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

Excruciating existential suffering and complicated grief: The essence of surviving the suicide of a son or daughter

BACKGROUND

Suicide is the fourth most common cause of death for the 15-29 age group. Research on the impact of suicide on parents is scarce and, therefore, poorly understood.

AIM

To explore parents' experiences who have lost a son or a daughter due to suicide and their experience of the services available to them.

METHODS

This phenomenological study involved 1-2 interviews with ten parents aged 40-65, seven mothers and three fathers in all 13 interviews. The age range of their sons and daughters was 17-37 years when they died.

RESULTS

For the parents, losing a son or a daughter to suicide is an overwhelming life experience characterised by Excruciating existential suffering and complicated grief where they are confronted with deep meaning-making and existential questions without answers since the person who can answer most of them is no longer alive. They, therefore, felt stuck in their grief for up to 4 years. The initial experience was an immense paralysing shock and sense of unreality. The subsequent period was a blur, and they were numb. Then, their psyche and bodies collapsed, and for a long time, they felt no grief processing was taking place. They sorely needed long-term professional trauma-informed support and felt that, in too many cases, they had to reach out for help themselves. They would have liked to see the healthcare system embrace them with more open arms, offer help and be met with information and individualised support.

CONCLUSIONS

Standard operating procedures must be installed to support suicide-bereaved parents better. Long-term professional support and trauma-focused care are required following such major trauma, and providing such support could help to reduce their adverse health impacts. Nurses and other health professionals must be better educated on existential suffering in this context.

The relationship between bereavement-related guilt and suicide ideation in Turkish bereaved adults

This study investigates risk factors for suicidal ideation among Turkish bereaved adults, focusing on bereavement-related guilt. Utilizing the Prolonged Grief Scale, Bereavement Guilt Scale, and Beck Depression Inventory's suicide item, 570 bereaved participants were assessed. Suicidal ideation prevalence was found to be 20.2%. Higher rates of low income, single status, and unnatural death, as well as younger ages of the bereaved and deceased, were observed in the suicidal ideation group. Additionally, significantly elevated scores on the Prolonged Grief Scale and Bereavement Guilt Scale subscales were found in this group. After controlling for other risk factors, scores for survivor guilt and perceived responsibility for the death significantly increased the likelihood of belonging to the suicidal ideation group. These findings underscore the critical role of addressing feelings of guilt in psychological interventions aimed at mitigating suicidal ideation among bereaved individuals.

Traumatic loss: a systematic review of potential risk factors differentiating between posttraumatic stress disorder and prolonged grief disorder

Background: When traumatic events and losses intersect in the form of traumatic loss, these events can trigger both posttraumatic stress disorder and pathological grief.Objective: This systematic review investigates which characteristics differentiate between the development of the respective disorders or are associated with comorbidity.Method: A systematic literature search using Medline, PubMed, APA PsycInfo and Web of Science yielded 46 studies which met the inclusion criteria. In these studies, PTSD was assessed using 17 and pathological grief using 16 different validated instruments. In the quality assessment, 12 studies were classified as average, 30 as above average, and 4 as excellent. The investigated risk factors were categorized into 19 superordinate clusters and processed using narrative synthesis.Results: The relationship to the deceased, mental health issues, and religious beliefs seem to be associated specifically with pathological grief symptoms compared to PTSD symptoms. Social support and social emotions emerged as significant correlates and potential risk factors for both PTSD and pathological grief. Included studies had mainly cross-sectional designs.Conclusions: Differentiating factors between pathological grief and PTSD appear to exist. The results should be considered within the limitations of the heterogeneity of the included studies and the research field. There is a lack of studies (1) using a longitudinal study design, (2) starting data collection early following the traumatic loss, (3) using standardized, up-to-date measurement instruments and (4) including comorbidity in their analyses. Further research is urgently needed for more accurate (acute) screenings, prognoses, and interventions following traumatic loss.

Vortex of regret: How positive and negative coping strategies correlate with feelings of guilt

Bad coping behavior and guilt may reinforce each other as a negative feedback loop. Social contexts and expectations may also create cognitive dissonance in coping individuals and affect the effectiveness of coping styles. This study examines the associations between the feeling of guilt and specific coping styles belonging to both groups of positive and negative coping styles. We conducted Bayesian Multiple Regression analyses on secondary data from 3784 high school students in China. Positive coping is associated more with reduced feelings of guilt compared to negative coping. However, some positive coping styles were found to be positively associated with a sense of guilt, especially those involving confrontation against or conformity to social expectations. Most negative coping styles are positively associated with guilt, and substance use has the strongest influence among the examined negative coping styles. The findings suggest that the consideration of sociocultural contexts is very important in supporting those with guilt issues, especially adolescents in societies with dominant traditional East Asian values.

Understanding the complexity of suicide loss: PTSD, complex PTSD and prolonged grief disorder following suicide bereavement

Suicide-bereaved individuals are often confronted with profound grief reactions and have an increased risk for mental health disorders. Little is known about the development of complex post-traumatic stress disorder (CPTSD) following a loss by suicide. This paper aims to assess the prevalence of CPTSD, PTSD, prolonged grief disorder (PGD), and depression as well as to identify sociodemographic and loss-related factors regarding their development. A total of 161 suicide loss survivors (91.3% female) completed a questionnaire, which collected symptoms of grief (TGI-SR+), PTSD, CPTSD (ITQ), and depression (PHQ-D). In total, 12.4% met the diagnosis for CPTSD, 5.0% for PTSD. A total of 22.0% fulfilled the diagnosis for PGD. 41.6% showed at least moderate symptoms of depression. Pearson's correlation showed that time since loss was negatively associated with PG and PTSD symptoms, kinship to the deceased was associated with PG severity. The sample scored high on all disturbances in self-organization (DSO) symptom clusters typical for CPTSD. A focus on symptoms of CPTSD may be a necessary component in the care of survivors of suicide loss.

Breaking the news of the violent death of a close person to children under 18 years of age: A qualitative interview study

Children who lose a close person to suicide or homicide will most likely receive this news from a carer. The caregiver's personal beliefs and approaches to addressing the topic will influence the child. A total of 10 interviews were conducted with carers of children aged 0-17 years, and the data were analyzed using reflexive thematic analysis. Four themes were developed, exploring: (1) how carers attempted to manage the task of delivering the news of death to the child and discussing it using careful wording; (2) how some carers' desire to protect the child from the truth hindered honesty and open conversations; (3) how and why some carers deliberately challenged societal taboos; and (4) how external influences prompted conversations about the topic. The discussion projects potential consequences for the children and their families. It also derives necessary societal changes, support measures, and further research suggestions.

Social-ecological perspective on the suicidal behaviour factors of early adolescents in China: a network analysis

Background

In early adolescence, youth are highly prone to suicidal behaviours. Identifying modifiable risk factors during this critical phase is a priority to inform effective suicide prevention strategies.

Aims

To explore the risk and protective factors of suicidal behaviours (ie, suicidal ideation, plans and attempts) in early adolescence in China using a social-ecological perspective.

Methods

Using data from the cross-sectional project 'Healthy and Risky Behaviours Among Middle School Students in Anhui Province, China', stratified random cluster sampling was used to select 5724 middle school students who had completed self-report questionnaires in November 2020. Network analysis was employed to examine the correlates of suicidal ideation, plans and attempts at four levels, namely individual (sex, academic performance, serious physical illness/disability, history of self-harm, depression, impulsivity, sleep problems, resilience), family (family economic status, relationship with mother, relationship with father, family violence, childhood abuse, parental mental illness), school (relationship with teachers, relationship with classmates, school-bullying victimisation and perpetration) and social (social support, satisfaction with society).

Results

In total, 37.9%, 19.0% and 5.5% of the students reported suicidal ideation, plans and attempts in the past 6 months, respectively. The estimated network revealed that suicidal ideation, plans and attempts were collectively associated with a history of self-harm, sleep problems, childhood abuse, school bullying and victimisation. Centrality analysis indicated that the most influential nodes in the network were history of self-harm and childhood abuse. Notably, the network also showed unique correlates of suicidal ideation (sex, weight=0.60; impulsivity, weight=0.24; family violence, weight=0.17; relationship with teachers, weight=-0.03; school-bullying perpetration, weight=0.22), suicidal plans (social support, weight=-0.15) and suicidal attempts (relationship with mother, weight=-0.10; parental mental illness, weight=0.61).

Conclusions

This study identified the correlates of suicidal ideation, plans and attempts, and provided practical implications for suicide prevention for young adolescents in China. Firstly, this study highlighted the importance of joint interventions across multiple departments. Secondly, the common risk factors of suicidal ideation, plans and attempts were elucidated. Thirdly, this study proposed target interventions to address the unique influencing factors of suicidal ideation, plans and attempts.

Needs for help and received help for those bereaved by a drug-related death: a cross-sectional study

Background and aims: Individuals bereaved after sudden and unexpected deaths can benefit from professional help to cope after the loss, and the bereaved call for proactive, early and flexible help from professional services. Most drug-related deaths (DRDs) happen suddenly and unexpectedly. DRDs are a significant public health issue, yet few studies have examined DRD-bereaved people's needs and experiences with professional help. This article investigates the needs for help and received help reported by DRD-bereaved family members and friends, and suggests improvements in services based on the findings. Data and method: A heterogeneous convenience sample of DRD-bereaved family members and close friends (n = 255) were recruited for a survey from February to December 2018. Descriptive analyses were conducted for experiences with professional help, chi-square analyses to find predictors for help needs and received help, and logistic regression analysis to find predictors for satisfaction with the help provided. Results: Most DRD-bereaved individuals reported a need for professional help after the death regardless of family relation to the deceased, and about half of the participants received help. Nearly half of them were satisfied with the help. Our results indicated higher satisfaction with help among older bereaved, and the participants who received help from a crisis team or psychotherapist. The latter was particularly stated for younger participants. Few participants with children in the family reported that the children had received help, and less than one-third were satisfied with this help. Conclusion: The study shows that younger age groups and children need particular recognition, and a family perspective from services is essential. When assessing the help needs of the DRD-bereaved, relations of both psychological and biological closeness should be recognised. Help efforts should be tailored according to established knowledge of the provided help that bereaved populations deem effective.

Modifiable risk factors of major depressive disorder: A Mendelian randomization study

Identifying modifiable risk factors early on is essential to prevent major depressive disorder (MDD). This study systematically investigated the causal relationship between 19 modifiable risk factors and MDD. Single-nucleotide polymorphisms (SNPs) associated with 19 potentially modifiable risk factors were screened via the genome-wide association study (GWAS) enrolling individuals of European descent. Summary-level data for MDD (59,851 cases and 113,154 controls) were extracted from the UK Biobank. The inverse-variance-weighted (IVW) method was utilized as the primary analysis. Sensitivity analyses were performed using the MR-Egger method, the Maximum likelihood method, the MR-pleiotropy residual sum outlier (MR-PRESSO) method, and MR-robust adjusted profile score (MR-RAPS) method. MR-Egger regression, heterogeneity tests, pleiotropy tests, and leave-one-out tests were also performed to analyze sensitivity. The MR Steiger test was used to verify the directionality of the exposure to the outcome. Genetically predicted smoking initiation increased the risk of MDD (P = 6.00E-09), while smoking status: never and past tobacco smoking decreased the risk of MDD (all P < 0.01). In addition, education level was inversely associated with MDD risk (all P < 0.01). Genetically instrumented sleeplessness/insomnia, daytime naps, and nap during the day were positively related to the risk of MDD (all P < 0.01). Personal feelings, including guilt, hurt, tension, and worry too long after an embarrassing experience, had a suggestive increased risk for MDD (all P < 0.000). The remaining five modifiable risk factors were all causally associated with the risk of MDD, including neuroticism, neuroticism scores, body mass index (BMI), average total household income before tax, and types of physical activity in the last 4 weeks (all P < 0.01). All 19 potentially modifiable risk factors were causally associated with the risk of MDD. The main hypothesis of this MR study was that identifying and intervening in these 19 potentially modifiable risk factors could be beneficial to the prevention and treatment of MDD and further reduce mortality and economic burden.

Role of the Psychiatric Nurse in Improving the Psychosocial Health of Families After Suicide

Suicide is defined as death that occurs as a result of deliberate self-harming behavior with the intention of ending one's life. Each suicide has many physical, economic and psychological short and long-term effects on the individual, family, friends and society. The death of an individual as a result of suicide creates a traumatic effect for family members and causes family members to experience various psychosocial problems. For this reason, it is very important to focus on the consequences of suicide in family members who have lost due to suicide, to evaluate the family's reactions to suicide, and to provide the needed psychosocial support. In this context, in this review, it is aimed to review the literature on the psychosocial problems experienced by families who have lost due to suicide and to present up-to-date information on the role of psychiatric nurse in improving the psychosocial health status of families.

Depression and Suicide Ideation among Suicide-Loss Survivors: A Six-Year Longitudinal Study

Suicide is not only a tragic end of life but also may be the beginning of a very challenging life for those left behind. Suicide-loss survivors (SLSs) are individuals who were exposed to the suicide of a close family member or a friend and endure highly emotional distress. The psychological stance and reactions of SLS are deeply colored by painful, intense emotions that are expressed through different psychiatric symptoms, including depression and suicide ideation (SI). The present study investigated the long-term effects of interpersonal factors such as social support, self-disclosure, thwarted belongingness, and perceived burdensomeness on depression and suicidal ideation among SLS. One hundred fifty-two Israeli SLS, aged 20-72, participated in this longitudinal study, during which their suicide ideation and depression levels were assessed at four points over six years (T1-baseline, and two (T2), four (T3), and six (T4) years after baseline). At the last time point, interpersonal factors were also assessed. SLSs' interpersonal variables significantly predicted depression and SI levels beyond their usual trajectories over the years. Significant correlations were found between both perceived burdensomeness and thwarted belongingness and depression levels at all measurement points. Moreover, thwarted belongingness was found to be a significant moderator of the relationship between former and current depression levels, as the contribution of depression-T3 to depression-T4 was lower among SLSs with low thwarted belongingness (b = 0.14, CI = 0.05-0.34) compared with SLSs with high thwarted belongingness (b = 0.25, CI = 0.22-0.45). These findings emphasize the vital healing role of interpersonal factors such as belongingness, as they may attenuate depression and SI symptoms over time. Hence, clinicians should focus on therapies that boost interpersonal interactions and belongingness, as they seem to be crucial stepping stones on the way to recovery. Moreover, national programs should be implemented to offer SLSs targeted interventions to reduce distress and depression in the aftermath of suicide loss.

Community sadness: Clinical recommendations for working with grieving Arab American families

Grief is a universal emotion, both layered and multidimensional. Grief in Arab cultures center around three ideals: culture, family, and religion. This paper examines the multiple different factors that influence Arabs during their grief, broken down into how different religions process and view death, along with the impact of Westernized ideals and other relationships. We explore physiological responses of grief, gender differences in expressing emotions, self-care practice, and utilizing religion as a strength. The rules and traditions surrounding grief and loss in Arab communities need to be acknowledged by clinicians and incorporated into their practice. Recommendations and future directions for clinicians to support Arab grief within the three lenses of culture, family, and religion.

Prolonged Grief Symptoms among Suicide-Loss Survivors: The Contribution of Intrapersonal and Interpersonal Characteristics

BACKGROUND

Suicide-loss survivors (SLSs) are a population with unique characteristics that place them at increased risk for developing grief complications and painful feelings of guilt that may impact their supportive social environment. However, no studies to date have examined the role of intrapersonal and interpersonal variables that may contribute to prolonged grief symptoms (PGS) as outlined by the new DSM-5 criteria. The present study aimed to extend knowledge regarding the role of interpersonal variables, such as perceived burdensomeness, thwarted belongingness, and self-disclosure, in determining the impact of guilt on the development of PGS among SLSs.

METHOD

This study is part of a longitudinal study, though, in this study, we used a cross-sectional examination of the recently completed fourth measurement. Study participants included 152 SLSs aged 22 to 76 who completed questionnaires measuring guilt, depression, perceived burdensomeness, thwarted belongingness, self-disclosure, and PGS using the Prolonged Grief-Revised Inventory. Participants' demographics and loss-related characteristics, such as time since suicide and participant's age at the time of suicide, were examined.

RESULTS

Confirming the hypotheses, intrapersonal variables (i.e., guilt and depression), as well as interpersonal variables (i.e., perceived burdensomeness, thwarted belongingness, and self-disclosure), contributed significantly to PGS beyond sociodemographic and loss-related factors. Perceived burdensomeness significantly moderated the contribution of guilt to PGS: for participants with high burdensomeness levels, guilt contributed to PGS more strongly than for participants with low burdensomeness.

CONCLUSION

Guilt is an important contributor to PGS among SLSs, and perceived burdensomeness plays a critical role in moderating this contribution. In light of these findings, it can be suggested that SLSs with high levels of guilt should receive special attention and may benefit from therapeutic interventions focusing on reducing maladaptive cognitions that elicit intense guilt or perceived burden.

Examining the Basic Assumption of Psychoanalytic Theory Regarding Normal and Abnormal Grief: Roles of Unfinished Businesses and Bereavement Related Guilt

To date, several theoretical models have been proposed to explain how the expected and natural grief processes turns into psychiatric disorders. Nevertheless, there is a paucity of empirical research examining the basic assumption of psychoanalytic theory regarding pre-death conflict and bereavement related guilt. Accordingly, the current study aimed to investigate the mediator role of bereavement related guilt in the relationship between the pre-death conflict and maladaptive grief process. The sample consisted of 447 bereaved adults who lost a loved one due to death in the last 5 years. The Unfinished Business in Bereavement (UBBS), Bereavement Guilt Scale (BGS), Beck Depression Inventory (BDI), and Prolonged Grief Disorder Scale (PG-13) scales were administered. The results indicated that the UBBS scores were positively correlated with both BDI and PG-13 scores, and BGS scores mediated these relationships. Obtained findings were discussed in relation to psychoanalytic theory and existing studies in the grief literature.

Prolonged grief disorder in Arabic-speaking treatment-seeking populations: Relationship with socio-demographic aspects, loss- and trauma-related characteristics, and mental health support

INTRODUCTION

Prolonged grief disorder (PGD) has been included as a new diagnosis in the ICD-11 and is set to be included in the DSM-5-TR. To better identify vulnerable individuals, different factors associated with PGD have to be taken into account, but results regarding these factors remain equivocal. Moreover, few studies on PGD are available from Arabic-speaking populations and from different countries dealing with conflicts and wars. The objective was thus to examine PGD prevalence and associated characteristics in these populations.

MATERIALS AND METHODS

A total of N = 1,051 bereaved participants from Arabic-speaking populations completed the PG-13 as part of a screening procedure for an online mental health intervention. Multiple linear regression was conducted to examine associated factors for PGD symptom severity, and multiple logistic regression was applied to investigate associated factors for PGD according to PG-13 diagnostic criteria.

RESULTS

Of the participants, 18.8% (n = 198) met the PGD diagnostic criteria, at an average of about 6 years post-loss. The multiple linear regression yielded eight associated factors for PGD symptom severity (age, gender, number of losses, number of traumatic event types, relationship with the deceased, age at loss, impairment during first year post-loss, perceived social support), which explained 40.2% of the variance [F _{(17, N=1,033)} = 40.82, p < 0.001, R ² = 0.402]. The multiple logistic regression yielded five significant associations with PGD (gender, relationship with the deceased, number of lost persons, impairment during first year post-loss, perceived social support), which explained 33.0% (Nagelkerke R ²) of the variance in PGD according to PG-13 diagnostic criteria.

DISCUSSION

A substantial proportion of the participants met the PG-13 criteria for PGD, emphasizing that therapeutic services are indispensable in this population. The associated factors for PGD found in our Arab-speaking sample are largely consistent with those found in studies from other regions. The slightly differing numbers of associated factors between the linear and logistic regression underline that a continuous score reflects the continuum between normal and dysfunctional grieving, and therefore also a range of factors associated with PGD.

Conflicted or close: Which relationships to the deceased are associated with loss-related psychopathology?

OBJECTIVES

Prior studies have shown that pre-loss closeness and conflict with a deceased person are associated with the severity of symptoms of prolonged grief and/or depression. Nevertheless, mechanisms underlying these relationships are not well understood. We propose a theoretical model in which past closeness and conflict are related to prolonged grief and depression via concrete and symbolic continuing bonds (CB). The aim of our study was to test this model in a sample of bereaved family members.

METHODS

Individuals (N = 244) who had lost a family member from 0.5 to 8.0 years before the survey completed the Quality of Relationships Inventory-Bereavement Version, the Continuing Bonds Scale, the Prolonged Grief Disorder-13 scale, and the Patient Health Questionnaire-9.

RESULTS

The findings partially confirmed our model. Closeness was positively and moderately associated with symptoms of prolonged grief but not with symptoms of depression. Conflict was positively and weakly associated with symptoms of depression and prolonged grief. All of these relationships were only partially mediated by concrete/maladaptive and symbolic/adaptive CB.

CONCLUSIONS

The differences in the relationship of past closeness and conflict to prolonged grief and depression symptoms suggest that inter- and intrapersonal mechanisms of prolonged grief and depressive symptoms may be distinct. If future, especially longitudinal studies, confirm our model, CB would be a possible target for interventions for bereaved persons who had a close and/or conflicted relationship with a deceased family member and experience loss-related psychopathology.

PRACTITIONER POINTS

Continuing bonds (CB) are a potential target of interventions for bereaved persons who had a close and/or conflicted relationship with a deceased family member and experience symptoms of prolonged grief and/or depression. Internalization of the capacity to care for yourself and feel autonomous in a safe and stable therapeutic relationship may lead to increased self-confidence, promote working through past experiences in the relationship with the deceased, and gradual reduction of concrete forms of CB. Increasing awareness and acceptance of emotional experiences may contribute to the appreciation of past relationship with a deceased person and the growth of symbolic forms of CB. Future research should focus on verifying the effectiveness of the attachment-informed therapeutic approach to working with CB.