Support received after bereavement by suicide and other sudden deaths: a cross-sectional UK study of 3432 young bereaved adults

Sharing is Caring: A Realist Evaluation of a Social Support Group for Individuals Who Have Been Bereaved by Suicide

AIM

To understand the experiences and perceived impact on the wellbeing of individuals attending a suicide bereavement social support group.

DESIGN

A qualitative study guided by a realist evaluation framework.

METHODS

Data were collected from May-July 2020 using online semistructured individual interviews with participants (N = 6), from the North West of England recruited from a suicide bereavement support group's social media. Data were analysed using thematic analysis informed by the realist framework.

RESULTS

Effective social support includes the prioritisation of building meaningful connections with like-minded individuals, providing a safe space for authentic self-expression aiding personal relationship maintenance. Contextual factors included: Societal and cultural stigma of suicide, self-stigma and gender norms. Mechanisms influencing support seeking include: Not wanting to burden loved ones due to judgement, and a lack of understanding.

IMPACT

Policymakers can reduce demand on healthcare systems by developing tailored support groups to suit individual needs.

Supportive and non-supportive social experiences following suicide loss: a qualitative study

BACKGROUND

Suicide bereavement entails profound social stressors, including stigma and communication barriers, which can impair social support for suicide loss survivors (SLS). Despite recognized benefits of empathetic interactions, social support, and self-disclosure in mitigating adverse mental health outcomes after suicide loss, we lack a comprehensive understanding of the factors influencing perceived social support among SLS within their broader social environments. To address this gap, our study explores the diverse social experiences of SLS beyond their immediate circles. Specifically, we identify characteristics that define both supportive and non-supportive social experiences of SLS, as well as the facilitators and barriers to social support in the context of suicide bereavement.

METHODS

In 2022, we conducted structured online individual interviews with a diverse sample of 18 SLS in Germany. We analyzed these interviews using qualitative content analysis.

RESULTS

We examined the social experiences of SLS across three phases and social contexts: (1) the immediate aftermath of the loss; (2) during bereavement practices; and (3) over time. Our findings show that proactive responses and personalized mourning rituals significantly enhance SLS' sense of community support, while encounters characterized by avoidance or intrusive curiosity lead to feelings of isolation. Over time, supportive interactions often emerge from peers with similar experiences, promoting openness and shared vulnerability. Conversely, superficial engagement, along with experiences of others depersonalizing and avoiding conversations about the loss, contribute to a sense of marginalization.

CONCLUSIONS

Our findings highlight the importance of proactive engagement and open dialogue, calling for societal and communicative shifts toward inclusive and compassionate approaches in addressing suicide loss. This study underscores the need for comprehensive strategies that enhance both suicide and grief literacy and address the taboo and stigma surrounding suicide, ultimately fostering supportive social environments for SLS.

General practitioner consultations for mental health reasons prior to and following bereavement by suicide

PURPOSE

Prior research has shown that the majority of those bereaved by suicide express a need for mental health care services. However, there is a lack of knowledge about these individuals' use of primary health care. The objective of our study was to estimate the association between suicide bereavement and general practitioner (GP) consultations for mental health reasons.

METHODS

A population-wide, register-based cohort study identifying 25,580 individuals bereaved by suicide. Estimations of increases in consultation rate were modeled through individual fixed-effects linear analyses adjusted for age and time-period.

RESULTS

Overall, 35% of those bereaved by suicide had a GP consultation for mental health reasons during the first 1-2 months, and 53% after two years. In the month immediately after bereavement by suicide, there was a large increase in the consultation rate with a GP for mental health reasons. In the months that followed, the consultation rate gradually decreased. One year after bereavement, the consultation rate stabilized at a somewhat higher level than before the death. The increase in consultation rate was evident across all kinship groups, and the increase was greatest for partners and smallest for siblings. Women had more contact with the GP before the suicide and a greater increase in contact than men.

CONCLUSION

Our findings suggest that many of those bereaved by suicide seek assistance from primary health care, and that some are in need of prolonged follow-up from the GP. Health governments should be aware of this and seek to strengthen the GPs knowledge of the needs and challenges associated with this patient group. Measures should also be taken to remove barriers to contact the health care system, especially for men and bereaved siblings.

Development of mental health first-aid guidelines for suicide risk: a Delphi expert consensus study in Argentina and Chile

BACKGROUND

Suicide continues to pose a significant global public health challenge and ranks as one of the leading causes of death worldwide. Given the prevalence of suicide risk in the community, there is a significant likelihood of encountering individuals who may be experiencing suicidal thoughts or plans, creating an opening for non-health professionals to offer support. This study aims to culturally adapt the original Australian Mental Health First Aid Guidelines for suicide risk to the Chilean and Argentine context.

METHODS

A two-round Delphi expert consensus study was conducted involving two panels, one comprising individuals with personal experience in suicide thoughts/attempts or caregiving for those with such experiences (n = 18), and the other consisting of professionals specialized in suicide assessment and support for individuals at risk (n = 25). They rated a total of 179 items mainly derived from guidelines developed by Australian experts and translated into Spanish (168), and new items included by the research team (11). The panel members were requested to assess each item utilizing a five-point Likert scale. During the second round, items that received moderate approval in the initial round were re-evaluated, and new items suggested by the local experts in the first round were also subjected to evaluation in the next round. Inclusion in the final guidelines required an 80% endorsement as "essential" or "important" from both panels.

RESULTS

Consensus of approval was reached for 189 statements. Among these, 139 statements were derived from the English-language guidelines, while 50 locally generated statements were accepted during the second round. A significant difference from the original guideline was identified concerning the local experts' reluctance to discuss actions collaboratively with adolescents. Furthermore, the local experts proposed the inclusion of an entirely new section addressing suicide risk in older individuals, particularly focusing on suicide methods and warning signs.

CONCLUSIONS

A Delphi expert consensus study was conducted to culturally adapt mental health first aid guidelines for assessing suicide risk in Chile and Argentina. This study involved professionals and individuals with lived experience. While many items were endorsed, some related to inquiring about suicide risk and autonomy, particularly for adolescents, were not. An additional section for older individuals was introduced. Future research should explore the implementation and impact of these adapted guidelines in training courses. This is vital for enhancing mental health support and implementing effective suicide prevention strategies in Chile and Argentina.

Social Reactions After Disclosing Suicide Loss Among Women

Background: Suicide loss is often concealed. While initial evidence suggests that disclosure is important for healthy grieving, observed beneficial effects may depend on social reactions. Aim: The current study aimed to identify social reactions and associated consequences experienced by persons who lost a loved one to suicide (i.e., suicide loss survivors). Method: We conducted qualitative interviews with 22 female adult suicide loss survivors focusing on social reactions after suicide loss. Interviews were transcribed and analyzed using qualitative content analysis. Results: When talking about their loss with others, suicide loss survivors experienced a broad range of social reactions including compassionate and supportive responses, speechlessness and insecurity, curiosity and gossip, stigmatization, and grieving expectations. Depending on these social reactions, disclosing suicide loss was associated with both negative and positive long-term effects. Limitations: The findings are limited to the current female sample. Conclusion: Interventions that help suicide loss survivors in finding supportive confidants, combined with public interventions to decrease public suicide stigma and improve the public's readiness to provide helpful support to suicide loss survivors, could improve grieving outcomes among this group.

Guiding principles for the implementation of a standardized psychological autopsy to understand and prevent suicide: a stakeholder analysis

Background

Around 700,000 people die by suicide each year. While the global number of suicides declined over the last decade, the rates remained unchanged in the Netherlands. With this study, we aimed to provide guiding principles for the implementation of a national standardized psychological autopsy to better understand and prevent suicide, by exploring stakeholder perceptions and needs, and barriers to implementation.

Methods

We interviewed 47 representative stakeholders from various fields (e.g., mental healthcare professionals, policy advisors, researchers). A semi structured interview design was used, based on the RE-AIM and Consolidated Framework for Implementation Research (CFIR) theoretical frameworks.

Results

Themes relating to stakeholder perceptions and needs for a standardized psychological autopsy included valorization, accountability, integrability and the needs of the bereaved. Stakeholders believed that participation in a psychological autopsy can help bereaved in their process of grief but noted that evidence to frame the psychological autopsy as postvention is insufficient. The primary focal point should accordingly be to better understand and prevent suicide. Several key limitations of the proposed psychological autopsy approach were detailed, both methodological and implementational.

Conclusion

The stakeholder analysis delineates guiding principles for implementation. Stakeholders believe that a standardized psychological autopsy has merit, provided that key considerations, including valorization and accountability, are integrated in its design. Routine evaluation should be ensured. The findings may guide policy makers and researchers in their endeavors to support a learning, community-based approach for suicide prevention based on a standardized psychological autopsy.

The Effects of Suicide Exposure on Mental Health Outcomes Among Post-9/11 Veterans: Protocol for an Explanatory, Sequential, Mixed Methods Study

BACKGROUND

The toll associated with suicide goes well beyond the individual who died. This study focuses on a risk factor for veteran suicide that has received little previous empirical attention-exposure to the suicide death of another person.

OBJECTIVE

The study's primary objective is to describe the mental health outcomes associated with suicide exposure among veterans who served on active duty after September 2001 ("post-9/11"). The secondary objective is to elucidate why some veterans develop persistent problems following suicide exposure, whereas others do not.

METHODS

This is an explanatory, sequential, mixed methods study of a nationally representative sample of post-9/11 veterans enrolled in Department of Veterans Affairs (VA) health care. Our sampling strategy was designed for adequate representation of female and American Indian and Alaska Native veterans to allow for examination of associations between suicide exposure and outcomes within these groups. Primary outcomes comprise mental health problems associated with trauma and loss (posttraumatic stress disorder and prolonged grief disorder) and suicide precursors (suicidal ideation, attempts, and planning). Data collection will be implemented in 3 waves. During wave 1, we will field a brief survey to a national probability sample to assess exposure history (suicide, other sudden death, or neither) and exposure characteristics (eg, closeness with the decedent) among 11,400 respondents. In wave 2, we will include 39.47% (4500/11,400) of the wave-1 respondents, stratified by exposure history (suicide, other sudden death, or neither), to assess health outcomes and other variables of interest. During wave 3, we will conduct interviews with a purposive subsample of 32 respondents exposed to suicide who differ in mental health outcomes. We will supplement the survey and interview data with VA administrative data identifying diagnoses, reported suicide attempts, and health care use.

RESULTS

The study began on July 1, 2022, and will end on June 30, 2026. This is the only national, population-based study of suicide exposure in veterans and the first one designed to study differences based on sex and race. Comparing those exposed to suicide with those exposed to sudden death for reasons other than suicide (eg, combat) and those unexposed to any sudden death may allow for the identification of the common and unique contribution of suicide exposure to outcomes and help seeking.

CONCLUSIONS

Integrating survey, qualitative, and VA administrative data to address significant knowledge gaps regarding the effects of suicide exposure in a national sample will lay the foundation for interventions to address the needs of individuals affected by a suicide death, including female and American Indian and Alaska Native veterans.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51324.

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.

When a Child Dies by Suicide: An Interpretative Phenomenological Analysis Study

Suicide is a global concern for the well-being of families. When parents experience their child's death by suicide, their well-being can be substantially impaired. This study aimed to explore the lived experiences of parents whose children died by suicide. Data were collected from 25 mothers through interviews between 2019 and 2021 and analyzed using interpretive phenomenological analysis. The data revealed five superordinate themes, including (1) who am I; (2) the unrelenting questions; (3) my existence on earth is brutal and cruel; (4) grief; and (5) the meaning. Each superordinate theme includes two to four supporting clusters. Parents' grief associated with a child's suicide is overwhelming and paralyzing but is often a journey to find the meaning or the reason for the death. Parents are traumatized and emotionally vulnerable. Healthcare providers need to support parents who lose their children to death by suicide.

A cross-sectional examination of sudden-death bereavement in university students

ObjectivesThe objective of this research was to determine the unique contributions of sudden death bereavement to the mental health of university students compared to non-sudden death bereaved university students. Methods: We surveyed 1047 bereaved university students (retention rate 92%) and compared the non-sudden death bereaved university student population to the sudden death bereaved university population on outcomes including mental health symptomatology, and complicated grief using logistic regressions. Results: Sixty two percent of the sample reported sudden death bereavement. There were no differences on measures of PTSD, generalized anxiety disorder, depression, suicidal ideation, and at-risk drinking behavior across types of bereavement. However, sudden death bereavement compared to general bereavement was associated with increased likelihood of complicated grief. Conclusions: Sudden death bereavement in university students is associated with elevated risk of complicated grief. These findings confirm previous research and provide more insight into the unique needs of university student coping with sudden loss.

Suicide postvention for staff and students on university campuses: a scoping review

OBJECTIVE

To examine current knowledge about suicide bereavement and postvention interventions for university staff and students.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY

We conducted systematic searches in 12 electronic databases (PubMed, PsycINFO, MEDLINE, CINAHL, Africa-Wide Information, PsycARTICLES, Health Source: Nursing/Academic Edition, Academic Search Premier, SocINDEX through the EBSCOHOST platform; Cochrane Library, Web of Science, SCOPUS), hand searched lists of references of included articles and consulted with library experts during September 2021 and June 2022. Eligible studies were screened against the inclusion criteria independently by two reviewers. Only studies published in English were included.

DATA EXTRACTION AND SYNTHESIS

Screening was conducted by two independent reviewers following a three-step article screening process. Biographical data and study characteristics were extracted using a data extraction form and synthesised.

RESULTS

Our search strategy identified 7691 records from which 3170 abstracts were screened. We assessed 29 full texts and included 17 articles for the scoping review. All studies were from high-income countries (USA, Canada, UK). The review identified no postvention intervention studies on university campuses. Study designs were mostly descriptive quantitative or mixed methods. Data collection and sampling were heterogeneous.

CONCLUSION

Staff and students require support measures due to the impact of suicide bereavement and the unique nature of the university context. There is a need for further research to move from descriptive studies to focus on intervention studies, particularly at universities in low-income and middle-income countries.

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.

Towards an Evidence-Based Model of Workplace Postvention

This instrumental case study explored what suicide postvention might offer workplaces using the example of a large metropolitan funeral company. A mixed methods approach was utilized to examine staff experiences with suicide bereavement funerals and responses to a bespoke postvention training package. Staff found funerals due to suicide difficult in terms of communication, engagement and emotionality. These challenges were commonly characterized by increased tension and concern. In the absence of a postvention informed approach, staff had developed individual ways to negotiate the identified challenges of this work. The introduction of a staff-informed postvention training package delivered improvements in staff confidence with communication, understanding and management of the impact of suicide bereavement, and increased willingness to share information about postvention services with families and mourners. The findings indicated that benefits of the training could be extended through organizational governance and integration of supports. The findings are used to inform a model of workplace postvention together with a methodology incorporating staff experience and organizational context.

Coping Styles Utilized during Suicide and Sudden Death Bereavement in the First Six Months

Individuals bereaved by suicide experience substantial emotional distress and are at risk for poorer mental health, substance use concerns, and suicidal behaviors. This study aimed to explore whether those bereaved by suicide reported different coping styles compared to those bereaved by sudden death in the first six months. It also aimed to determine whether a previous mental health diagnosis (PMHD) and experiencing stigma and/or shame impacted the utilization of adaptive and maladaptive coping. The sample was constituted by individuals bereaved by suicide (n = 142) compared to those bereaved by sudden death (n = 63), six months after loss. The study included immediate family members who were 18 years or older and understood the English language. After controlling for demographics there were no significant differences in coping styles between bereavement types. Regardless of bereavement type, having a PMHD was associated with increased avoidant and problem-focused coping, and stigma and shame were each associated with increased avoidant coping. Women were also more likely to report using adaptive coping. Findings demonstrate no difference by bereavement type and have implications for the tailoring of grief/postvention supports that are sensitive to perceived stigma/shame to better facilitate utilization of adaptive emotion-focused coping, particularly for men and those with pre-existing mental health problems.

Investigating Whether Bereavement by Suicide and Other Unnatural Causes Has a Deterrent Effect on Alcohol or Drug Use in Young Adults

Bereavement by suicide and other unnatural causes is associated with suicide but evidence regarding risk of substance misuse is inconsistent. This may be due to heterogeneity in patterns of alcohol or drug use after traumatic bereavement; some increasing use to cope with the loss and others reducing use. To highlight the problems of focussing on diagnostic thresholds when investigating substance use after traumatic loss, we aimed to test whether people bereaved by suicide or other unnatural causes are more likely to reduce or stop their substance use than people bereaved by sudden natural causes. Using multivariable logistic regression and data from an online survey of 1854 UK-based bereaved adults, we tested the association between bereavement by suicide and other unnatural causes and post-bereavement reduction/cessation in (i) alcohol and (ii) drug use. There were no group differences in the proportions who reduced/stopped alcohol use, but a significantly greater proportion of people bereaved by sudden unnatural causes reduced/stopped drug use post-bereavement than people bereaved by sudden natural causes (AOR = 2.61; 95% CI = 1.44-4.71; p = 0.001; 4.1% versus 1.7%). In sub-group analyses this applied separately to people bereaved by suicide and non-suicide unnatural causes. Research into post-bereavement substance use should accommodate apparent divergent sub-diagnostic patterns.

Suicide bereavement in the UK: Descriptive findings from a national survey

BACKGROUND

Those bereaved by suicide are a high-risk group of adverse health outcomes and suicidal behavior, yet little is known about the experiences and support needs of these individuals in the UK.

METHODS

We conducted a national cross-sectional study using an online survey and analyzed the experiences of 7158 participants who had been bereaved or affected by suicide.

RESULTS

Suicide had a major impact on 77% of participants, including those who had lost a friend and those exposed to suicide at a professional level. Mental and physical health problems linked to the suicide were reported in half. Adverse social outcomes and engaging in high-risk behaviors following the suicide were common. Over a third reported suicidal ideation and 8% had attempted suicide as a direct result of the suicide loss. Most had not accessed support services, with the majority viewing provision of local suicide bereavement support as inadequate.

CONCLUSIONS

Our results highlight the need for a multi-disciplinary approach in postvention and the provision of proactive outreach to support those bereaved by suicide. Postvention efforts need to acknowledge the death of a friend by suicide as a significant loss.

Use of Health Services and Support Resources by Immediate Family Members Bereaved by Suicide: A Scoping Review

The knowledge on health service use, systematic follow-up, and support for families bereaved by suicide remains scarce. This scoping review includes studies from 2010 to March 2022 that investigate the follow-up and support offered by health services, peer support services, and other resources available (e.g., internet-based resources) for families bereaved by suicide. We followed the scoping review framework provided by the Johanna Briggs Institute and performed a double-blinded screening process using Covidence. Data were extracted by four researchers and a thematic analysis was performed to summarize the results. The PRISMA Extension for Scoping reviews was used for reporting results. Of 2385 studies screened by title, 190 by abstract, and 93 by full-text reading, we included 63 original articles of which 24, 29 and 10 were quantitative, qualitative, or mixed-methods studies, respectively. The review shows that we have some knowledge about the need for, and experiences with, health services and support resources for immediate family members bereaved by suicide, but a lack of knowledge about their help-seeking behaviour, patient pathways, systematic follow-up, coordination between services, and long-term outcomes. We need more longitudinal observational studies of health service use and patient trajectories for people bereaved by suicide.

Characteristics of Survivors of Suicide Seeking Counseling From an NGO in Denmark: Analyses of a National Database

OBJECTIVE

The loss of a friend or family member to suicide, i.e., surviving suicide, can be devastating. Yet, little is known regarding the support received by survivors of suicide. We aimed to examine the characteristics of survivors of suicide who sought counseling from a Danish volunteer organization.

METHOD

Data on all users of the Danish Network for those Affected by Suicidal Behavior (NASB) were obtained during 2012-2018. Information on age, sex, relation, time of loss, municipality was analyzed, and geographical driving distances calculated.

RESULTS

Altogether, 1,268 survivors of suicide (mean age 43.3; 29.8% of all suicides) received counseling from NASB. In all, 81.8% of service users had lost a partner or first-degree relative; those being spouses/partners (15.3%), parents (28.5%), children (19.0%), and siblings (15.4%). Female service users (71.1%) outnumbered males (28.7%). A third of users sought counseling within 6-months of the death. A help-seeking rate of 6 users per 10 suicide deaths was found within close proximity to a counseling venue; equivalent of 5.5 (95% CI: 5.0-6.0) users per 100,000 inhabitants. Each additional 10 km of driving distance was associated with a 15% lower rate of use (b: -0.015; 95% CI: 0.027 to 0.003; p = 0.013).

CONCLUSION

Geographical proximity to help centers was important and could suggest that support might be lacking in some parts of the country. It seems likely that more than 0.6 persons per suicide might seek counseling from volunteer organizations if services were available within short driving distance.HIGHLIGHTSMore than one out of three who sought support after a suicide death were partners or first-degree relatives and only a third of users who sought counseling did so within 6-months of the death. Also, female sought counseling more frequently than males.Approximately 5.5 people per 100,000 inhabitants sought help after a suicide in areas where a counseling venue was within short driving distance.Based on the region with most counseling venues, 6 survivors would seek support per 10 suicide deaths.

Bereavement and suicide bereavement as an antecedent of suicide in children and young people: Prevalence and characteristics

INTRODUCTION

There is limited research into bereavement and suicide bereavement as an antecedent of suicide in young people.

METHODS

We extracted information on the antecedents of suicide from official reports, primarily coroner inquests, on a 3-year national consecutive case series of all UK deaths by suicide in people aged 10-19.

RESULTS

Between 2014 and 2016, there were 595 suicides by young people. 134 (25%) had been previously or recently bereaved; 51 (9%) by suicide, mainly of a friend or acquaintance. This is equivalent to 1 in 4 and 1 in 11, respectively, of all young people who die by suicide. Bereavement added to existing adversities - many antecedents of suicide were more likely in young people who were bereaved compared to those who were not, but there were few differences in the experiences of young people bereaved by suicide compared to other causes.

LIMITATIONS

This was an observational, not a risk factor study, and we did not use a control group. It is difficult to obtain data on non-suicide controls due to the ethical implications in contacting families, and the fact of suicide itself, its impact on disclosure and the reluctance of potential controls distorting any comparisons.

CONCLUSION

Lasting bereavement support needs to be routinely and immediately available for young people, including those who have experienced the death of a friend or acquaintance. Vigilance of agencies for bereaved young people is required, especially if there is evidence of other adversities.

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.

Ethnic Minority Groups' Experiences of Suicide Bereavement: A Qualitative Exploratory Study

It is estimated that between 36,000 and 360,000 people are affected by suicide every year in the UK, and a proportion may develop depression and post-traumatic stress disorder, or engage in high-risk behaviours. Recent systematic analyses have revealed a clear gap in research on suicide bereavement in minority ethnic groups. This study aimed to understand the experiences and support needs of individuals from ethnic minority backgrounds bereaved by suicide and was the first in the UK to investigate this matter. The study was a secondary analysis of data. Participants were 7158 people residing in the UK who completed an online survey about their experiences of suicide. Free-text qualitative responses of 227 participants who did not identify as White British were analysed using thematic analysis. Four themes were identified: maladaptive coping strategies, emotional processes following suicide, lack of support from agencies, and the importance of mental health awareness. Ethnic minority groups reported a lack of support despite attempts to engage with services, noted the prevalence of stigma within ethnic minority groups, and expressed a need to tackle this. These preliminary results suggest that ethnic minority individuals require visible and accessible services that can successfully engage with and support them.

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.

Very Young Child Survivors' Perceptions of Their Father's Suicide: Exploring Bibliotherapy as Postvention Support

Each year in the United States, 7000 to 30,000 children experience their parent's suicide. Due to the stigma associated with suicide, feelings of guilt, and intense grief, surviving family members avoid talking about suicide. Over time, children struggle with confusion and intense emotions associated with their parent's suicide. In this study, seven adults, who reported being younger than six years old at the time of their father's suicide, participated in individual semi-structured interviews. Participants' responses highlight the challenges that young children face due to limited memories of their deceased parent. Interviews concluded with an opportunity for participants to review and express their impressions of 10 children's picture books. Participants offered impressions about how these books may or may not be helpful in supporting young child survivors. Implications for applied practice include considering how children's literature may open communication and assist children in navigating Worden's tasks of grief: (a) accepting the reality of their parent's death; (b) facing the grief and pain; (c) adapting to life changes due to their father's suicide, in particular adapting to altered family relationships; and (d) building memories of the deceased loved one, when possible, to ensure healthy attachment to the deceased parent. Participants' insights provide considerations for selecting children's literature for bibliotherapy. Due to young child survivors' increased risk for attempting and completing suicide, supporting child survivors of parent suicide not only addresses postvention needs but aligns with suicide prevention.

COVID-19 Suicide Survivors-A Hidden Grieving Population

Present time has been dominated by the COVID-19 pandemic. People are grieving several non-death related situations: the loss of a job, of a status, of a role, of their life. Restrictive measures and uncertainty about the future makes individuals vulnerable to feelings of hopelessness and helplessness. Mental health support has been hindered and teams are reinventing themselves to reach people in need. Nevertheless, decompensation of previous psychiatric disorders, increasing levels of depression and anxiety, economical handicaps and fear of the infection, are prompting several cases of COVID-19 related suicides worldwide. Every suicide affects between 5 and 80 individuals, which are known as suicide survivors. Suicide grief is particularly challenging, with rates of complicated grief as high as 40%. Suicide survivors are at increased risk of developing depression, anxiety disorders and of suicidal behaviors. Moreover, feelings of guilt and shame, as well as social stigma, are major obstacles for them to reach form help. This article aims to review the existing literature on COVID-19 related suicides, complicated grief in suicide survivors and highlight modifiable risk factors for both conditions, as well as propose some public health measures to reduce the impact of the pandemic context on self-inflicted harm and its consequences on families, friends and the community. Obstacles to access to mental health support need to be overcome through the use of technology. Technicians should actively approach populations more vulnerable to develop suicidal ideation. Social media have the obligation to provide accurate an non-sensationalistic information. Families and friends should maintain social proximity, despite the need for physical distancing. When a suicide death occurs, police forces and health staff should be prepared to share the news with the family using an empathic and humane approach and providing psychological support. Funerals, memorials and other services should be held as much as possible. Closer contacts should be signalized and closely followed in order to detect the need for specific interventions. Help seeking behaviors should be promoted. Additionally, people should be educated on suicide and its impacts, in order to reduce stigma.

Older Adults' Conduct of Everyday Life After Bereavement by Suicide: A Qualitative Study

Background

The loss of a loved one to suicide can be a devastating experience that can have negative long-term effects on the social life and physical and mental health of the bereaved person. Worldwide, an estimated 237 million older adults have experienced suicide bereavement. As assumed in critical psychology, “the conduct of everyday life” reflects the social self-understanding by which people actively organize their lives based on their personal concerns, negotiation with co-participants in various action contexts, and their life interests. Bereaved people may change their social self-understanding as they adjust to their new roles and relationships in everyday life. The aim of this study was to investigate how older adults bereaved by suicide conducted their everyday life during the first 5 years after the loss of a loved one.

Methods

This was a semi-structured qualitative interview study carried out by a research team consisting of co-researchers (older adults aged ≥60 years and bereaved by suicide), professionals, and researchers. The team conducted 15 semi-structured interviews with 20 older adults bereaved by suicide. The interviews were audio-recorded and verbatim transcribed. The participants’ mean age was 67.6 (range 61–79) years at the time of the loss. Data were thematically analyzed through a “conduct of everyday life” theoretical perspective.

Results

We constructed a central theme, “the broken notion of late-life living” in that late-life would no longer be as the participants had imagined. They struggled with their understanding of themselves and other people in social communities when they pursued their concerns adjusting to their broken notions of late-life living. We construed three primary concerns: (1) seeking meaning in the suicide, (2) keeping the memory of the deceased alive, and (3) regaining life despite the loss.

Conclusion

The participants’ bereavement process was influenced by their stage in life. They perceived themselves as having reduced possibilities to restore their life project and limited time to re-orient their life. Age-related factors influenced their possibilities to pursue their concerns in order to adjust to their new life conditions.

Perceptions of the Use of Alcohol and Drugs after Sudden Bereavement by Unnatural Causes: Analysis of Online Qualitative Data

Bereavement is associated with an increased risk of psychiatric morbidity and all-cause mortality, particularly in younger people and after unnatural deaths. Substance misuse is implicated but little research has investigated patterns of drug or alcohol use after bereavement. We used a national online survey to collect qualitative data describing whether and how substance use changes after sudden bereavement. We conducted thematic analysis of free-text responses to a question probing use of alcohol and drugs after the sudden unnatural (non-suicide) death of a family member or a close friend. We analysed data from 243 adults in British Higher Education Institutions aged 18–40, identifying two main themes describing post-bereavement alcohol or drug use: (1) sense of control over use of drugs or alcohol (loss of control versus self-discipline), (2) harnessing the specific effects of drugs or alcohol. Across themes we identified age patterning in relation to substance misuse as a form of rebellion among those bereaved in childhood, and gender patterning in relation to men using alcohol to help express their emotions. The limitations of our sampling mean that these findings may not be generalizable from highly-educated settings to young people in the general population. Our findings describe how some young bereaved adults use drugs and alcohol to help them cope with traumatic loss, and suggest how clinicians might respond to any difficulties controlling substance use.

Perceived Social Support and Mental Health After Suicide Loss

Abstract. Background: Despite great need, social support is limited after suicide loss, which could contribute to worse mental health outcomes including increased suicidality among suicide loss survivors. Aims: To examine the associations between perceived social support, grief difficulties, depressive symptoms, suicidality, and personal growth among 195 suicide loss survivors. Method: The associations between perceived social support, grief difficulties, depressive symptoms, suicidality, and personal growth were tested using linear regression modeling. Results: In controlled models, more perceived social support was significantly associated with decreased grief difficulties, depressive symptoms, and suicidality, as well as with increased personal growth. Limitations: Participants were mostly Caucasian women who participated in a cross-sectional online survey. Conclusion: Our findings suggest that programs to increase social support after suicide loss may be an important aspect of suicide postvention.

Web-Based Bereavement Care: A Systematic Review and Meta-Analysis

BACKGROUND

Web-based interventions have been introduced as novel and effective treatments for mental disorders and, in recent years, specifically for the bereaved. However, a systematic summary of the effectiveness of online interventions for people experiencing bereavement is still missing.

OBJECTIVE

A systematic literature search was conducted by four reviewers who reviewed and meta-analytically summarized the evidence for web-based interventions for bereaved people.

METHODS

Systematic searches (PubMed, Web of Science, PsycInfo, PsycArticles, Medline, and CINAHL) resulted in seven randomized controlled trials (N = 1,257) that addressed adults having experienced bereavement using internet-based interventions. We used random effects models to summarize treatment effects for between-group comparisons (treatment vs. control at post) and stability over time (post vs. follow-up).

RESULTS

All web-based interventions were based on cognitive behavioral therapy (CBT). In comparison with control groups, the interventions showed moderate (g = .54) to large effects (g = .86) for symptoms of grief and posttraumatic stress disorder (PTSD), respectively. The effect for depression was small (g = .44). All effects were stable over time. A higher number of treatment sessions achieved higher effects for grief symptoms and more individual feedback increased effects for depression. Other moderators (i.e. dropout rate, time since loss, exposure) did not significantly reduce moderate degrees of heterogeneity between the studies.

LIMITATIONS

The number of includable studies was low in this review resulting to lower power for moderator analyses in particular.

CONCLUSIONS

Overall, the results of web-based bereavement interventions are promising, and its low-threshold approach might reduce barriers to bereavement care. Nonetheless, future research should further examine potential moderators and specific treatment components (e.g. exposure, feedback) and compare interventions with active controls.

How suicide-bereaved family members experience the inquest process: a qualitative study using thematic analysis

PURPOSE

Suicide bereavement confers unique risk and distress. In several countries, bereaved family members are called on to attend an inquest, an official public inquiry into deaths caused by external factors. The current study aimed to explore how suicide-bereaved family members (n = 18) experienced the inquest process, through qualitative semi-structured interviews.

METHOD

Participants were identified via coroner's records and had previously taken part in a case-control study.

RESULTS

Qualitative findings indicated four overall themes with respect to family members' experiences of the inquest process: "inquest as fearfully unknown", "structural processes of the inquest", "enduring public and private pain to obtain answers" and "gaining answers and making sense". Most family members experienced distress and fear as a result of several elements of the inquest process. Some participants had positive experiences but these did not outweigh the distress experienced by the majority of family members regarding their overall experience of the inquest process.

CONCLUSIONS

Key recommendations include informing family members of the main aspects and purpose of the inquest process beforehand, adapting the process to maximise the privacy and comfort of the bereaved relatives, and restricting graphic evidence being heard, where possible, to minimise distress experienced by family members.

Suicide Postvention Service Models and Guidelines 2014-2019: A Systematic Review

Background: Suicide bereavement can have a lasting and devastating psychosocial impact on the bereaved individuals and communities. Many countries, such as Australia, have included postvention, i.e., concerted suicide bereavement support, in their suicide prevention policies. While little is known of the effectiveness of postvention, this review aimed to investigate what is known of the effects of postvention service delivery models and the components that may contribute to the effectiveness.

Method: Systematic review and quality assessment of peer reviewed literature (Medline, PsycINFO, Embase, EBM Reviews) and gray literature and guidelines published since 2014.

Results: Eight studies and 12 guidelines were included, with little evidence of effectiveness. Still, providing support according to the level of grief, involvement of trained volunteers/peers, and focusing the interventions on the grief, seem promising components of effective postvention.

Conclusions: Adopting a public health approach to postvention can allow to tailor the service delivery to needs of the bereaved individuals and to align postvention with suicide prevention programs.

Adapting Digital Social Prescribing for Suicide Bereavement Support: The Findings of a Consultation Exercise to Explore the Acceptability of Implementing Digital Social Prescribing within an Existing Postvention Service

This paper describes a consultation exercise to explore the acceptability of adapting digital social prescribing (DSP) for suicide bereavement support. Bereavement by suicide increases the risk of suicide and mental health issues. Social prescribing improves connectedness and empowerment and can provide digital outcomes-based reporting to improve the capacity for measuring the effectiveness of interventions. Our aim was to consult on the acceptability and potential value of DSP for addressing the complexities of suicide bereavement support. Our approach was underpinned by implementation science and a co-design ethos. We reviewed the literature and delivered DSP demonstrations as part of our engagement process with commissioners and service providers (marrying evidence and context) and identified key roles for stakeholders (facilitation). Stakeholders contributed to a co-designed workshop to establish consensus on the challenges of providing postvention support. We present findings on eight priority challenges, as well as roles and outcomes for testing the feasibility of DSP for support after suicide. There was a consensus that DSP could potentially improve access, reach, and monitoring of care and support. Stakeholders also recognised the potential for DSP to contribute substantially to the evidence base for postvention support. In conclusion, the consultation exercise identified challenges to facilitating DSP for support after suicide and parameters for feasibility testing to progress to the evaluation of this innovative approach to postvention.

Use of Alcohol and Unprescribed Drugs after Suicide Bereavement: Qualitative Study

Studies describing the impact of suicide bereavement report an excess risk of suicide, suicide attempt, psychiatric illness, and drug and alcohol use disorders compared with the general population. However, the nature of patterns of drug and alcohol use after suicide bereavement is unclear. We used an online survey to collect qualitative data to understand whether and how drug and alcohol use changes after suicide bereavement. We conducted thematic analysis of free-text responses to a question capturing their use of alcohol and drugs after the suicide of a family member or a close friend. Analysing data from 346 adults in Britain aged 18-40, we identified three main themes describing the relationship of suicide bereavement to alcohol or drug use: (1) control over drug or alcohol use, (2) the perceived purpose of using drugs or alcohol, and (3) the attribution of drug or alcohol misuse to external factors. Overlying these themes were dimensions of control and of awareness of potential harms. This study highlights that increased use of drugs and alcohol after suicide bereavement may form part of a bereaved person's coping strategies, and that sensitive approaches are needed when judging whether and when to intervene.

The Perceived Impact of Suicide Bereavement on Specific Interpersonal Relationships: A Qualitative Study of Survey Data

People bereaved by suicide have an increased risk of suicide and suicide attempt, yet report receiving less support than people bereaved by other sudden deaths. Reductions in support may contribute to suicide risk, yet their nature is unclear. We explored the impact of suicide bereavement on the interpersonal relationships of young adults in the UK using an online survey to collect qualitative data. We conducted thematic analysis of free-text responses from 499 adults to questions capturing the impact of bereavement on relationships with partners, close friends, close family, extended family, and other contacts. We identified four main themes describing the changes in relationships following the suicide: (1) Social discomfort over the death (stigma and taboo; painfulness for self or others to discuss; socially prescribed grief reactions); (2) social withdrawal (loss of social confidence; withdrawal as a coping mechanism); (3) shared bereavement experience creating closeness and avoidance; (4) attachments influenced by fear of further losses (overprotectiveness towards others; avoiding attachments as protective). These findings contribute to understanding deficits in support and pathways to suicidality after suicide bereavement. Such disrupted attachments add to the burden of grief and could be addressed by public education on how to support those bereaved by suicide.

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.

Family Patterns and Suicidal and Violent Behavior among Adolescent Girls-Genogram Analysis

An increase in extreme self-destructive and aggressive behaviors in adolescents has been observed in recent years. Therapeutic effectiveness seems to depend on an adequate recognition of factors that might increase the risk of extreme destructive behaviors. The aim of this study was to identify the family patterns that should draw therapeutic attention due to their importance for suicidal or violent behaviors in adolescent girls. The study involved 140 participants, aged 13⁻17, including 40 girls after suicide attempts, 40 girls using violence, and 60 girls without destructive behavior at all. The Genograms were used to assess the family structure, relationships between family members, and family projections. The data was analyzed by polynomial logistic regression, analysis of variance, and discriminant analysis. Emotional distance and hidden projections (related to diseases) were the most significant predictors of suicidal behaviors in the studied adolescent girls. Alcohol abuse by significant family members, especially by male family members, and a lesser role of hidden projections, were the most significant predictors of violent behaviors. Interventions designed to reduce risk of destructive behaviors among adolescents need to take account of the specific family patterns.

Support Needs and Experiences of People Bereaved by Suicide: Qualitative Findings from a Cross-Sectional British Study of Bereaved Young Adults

People bereaved by suicide are at increased risk of suicide, but evidence is lacking that available interventions reduce suicide risk. Few large-scale studies have described the views of suicide-bereaved people regarding their needs for support. Our objective was to explore the nature of young adults' experiences of support after bereavement by suicide and their views on valued and unhelpful aspects. We conducted a cross-sectional study of staff and students aged 18-40 at 37 United Kingdom (UK) higher educational institutions in 2010, eliciting qualitative responses to two questions probing experiences of support and unmet needs after the suicide of a close contact. We conducted thematic analysis of responses from 420 adults bereaved by suicide, of whom 75% had received support after the loss. We identified three broad descriptive areas corresponding to important aspects of support: value and experiences of the support received; views on specific support needs; and reasons for not seeking support. We found that needs for emotional support exist throughout the social networks of people who die by suicide but are often hidden. Our findings suggest a need for proactive offers of support from family, friends, and professionals after suicide, repeated regularly in case a bereaved person does not feel ready for support early on.

Addressing suicide risk in partners and relatives bereaved by suicide

Analyses of population-based registers provide evidence to support an increased risk of suicide and mental illness after the suicide of a relative or partner. This editorial explores the implications of this work for progressing recommendations made in suicide prevention strategies regarding the specific support provided to people bereaved by suicide. Declaration of interest A.P. served on the Public Health England expert reference committee contributing to local guidance on commissioning and delivering postvention support (Public Health England, 2016. Support After a Suicide: A Guide to Providing Local Services) and has submitted applications for funding to investigate mediators of suicide risk after suicide bereavement. Since writing this article she has become a Patron of the Support After Suicide Partnership.

The Impact of Suicide Bereavement on Educational and Occupational Functioning: A Qualitative Study of 460 Bereaved Adults

People bereaved by suicide are at an increased risk of suicide and of dropping out of education or work. Explanations for these associations are unclear, and more research is needed to understand how improving support in educational or work settings for people bereaved by suicide might contribute to reducing suicide risk. Our objective was to explore the impact of suicide on occupational functioning. We conducted a cross-sectional online study of bereaved adults aged 18-40, recruited from staff and students of British higher educational institutions in 2010. We used thematic analysis to analyse free text responses to two questions probing the impact of suicide bereavement on work and education. Our analysis of responses from 460 adults bereaved by suicide identified three main themes: (i) specific aspects of grief that impacted on work performance, cognitive and emotional domains, and social confidence; (ii) structural challenges in work or educational settings including a lack of institutional support, the impact of taking time off, and changes to caring roles; and (iii) new perspectives on the role of work, including determination to achieve. Institutional support should be tailored to take account of the difficulties and experiences described.

What are the physical and psychological health effects of suicide bereavement on family members? An observational and interview mixed-methods study in Ireland

OBJECTIVES

Research focussing on the impact of suicide bereavement on family members' physical and psychological health is scarce. The aim of this study was to examine how family members have been physically and psychologically affected following suicide bereavement. A secondary objective of the study was to describe the needs of family members bereaved by suicide.

DESIGN

A mixed-methods study was conducted, using qualitative semistructured interviews and additional quantitative self-report measures of depression, anxiety and stress (DASS-21).

SETTING

Consecutive suicide cases and next-of-kin were identified by examining coroner's records in Cork City and County, Ireland from October 2014 to May 2016.

PARTICIPANTS

Eighteen family members bereaved by suicide took part in a qualitative interview. They were recruited from the Suicide Support and Information System: A Case-Control Study (SSIS-ACE), where family members bereaved by suicide (n=33) completed structured measures of their well-being.

RESULTS

Qualitative findings indicated three superordinate themes in relation to experiences following suicide bereavement: (1) co-occurrence of grief and health reactions; (2) disparity in supports after suicide and (3) reconstructing life after deceased's suicide. Initial feelings of guilt, blame, shame and anger often manifested in enduring physical, psychological and psychosomatic difficulties. Support needs were diverse and were often related to the availability or absence of informal support by family or friends. Quantitative results indicated that the proportion of respondents above the DASS-21 cut-offs respectively were 24% for depression, 18% for anxiety and 27% for stress.

CONCLUSIONS

Healthcare professionals' awareness of the adverse physical and psychosomatic health difficulties experienced by family members bereaved by suicide is essential. Proactively facilitating support for this group could help to reduce the negative health sequelae. The effects of suicide bereavement are wide-ranging, including high levels of stress, depression, anxiety and physical health difficulties.

The stigma associated with bereavement by suicide and other sudden deaths: A qualitative interview study

Quantitative studies have found that suicide bereavement is associated with suicide attempt, and is perceived as the most stigmatising of sudden losses. Their findings also suggest that perceived stigma may explain the excess suicidality. There is a need to understand the nature of this stigma and address suicide risk in this group. We aimed to describe and compare the nature of the experiences of stigma reported by people bereaved by suicide, sudden unnatural death, and sudden natural death, and identify any commonalities and unique experiences. We conducted a population-based cross-sectional survey of 659,572 staff and students at 37 British higher educational institutions in 2010, inviting those aged 18-40 who had experienced sudden bereavement of a close contact since the age of 10 to take part in an on-line survey and to volunteer for an interview to discuss their experiences. We used maximum variation sampling from 1398 volunteer interviewees to capture a range of experiences, and conducted individual face-to-face semi-structured interviews to explore perceptions of stigma and support. We continued sampling until no new themes were forthcoming, reaching saturation at n = 27 interviews (11 participants bereaved by suicide). We employed thematic analysis to identify any distinct dimensions of reported stigma, and any commonalities across the three groups. We identified two key themes: specific negative attitudes of others, and social awkwardness. Both themes were common to interviewees bereaved by suicide, sudden unnatural death, and sudden natural death. All interviewees reported the experience of stigmatising social awkwardness, but this may have been experienced more acutely by those bereaved by suicide due to self-stigma. This study provides evidence of a persistent death taboo in relation to sudden deaths. There is potential for anti-stigma interventions to reduce the isolation and social awkwardness perceived by people bereaved suddenly, particularly after suicide loss.

The stigma associated with bereavement by suicide and other sudden deaths: A qualitative interview study

Quantitative studies have found that suicide bereavement is associated with suicide attempt, and is perceived as the most stigmatising of sudden losses. Their findings also suggest that perceived stigma may explain the excess suicidality. There is a need to understand the nature of this stigma and address suicide risk in this group. We aimed to describe and compare the nature of the experiences of stigma reported by people bereaved by suicide, sudden unnatural death, and sudden natural death, and identify any commonalities and unique experiences. We conducted a population-based cross-sectional survey of 659,572 staff and students at 37 British higher educational institutions in 2010, inviting those aged 18–40 who had experienced sudden bereavement of a close contact since the age of 10 to take part in an on-line survey and to volunteer for an interview to discuss their experiences. We used maximum variation sampling from 1398 volunteer interviewees to capture a range of experiences, and conducted individual face-to-face semi-structured interviews to explore perceptions of stigma and support. We continued sampling until no new themes were forthcoming, reaching saturation at n = 27 interviews (11 participants bereaved by suicide). We employed thematic analysis to identify any distinct dimensions of reported stigma, and any commonalities across the three groups. We identified two key themes: specific negative attitudes of others, and social awkwardness. Both themes were common to interviewees bereaved by suicide, sudden unnatural death, and sudden natural death. All interviewees reported the experience of stigmatising social awkwardness, but this may have been experienced more acutely by those bereaved by suicide due to self-stigma. This study provides evidence of a persistent death taboo in relation to sudden deaths. There is potential for anti-stigma interventions to reduce the isolation and social awkwardness perceived by people bereaved suddenly, particularly after suicide loss.

•

Explores stigma after suicide, unnatural deaths and sudden natural deaths.

•

First qualitative study internally comparing these three groups' experiences.

•

All three groups described stigmatising social awkwardness.

•

The death taboo in relation to sudden deaths is particularly marked after suicide.

Attitudes to suicide following the suicide of a friend or relative: a qualitative study of the views of 429 young bereaved adults in the UK

BACKGROUND

People bereaved by suicide are at increased risk of suicide attempt and suicide, but explanations for these associations remain theoretical. It is possible that the experience of suicide bereavement modifies personal attitudes towards suicide, but the nature of these changes remains unexplored. There is a need to understand personal attitudes to suicide following suicide bereavement, as this may inform the development of suicide prevention interventions. Our aim was to explore the attitudes of young adults bereaved by suicide towards their own likelihood of dying by suicide.

METHODS

We conducted a cross-sectional study of staff and students aged 18-40 at 37 United Kingdom (UK) higher educational institutions in 2010. Ethical approval was granted by the UCL Research Ethics Committee. Qualitative responses to a question probing attitudes to own suicide were provided by 429 respondents who had experienced bereavement by the suicide of a close contact. We identified key themes in this dataset using thematic analysis.

RESULTS

Analysis identified four main themes: suicide as a more tangible option (whether feared or not); identification with the deceased and awareness of shared vulnerabilities to suicide; personal determination to avoid suicide; and beliefs regarding safeguards against suicide. These themes reflected a broad split in participants' views regarding own likelihood of dying by suicide, influenced by the degree to which own suicide was feared and the extent to which they felt in control of determining a suicide death. Whilst the majority described an aversion to the idea of attempting suicide themselves, largely through an awareness of the impact on others, a minority described their experiences as having normalised suicide as a personal option.

CONCLUSIONS

The views of a sample of UK-based adults bereaved by suicide suggest that exposure to the suicide of a close friend or relative can influence attitudes to suicide in ways that could influence own risk of suicide attempt. The normalising attitudes to suicide observed in a minority of respondents could contribute to the observed association between suicide bereavement and suicide attempt.

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.