Suicide after bereavement: an overlooked problem

Prairie voles as a model for adaptive reward remodeling following loss of a bonded partner

Loss of a loved one is a painful event that substantially elevates the risk for physical and mental illness and impaired daily function. Socially monogamous prairie voles are laboratory-amenable rodents that form life-long pair bonds and exhibit distress upon partner separation, mirroring phenotypes seen in humans. These attributes make voles an excellent model for studying the biology of loss. In this review, we highlight parallels between humans and prairie voles, focusing on reward system engagement during pair bonding and loss. As yearning is a unique feature that differentiates loss from other negative mental states, we posit a model in which the homeostatic reward mechanisms that help to maintain bonds are disrupted upon loss, resulting in yearning and other negative impacts. Finally, we synthesize studies in humans and voles that delineate the remodeling of reward systems during loss adaptation. The stalling of these processes likely contributes to prolonged grief disorder, a diagnosis recently added to the Diagnostic and Statistical Manual for Psychiatry.

Impacts of suicide bereavement on men: a systematic review

Introduction

This systematic review examines the impacts of suicide bereavement on men's psychosocial outcomes relating to suicidality, mental health, substance use, grief, and social functioning. Given the high global incidence of suicide and the substantial number of individuals affected by each suicide, understanding the specific experiences and outcomes for men is crucial, particularly in the context of observed gender differences in suicide rates, grief coping styles and mental health outcomes.

Methods

Adhering to PRISMA guidelines, this review included peer-reviewed, English-language studies that involved men bereaved by suicide using quantitative, qualitative and mixed-methods designs. Searches were conducted in MEDLINE, Embase, Emcare, PsycINFO, and Scopus. Analysis used narrative synthesis methods due to the heterogeneity of findings. These were categorised based on comparison groups: non-bereaved men, or women bereaved by suicide. Prospero registration: CRD42023437034.

Results

The review included 35 studies (25 quantitative, 8 qualitative, 2 mixed-methods) published between 1995 and 2023. Compared to non-bereaved men, suicide-bereaved men are more likely to experience adverse psychosocial outcomes included increased suicide mortality, heightened susceptibility to mental health problems such as depression and posttraumatic stress disorder, and challenges in interpersonal relationships and social functioning. The review also identified gender differences in grief responses and coping strategies, with men often exhibiting more pronounced grief reactions and facing unique challenges due to societal expectations and norms regarding masculinity.

Discussion

The findings of this review underscore the elevated risk of adverse suicide- and mental-health related outcomes for suicide-bereaved men and the need for tailored postvention supports for this cohort. Gender-specific factors, including cultural norms and coping strategies, significantly influence men's experiences of suicide bereavement. Further qualitative and longitudinal quantitative exploration is needed to enhance understanding and effective support for men bereaved by suicide.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023437034.

Sociodemographic inequalities of suicide: a population-based cohort study of adults in England and Wales 2011-21

BACKGROUND

The risk of suicide is complex and often a result of multiple interacting factors. Understanding which groups of the population are most at risk of suicide is important to inform the development of targeted public health interventions.

METHODS

We used a novel linked dataset that combined the 2011 Census with the population-level mortality data in England and Wales. We fitted generalized linear models with a Poisson link function to estimate the rates of suicide across different sociodemographic groups and to identify which characteristics are independent predictors of suicide.

RESULTS

Overall, the highest rates of suicide were among men aged 40-50 years, individuals who reported having a disability or long-term health problem, those who were unemployed long term or never had worked, and those who were single or separated. After adjusting for other characteristics such as employment status, having a disability or long-term health problem, was still found to increase the incidence of suicide relative to those without impairment [incidence rate ratio minimally adjusted (women) = 3.5, 95% confidence interval (CI) = 3.3-3.6; fully adjusted (women) 3.1, 95% CI = 3.0-3.3]. Additionally, while the absolute rate of suicide was lower in women compared with men, the relative risk in people reporting impairments compared with those who do not was higher in women compared with men.

CONCLUSIONS

The findings of this work provide novel population-level insights into the risk of suicide by sociodemographic characteristics in England and Wales. Our results highlight several sociodemographic groups who may benefit from more targeted suicide prevention policies and practices.

Investigating risk of self-harm and suicide on anniversaries after bereavement by suicide and other causes: a Danish population-based self-controlled case series study

AIMS

To investigate mechanisms of suicide risk in people bereaved by suicide, prompted by observations that bereaved people experience higher levels of distress around dates of emotional significance. We hypothesised that suicide-bereaved first-degree relatives and partners experience an increased risk of self-harm and suicide around dates of (i) anniversaries of the death and (ii) the deceased's birthday, compared with intervening periods.

METHODS

We conducted a self-controlled case series study using national register data on all individuals living in Denmark from 1 January 1980 to 31 December 2016 and who were bereaved by the suicide of a first-degree relative or partner (spouse or cohabitee) during that period, and who had the outcome (any episode of self-harm or suicide) within 5 years and 6 weeks of the bereavement. We compared relative incidence of suicidal behaviour in (i) the first 30 days after bereavement and (ii) in the aggregated exposed periods (6 weeks either side of death anniversaries; 6 weeks either side of the deceased's birthdays) to the reference (aggregated unexposed intervening periods). As an indirect comparison, we repeated these models in people bereaved by other causes.

RESULTS

We found no evidence of an elevated risk of suicidal behaviour during periods around anniversaries of a death or the deceased's birthdays in people bereaved by suicide (adjusted incidence rate ratio [IRRadj] = 1.00; 95% confidence interval [CI] = 0.87-1.16) or other causes (IRRadj = 1.04; 95% CI = 1.00-1.08) compared with intervening periods. Rates were elevated in the 30 days immediately after bereavement by other causes (IRRadj: 1.95, 95% CI: 1.77-2.22).

CONCLUSIONS

Although people bereaved by suicide are at elevated risk of self-harm and suicide, our findings do not suggest that this risk is heightened around emotionally significant anniversaries. Bereavement care should be accessible at all points after a traumatic loss as needs will differ over the grief trajectory.

Suicide Following the COVID-19 Pandemic Outbreak: Variation Across Place, Over Time, and Across Sociodemographic Groups. A Systematic Integrative Review

PURPOSE OF REVIEW

To systematically examine changes in suicide trends following the initial COVID-19 outbreak, focusing on geographical and temporal heterogeneity and on differences across sociodemographic subgroups.

RECENT FINDINGS

Of 46 studies, 26 had low risk of bias. In general, suicides remained stable or decreased following the initial outbreak - however, suicide increases were detected during spring 2020 in Mexico, Nepal, India, Spain, and Hungary; and after summer 2020 in Japan. Trends were heterogeneous across sociodemographic groups (i.e., there were increases among racially minoritized individuals in the US, young adults and females across ages in Japan, older males in Brazil and Germany, and older adults across sex in China and Taiwan). Variations may be explained by differences in risk of COVID-19 contagion and death and in socioeconomic vulnerability. Monitoring geographical, temporal, and sociodemographic differences in suicide trends during the COVID-19 pandemic is critical to guide suicide prevention efforts.

Measuring Vulnerability in Grief: The Psychometric Properties of the Italian Adult Attitude to Grief Scale

Although experiences of loss and the consequent grief are natural in human life, some individuals may have difficulty managing these events, to the point of developing significant impairment in their functioning in important life areas. Given this, the present research aimed to explore the psychometric properties of the Italian version of the Adult Attitude to Grief scale (AAG) to facilitate research on adult vulnerability to grief among Italian-speaking populations. A sample of 367 participants (M_age = 30.44, SD = 11.21; 78% females) participated in this research. A back-translation procedure was implemented to develop the Italian AAG. Then, participants completed the Italian AAG alongside a battery of other self-report psychometric scales in order to assess aspects of the construct validity of the AAG: the Forty-Item Defense Style Questionnaire, the Impact of Event Scale-Revised, and the Beck Depression Inventory-II. A bifactor structure was found to have the best fit to the data, supporting the possibility of using both the general factor (i.e., vulnerability) and three dimensions (i.e., overwhelmed, controlled, and resilient). Unlike the original version, the control dimension emerged as a "protective" factor in the Italian population, together with the resilient factor. Furthermore, results provided satisfactory indications of internal consistency and construct validity. In conclusion, the Italian AAG was shown to be a valid, reliable, quick, and easy-to-use scale that can be used both for research and clinical practice in the Italian context.

The impact of the COVID-19 pandemic on suicide mortality in Spain: Differences by sex and age

BACKGROUND

Variations in suicide following the initial COVID-19 pandemic outbreak were heterogeneous across space, over time, and across population subgroup. Whether suicide has increased during the pandemic in Spain, a major initial COVID-19 hotspot, remains unclear, and no study has examined differences by sociodemographic group.

METHODS

We used 2016-2020 data on monthly suicide deaths from Spain's National Institute of Statistics. We implemented Seasonal Autoregressive Integrated Moving Average (SARIMA) models to control seasonality, non-stationarity, and autocorrelation. Using January 2016-March 2020 data, we predicted monthly suicide counts (95 % prediction intervals) between April and December 2020, and then compared observed and predicted monthly suicide counts. All calculations were conducted for the overall study population and by sex and age group.

RESULTS

Between April and December 2020, the number of suicides in Spain was 11 % higher-than-predicted. Monthly suicide counts were lower-than-expected in April 2020 and peaked in August 2020 with 396 observed suicides. Excess suicide counts were particularly salient during the summer of 2020 - largely driven by over 50 % higher-than-expected suicide counts among males aged 65 years and older in June, July, and August 2020.

DISCUSSION

The number of suicides increased in Spain during the months following the initial COVID-19 pandemic outbreak in Spain, largely driven by increases in suicides among older adults. Potential explanations underlying this phenomenon remain elusive. Important factors to understand these findings may include fear of contagion, isolation, and loss and bereavement - in the context of the particularly high mortality rates of older adults during the initial phases of the pandemic in Spain.

The Effects of Bereavement Time on the Relationship Between Coping Strategies and Psychological Distress

The purpose of this study was to investigate the relationship between bereaved individuals' coping patterns, mental health, and time post-loss. A questionnaire using the Coping with Bereavement Scale (CBS) and the Kessler Psychological Distress Scale (K6) was completed by 173 family members of individuals who died from cancer between August 2013 and March 2016. Confirmatory factor analysis revealed a three-factor solution for the CBS comprised of "life orientation," "avoidance," and "retaining ties" with the deceased. Scores on retaining ties were significantly but weakly correlated with K6 scores; however, the intensity of this relationship increased with more time post-bereavement, and individuals who retained strong ties with the deceased for two years or more demonstrated poorer mental health. Although retaining ties with the deceased might be an adaptive psychological process following bereavement, in this study, long-term persistence with that coping strategy was associated with greater overall psychological distress. Further research is needed to identify optimal coping methods to address evolving needs during the bereavement process.

The Association Between Personality Disorder Traits and Suicidality Following Sudden Bereavement: A National Cross-Sectional Survey

Personality disorder is associated with increased risk of suicidal behavior. The authors aimed to investigate the association between number of personality disorder traits and suicidality risk following sudden bereavement. A secondary analysis of cross-sectional data on 3,167 young adults in the United Kingdom who had experienced sudden bereavement investigated the association between number of traits (measured using a standardized screening instrument) and postbereavement suicide attempt and suicidal ideation. Using multivariable logistic regression, the authors found a linear relationship between number of traits and suicide attempt (adjusted odds ratio [AOR] = 1.36, 95% CI [1.23, 1.49]) and suicidal ideation (AOR = 1.31, 95% CI [1.25, 1.38]) following bereavement. This represented an increase in odds by 36% and 31%, respectively, for each additional personality trait. The authors suggest that individuals with a greater number of traits suggestive of a personality disorder diagnosis are at increased risk of suicidality after a negative life event.

The "men in grief" phenomenon among suicide bereaved Chinese men in Hong Kong

This qualitative study addressed the intersectionality between masculine grief and gender role expectations during the grief process among men. The sample comprised 10 Chinese men in Hong Kong who had lost their wife or child to suicide. The study found that the "men in grief" phenomenon comprised three themes: making sense of hidden grief, processing grief-related guilt, and removing the stigma of masculine grieving. Future research on the masculine grieving process can focus on the association between perceived weaknesses and expected help-seeking behaviors in men who experience multiple losses after a suicide death in the family.

Widowhood and mortality: a Danish nationwide register-based cohort study

AIMS

Widowed people have increased mortality compared to married people of the same age. Although most widowed people are of older age, few studies include the oldest old. As life expectancy is increasing, knowledge of widowhood into older age is needed. This study aimed to examine mortality and widowhood in older age by comparing mortality in widowed and married people by sex, age, time since spousal loss and cause of death.

METHODS

A Danish register-based matched cohort study of 10% of widowed persons ⩾65 years in the years 2000-2009. For each randomly drawn widowed person, five married persons were matched on sex and age. Mortality rate ratios (MRR) were calculated using Poisson regression, and stratified according to sex and 5-year age intervals. MRRs were furthermore calculated by time since spousal loss and by specific cause of death.

RESULTS

The study included 82 130 persons contributing with 642 914.8 person-years. The overall MRR between widowed and married persons with up to 16 years of follow-up was 1.25 (95% CI 1.23-1.28). At age ⩾95 years for men, and ⩾90 years for women, no differences in mortality rates were seen between widowed and married persons. Mortality in widowed persons was increased for most specific causes of death, with the highest MRR from external causes (MRR 1.53 [1.35-1.74]) and endocrine diseases (MRR 1.51 [1.34-1.70]).

CONCLUSIONS

Widowhood was associated with increased mortality in older age for both men and women until age ⩾95 and ⩾90 years, respectively. Increased mortality was observed for almost all causes of death.

Self-harm and violent criminality linked with parental death during childhood

BACKGROUND

Adverse health and social outcomes are known to occur more frequently following parental death during childhood, but evidence is lacking for comparing long-term risks of internalised v. externalised harm.

METHODS

This national register-based cohort study consisted of Danish persons born 1970-2000. The Civil Registration System and National Causes of Death Register were linked to ascertain parental deaths by cause before cohort members' 15th birthdays. From age 15 years, hospital-treated self-harm episodes were ascertained through linkage to the National Patient Register and the Psychiatric Central Research Register, and violent crimes were identified via linkage to the National Crime Register. Hazard ratio and cumulative incidence values were estimated.

RESULTS

Self-harm and violent criminality risks were elevated following parental death during childhood. Covariate adjustment for gender, birth year and first-degree relatives' mental illnesses attenuated these associations, although significantly heightened risks persisted. The estimated hazard ratios did not differ greatly according to which parent died, but losing both parents conferred particularly large risk increases. Risks for both adverse outcomes were higher in relation to unnatural v. natural parental death; violent criminality risk was especially raised among individuals exposed to parental death by unnatural causes other than suicide. The association was strongest when pre-school age children experienced parental death.

CONCLUSIONS

Effective early intervention is needed to help youngsters who have experienced the death of one or both parents to develop immediate and sustained coping strategies. Enhanced cooperation between health and social services and criminal justice agencies may mitigate risks for these two destructive behaviours.

Grief Before and After Bereavement in the Elderly: An Approach to Care

Grief is the natural response to the death of a loved one and is encountered frequently in clinical practice with the elderly; it can also precede the death. Knowledge about four distinct forms of grief can aid clinicians with the conceptualization of grief, and the assessment and care of grievers. First, predeath grief is experienced by many caregivers of terminally ill patients. Second, acute grief arises immediately after the death of a loved one; and third, this normally evolves to a permanent state of integrated grief after a process of adaptation. Finally, failure of adaptation results in Prolonged Grief Disorder (PGD) which has been recently included in ICD-11. The hallmark feature of PGD is intense longing for the deceased or persistent preoccupation with the deceased that lasts longer than 6 months after the death. Validated instruments are available to assist practitioners with assessment of predeath grief and screening for PGD, thereby enabling identification of patients in need of additional support. Increased risks of morbidity and mortality following bereavement are important health issues for clinicians to be aware of. All grievers can benefit from support focused on understanding their grief, managing emotional pain, thinking about the future, strengthening their relationships, telling the story of the death, learning to live with reminders of the deceased, and connecting with memories. A short-term evidence-based intervention for PGD is based upon these seven themes and is efficacious in the elderly. Caregivers of the terminally ill benefit from psychological support that validates and normalizes their grief experiences and helps them recognize and accept their losses.

Bereavement risk assessment of family caregivers of patients with cancer: Japanese version of the Bereavement Risk Assessment Tool

OBJECTIVES

The Bereavement Risk Assessment Tool (BRAT) seems to be useful in identifying those who are likely to suffer from the more severe consequences of bereavement. To date, however, only a few studies have examined bereavement risk using the BRAT. This study investigated bereavement risk in family caregivers of patients with cancer using the Japanese version of the Bereavement Risk Assessment Tool (BRAT-J). We also investigated the relationship of bereavement risk with psychological distress and resilience among caregivers to determine the validity of the BRAT-J.

METHODS

We conducted family psychoeducation in the palliative care unit of Tohoku University Hospital with participants who were recruited in this study. Among the participants, 50 family caregivers provided their written informed consent and were included in this study. Participants were assessed using the BRAT-J and completed the Japanese version of the Kessler Psychological Distress Scale (K6) and the Tachikawa Resilience Scale (TRS).

RESULTS

According to the BRAT-J, five individuals (10%) were in the high category of bereavement risk (level 4 or 5). We also found that family caregivers of patients experienced many different pressures, such as facing the unknown; their own work; and insufficient financial, practical, or physical resources. These issues are associated with various mental problems. Additionally, the level of bereavement risk was significantly correlated with K6 scores (ρ = 0.30, p = 0.032), and the TRS score (ρ = -0.44, p = 0.001). These correlations confirmed previous findings and that the BRAT-J can be an efficient screening tool for the bereavement risk of family caregivers of patients with cancer.

SIGNIFICANCE OF RESULTS

It appears that the BRAT-J is useful in predicting the likelihood of difficulties or complications in bereavement for family caregivers and could help to provide support with these issues when needed.

The neuroscience of sadness: A multidisciplinary synthesis and collaborative review

Sadness is typically characterized by raised inner eyebrows, lowered corners of the mouth, reduced walking speed, and slumped posture. Ancient subcortical circuitry provides a neuroanatomical foundation, extending from dorsal periaqueductal grey to subgenual anterior cingulate, the latter of which is now a treatment target in disorders of sadness. Electrophysiological studies further emphasize a role for reduced left relative to right frontal asymmetry in sadness, underpinning interest in the transcranial stimulation of left dorsolateral prefrontal cortex as an antidepressant target. Neuroimaging studies - including meta-analyses - indicate that sadness is associated with reduced cortical activation, which may contribute to reduced parasympathetic inhibitory control over medullary cardioacceleratory circuits. Reduced cardiac control may - in part - contribute to epidemiological reports of reduced life expectancy in affective disorders, effects equivalent to heavy smoking. We suggest that the field may be moving toward a theoretical consensus, in which different models relating to basic emotion theory and psychological constructionism may be considered as complementary, working at different levels of the phylogenetic hierarchy.

Health in widowhood: The roles of social capital and economic resources

A sizeable literature has demonstrated strong negative associations between widowhood and health, but longitudinal evidence on moderating factors has been mixed. This study assesses the roles of pre-existing social capital and wealth in moderating changes in health in the event of spousal death. Samples of widowed individuals (n = 796) and matched married controls (n = 8233) are employed from 17 consecutive waves of the Household, Income and Labour Dynamics in Australia Survey (2001-2017). Individual-level fixed-effects models are used to estimate changes in physical and mental health before and after spousal death, in reference to one's own health more than two years before widowhood. Results show a temporary physical health improvement in the year of spousal death, and a decline in mental health beginning up to two years before spousal death, lasting up to two years after spousal death. Using social capital-from children, club membership or volunteering status, and social connections-observed earlier than two years before spousal death, this study finds that widowed individuals with higher social capital show poorer mental health than those with less capital. This negative moderating role is more marked among widowed males than females. In contrast, greater wealth, particularly from non-financial assets, is associated with earlier psychological adjustment among males. For females, mental health in widowhood shows little difference by wealth. These findings suggest that social capital may not be sufficient to protect deteriorations in mental health among widowed individuals, and that the pursuit of alternative avenues may be especially important among the less wealthy.

Rethinking suicides as mental accidents: Towards a new paradigm

BACKGROUND

Since its beginnings, suicide research has made great progress in terms of empirical findings. However, in contrast to empirical knowledge, the theoretical understanding of suicides has shown only minimal progress. Missing interdisciplinary bridges and the lack of a unifying paradigm have been major obstacles. This paper examines the starting points for a rethink.

METHODS

In the first step, we identified major challenges in suicide research, which have been obstructing a better understanding. In the second step, we determined a new concept of suicide that is highly compatible with epidemiological results and meets the requirements of interdisciplinary usability. In the third step, the implications of this paradigm were explored by relating it to two process typologies, the one characterizing the temporal dynamics of suicide processes, and the other representing risk mechanisms / factors occurring at different stages of suicide processes.

RESULTS

Since suicides are rare events and often appear to be "rash acts", they can be conceived of as mental accidents or, more precisely, as failures to withstand temporary suicide impulses. This paradigm is suitable for synchronously implementing different personal, psychopathological, societal and situational perspectives. It applies to a high proportion of suicides and works well when being exposed to different typologies of suicide processes.

CONCLUSIONS

The mental accident paradigm provides an interdisciplinary starting point in suicidology that offers new perspectives in research, prediction and prevention.

The tide does turn: Predictors of remission from suicidal ideation and attempt among Canadians who previously attempted suicide

The objectives of this study were to identify factors that contribute to (1) remission from suicidal ideation, and (2) remission from suicide attempt, among Canadians with a lifetime history of suicide attempt. Data for this study came from Statistics Canada's nationally representative 2012 Canadian Community Health Survey-Mental Health. A sample of 769 adult respondents who had ever attempted suicide was analyzed with remission from past year suicidal ideation and remission from past year suicide attempt as outcome variables. Of the 769 respondents who had ever attempted suicide, more than two-thirds (69%) were free from suicidal ideation within the past year, and approximately 87% were free from suicide attempts within the past year. Compared to men, odds were 2.66 times greater for women to be free of suicide attempt and 2.65 times greater to be free of suicidal ideation in the past year. Older age, being free of sleep problems and major depressive episode, having no history of chronic childhood physical abuse, and having two or fewer previous suicide attempts were associated with higher odds of remission from both suicide attempt and ideation in the past year.

Prevalence of common mental disorders in widowhood: A systematic review and meta-analysis

BACKGROUND

Widowed people have a high risk of common mental disorders, however no summary estimates of the prevalences exist. The aim of this study was to conduct a systematic review and meta-analysis of the prevalence of common mental disorders in widowed people in the community.

METHODS

MEDLINE, Embase and PsycInfo were searched for papers reporting on prevalence of common mental disorders and widowhood. Eligible studies were included in random effects meta-analyses of the prevalence of depression and anxiety disorders. Subgroup analyses were performed on method of assessment of depression and age and sex.

RESULTS

The literature search identified 13,781 titles of which 42 were eligible for meta-analysis. The pooled prevalence of depression in studies using a screening scale was 40.6% (33.6%-47.6%) (n = 30). For studies using full diagnostic criteria the pooled prevalence of depression was 19.2% (13.4%-25.0%) (n = 12). Subgroup analyses of age (≥ or < 65) and sex did not show any differences regarding depression. Five studies reported the prevalence of anxiety disorders. The pooled prevalence estimate was 26.9% (8.1%-45.7%).

LIMITATIONS

The prevalence estimates in this study are summary estimates of prevalences from existing literature. Although the reporting bias assessment showed no evidence, there could be some reporting bias, as studies might only present results if there is a high prevalence.

CONCLUSIONS

Widowed people have a high prevalence of depression and anxiety disorders. The high prevalence of depression was independent of age and sex. The study identifies a population group at high risk needing special attention in clinical practice.

Bereavement, multimorbidity and mortality: a population-based study using bereavement as an indicator of mental stress

BACKGROUND

Mental stress is associated with higher mortality, but it remains controversial whether the association is causal or a consequence of a higher physical disease burden in those with a high mental stress load. Understanding causality is important when developing targeted interventions. We aimed to estimate the effect of mental stress on mortality by performing a 'natural' experiment using spousal bereavement as a disease-independent mental stressor.

METHODS

We followed a population-based matched cohort, including all individuals in Denmark bereaved in 1997-2014, for 17 years. Prospectively recorded register data were obtained for civil and vital status, 39 mental and physical diagnoses, and socioeconomic factors.

RESULTS

In total, 389 316 bereaved individuals were identified and 137 247 died during follow-up. Bereaved individuals had higher all-cause mortality than non-bereaved references in the entire study period. The relative mortality in the bereaved individuals was highest shortly after the loss (adjusted hazard ratio (aHR), first month: 2.50, 95% confidence interval (CI) 2.37-2.63; aHR, 6-12 months: 1.38, 95% CI 1.34-1.42). The excess mortality rate associated with bereavement rose with increasing number of physical diseases (1.33 v. 7.00 excess death per 1000 person-months for individuals with 0 v. ⩾3 physical conditions during the first month) and was exacerbated by the presence of mental illness. The excess mortality among bereaved individuals was primarily due to death from natural causes.

CONCLUSIONS

Bereavement was associated with increased short-term and long-term mortality, even after adjustment for morbidities, which suggests that mental stress may play a causal role in excess mortality.

Death of a Close Relative and the Risk of Suicide in Sweden-A Large Scale Register-Based Case-Crossover Study

Background

Bereavement is thought to be a risk factor for suicide but the association has not been thoroughly investigated according to specific sensitive time periods and risk groups using a self-matched design. We aimed to 1) determine the risk of suicide within the first year after death of a close relative, 2) investigate if and how the risk changes within this time window and 3) determine if sex, age, and type of relationship, affect this association.

Methods

A self-matched, case-crossover study was performed by linking Swedish registers. In total, 31 059 individuals with suicide between 1990 and 2011 were included. Different periods within the year prior to the suicide were compared with corresponding periods one year earlier in the same individual’s life. Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for suicide after death of a close relative.

Results

Increased ORs of suicide were seen during the first month, OR 1·77 (95% CI 1·35–2·34), and the first half-year, 1·27 (1·13–1·43). An even higher OR was found within the first week, 3·43 (1·89–6·22). Patterns were similar for women and men and across age groups. Death of a partner or child but not death of a sibling or parent was associated with a significantly increased suicide risk. The strongest association was seen after death of a partner in individuals aged 45 and older.

Discussion

These findings provide knowledge of sensitive time periods and at-risk groups in the early period of bereavement. Due to the use of a self-matched study design, methodological challenges of unmeasured residual confounding could be overcome.

Ambient air pollution and suicide in Tokyo, 2001-2011

BACKGROUND

Some evidence suggests an association may exist between the level of air pollution and suicide mortality. However, this relation has been little studied to date. The current study examined the association in Tokyo, Japan.

METHODS

Suicide mortality data for Tokyo for the 11-year period 2001-2011 were obtained together with data on four air pollutants: fine particulate matter (PM2.5), suspended particulate matter (SPM), sulphur dioxide (SO2) and nitrogen dioxide (NO2). A time-stratified case-crossover study design was used to examine the daily association between the level of air pollution and suicide mortality.

RESULTS

During the study period there were 29,939 suicide deaths. In stratified analyses an interquartile range (IQR) increase in the same-day concentration of NO2 was linked to increased suicide mortality among those aged under 30 (percentage change: 6.73%, 95% CI: 0.69-13.12%). An IQR increase in PM2.5 and SO2 was associated with a 10.55% (95% CI: 2.05-19.75%) and 11.47% (95% CI: 3.60-19.93%) increase, respectively, in suicide mortality among widowed individuals for mean exposure on the first four days (average lags 0-3). Positive associations were observed for the air pollutants in the summer although associations were reversed in autumn.

LIMITATIONS

We relied on monitoring data to approximate individual exposure to air pollutants.

CONCLUSIONS

Higher levels of air pollution are associated with increased suicide mortality in some population subgroups in Tokyo. Further research is needed to elucidate the mechanisms linking air pollutants and suicide in this setting.

Increased risk of death immediately after losing a spouse: Cause-specific mortality following widowhood in Norway

OBJECTIVE

This paper examines the short-term risk of cause-specific death following widowhood.

METHOD

We followed all individuals registered as married in Norway in 1975 for marital status and mortality until 2006. Widowed individuals were followed for mortality for 7years following widowhood. Causes of death were categorized into five cause-groups. Life tables were used in survival analyses.

RESULTS

Deaths among the widowed were most frequent in the week following widowhood. In this week and compared to married individuals, there were more deaths including those from malignant cancer in men (hazard ratio (HR) of 1.51; 95% CI: 1.12, 1.89), from external causes in men (HR=3.64; 95% CI: 2.01, 5.28), and from respiratory diseases (HR=2.18; 95% CI: 1.52, 2.84 in men and HR=3.18; 95% CI: 2.26, 4.09 in women). A majority of respiratory deaths were from pneumonia. Thereafter excess mortality among the widowed dropped gradually. Although these numbers stabilized, they were still elevated in year 7. Excess mortality was particularly high in the youngest age group considered (55-64years) and decreased with age, though more so in men than in women. Only a few more widowed individuals than expected died of a condition in the same cause-group as their spouses.

CONCLUSION

A novel finding was that excess deaths in the week following widowhood also were from cancer and respiratory diseases. Men in the youngest age group seemed most vulnerable. Prevention should be considered directly after the death of a spouse, and measures should be aimed at virtually all causes of death.

Associations between marital and educational status and risk of completed suicide in Hungary

BACKGROUND

Suicide rates in Hungary are notoriously high. According to the literature, marital and educational status are associated with suicidal behaviour and these associations are somewhat influenced by gender. Since in Hungary these associations have not yet been investigated by means of large-scale multivariate epidemiological studies we aimed to investigate these in the current paper.

METHOD

Census data on marital and educational status, age and gender from 1980, 1990, 2001 and 2011 were used for the general population. Corresponding data from the same years for suicide victims derived from the Hungarian Demographic Register. Suicide victims younger than 20 years were excluded. Negative binomial regression analyses were used to reveal the effects of the above variables on suicide. All statistical procedures were conducted using Stata 12 software (StataCorp. 2011).

RESULTS

Female gender, young age, higher educational attainment and marriage were significantly associated with decreased risks of suicide. Intriguingly, effects of educational and marital status on suicide were stronger in males.

LIMITATIONS

Data on the length of the periods between changes in marital status and suicides were unavailable. Our four categories are not suitable to cover the whole gamut of marital statuses in a modern society (e.g. we did not have a specific category for people living in cohabitation). Ecological study design.

CONCLUSION

We found that in Hungary between 1980 and 2011 the effects of some frequently investigated societal factors (e.g. educational and marital status) on suicide risk were very similar to those found in the majority of other countries. The effects of studied determinants of suicide have not changed dramatically over the past three decades in Hungary.

Exploring barriers to assessment of bereavement risk in palliative care: perspectives of key stakeholders

Background

Palliative care standards advocate support for grieving caregivers, given that some bereaved people fail to integrate their loss, experience ongoing emotional suffering and adverse health outcomes. Research shows that bereavement support tends to be delivered on an ad hoc basis without formal assessment of risk or need. To align support with need, assessment of bereavement risk is necessary. The overall aim is to develop a bereavement risk assessment model, based on a three-tiered public health model, congruent with palliative care bereavement standards for use in palliative care in Western Australia. The specific aim of this phase of the study was to explore the perspectives of key stakeholders and to highlight issues in relation to the practice of bereavement risk assessment in palliative care.

Methods

Action research, a cyclical process that involves working collaboratively with stakeholders, was considered as the best method to effect feasible change in practice. The nine participants were multidisciplinary health professionals from five palliative care services, and a bereaved former caregiver. Data were obtained from participants via three 90 min group meetings conducted over five weeks. An inductive thematic analysis approach was used to analyse data following each meeting until saturation was reached, and the research team was satisfied that the themes were congruent with research aims.

Results

Existing measures were found unsuitable to assess bereavement risk in palliative care. Assessment following the patient’s death presented substantial barriers, directing assessment to the pre-death period. Four themes were identified relating to issues in need of consideration to develop a risk assessment model. These were systems of care, encompassing logistics of contact with caregivers; gatekeeping; conflation between caregiver stress, burden and grief; and a way forward.

Conclusions

These group discussions provide a data-driven explanation of the issues affecting bereavement risk assessment in palliative care settings. A number of barriers will need to be overcome before assessment can become routine practice. We recommend the development of a brief, pre-death caregiver self-report measure of bereavement risk that may empower caregivers, lead to early intervention, and allow staff to remain focused on patient care, reducing burden on staff and palliative care services.

Individual and area-level factors correlated with death by suicide in older adults

OBJECTIVE

To determine the influence of individual and area-level characteristics associated with suicide in older adults.

METHOD

This study used two complementary data sources. The first used administrative data from the Quebec Coroner's office and included information on suicide deaths in older adults aged 65years and over who died by suicide between 2000 and 2005 (n=903 persons). The second data source, which was used to identify the control group, came from a longitudinal study on seniors' health that was conducted in Quebec between 2004 and 2005 (n=2493 persons). Logistic regression analyses were used to test for associations between suicide and individual and area-level level characteristics.

RESULTS

Suicide was associated with male gender, age, the presence of a physical and mental disorder and the use of health services. At the area-level level, suicide was associated with a higher population density, concentration of men, lower rates of education and higher rate of unemployment. Gender specific analyses also showed different patterns of associations on suicide risk.

CONCLUSIONS

Suicide in older adults is associated with area-level and individual characteristics. This suggests that policies targeting only one level of risk factors are less likely to significantly influence suicide among this population.

E-mental health care among young adults and help-seeking behaviors: a transversal study in a community sample

Background

The Internet is widely used by young people and could serve to improve insufficient access to mental health care. Previous information on this topic comes from selected samples (students or self-selected individuals) and is incomplete.

Objective

In a community sample of young adults, we aimed to describe frequency of e-mental health care study-associated factors and to determine if e-mental health care was associated with the use of conventional services for mental health care.

Methods

Using data from the 2011 wave of the TEMPO cohort study of French young adults (N=1214, aged 18-37 years), we examined e-mental health care and associated factors following Andersen’s behavioral model: predisposing factors (age, sex, educational attainment, professional activity, living with a partner, children, childhood negative events, chronic somatic disease, parental history of depression), enabling factors (social support, financial difficulties, parents’ income), and needs-related factors (lifetime major depression or anxiety disorders, suicidal ideation, ADHD, cannabis use). We compared traditional service use (seeking help from a general practitioner, a psychiatrist, a psychologist; antidepressant or anxiolytics/hypnotics use) between participants who used e-mental health care versus those who did not.

Results

Overall, 8.65% (105/1214) of participants reported seeking e-mental health care in case of psychological difficulties in the preceding 12 months and 15.7% (104/664) reported psychological difficulties. Controlling for all covariates, the likelihood of e-mental health care was positively associated with 2 needs-related factors, lifetime major depression or anxiety disorder (OR 2.36, 95% CI 1.36-4.09) and lifetime suicidal ideation (OR 1.91, 95% CI 1.40-2.60), and negatively associated with a predisposing factor: childhood life events (OR 0.60, 95% CI 0.38-0.93). E-mental health care did not hinder traditional care, but was associated with face-to-face psychotherapy (66.2%, 51/77 vs 52.4%, 186/355, P=.03).

Conclusions

E-mental health care represents an important form of help-seeking behavior for young adults. Professionals and policy makers should take note of this and aim to improve the quality of online information on mental health care and to use this fact in clinical care.

Life and death in the family: early parental death, parental remarriage, and offspring suicide risk in adulthood

Early-life parental death (PD) may increase suicide and other mortality risk in adulthood. The potential implications of subsequent remarriage of the widowed parent (RWP) for suicide have not been well examined. Data came from the Utah Population Database for birth cohorts between 1886 and 1960, yielding a sample of N = 663,729 individuals, including 4533 suicides. Cox models showed PD was associated with increased adult suicide risk before age 50, and with increased risk of cardiovascular disease deaths (CVD) for adults of all ages. For females, RWP attenuated the suicide relationship before age 50 (though not statistically significant), but significantly exacerbated it after age 50. RWP had no significant impact for males. Further, for females, PD's positive association with suicide was stronger than with CVD before age 50. These findings reinforce the importance of biological and social mechanisms in linking early-life stressors to adult mental and physical health.

Marital status and suicidal ideation among Australian older adults: the mediating role of sense of belonging

BACKGROUND

Marriage has been identified as a protective factor in relation to suicide among older adults. The current study aimed to investigate whether sense of belonging mediated the marital status-suicidal ideation relationship, and whether gender moderated the mediation model. It was hypothesized that the relationship between being widowed and lower levels of sense of belonging, and between lower levels of belonging and higher levels of suicidal ideation, would be stronger for older men than older women.

METHODS

A community sample of Australian men (n = 286) and women (n = 383) aged from 65 to 98 years completed the psychological subscale of the Sense of Belonging Instrument and the suicide subscale of the General Health Questionnaire.

RESULTS

The results supported the moderated mediation model, with gender influencing the marital status-sense of belonging relation. For men, widowhood was associated with lower levels of belongingness, whereas for women, marital status was unrelated to sense of belonging.

CONCLUSIONS

It would appear crucial to develop and implement interventions which assist older men to find new ways to feel important and valued after the death of their spouse.

Understanding bereavement-related depression: the polemical journey of DSM-5

OBJECTIVE

This paper will bring you on a polemical journey to understand the issues related in conceptualizing bereavement-related depression.

METHOD

A critical narrative review was carried out to evaluate arguments and controversies surrounding DSM-IV classifications of bereavement exclusion for the diagnosis of major depressive disorder (MDD). Result Available studies that are associated with bereavement exclusion criteria, the open trials and treatments with the implications of such conceptualizations and the current removal of the bereavement exclusion from MDD in DSM-5 were addressed.

CONCLUSION

The review highlights the never-ending polemical journey of conceptualizing any mental disorders, bereavement-related depression included.

Predictive validation of single-episode uncomplicated depression as a benign subtype of unipolar major depression

OBJECTIVE

To evaluate the predictive validity of a proposed benign major depressive disorder (MDD) subtype, single-episode 'uncomplicated MDD', defined as MDD that remits within 6 months and lacks severe impairment, psychotic ideation, suicidal ideation, psychomotor retardation, and feeling worthless.

METHOD

Using two-wave National Epidemiologic Survey on Alcohol and Related Conditions data, four groups differing in wave 1 lifetime MDD history (no history [n = 27 609]; single-episode uncomplicated [n = 418]; other single-episode [n = 1943]; multiple episode [n = 2473]) were evaluated for 3-year follow-up rates of major depressive episode (MDE), generalized anxiety disorder (GAD), and suicide attempt.

RESULTS

Follow-up rates for no-MDD-history, single-episode uncomplicated MDD, other single-episode MDD, and multiple-episode MDD, respectively, were depressive episode 6.1%, 6.9%, 19.5%, 27.1%; GAD 2.7%, 4.3%, 7.8%, 11.2%; and suicide attempt 0.3%, 0.1%, 0.8%, 1.7%. For all validators, 3-year rates for single-episode uncomplicated cases were not significantly different from no-MDD-history rates, but significantly lower than both single- and multiple-episode other-MDD rates. Mild MDD, defined by having only five or six symptoms, did not yield similarly benign results; logistic regression showed 'uncomplicated' provides incremental validity over 'mild' in explaining validator rates. Validator differences were not explainable by treatment-rate differences.

CONCLUSION

Single-episode uncomplicated MDD is a benign subtype lacking typical MDD negative sequelae. The planned DSM-5.1 revision should reinstitute an extended bereavement exclusion applied to all stressors.

A CBT-Based Psychoeducational Intervention for Suicide Survivors

Background: Bereavement following suicide is associated with an increased vulnerability for depression, complicated grief, suicidal ideation, and suicide. There is, however, a paucity of studies of the effects of interventions in suicide survivors. Aims: This study therefore examined the effects of a cognitive behavioral therapy (CBT)-based psychoeducational intervention on depression, complicated grief, and suicide risk factors in suicide survivors. Method: In total, 83 suicide survivors were randomized to the intervention or the control condition in a cluster randomized controlled trial. Primary outcome measures included maladaptive grief reactions, depression, suicidal ideation, and hopelessness. Secondary outcome measures included grief-related cognitions and coping styles. Results: There was no significant effect of the intervention on the outcome measures. However, the intensity of symptoms of grief, depressive symptoms, and passive coping styles decreased significantly in the intervention group but not in the control group. Conclusion: The CBT-based psychoeducational intervention has no significant effect on the development of complicated grief reactions, depression, and suicide risk factors among suicide survivors. The intervention may, however, serve as supportive counseling for suicide survivors.

Bereavement after the suicide of a significant other

CONTEXT

It is estimated that approximately one in four people know someone who has taken their own life and that one suicide death leaves six or more suicide survivors.

AIMS

The aim of this paper was to review the literature regarding the association between suicide and bereavement, focusing also on the supportive and therapeutic resources available for survivors.

MATERIALS AND METHODS

Careful MedLine and PsycINFO searches for the period 1980-2013.

RESULTS

The review of the literature indicates that emotional turmoil in suicide survivors may last a long time and, in some cases, may end with their own suicide.

CONCLUSION

Future research should evaluate the efficacy of professional treatments and of support groups targeting suicide survivors.

PRACTICE IMPLICATIONS

It is crucial to understand the bereavement process after the suicide of a significant other in order to provide proper care, reduce stigma, and improve the outcomes of related psychiatric conditions.

Events prior to completed suicide: perspectives of family survivors

Relatively little is known about the experiences of those bereaved by suicide, particularly in the weeks leading to the death of a loved one. This study used a qualitative methodology to explore the perspectives of close survivors of a completed suicide. Ten people who were bereaved by suicide participated in face-to-face interviews that were digitally recorded, transcribed verbatim, and thematically analysed. Analysis revealed the following three themes: He Tried to Hang Himself: Purposeful indications of the intent to end life; They Still Ignored It: Disappointment with health services; and Nobody Talked to Me: Exclusion of family members from treatment information. Prior to the suicide of their loved one, participants had identified that the loved one was at risk and perceived they were unable to acquire appropriate assistance from services. Rather, services were perceived by participants as unsupportive and inadequate. Health and social service professionals could benefit from further specialised education concerning suicide and its sequelae to ensure more effective and sensitive care delivery to suicide survivors.

An integrative and socio-cultural perspective of health, wealth, and adjustment in widowhood

Women comprise a larger proportion of the ageing population than men, often outlive their spouses, and face a variety of challenges upon widowhood. Discrete aspects of the health impact of widowhood have been described in the literature; however, the expanse of sociocontextual issues that impact on older women's adjustment is less prominent. We undertook a literature review to synthesize recent research and interventions and identify current trends and gaps in knowledge and services. Although many health, social, cultural, and economic factors impact on recently widowed older women throughout the world, we found that few interventions targeting this population incorporate these factors.

Complicated grief in Aboriginal populations

To date there have been no studies examining complicated grief (CG) in Aboriginal populations. Although this research gap exists, it can be hypothesized that Aboriginal populations may be at increased risk for CG, given a variety of factors, including increased rates of all-cause mortality and death by suicide. Aboriginal people also have a past history of multiple stressors resulting from the effects of colonization and forced assimilation, a significant example being residential school placement. This loss of culture and high rates of traumatic events may place Aboriginal individuals at increased risk for suicide, as well as CG resulting from traumatic loss and suicide bereavement. Studies are needed to examine CG in Aboriginal populations. These studies must include cooperation with Aboriginal communities to help identify risk factors for CG, understand the role of culture among these communities, and identify interventions to reduce poor health outcomes such as suicidal behavior.

ATTEND: toward a mindfulness-based bereavement care model

Few, if any, mindfulness-based bereavement care models exist. The ATTEND (attunement, trust, touch, egalitarianism, nuance, and death education) model is an interdisciplinary paradigm for providers, including physicians, social workers, therapists, nursing staff and others. Using a case example to enhance the breadth and depth of understanding, this article focuses on attunement as a means to moderate the negative effects of traumatic bereavement, support the framework for posttraumatic growth in the bereaved, improve psychological outcomes for providers, and set the stage for the other aspects of the ATTEND model.

Understanding suicide risk: identification of high-risk groups during high-risk times

BACKGROUND

The assessment of suicide risk is a complex task for mental health professionals. Certain demographic groups are associated with completed suicide including males, divorced adults, and Caucasians. However, demographic variables alone provide a crude assessment of suicide risk. Psychiatric diagnosis and recent life events might improve the identification of high-risk individuals.

METHOD

The current study evaluated 148 individuals who died by suicide compared with 257 adults who died suddenly from accidents or medical problems. Psychological autopsy was used to assess Axis I psychiatric diagnosis and recent stressful life events.

RESULTS

Suicide completers were significantly more likely than comparison subjects to have a depressive disorder, a substance abuse disorder, and to have experienced interpersonal conflict in the months leading up to their death. A discriminant function analysis revealed that the combination of demographic variables, recent stressful life events, and psychiatric diagnoses best discriminated between suicide completers and comparison subjects.

CONCLUSIONS

Proper assessment of suicide risk should include a comprehensive evaluation of demographic characteristics, recent life stressors, and psychiatric diagnosis.

Inter-rater reliability of the Bereavement Risk Assessment Tool

Objective:

The Bereavement Risk Assessment Tool (BRAT) was designed to consistently communicate information affecting bereavement outcomes; to predict the risk for difficult or complicated bereavement based on information obtained before the death; to consider resiliency as well as risk; and to assist in the efficacy and consistency of bereavement service allocation. Following initial development of the BRAT's 40 items and its clinical use, this study set out to test the BRAT for inter-rater reliability along with some basic validity measures.

Method:

Case studies were designed based on actual patients and families from a hospice palliative care program. Bereavement professionals were recruited via the internet. Thirty-six participants assessed BRAT items in 10 cases and then estimated one of 5 levels of risk for each case. These were compared with an expert group's assignment of risk.

Results:

Inter-rater reliability for the 5-level risk scores yielded a Fleiss’ kappa of 0.37 and an intra-class correlation (ICC) of 0.68 (95% CI 0.5-0.9). By collapsing scores into low and high risk groups, a kappa of 0.63 and an ICC of 0.66 (95% CI 0.5-0.9) was obtained. Participant-estimated risk scores yielded a kappa of 0.24. Although opinion varied on the tool's length, participants indicated it was well organized and easy to use with potential in assessment and allocation of bereavement services. Limitations of the study include a small sample size and the use of case studies. Limitations of the tool include the subjectivity of some items and ambiguousness of unchecked items.

Significance of results:

The collapsed BRAT risk levels show moderately good inter-rater reliability over clinical judgement alone. This study provides introductory evidence of a tool that can be used both prior to and following a death and, in conjunction with professional judgment, can assess the likelihood of bereavement complications.

Complicated grief and related bereavement issues for DSM-5

Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally, grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence, some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over-and under-diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over-diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This article focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders.