., & Becker-Blease, K.A. (2007). Online mental health USE THIS ARTICLE FOR JOURNAL CLUB
treatment: Concerns and considerations. Cyberpsychology and Behavior, 10, 453–459.
doi:10.1089/cpb.2006.9933 Journal club programs can help to increase your ability to evaluate the
Wittouck, C., Van Autreve, S., De Jaegere, E., Portzky, G., & van Heeringen, K. (2011). The pre- literature and translate those research findings to clinical practice, educa-
vention and treatment of complicated grief: A meta-analysis. Clinical Psychology Review, tion, administration, and research. Use the following questions to start the
31, 69–78. doi:10.1016/j.cpr.2010.09.005 discussion at your next journal club meeting.
Yopp, J.M., Park, E.M., Edwards, T., Deal, A., & Rosenstein, D.L. (2015). Overlooked and under- ɔɔ Name two psychological problems associated with complicated grief (CG).

served: Widowed fathers with dependent-age children. Palliative and Supportive Care, 13, ɔɔ What are some of the characteristics found in individuals at risk for CG?

1325–1334. doi:10.1017/s1478951514001321 ɔɔ What are your initial interventions for individuals experiencing CG?

Zisook, S., Shuchter, S.R., Pedrelli, P., Sable, J., & Deaciuc, S.C. (2001). Bupropion sustained re- ɔɔ What resources have you mobolized in your practice to support individ-

lease for bereavement: Results of an open trial. Journal of Clinical Psychiatry, 62, 227–230. uals experiencing CG?
Zygmont, M., Prigerson, H.G., Houck, P.R., Miller, M.D., Shear, M.K., Jacobs, S., & Reynolds, Visit http://bit.ly/1vUqbVj for details on creating and participating in a jour-
C.F., 3rd. (1998). A post hoc comparison of paroxetine and nortriptyline for symptoms of nal club. Photocopying of this article for discussion purposes is permitted.
traumatic grief. Journal of Clinical Psychiatry, 59, 241–245.

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