bereavement by suicide

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Presentation from the International Congress of the Royal College of Psychiatrists 24-27 June 2014, London

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Page 1: 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

Page 3: Bereavement by suicide

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)

Page 4: Bereavement by suicide

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

Page 5: Bereavement by suicide

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

Page 6: Bereavement by suicide

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

Page 7: Bereavement by suicide

Suicide prevention strategy since 2002

Department of Health, 2002

U.S. Department of Health &

Human Services, 2001

Page 8: Bereavement by suicide

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

Page 9: Bereavement by suicide

International suicide prevention strategies

support for people

bereaved by suicide

Page 10: Bereavement 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)

Page 13: Bereavement by suicide

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

Page 14: Bereavement by suicide

Results

• Partners

• Parents

• Offspring

• Siblings

• Peers

• Mixed kinship groups

• Strong evidence

• Weak evidence

Page 15: Bereavement by suicide

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

Page 16: Bereavement by suicide

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)

Page 17: Bereavement by suicide

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)

Page 18: Bereavement by suicide

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)

Page 19: Bereavement by suicide

Children bereaved by parental suicide

• possible ↑ severity of depression in SB

schoolchildren compared with schoolchildren

bereaved by parental cancer death

(Pfeffer et al, 2000)

Page 20: Bereavement by suicide

Sibling suicide

• no apparent differences in depression in adults

bereaved by sibling suicide compared with sibling

non-suicide deaths (Kessing et al 2003)

Page 21: Bereavement by suicide

Peer suicide

• no studies using bereaved controls

Page 22: Bereavement by suicide

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

Page 23: Bereavement by suicide

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)

Page 24: Bereavement by suicide

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)

Page 25: Bereavement by suicide

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

Page 26: Bereavement by suicide

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

Page 27: Bereavement by suicide

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)

Page 29: Bereavement by suicide

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

Page 30: Bereavement by suicide

Acceptable interventions

• GP screening

• peer support

• voluntary sector