Download - 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