Development of the Grief Experience Questionnaire

The Inventory of Social Expectations in Bereavement: Development and psychometric validation of a new instrument

Negative expectations concerning social interactions contribute to feelings of loneliness. Since loneliness is one of the most pronounced challenges for bereaved individuals, we investigated grief-specific social expectations and its association with loneliness and grief severity. Initially, we developed an Inventory of Social Expectations in Bereavement (ISEB). Its factorial and psychometric validity was then tested in a bereaved sample (N = 344; 28.3 ± 11.1 years; 74.4% female). A two-factor solution for the scale fit the data best (factor 1: "relationship to others," factor 2: "relationship to the deceased") and demonstrated good psychometric validity. Higher ISEB-levels were associated with higher levels in grief severity and loneliness. The results suggest that individual social expectations affect the experience of loneliness after the loss of a significant other. The ISEB assesses these expectations time-efficiently and provides a basis for therapeutic interventions. Expressing expectations as probabilistic beliefs about the future renders them amenable for corrective experiences in clinical practice.

Measuring Grief in the Context of Traumatic Loss: A Systematic Review of Assessment Instruments

Following traumatic loss, defined as the death of a loved one due to unexpected or violent circumstances, adults may experience a myriad of grief-related problems. Given the addition of Prolonged Grief Disorders into the Diagnostic and Statistical Manual for Mental Disorders Fifth Edition, Text-Revision and influx of unexpected deaths due to the global Coronavirus pandemic, there is heightened interest in the measurement of grief-related processes. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify measures of grief used in studies of adults who experienced traumatic loss. Searches yielded 164 studies that used 31 unique measures of grief-related constructs. The most commonly used instrument was the Inventory of Complicated Grief-Revised. Half of the measures assessed constructs beyond diagnosable pathological grief responses. Given the wide variation and adaptations of measures reviewed, we recommend greater testing and uniformity of measurement across the field. Future research is needed to adapt and/or design measures to evaluate new criteria for Prolonged Grief Disorder.

Investigating the mediating influence of distress tolerance on the relationship between existential thinking, sense of coherence, and the severity of mourning among families who lost a loved one to COVID-19: A cross-sectional study

Background and Aims

The objective of the current study was to examine how distress tolerance functions as a mediator in the relationship between existential thinking, sense of coherence, and the severity of mourning experienced by families who have lost a loved one to COVID-19.

Methods

The present study employed a descriptive correlational research design, targeting family members of those who passed away due to COVID-19 in the city of Mianeh in 2022. A sample of 160 individuals was selected for statistical analysis. The research instruments used in this study consisted of Flensberg's sense of coherence questionnaire (2006), Simmons and Gaher's emotional distress tolerance questionnaire (2005), Sugbart and Scott's grief experience questionnaire (1989), and Branton Scherer's existential thinking questionnaire (2006). The collected data were analyzed using path analysis, as well as SPSS and Amos software.

Results

The findings of the study revealed a significant correlation coefficient between existential thinking (r = 0.465), sense of coherence (r = 0.401), and distress tolerance (r = 0.521) with the severity of mourning experienced by families who lost a loved one to COVID-19. Moreover, the results indicated a positive and significant relationship (p > 0.01) between distress tolerance and sense of coherence (r = 0.126), as well as between distress tolerance and existential thinking (r = 0.059) among the bereaved families. However, the bootstrap test results suggested that distress tolerance did not mediate the relationship between sense of coherence and the severity of mourning in the families of COVID-19 victims.

Conclusion

Consistent with prior research, the current study's findings indicated that both existential thinking and sense of coherence had a direct impact on the severity of mourning experienced by families who lost a loved one to COVID-19. Additionally, the results revealed that the influence of existential thinking on the severity of mourning was mediated indirectly by increasing distress tolerance.

Predictors of Stigma, Guilt, and Shame among Adults Bereaved by Fatal Overdose

With the spectacular rise of US overdose deaths, bereavement for these affected families has become a matter of increasing concern. Qualitative research has highlighted the role of stigmatization as well as guilt and shame among this population. However, the magnitude and pre-death predictors of stigmatization, guilt, and shame have yet to be assessed quantitatively. In the current study, we assess the magnitude of stigmatization, guilt, and shame among 115 adults bereaved by overdose by drawing comparisons with 185 adults bereaved by suicide. Results revealed no significant differences regarding overall levels of stigmatization, guilt, and shame between the overdose and suicide bereaved. Among the overdose bereaved, regression models indicated a number of pre-death factors associated with stigmatization, guilt, and shame, such as the frequency of the decedent's drug use, family drug use severity, and interpersonal conflict between the bereaved and the decedent. Implications and future directions for research are discussed.

The Information Seeking Behaviors and Needs of Suicide Survivors During Bereavement

The suicide of one person impacts 60 people, known as suicide survivors. These survivors are at an increased risk for negative mental health outcomes including PTSD, suicidal ideation, and suicide contagion. Despite these consequences, there have not been any information science studies that have explored the information behaviors of people who have recently survived the suicide of a loved one. This article takes a unique approach in combining autoethnography with traditional survey research. One hundred and ninteen participants sourced from a private Facebook suicide bereavement group responded to a survey asking them about their information-seeking after a loved one committed suicide. The qualitative data were fragmented and grouped into like-responses and thematic codes that gave explanation to the research questions. These results are coupled with the author’s ethnographic recounting of a similar experience. Brenda Dervin’s sense-making is employed as the methodological lens through which the study is conducted. It is found that suicide survivors are highly unlikely to have their informational needs met. In the immediate aftermath of their loss, they are most likely to look for information related to the suffering of the deceased. As time passes, they begin to look for information about coping with their loss and preventing suicide of other people; either those close to them or in a larger community scale. Being a survivor motivated many participants to advocacy work. Finally, the author argues that the findings of this article should compel further research and the creation of information policy to aid survivors and prevent suicide contagion.

Suicide stigma measures: A scoping review

BACKGROUND

Worldwide, approximately 800,000 people die by suicide every year, and non-fatal suicidal thoughts and behaviours are common. Stigma is likely a major barrier to preventing suicide. The purpose of our review is to scope the development, psychometric properties and use of measures that explicitly seek to measure the construct of suicide stigma.

METHODS

We conducted a scoping review. We searched PubMed, PsycINFO, Embase and CINAHL using search terms related to suicide, stigma and measures/scales with no date limits. We included any measure the authors defined as measuring suicide-related stigma. Only peer-reviewed articles published in English were included.

RESULTS

We included 106 papers discussing 23 measures of suicide stigma; 82 provided data on psychometric properties. Measures assessed personal or public stigma; and stigma toward a range of suicidal phenomena (e.g., suicidal thoughts, those bereaved by suicide). 'Stigma' definitions varied and were not always provided. The Grief Experience Questionnaire, Suicide Opinion Questionnaire and Stigma of Suicide Scale were the most commonly cited. Measures varied in the strength of their psychometric properties.

LIMITATIONS

We only included papers in English. Because we included any measures authors defined as measuring suicide stigma, we may have included measures not commonly considered as measures of suicide stigma, and conversely we might have excluded relevant measures because they did not use the term 'stigma'.

DISCUSSION

This review aimed to assist in better understanding available suicide stigma measures, their strengths and weaknesses and current uses, and will inform the development of future suicide stigma measures.

The Effectiveness of Integrated Group Therapy on Prolonged Grief Disorder of Bereaved People from COVID-19 Randomized Controlled Trial

This study aimed to evaluate the integrated cognitive-behavioral group therapy and Gestalt empty chair technique on bereaved individuals with COVID-19-caused PGD (prolonged grief disease). Thirty-six patients with PGD resultant from COVID-19 were randomly assigned intervention and control groups. The intervention group underwent 16 90-minute integrated group therapy sessions twice a week. Both groups completed the BDI II depression, NAI anger, and GASP guilt scale before, after, and 2 months after the study's conclusion. The intervention and control groups significantly differed in the depression, anger, and guilt indices after the therapeutic intervention (p < .001). This difference remained in the follow-up phase. Integrated group therapy in treating could help with some of the symptoms of PGD resulting from the corona-caused loss of loved ones. This reduction in symptoms was also stable over time.

"I lost so much more than my partner" - Bereaved partners' grief experiences following suicide or physician-assisted dying in case of a mental disorder

BACKGROUND

There is a lack of existing research on grief following the intentional death of people suffering from a mental disorder. Our study aims to provide insight into grief experiences and social reactions of bereaved persons who lost their life partners, who were suffering from a mental disorder, to physician-assisted dying (PAD) or suicide.

METHODS

For this mixed-methods research, we conducted a survey and in-depth interviews with 27 persons living in the Netherlands and bereaved by the death of their life partners. The deceased life partners suffered from a mental disorder and had died by physician-assisted dying (n = 12) or suicide (n = 15). Interviews explored grief experiences and social reactions. In the survey we compared self-reported grief reactions of partners bereaved by suicide and PAD using the Grief Experience Questionnaire.

RESULTS

Compared to suicide, physician-assisted dying was associated with less severe grief experiences of the bereaved partners. Participants reported that others rarely understood the suffering of their deceased partners and sometimes expected them to justify their partners' death. Following physician-assisted dying, the fact that the partner's euthanasia request was granted, helped others understand that the deceased person's mental suffering had been unbearable and irremediable. Whereas, following suicide, the involvement of the bereaved partners was sometimes the focus of judicial inquiry, especially, if the partner had been present during the death.

CONCLUSION

When individuals suffering from a mental disorder die by suicide or PAD, their bereaved partners may experience a lack of understanding from others. Although both ways of dying are considered unnatural, their implications for bereaved partners vary considerably. We propose looking beyond the dichotomy of PAD versus suicide when studying grief following the intentional death of people suffering from a mental disorder, and considering other important aspects, such as expectedness of the death, suffering during it, and partners' presence during the death.

Examining grieving problem correlates of anticipation of the death vs. shock among overdose death and suicide bereaved adults

We conducted an online survey with individuals bereaved by drug deaths (n = 115), suicide (n = 185) and sudden natural deaths (n = 103), including questions about anticipating the death vs. shock, other behaviors, established measures of mental health and grieving difficulties. Results showed more drug death bereaved anticipating their loved one's death while suicide bereaved were more shocked. Death shocked respondents showed greater PTSD, other mental health, and grieving problems; those anticipating the death had less PTSD, grieving problems, and engaged in more meaning-making. These contrasting patterns should call for diverging clinical strategies in offering aid to these traumatically bereaved mourners.

Psychosocial Outcomes of Individuals Attending a Suicide Bereavement Peer Support Group: A Follow-Up Study

Individuals bereaved by suicide represent an important group in terms of postvention. While peer support groups are often accessed by those bereaved, few studies have examined their impact in terms of physical and mental health wellbeing. The aim of this study was to examine psychosocial outcomes of individuals attending suicide bereavement peer support groups in Ireland. Between August 2020 and June 2021, all members were invited to complete a survey, with new members also surveyed at three- and six-month follow-up, to examine changes in wellbeing, depressive symptoms and grief reactions. Results were analyzed using descriptive statistics and mixed linear regression models. The 75 participants were mostly female, with lower levels of overall wellbeing and a higher prevalence of depressive symptoms and suicidal ideation than the general population. Participants also reported high levels of social adjustment difficulties and grief reactions, which were more pronounced for those more recently bereaved. At follow-up (n = 28), a significant improvement in wellbeing and a reduction in grief reactions were found, adjusting for time since bereavement. Participants identified the groups as creating a safe space and providing a sense of belonging and hope. Notwithstanding the small number of participants at follow-up, these findings underline the enduring mental health challenges for those bereaved by suicide and provide further evidence for the role of peer support in postvention.

Bereavement in the Aftermath of Suicide, Overdose, and Sudden-Natural Death: Evaluating a New Measure of Needs

Bereavement has been associated with a number of adverse outcomes, including mortality, particularly among those who experience the sudden loss of a close other. With rising rates of sudden death in the United States, fueled by an alarming increase in fatal overdose deaths, identifying bereavement-related needs among the sudden-death bereaved is essential. The present study investigated the factor structure, internal reliability, and validity of the Sudden Bereavement Needs Inventory (SBNI) in a sample of sudden loss survivors (i.e., fatal overdose, suicide, and sudden-natural loss; N = 403). Confirmatory factor analysis supported a six-factor structure, with items reflecting pragmatic, informational, spiritual, relational, meaning, and emotional needs. SBNI factors showed adequate internal consistency, with significant associations between SBNI scores, loss characteristics, and mental health outcomes (e.g., prolonged grief symptoms, meaning-making, posttraumatic stress disorder [PTSD] symptoms, and anxiety), supporting the scale's validity and highlighting the potential applicability of the instrument in both research and clinical contexts. Future research should examine test-retest reliability of the SBNI, particularly through the lens of understanding whether and how bereavement needs change over time.

Exploring experiences of supports for suicide bereavement in Ireland: protocol for a national survey

Background

A suicide death impacts upon the wellbeing of close family members and friends but has also been shown to affect many people outside of this immediate circle. This will be the first large-scale national study of adults bereaved or affected by suicide in Ireland, using a cross-sectional online survey. The overarching aim will be to gain insight into the experiences of supports received by people bereaved or affected by suicide and to identify the barriers to engagement following their loss.

Methods

A cross-sectional survey will be conducted among adults in Ireland who have been bereaved or affected by suicide. This project will seek to represent people with different demographics and backgrounds in the Irish population using a multifaceted approach to survey recruitment. A range of validated measures will be used to examine participants’ current wellbeing and grief experience. A combination of closed and open-ended questions will provide participants the opportunity to share their individual experiences, the services and supports available to them, and barriers and enablers to accessing supports.

Results

Quantitative data will be analysed using descriptive statistics. Chi-squared tests will be used to compare subgroups within categorical data items, and multivariable regression models will be used to examine differences in psychosocial and physical wellbeing across key groups. Qualitative content analysis will be used for qualitative responses to open-ended questions.

Conclusions

The survey will provide an in-depth understanding of the psychosocial and mental health impacts of suicide bereavement in Ireland; insight into the range of informal and formal supports accessed; and will identify unmet needs and challenges of accessing appropriate and timely supports. The findings will inform current national actions aimed at ensuring the standardisation and quality of the services and supports for those bereaved or affected by suicide.

Exploring experiences of supports for suicide bereavement in Ireland: protocol for a national survey

Background A suicide death impacts upon the wellbeing of close family members and friends but has also been shown to affect many people outside of this immediate circle. This will be the first large-scale national study of adults bereaved or affected by suicide in Ireland, using a cross-sectional online survey. The overarching aim will be to gain insight into the experiences of supports received by people bereaved or affected by suicide and to identify the barriers to engagement following their loss. Methods A cross-sectional survey will be conducted among adults in Ireland who have been bereaved or affected by suicide. This project will seek to represent people with different demographics and backgrounds in the Irish population using a multifaceted approach to survey recruitment. A range of validated measures will be used to examine participants' current wellbeing and grief experience. A combination of closed and open-ended questions will provide participants the opportunity to share their individual experiences, the services and supports available to them, and barriers and enablers to accessing supports. Results Quantitative data will be analysed using descriptive statistics. Chi-squared tests will be used to compare subgroups within categorical data items, and multivariable regression models will be used to examine differences in psychosocial and physical wellbeing across key groups. Qualitative content analysis will be used for qualitative responses to open-ended questions. Conclusions The survey will provide an in-depth understanding of the psychosocial and mental health impacts of suicide bereavement in Ireland; insight into the range of informal and formal supports accessed; and will identify unmet needs and challenges of accessing appropriate and timely supports. The findings will inform current national actions aimed at ensuring the standardisation and quality of the services and supports for those bereaved or affected by suicide.

An integrative systematic review of online resources and interventions for people bereaved by suicide

Suicide bereavement is frequent in the general population and it can have deleterious consequences on the mental health and social functioning of the bereaved individuals. However, those bereaved can face substantial barriers to receive support, and online resources may improve the accessibility of support. This systematic review aimed at examining the use and benefits of online resources dedicated to people bereaved by suicide and appraising the quality of the research in this field. Systematic review according to PRISMA guidelines, involving searches in Pubmed, Scopus and Web of Science, conducted in August 2020. The integrative systematic review involved extracting and merging qualitative and quantitative data. Quality assessment was conducted with the Mixed Methods Appraisal Tool (MMAT). The review included 12 studies, mostly of moderate quality. Online resources are predominantly used by middle-aged women, parents who lost their child by suicide, and recently bereaved individuals. Online resources offer a way for help-seeking around the clock for less educated, more disadvantaged and isolated people. People bereaved by suicide use online resources to seek and share support, share and find information, memorialize their loved one and for meaning-making. Negative effects of online resources are rare. The evidence on the use and benefits of online resources for people bereaved by suicide remains scarce but show encouraging results regarding their positive impact on the mental and psychosocial health of the users.

The relationship between guilt, depression, prolonged grief, and posttraumatic stress symptoms after suicide bereavement

OBJECTIVE

A profound feeling of guilt and its role in complicating psychological reactions are accepted as central issues in suicide bereavement. However, research examining the relationship of guilt with mental disorders commonly following suicide bereavement is still lacking. This study aimed to examine the association between guilt and symptoms of depression, prolonged grief disorder, and posttraumatic stress disorder (PTSD) after suicide bereavement, as well as its moderating role in the association between the time which elapsed since bereavement and psychopathological symptoms.

METHODS

154 self-selected adult German participants bereaved by suicide completed online questionnaires assessing sociodemographics, characteristics related to the loss, guilt, depression, prolonged grief, and PTSD.

RESULTS

Significant positive correlations were found between guilt and all assessed psychopathological symptoms. Further, guilt was a significant correlate with symptoms of depression, prolonged grief, PTSD over and above sociodemographic factors, and time that elapsed since the loss. Guilt furthermore moderated the link between the time which elapsed since bereavement and depressive symptoms, while this effect was not observed for prolonged grief and posttraumatic stress symptoms.

CONCLUSION

Our findings replicate theoretical frameworks linking feelings of guilt with mental disorders after suicide bereavement. Accordingly, they highlight the necessity to adapt psychotherapeutic interventions according to the specific needs of this population to maximize treatment effectiveness.

Efficacy of an Internet-based cognitive-behavioural grief therapy for people bereaved by suicide: a randomized controlled trial

Background: The loss of a loved one due to suicide can be a traumatic event associated with prolonged grief and psychological distress. Objective: This study examined the efficacy of an Internet-based cognitive-behavioural grief therapy (ICBGT) specifically for people bereaved by suicide. Methods: In a randomized controlled trial, 58 participants with prolonged grief disorder (PGD) symptoms who had lost a close person to suicide were randomly allocated either to the intervention group (IG) or waitlist-control group (WCG). The 5-week intervention comprised ten writing assignments in three phases: self-confrontation, cognitive restructuring, and social sharing. Symptoms of PGD, common grief reactions after suicide, depression, and general psychopathology were assessed at pre-, post-test and follow-up. Results: Between-group effect sizes were large for the improvement of PGD symptoms in treatment completers (d_ppc2 = 1.03) and the intent-to-treat analysis (d_ppc2 = 0.97). Common grief reactions after suicide and depressive symptoms also decreased in the IG compared to the WCG (moderate to large effects). The results are stable over time. Only for general psychopathology, there was no significant time by group interaction effect found. Conclusions: The ICBGT represents an effective treatment approach for people suffering from PGD symptoms after bereavement by suicide. Considering the effect sizes, the small treatment dose, duration, and the stability of the results, the ICBGT constitutes an appropriate alternative to face-to-face grief interventions.

The association of loneliness after sudden bereavement with risk of suicide attempt: a nationwide survey of bereaved adults

PURPOSE

We aimed to test the hypothesis that among people who experience sudden bereavement, loneliness is associated with post-bereavement suicide attempt and post-bereavement suicidal ideation, even when adjusting for network size.

METHODS

We analysed cross-sectional data collected in the 2010 UCL Bereavement Study, to identify 3193 respondents who had experienced sudden bereavement. We used multivariable logistic regression to test for an association between loneliness (using a newly-developed eight-item loneliness measure) and post-bereavement suicide attempt and suicidal ideation, adjusting for socio-demographic factors, pre-bereavement depression and self-harm, and network size.

RESULTS

Among bereaved adults, loneliness was significantly associated with probability of post-bereavement suicide attempt (AOR 1.19; 95% CI 1.14-1.25) and of post-bereavement suicidal ideation (AOR 1.24; 95% CI 1.20-1.28), with estimates unchanged by adding perceived stigma of the bereavement to adjusted models. There was no association between suicide bereavement and loneliness (adjusted coefficient 0.22; 95% CI - 0.12 to 0.45; p = 0.063). The association of loneliness and suicide attempt risk was similar whether participants were bereaved by suicide or not.

CONCLUSIONS

People who report feeling lonely after sudden bereavement are more likely to make a suicide attempt after their loss, even when taking into account their network size and the perceived stigma of the sudden bereavement. There is no evidence that the effects of loneliness on suicidality are specific to suicide bereavement. This work identifies loneliness as a potential target for suicide prevention interventions among bereaved people. It also fuels interest in longitudinal research investigating loneliness as a putative mediator of suicide risk.

Development of the Bereavement and Interpersonal Domains codebook

We describe the development of an empirically-derived codebook for qualitative data concerning the impact of grief on the interpersonal relationships of bereaved individuals. Relatives (N = 39) of deceased military service members participated in focus groups concerning how grief influenced their relationships across multiple interpersonal domains, including family, friends, community, and with the deceased. Focus group transcripts were coded using a stepwise process consistent with grounded theory to identify and categorize recurrent themes. The process yielded a comprehensive codebook containing 44 nodes with definitions and examples. The codebook provides researchers with an empirically-grounded analytic tool for future studies on bereavement.

[Psychological Interventions for People Bereaved by Suicide: A Systematic Review]

BACKGROUND

Suicide bereavement is a significant risk factor for psychological and somatic disorders. However, to date there exists only a limited number of suicide bereavement interventions, and little is known about their efficacy.

METHODS

A computerized search in databases such as PsychINFO, PubMed, Medline was conducted. Randomized controlled trials (RCTs) that compared an intervention for suicide bereaved to a control condition were included after a quality assessment of two independent researchers. In total, six studies with N = 473 participants were included. Cohen's d was used to calculate the effect sizes.

RESULTS

The results indicated small to medium effect sizes for within-group differences for the main outcomes in the intervention condition, while no significant between-group differences were revealed.

CONCLUSIONS

Interventions for suicide bereavement can reduce mental health symptoms, however the results do not appear robust between group comparisons. Thus, it could not be demonstrated that an intervention following the suicide of a close relative is more effective than no intervention or an unspecific intervention. Future research should focus on high-quality intervention studies.

Factors of Seeking Professional Psychological Help by the Bereaved by Suicide

Background

Studies show that people bereaved by suicide often feel a strong need for professional help. It is hypothesized that aspects related to suicide bereavement, such as stigmatization, shame or guilt, hinder help-seeking process of the bereaved. However, little is known about help-seeking behaviors of people who has lost someone due to suicide.

Aims

This study was conducted to attain a better understanding of the contributing factors, including the specific features of grief following suicide, to help-seeking behaviors of the bereaved by suicide.

Methods

The sample consisted of 82 adults bereaved by suicide (64 female; average age 37.79, SD = 14.33). Instruments assessing stigmatization, shame, guilt levels, well-being, tendency to disclose emotional distress and attitudes toward seeking professional psychological help were used. The participants were also asked an open-ended question what professional help-seeking barriers they had encountered. Comparisons between the groups, logistic regression analysis and thematic analysis of the qualitative data were performed.

Results

The findings revealed that bereaved participants who sought professional psychological help reported experiencing stigmatization and feeling guilty after the loss significantly more often. Also the results showed that attitudes toward mental health specialists had the highest prognostic value in predicting help-seeking behaviors of the bereaved. The participants themselves identified the gaps in the health care system as main barriers to seeking help.

Conclusion

The results challenge previously spread notion that stigmatization, guilt and shame after suicide can act only as help-seeking barriers.

Feelings of Blameworthiness and Their Associations With the Grieving Process in Suicide Mourning

AIMS

This study focuses on identifying the correlates associated with the emergence of feelings of blameworthiness associated with a suicide or other traumatic death and its associations with grief complications.

METHODS

Based on a mailed questionnaire survey of 575 mostly white and economically advantaged bereaved parents, 462 who lost a child to suicide, 48 to a drug overdose, 37 to ordinary accidents, and 24 to natural causes, we utilized chi-square tests, correlations and multiple regression analysis to compare and contrast patterns in the data.

RESULTS

Findings showed feelings of blameworthiness associated with grief difficulties, complicated grief, PTSD, depression and other mental health difficulties among suicide bereaved parents. Results among suicide bereaved parents also showed that being stigmatized by socially significant others, having a mixed or negative relationship with the deceased child prior to the death and a less happy marriage, among those presently married couples, all contributed to higher feelings of blameworthiness among these bereaved.

CONCLUSION

Based on these findings, feelings of blameworthiness could serve as a good shorthand indicator of grief problems since it correlates so well with other grief difficulties and mental health problem measures. The importance of peer support is essential for avoiding the downward spiral associated with feelings of blameworthiness that can occur at any time during the grieving process.

Community Based Support for People at Risk for Suicide and Those Who Care for them - Areas for Improvement

To systematically review the quality of evidence regarding the effectiveness of supports for people affected by suicide. EMBASE, MEDLINE, and PsychINFO were searched for evaluations of community-based supports for people affected by suicide. Outcomes included suicide-related behavior, depression, grief, quality of life, caring ability, and qualitative experiences. Fifteen studies evaluated 15 supports of various modalities. Study quality was generally poor; most studies examined bereaved individuals with mixed findings. Few reduced suicide-related behavior, half improved depression, and grief, while studies of caring ability, quality of life, or qualitative experiences reported positive effects. Supports associated with better outcomes connected peers with similar experiences, were provided over a period of months, and involved veteran rather than novice facilitators. Supports for people affected by suicide may be effective for improving suicide-related behavior, psychological adjustment, quality of life and caregiving, but require further evaluation.

Suicide and sudden death bereavement in Australia: A longitudinal study of family members over 2 years after death

OBJECTIVE

Grief reactions change over time. However, only a limited number of studies, and none in Australia, have analysed changes in individual grief reactions longitudinally. The aim is to examine changes in grief reactions, mental health and suicidality of close family members bereaved by suicide, 6, 12 and 24 months after their loss compared with those bereaved by other forms of sudden death, adjusting for confounding factors.

METHOD

Participants were 142 adult family members bereaved by suicide and 63 by other sudden death, followed up at 6, 12 and 24 months in Queensland, Australia. The Grief Experience Questionnaire, Depression Anxiety Stress Scale and Beck Scale for Suicide Ideation were used as main outcomes. Mixed-effects linear and logistic regressions were utilized for statistical analyses.

RESULTS

There were significant differences in rejection, stigmatization, shame and responsibility between the suicide and sudden death bereaved over the 2-year period, after adjusting for potential confounding factors. Rejection, stigmatization, search for explanation, somatic reactions and symptoms of depression and anxiety (Depression Anxiety Stress Scale) declined significantly over time in both groups. Rejection and somatic reactions showed group-by-time interaction effects, with a decrease in the suicide bereaved and no change in the sudden death bereaved. Loss of social support and suicidal ideation did not show a group or time effect.

CONCLUSION

Although our findings confirm that there are several common dimensions to experiencing a sudden death of a family member, several differences were found between the suicide and non-suicide sudden death bereaved including significantly higher levels of rejection, stigmatization, shame and responsibility remaining in the suicide compared to sudden death bereaved 2 years after their loss. These findings should be considered in clinical practice and when designing postvention services in Australia.

Suicide Notes: Assessing Their Impact on the Bereaved

OBJECTIVE

Although suicidologists have devoted great interest toward the importance of suicide notes, scant attention has been paid to their impact upon the suicide bereaved.

METHOD

To address this issue we conducted on an online survey querying 146 mostly American suicide bereaved adults who indicated severe emotional distress after their losses, 80% of whom had lost first degree-relatives.

RESULTS

We found no significant differences in mental health outcomes between those who received suicide notes and those who had not; nor were differences noted between those whose notes contained helpful or unhelpful information and those who had not received such information.

CONCLUSION

We also observed poorer mental health outcomes among the suicide bereaved who expected to receive a suicide note after their loved one died-and did not receive any communication- indicating needs for clinical support among this vulnerable subgroup.

Suicidal Ideation in Bereavement: A Systematic Review

Background: Bereavement is associated with impaired mental health, increases in adverse health behaviors, and heightened risk of suicidal ideation, attempts, and death by suicide. The purpose of this literature review was to explore associations between cause of death and suicidal thoughts among bereaved individuals. Our aim was to compare incidence of suicidal ideation by cause of death and identify gaps in this literature to guide future research and clinical intervention. Methods: PRISMA-P guidelines were used to structure an electronic literature search in the PsycINFO, MEDLINE, and Web of Science databases. The search focused on English language studies that were published before February 2019 and sought to compare rates of suicidal ideation among bereaved people who lost a loved one to suicide, accidental overdose, cancer, dementia, cardiovascular disease, and HIV/AIDs. Results: Ten articles were identified with suicide as cause of death, zero articles for accidental overdose, zero articles for cardiovascular disease, eight articles for cancer, one article for dementia, and one article for HIV/AIDs. Given the limited number of articles generated by our search, a formal meta-analysis was not appropriate. However, a comparison of results did suggest that suicide bereavement was associated with the highest rates of suicide ideation (14.1% to 49%). Stigma, isolation, avoidance behaviors, and psychological distress were associated with suicidal thoughts among bereaved individuals, regardless of the deceased's cause of death. Conclusions: Findings of this literature search revealed significant gaps in the literature, especially regarding thoughts of suicide in bereaved survivors of accidental overdose and cardiovascular disease. Results suggest that multiple causes of death are associated with suicidal ideation in bereavement, but that suicide bereavement may be the cause of death associated with the highest risk of suicidal ideation. More research is needed to understand the ways in which cause of death influences prevalence, risk, and protective factors associated with suicidal thoughts among bereaved individuals.

Effectiveness of interventions for people bereaved through suicide: a systematic review of controlled studies of grief, psychosocial and suicide-related outcomes

BACKGROUND

Suicide bereavement is a risk factor for adverse outcomes related to grief, social functioning, mental health and suicidal behaviour. Consequently, suicide bereavement support (i.e., postvention) has been identified as an important suicide prevention strategy. However, little is known about its effectiveness. To redress this gap, this review aimed to assess the evidence of effectiveness of interventions for people bereaved by suicide, and appraise the quality of the research in this field.

METHODS

We conducted a systematic review according to PRISMA guidelines. Searches of peer-reviewed literature in Medline, PsycINFO, Embase and EBM Reviews identified 12 papers reporting on 11 relevant studies conducted between 1984 and 2018.

RESULTS

Across studies, there was a wide variety of intervention modalities, study populations, control groups, and grief, psychosocial and suicide-related outcome measures. Overall, the quality of studies was weak. While there was some evidence of the effectiveness of interventions for uncomplicated grief, evidence of the effectiveness of complicated grief interventions was lacking. Based on this scant evidence, interventions which seem to show promise include supportive, therapeutic and educational approaches, involve the social environment of the bereaved, and comprise a series of sessions led by trained facilitators.

CONCLUSIONS

There is a clear need for additional methodologically sound studies in this area. Specifically, selection procedures, sample sizes, randomization, and the use of appropriate measures are crucial. As people bereaved by suicide are at-risk of adverse grief, mental ill-health and suicidal behaviour, further research across the life-span is essential to prevent grief and mental health ramifications.

Suicide and other sudden death bereavement of immediate family members: An analysis of grief reactions six-months after death

INTRODUCTION

While suicide bereavement has been assumed to be different from bereavement following death by other modes, a number of studies have reported that there are several similarities, particularly for violent deaths. The aims of the current study are to test, using confirmatory factor analysis, the factor structure of Grief Experience Questionnaire (GEQ) that has been proposed in other studies; and to compare short term grief reactions, mental health, and suicidality six-months after bereavement in close family members bereaved by suicide versus sudden death.

METHODS

Participants were 142 adults who were bereaved following a suicide and 63 who were bereaved following the sudden death of a family member. Data were collected six-months after the death.

RESULTS

Analyses did not show good fits for the factor structures proposed for the GEQ in earlier studies. However, a relatively good fit was found for an 8-factor version of the originally proposed GEQ. Bereavement type (suicide vs. sudden death) significantly predicted rejection, somatic reactions, stigmatisation, responsibility and shame on the GEQ, after adjusting for kinship type, gender, age, pre-bereavement diagnosis of mental illness and self-harm behaviours of both the deceased and the bereaved, and current mental health and suicidal ideation of the bereaved.

LIMITATIONS

Different recruitment methods were used and response rates were relatively low.

CONCLUSIONS

The new knowledge of bereaved experiences specific to suicide loss at six-months post death, should be channelled into determining the most practical and satisfactory ways to alleviate the impacts of these potentially changeable states of experience.

Disclosure in traumatic deaths as correlates of differential mental health outcomes

This analysis addresses the controversial question of whether disclosure of a significant other's traumatic death cause is associated with mental health outcomes. Consistent with the limited previous research, this data, collected from 131 suicide bereaved, 10 exclusively drug death bereaved, and six other bereaved respondents, showed fewer grief difficulties and better self-rated mental health among those inclined to openly disclose a significant other's death cause, compared to those who feared incurring shame and embarrassment from doing so. Regression analyses suggested that the tendency to openly discuss the death was the single most powerful correlate to explaining variations in grief difficulties.

Assessment and Predictors of Grief Reactions among Bereaved Chinese Adults

BACKGROUND

The Texas Revised Inventory of Grief-Present Scale (TRIG-Present) is a widely used tool to measure grief. Most existing research related to the assessment and characteristics of grief has been conducted sampling bereaved Western subjects and, as such, limited information is available on the experience of grief in Chinese samples.

OBJECTIVE

This study aims to validate the Chinese version of the TRIG-Present (TRIG-Present-C) and explore the predictors of grief among bereaved adults in China.

METHODS

Responses from 460 bereaved Chinese adults were collected through an online survey. Subjects completed a specially developed questionnaire covering demographic data/loss-related variables, the TRIG-Present-C, and Center for Epidemiologic Studies Depression Scale (CES-D-9).

RESULTS

Confirmatory factor analysis validates the original one-factor structure. The overall content validity index is equal to 1.0. Significant correlations were observed, with CES-D-9 and factor subscales (r ranged from -0.228 to 0.607, p < 0.05) indicating the convergent validity. The TRIG-Present-C scores distinguished grieving individuals from those experiencing unanticipated death and those where death was anticipated. The internal consistency is satisfactory (Cronbach's α = 0.957). In multiple regression analyses, with grief severity as the dependent variable, 28.6% of the variance was explained by religious belief, the immediacy of the loss, the loss of a first-degree relative, and where the deceased was relatively young.

CONCLUSIONS

The TRIG-Present-C scale is a reliable and valid instrument for assessing grief reaction among bereaved Chinese adults. Religious belief, loss of a first-degree relative, where the deceased was relatively young, and the immediacy of loss were associated with higher levels of grief.

Suicide bereavement: piloting a longitudinal study in Australia

OBJECTIVES

The pilot study were (1) to test the technical and administrative feasibility of a full-scale study, including recruitment process, response and retention rate, questionnaire design for an investigation to improve understanding of the suicide bereavement processes compared with bereavement by sudden deaths and (2) to present the differences and changes in the main outcomes-grief reactions of close relatives exposed to suicide and sudden death over 2 years.

DESIGN

A longitudinal prospective study comparing bereavement by suicide to other types of sudden deaths over time (6, 12 and 24 months).

SETTING

Queensland, Australia.

PARTICIPANTS

25 suicide-bereaved and 15 sudden-death-bereaved persons.

OUTCOME MEASURES

Grief reactions (measured with the Grief Experience Questionnaire).

RESULTS

The response rate was 52.1% in the suicide bereaved and 45.5% in the sudden-death group. There was a small number of dropouts, with the retention rate over 85% for both groups. Linear mixed modelling for repeated measures showed a significant group effect (higher in suicide bereaved) for total grief, responsibility, rejection and unique reactions. A significant time effect (reduction) was measured for total grief, somatic reactions, general grief reactions and search for explanation. One significant time and group interaction was measured; rejection showed a decline in suicide and an increase in sudden-death bereaved.

CONCLUSIONS

The pilot study presented the appropriateness of the study methodology. This type of study has implications for counselling and treating people bereaved by suicide and for designing postvention activities.

Patient- and Caregiver-Reported Assessment Tools for Palliative Care: Summary of the 2017 Agency for Healthcare Research and Quality Technical Brief

CONTEXT

Assessment tools are data collection instruments that are completed by or with patients or caregivers and which collect data at the individual patient or caregiver level.

OBJECTIVES

The objectives of this study are to 1) summarize palliative care assessment tools completed by or with patients or caregivers and 2) identify needs for future tool development and evaluation.

METHODS

We completed 1) a systematic review of systematic reviews; 2) a supplemental search of previous reviews and Web sites, and/or 3) a targeted search for primary articles when no tools existed in a domain. Paired investigators screened search results, assessed risk of bias, and abstracted data. We organized tools by domains from the National Consensus Project Clinical Practice Guidelines for Palliative Care and selected the most relevant, recent, and highest quality systematic review for each domain.

RESULTS

We included 10 systematic reviews and identified 152 tools (97 from systematic reviews and 55 from supplemental sources). Key gaps included no systematic review for pain and few tools assessing structural, cultural, spiritual, or ethical/legal domains, or patient-reported experience with end-of-life care. Psychometric information was available for many tools, but few studies evaluated responsiveness (sensitivity to change) and no studies compared tools.

CONCLUSION

Few to no tools address the spiritual, ethical, or cultural domains or patient-reported experience with end-of-life care. While some data exist on psychometric properties of tools, the responsiveness of different tools to change and/or comparisons between tools have not been evaluated. Future research should focus on developing or testing tools that address domains for which few tools exist, evaluating responsiveness, and comparing tools.

Do Primary Care Physicians Help the Bereaved With Their Suicide Losses: Loss Survivor Perceptions of Helpfulness From Physicians

Several previous studies suggested that primary care physicians can provide important bereavement assistance to survivors of suicide, yet no study has investigated whether suicide-bereaved patients perceive their physicians as helpful. Contacting bereavement communities on social media, we collected online survey data from 146 bereaved respondents reporting suicides causing them severe emotional distress. Data analysis suggested that nearly half (48%) of the respondents encountered positive, help-offering responses from physicians, compared to 10% whose responses were deemed as negative. Analysis of our data suggested that loss survivors' perceptions of a physician's helping or reproachful responses were associated with differences in grief difficulties and mental health distress.

Mental Health Symptomatology and Exposure to Non-Fatal Suicidal Behavior: Factors That Predict Vulnerability and Resilience Among College Students

Despite efforts to identify risk factors following exposure to completed suicide, research has paid less attention to the associations between exposure to non-fatal suicide behavior (NFSB) and mental health symptomatology-factors that may underlie one's susceptibility to future suicidal thoughts and behaviors. This study examined differences in mental health symptomatology among 192 college students exposed to NFSB and 202 exposed to general stressors. Results indicated that students exposed to NFSB had significantly higher levels of depression and anxiety compared to those exposed to a variety of other stressors but not NFSB. Furthermore, among those exposed, a number of risk and protective factors emerged in relation to psychological sequelae, such as emotional stability, social support, and the quality of the relationship between the exposed and suicidal individual. These findings highlight the importance of enhancing provisions of support for those exposed to NFSB.

Grief interventions for people bereaved by suicide: A systematic review

BACKGROUND

Adaption to the loss of a loved one due to suicide can be complicated by feelings of guilt, shame, responsibility, rejection, and stigmatization. Therefore people bereaved by suicide have an increased risk for developing complicated grief which is related to negative physical and mental disorders and an increased risk for suicidal behavior. Grief interventions are needed for this vulnerable population. The aim of this systematic review was to provide an overview of the current state of evidence concerning the effectiveness of interventions that focus on grief for people bereaved by suicide.

METHODS

We conducted a systematic literature search using PubMed, Web of Science, and PsycINFO for articles published up until November 2016. Relevant papers were identified and methodological quality was assessed by independent raters. A narrative synthesis was conducted.

RESULTS

Seven intervention studies met the inclusion criteria. Two interventions were based on cognitive-behavioral approaches, four consisted of bereavement groups, and one utilized writing therapy. As five of the seven interventions were effective in reducing grief intensity on at least one outcome measure, there is some evidence that they are beneficial. Bereavement groups tend to be effective in lowering the intensity of uncomplicated grief, as are writing interventions in lowering suicide-specific aspects of grief. Cognitive-behavioral programs were helpful for a subpopulation of people who had high levels of suicidal ideation.

LIMITATION

On average, methodological quality was low so the evidence for benefits is not robust. The stability of treatment effects could not be determined as follow-up assessments are rare. Generalizability is limited due to homogeneous enrollments of mainly female, white, middle-aged individuals.

CONCLUSIONS

People bereaved by suicide are especially vulnerable to developing complicated grief. Therefore, grief therapies should be adapted to and evaluated in this population. Prevention of complicated grief may be successful in populations of high risk individuals.

Perceived Stigma of Sudden Bereavement as a Risk Factor for Suicidal Thoughts and Suicide Attempt: Analysis of British Cross-Sectional Survey Data on 3387 Young Bereaved Adults

The sudden death of a friend or relative, particularly by suicide, is a risk factor for suicide. People who experience sudden bereavement report feeling highly stigmatised by the loss, potentially influencing access to support. We assessed whether perceived stigma following sudden bereavement is associated with suicidal thoughts and suicide attempt. We analysed cross-sectional survey data on 3387 young adults bereaved by the sudden death of a close contact. We tested the association of high versus low perceived stigma (on the stigma sub-scale of the Grief Experience Questionnaire) with post-bereavement suicidal ideation and suicide attempt, using random effects logistic regression, adjusting for socio-demographic factors, pre-bereavement psychopathology, and mode of sudden bereavement (natural causes/unnatural causes/suicide). Subjects with high perceived stigma scores were significantly more likely to report post-bereavement suicidal thoughts (adjusted odds ratio (AOR) = 2.74; 95% confidence interval (CI) = 1.93-3.89) and suicide attempt (AOR = 2.73; 95% CI = 2.33-3.18) than those with low stigma scores. People who feel highly stigmatised by a sudden bereavement are at increased risk of suicidal thoughts and suicide attempt, even taking into account prior suicidal behaviour. General practitioners, bereavement counsellors, and others who support people bereaved suddenly, should consider inquiring about perceived stigma, mental wellbeing, and suicidal thoughts, and directing them to appropriate sources of support.

Fruits of trauma? Posttraumatic growth among suicide-bereaved parents

BACKGROUND

While there is evidence that suicide-bereaved individuals may be at higher risk for trauma-related outcomes, such as posttraumatic stress disorder or prolonged grief, positive psychology suggests that suicide bereavement may also promote personal growth within the confines of distress characterized as posttraumatic growth (PTG).

AIMS

The aim of this study was to investigate PTG and what variables, such as reflective rumination, resilience, personality variables, and mood states, contribute to PTG among suicide-bereaved parents.

METHOD

Online survey methods were employed using a convenience sample of 154 parents bereaved by the suicide death of their child within 2 years.

RESULTS

Multiple regression analyses revealed that resilience inversely predicted PTG scores, but reflective rumination did not predict PTG. PTG scores were in the low-moderate range and were lower than those of parents bereaved by other causes of death. Items endorsed most strongly corresponded to the PTG factors Relating to Others, Spiritual Change, and Appreciation of Life.

CONCLUSION

In this study, PTG manifests among suicide-bereaved parents, but may be complicated by the proximity to the death and by concurrent brooding and reflective rumination unique to answering the question of "why" in this population.

The Stigma of Suicide Survivorship and Related Consequences-A Systematic Review

Background

considerable proportion of the population experiences major life disruptions after losing a loved one to suicide. Social stigma attached to suicide survivors adds to complications occurring in the course of suicide bereavement. Despite its known risks, stigma related to suicide survivors has been sparsely investigated.

Methods

We conducted a systematic literature search in PubMed, Web of Science, PsycInfo and PsyArticles, of studies indexed up through August 2015. Articles were eligible for inclusion if they addressed experiences of stigma in suicide survivors, compared them to other bereavement populations, or investigated stigmatizing attitudes within the public. The search was restricted to English-language studies.

Results

25 records matched inclusion criteria. Study designs were heterogeneous, making comparisons difficult. Results demonstrated that suicide survivors experience stigma in the form of shame, blame, and avoidance. Suicide survivors showed higher levels of stigma than natural death survivors. Stigma was linked to concealment of the death, social withdrawal, reduced psychological and somatic functioning, and grief difficulties. Only one study investigated stigmatizing attitudes towards suicide survivors among the general population.

Limitations

Internal and external validity of the studies was restricted by a lack of valid measures and selection bias.

Conclusions

More methodologically sound research is needed to understand the impact of stigma on suicide survivors’ grief trajectories and to separate it from other grief aspects. Clinicians and grief-counselors as well as the public should be educated about the persistent stigma experienced by suicide survivors.

Survivors of Suicide: A Comprehensive Bibliography Update, 1986–1995

An update of a 1985–86 Omega bibliography of the literature on survivors of suicide is presented. Following brief introductory comments, including the identification of research and therapy needs and unresolved issues, the bibliography listings are organized by the following subtopics: general references on family members and friends as suicide survivors; children, adolescents, youth, and parents as survivors; school and educational settings; parental suicide; elderly suicide survivors; mental health professionals and clinicians in training as survivors; survivors of professionals' suicides; and research on attitudes toward survivors. Published works in professional journals, books, book chapters, and doctoral dissertations on the topic of survivor-victims are included.

The stigma perceived by people bereaved by suicide and other sudden deaths: A cross-sectional UK study of 3432 bereaved adults

OBJECTIVE

To test the hypothesis that perceived stigma scores in young adults bereaved by suicide are significantly higher than in young adults bereaved by other sudden deaths, whether blood-related to the deceased or not.

METHODS

We conducted a cross-sectional study of all staff and students aged 18-40 at 37 UK higher educational institutions in 2010, and identified 3432 respondents who had experienced a sudden bereavement of a close contact since reaching the age of 10, either due to sudden natural causes, sudden unnatural causes, or suicide. We used multivariable regression to compare scores on the stigma, shame, responsibility and guilt subscales of the Grief Experience Questionnaire, adjusting for socio-demographic factors and pre-bereavement psychopathology.

RESULTS

People bereaved by suicide (n=614) had higher stigma scores than people bereaved by sudden natural death (n=2106; adjusted coefficient=2.52; 95% CI=2.13-2.90; p=<0.001) and people bereaved by sudden unnatural death (n=712; adjusted coefficient=1.69; 95% CI=1.25-2.13; p=<0.001). Shame, responsibility and guilt scores were also significantly higher in people bereaved by suicide, whether compared with bereavement by sudden natural death or sudden unnatural death. Associations were not modified by whether the bereaved was blood-related to the deceased or not.

CONCLUSIONS

Stigma was perceived more acutely by the relatives and friends of those who died by suicide than those bereaved by other causes of sudden natural or sudden unnatural death. Their high levels of perceived stigma, shame, responsibility and guilt require qualitative investigation to identify whether these grief dimensions limit social functioning, help-seeking behaviour and/or support offered.

The Bereavement Guilt Scale

The rationale, development, and validation of the Bereavement Guilt Scale (BGS) are described in this article. The BGS was based on a theoretically developed, multidimensional conceptualization of guilt. Part 1 describes the generation of the item pool, derived from in-depth interviews, and review of the scientific literature. Part 2 details statistical analyses for further item selection (Sample 1, N = 273). Part 3 covers the psychometric properties of the emergent-BGS (Sample 2, N = 600, and Sample 3, N = 479). Confirmatory factor analysis indicated that a five-factor model fit the data best. Correlations of BGS scores with depression, anxiety, self-esteem, self-forgiveness, and mode of death were consistent with theoretical predictions, supporting the construct validity of the measure. The internal consistency and test–retest reliability were also supported. Thus, initial testing or examination suggests that the BGS is a valid tool to assess multiple components of bereavement guilt. Further psychometric testing across cultures is recommended.

A scoping review of bereavement risk assessment measures: Implications for palliative care

BACKGROUND

Palliative care standards and policies recommend that bereavement support be provided to family caregivers, yet uncertainty surrounds whether support currently offered by palliative care services throughout developed countries meets caregiver needs. The public health model of bereavement support, which aligns bereavement support needs with intervention, may address this gap between policy and practice.

AIM

The aim was to review the literature to identify bereavement risk assessment measures appropriate for different points in the caring and bereavement trajectories, evaluate their psychometric properties and assess feasibility for use in palliative care.

DESIGN

A scoping review was systematically undertaken following Arksey and O'Malley's methodological framework.

DATA SOURCES

PsycINFO, CINAHL, PubMed and Cochrane Reviews databases, as well as grey literature including Internet searches of Google, World Health Organization, CareSearch, the Grey Literature Report and OAIster were searched. Bereavement organisations and palliative care websites, reference lists in obtained articles and grief and bereavement handbooks were also scrutinised.

RESULTS

Of 3142 records screened, 356 records yielded 70 grief measures. In all, 19 measures published between 1982 and 2014 were identified for inclusion in this review, and categorised for use with family caregivers at three points in time - before the patient's death (n = 5), in the period following the death (n = 10) and for screening of prolonged or complex grief (n = 4). The majority had acceptable psychometric properties; feasibility for use in palliative care varied substantially.

CONCLUSION

This review is an important preliminary step in improving the assessment of bereavement risk and, consequently, better bereavement outcomes for palliative care family caregivers.

Guilt in bereavement: a review and conceptual framework

Thirty-four quantitative and 9 qualitative studies are reviewed to indicate current understanding of the nature and impact of guilt in bereavement. This overview suggests that guilt is especially prevalent among some vulnerable subgroups, and it is associated with maladaptive health outcomes. Being male, longer bereavement time, and good end-of life experience seem to be associated with less guilt feelings. However, definition ambiguity, measurement difficulties, and cultural insensitivity are evident in studies. Therefore, a multidimensional conceptualization of guilt and a structural model to guide future investigation of this phenomenon in the bereavement context is proposed.

Professionals' reactions following a patient's suicide: review and future investigation

The objective of this study was to review the literature and make suggestions for further investigation into the topic of professionals' reactions following a patient's suicide. An extensive search of the literature has been undertaken using computer database search. Even if findings are heterogenous, most studies suggest limited stress-related or affective-related reactions for the majority of respondents. Whereas, findings with regards to the impact on professional practice are consistent in identifying important consequences in the way professionals conduct their clinical assessment and reach treatment decisions after a patient's suicide. Future research should investigate how this event changes the clinician's personal growth and capacity to establish a therapeutic alliance with other suicidal patients.

Stigma of Suicide Attempt (STOSA) scale and Stigma of Suicide and Suicide Survivor (STOSASS) scale: two new assessment tools

This study aimed at validating two new assessment tools, the Stigma of Suicide Attempt (STOSA) scale and the Stigma of Suicide and Suicide Survivor (STOSASS) scale. The Devaluation-Discrimination scale of Link et al. was translated into Italian and adapted to measure stigma towards suicidal behavior. Both scales were administered to a mixed sample including members of the general population (n=282), patients with a mental disorder (n=113), suicide attempters (n=57) and people who had lost a significant other to suicide (n=75). Reliability of the scales was good in terms of both internal coherence and test-retest stability. Factor analysis produced an acceptable solution for the STOSA-scale. Items were distributed into two factors, one grouping items to measure supportive, respectful and caring attitudes, the other factor grouping items oriented towards stigmatizing attitudes and beliefs. The clinical populations were more inclined towards stigmatization of suicide than were people from the general population, who might be less aware of the stigma attached to suicide. The two scales may be helpful to quantify stigma at individual level in order to provide targeted supportive interventions, and at population level to measure changes in the beliefs and attitudes of the general population.

Mediators between bereavement and somatic symptoms

Background

In our research we examined the frequency of somatic symptoms among bereaved (N = 185) and non-bereaved men and women in a national representative sample (N = 4041) and investigated the possible mediating factors between bereavement status and somatic symptoms.

Methods

Somatic symptoms were measured by the Patient Health Questionnaire (PHQ-15), anxiety with a four-point anxiety rating scale, and depression with a nine-item shortened version of the Beck Depression Inventory.

Results

Among the bereaved, somatic symptoms proved to be significantly more frequent in both genders when compared to the non-bereaved, as did anxiety and depression. On the multivariate level, the results show that both anxiety and depression proved to be a mediator between somatic symptoms and bereavement. The effect sizes indicated that for both genders, anxiety was a stronger predictor of somatic symptoms than depression.

Conclusions

The results of our research indicate that somatic symptoms accompanying bereavement are not direct consequences of this state but they can be traced back to the associated anxiety and depression. These results draw attention to the need to recognize anxiety and depression looming in the background of somatic complaints in bereavement and to the importance of the dissemination of related information.

Grief experiences and expectance of suicide

Suicide is generally viewed as an unexpected cause of death. However, some suicides might be expected to a certain extent, which needs to be further studied. The relationships between expecting suicide, feeling understanding for the suicide, and later grief experiences were explored. In total, 142 bereaved participants completed the Grief Experience Questionnaire and additional measurements on expectance and understanding. Results supported the prediction of a link between expecting suicide and understanding the suicide. Higher expectance and understanding were related to less searching for explanation and preoccupation with the suicide. There was no direct association with other grief experiences. We conclude that more attention should be brought to the relation between expecting the suicide of a loved one and later grief responses in research and in clinical practice.

Parental grief after a child's drug death compared to other death causes: investigating a greatly neglected bereavement population

This comparative survey contrasted 571 parents who lost children to various death causes: 48 to drug-related deaths and overdoses, 462 to suicide, 24 to natural death cases, and 37 to mostly accidental death cases. Groups were compared in terms of grief difficulties, mental health problems, posttraumatic stress, and stigmatization. Results did not show any appreciable differences in these respects between the suicide bereaved parents and those losing children to drug-related deaths. However, when the suicide and drug-related death survivors were specifically contrasted against accidental and natural death loss cases, a consistent pattern emerged showing the former group was consistently more troubled by grief and mental health problems than the latter two sub-groups. These differences remained when controls of time since the loss and gender differences were employed as covariates. These findings suggest that the powerful and intense stigma against drug use and mental illness, shared among the public-at-large, imposes challenges in healing of immense proportion for these parents as they find less compassionate responses from their significant others, following their losses.