bereavement by suicide

Bereavement by suicide:

an emergent risk factor for suicide &

mental health problems

Wednesday 25th June 2014

International Congress of the Royal College of Psychiatrists

Barbican Centre, London

Dr Alexandra Pitman

Clinical Research Fellow

UCL Division of Psychiatry

Policy-making & evidence

2008

systematic

review

2014

systematic

review

first clinical

concerns

published

DH

2002

DH

2012

paper paper

paper

paper

paper paper

paper

Clinical background

• clinical impression that suicide bereavement has

more damaging psychosocial impact

• task of grieving a loss

• extra burden of:

– horror of a violent death

– agonizing self-questioning

– blaming oneself & others

– concealing the cause

– stigma (Cvinar, 2005)

Cultural background

• cultural taboo around violent deaths

• stigma associated with suicide (Harwood et al, 2002)

– people crossing the road to avoid the bereaved

– few sympathy cards

– blaming attitudes

– embarrassment

– disgust

– fear of violating social rules

Theoretical basis

• Factors thought to elevate risk of suicidality in SB:

– heritability

– self-fulfilling prophecy

– assortative mating & relating

– shared environments

– social modelling

– depression

– lack of support

– reduced helpseeking

Exposure to suicide bereavement

• 6 - 425 people affected by each suicide

• best estimate: 20 family, 20 friends, 20 colleagues

= 60 total (Berman, 2011)

• UK incidence: 350,000 – 4.5 million people

• Worldwide incidence: 48-500 million people

Suicide prevention strategy since 2002

Department of Health, 2002

U.S. Department of Health &

Human Services, 2001

Featured risk factors for suicide

past suicide

attempt &

NSSI

male

gender

age

specific

occupational

groups

bereavement

by suicide

psychiatric

illness substance

misuse

recent

psychiatric

discharge

prisoners

specific

ethnic

groups

International suicide prevention strategies

support for people

bereaved by suicide

1st systematic review (2008)

• few differences between people bereaved by

suicide & other causes in relation to:

– general mental health

– depression, PTSD, anxiety

– suicidal ideation

• suicide-bereaved group reported:

– ↑ stigma ↑ blame ↑ rejection

(Sveen & Walby, 2008)

Problems with the evidence base

• many have methodological problems

• small convenience samples

• not hypothesis-driven

• numerous unstandardized measures

• mainly US and Canada – ?generalisability

October 2013 systematic review

(Pitman et al, 2014)

Method

• inclusion criteria:

– bereavement by suicide (confirmed relationship)

– bereaved control group

– primary data, any recorded outcomes

– English language

• 4 databases: Medline, CINAHL, PsycINFO, EMBASE

• secondary searching of references cited

• identified 7,504 records

• n = 57 studies eligible for inclusion

Results

• Partners

• Parents

• Offspring

• Siblings

• Peers

• Mixed kinship groups

• Strong evidence

• Weak evidence

Partners bereaved by suicide

• ↑ risk suicide in SB women and men vs partner’s

death by other causes (Agerbo 2005)

• 9 studies found no apparent differences in:

– depression

– psychopathology

– grief

Parents bereaved by offspring suicide:

Europe

• ↑ risk suicide in SB mothers vs other causes

(Qin & Mortensen, 2003)

• no differences in suicide risk in SB parents vs

other causes (Agerbo 2005)

• no differences in risk of grief or distress between

SB parents & those bereaved by accidental death

(Dyregrov et al 2003)

Parents bereaved by offspring suicide:

Canada

• no differences between SB parents & those

bereaved by accidental death in risk of:

– suicide attempts

– specific mental disorders

– relationship breakdown

– £ hardship

• ↑ risk psychiatric admission in SB parents

• ↓ risk depression in SB parents (Bolton et al 2013)

Adults bereaved by parental suicide

• possible ↑ risk depression in adults bereaved by

maternal suicide compared with maternal non-

suicide bereavement (Kessing et al 2003)

• no apparent differences in depression in offspring

bereaved by paternal suicide compared with

paternal non-suicide bereavement

(Kessing et al 2003)

Children bereaved by parental suicide

• possible ↑ severity of depression in SB

schoolchildren compared with schoolchildren

bereaved by parental cancer death

(Pfeffer et al, 2000)

Sibling suicide

• no apparent differences in depression in adults

bereaved by sibling suicide compared with sibling

non-suicide deaths (Kessing et al 2003)

Peer suicide

• no studies using bereaved controls

Mixed kinship groups

• compared with bereavement by natural and

unnatural causes, SB groups had:

– ↑ self-perceived stigma

– ↑ responsibility

– ↑ shame

– ↑ rejection

• compared with bereavement by violent causes:

– ↑ rejection

– ↑ shame

Similarities between bereavement by suicide

and by accidental death

• n=21 studies found no differences between

people bereaved by suicide and those bereaved

by sudden violent deaths on measures of:

– grief intensity

– stress reactions

– psychopathology

• Canadian study found ↑ risk depression in parents

bereaved by child’s RTA death compared with SB

(Bolton et al 2013)

More recent findings: China

• Setting: rural China

• Compared: family members bereaved by suicide

to those bereaved by accidental death

• Primary outcome: Chinese version of SCL-90-R

• Finding: no sig differences

(Xu & Li, 2014)

Summary findings

• ↑ risk suicide in partners and mothers

• ↑ risk psychiatric hospitalisation in parents

• ↑ risk of rejection and shame compared to other

violent bereavements

• many similarities to non-suicide violent †

• ↓ risk depression in parents

Policy implications

• clear risk of suicide in specific kinship groups

• justifies inclusion in suicide prevention strategy

• ? include people bereaved by accidental deaths

• need to identify best means of offering support

Interventions following suicide bereavement

• heterogeneous group

• needs vary over time

• Interventions for the SB:

– poor evidence base

– reliance on voluntary sector

(Hawton & Simkin, 2003;

McDaid et al, 2008; DH, 2010)

Research implications: gaps in evidence

• peer suicide

• comparing outcomes in specific kinship groups:

– FSA investigated only in relation to deceased partners

& children

– NFSA investigated only in relation to deceased children

• specific cultural settings

• interventional studies focussed on specific groups:

– bereaved by suicide

– bereaved by other violent causes

Acceptable interventions

• GP screening

• peer support

• voluntary sector