Harmful or Helpful? A Systematic Review of How Those Bereaved Through Suicide Experience Research Participation

Is there still a place for psychological autopsy in suicide research? A literature review of methodological limitations and recommendations for future development

Psychological autopsies refer to retrospective interviews between researchers and informants who were close to a person who died by suicide, to explore and better understand the circumstances and contributing factors to that suicide. However, several issues persist with psychological autopsy as a methodology. We assessed the academic literature regarding psychological autopsies and extracted key themes about methodological limitations and weaknesses. The aim was to formulate recommendations and present suggestions for future methodology that would protect the benefits of psychological autopsy, particularly the personal narratives, while addressing methodological limitations. A literature review of nine relevant healthcare research databases yielded twenty-two relevant papers. Each of these publications were reviewed and themes regarding methodological limitations of psychological autopsies were identified and collated. Limitations identified from the review included issues of validity and reliability, lack of standardisation, biases, control variables, cultural considerations, ethics, and data handling. New limitations regarding cultural nuance, modern communication channels, and 'invisible informants' were identified. Recommendations for the future development of the psychological autopsy method include embracing modern communication methods and 'invisible informants', cultural intersections, safeguarding of reliability and validity, and the use of feasibility trials. The emphasis remains upon collating the raw narratives at the core of these interviews which make the psychological autopsy such a unique and insightful tool.

The use of social media after bereavement by suicide: results from a French online survey

BACKGROUND

According to recent research, the Internet and social media are shaping and changing how we die and mourn. However, the use of social media after bereavement by suicide remains poorly understood. Thus, emerging research is needed to better assess the role that social media can play after bereavement by suicide. The objective of our study was to evaluate the use of social media in French people bereaved by suicide and to assess their expectations toward social media.

METHOD

We conducted a national cross-sectional online survey including French people bereaved by suicide assessing their use of social media after the death of their relative. All adults bereaved by suicide were eligible to participate in the study. An online 26-item questionnaire collected sociodemographic and loss-related characteristics and evaluated four dimensions: (1) the use of social media in daily life, (2) the perceived needs regarding suicide bereavement, (3) the use of social media associated with the suicide loss, and (4) the expectations regarding the development of an online resource for people bereaved by suicide and proposals regarding the development of such a resource.

RESULTS

Among 401 participants, 61.6% reported using social media after the death of their relative by suicide, especially those recently bereaved, those receiving counseling and bereaved parents. The participants mainly used social media to reach peers bereaved by suicide and to memorialize, while they expected social media to help them finding information on suicide and accessing bereaved peers. Younger participants were more prone to use social media to memorialize, while bereaved partners and those bereaved by the suicide of a parent were less prone to use them with such aim.

DISCUSSION

A large part of people bereaved by suicide use social media for their grief process, mainly to contact peers bereaved by suicide and to memorialize their loved one. According to or results, social media contributes to contemporary grief processes after suicide bereavement and can be seen as putative means to improve the well-being of people bereaved by suicide.

The Needs, Use and Expectations of People Bereaved by Suicide Regarding Online Resources: An Online Survey

BACKGROUND

Online resources constitute a new and effective way to obtain support or information during bereavement processes. However, little is known about the needs, use and expectations of people bereaved by suicide regarding online resources.

METHOD

The objective of our national cross-sectional online survey was to collect the use, needs and expectations of people bereaved by suicide regarding online resources. The data were collected from July to October 2021 through a 26-item online questionnaire hosted on the website LimeSurvey.

RESULTS

A total of 401 respondents fully completed the questionnaire. Their mean age was 45.7. The majority of participants were women bereaved by the suicide of their child or partner. Half of the participants were bereaved for less than 3 years and benefited from counselling during their bereavement process. Three-quarters of the participants used the Internet for their bereavement process, mainly to obtain information on suicide bereavement and suicide prevention and to access testimonies of other people bereaved by suicide. Three-quarters of the participants found that available online resources for people bereaved by suicide are insufficient and expected a dedicated web platform to be developed. Finding information on suicide bereavement and on suicide prevention, discussing with a mental health professional and accessing testimonies of other people bereaved by suicide were expected by a majority of the participants regarding the future platform. Receiving counselling and being bereaved by the death of a child were the most important factors in explaining patterns of use and expectations regarding online resources.

DISCUSSION

Our results offer precise insights into the needs, use and expectations of people bereaved by suicide regarding online resources. The development of web platforms offering access to reliable information on suicide bereavement and on suicide prevention to peers bereaved by suicide and help to seek counselling are urgently needed.

Ethical Issues in Bereavement Research with Minors: A Scoping Review

There are various ethical issues in bereavement research. Most of the literature focuses on ethical issues involving adult participants. However, it is conceivable that research with minors poses particular ethical challenges, and little is known of the ethical issues involved in bereavement research with minors. A scoping review adhering to the PRISMA-ScR guidelines was conducted to address this gap and to contribute to better research practices. Searches in Embase, Emcare, EBM Reviews, Medline, PsycINFO (all accessed via Ovid), CINAHL, Scopus, SSCI, and the journals Death Studies and OMEGA identified 40 relevant peer-reviewed articles, while 25 relevant theses/dissertations were identified through ProQuest Global. The main ethical concerns identified include informed consent, risk to participants, and privacy and confidentiality. Findings of this review may inform bereavement researchers when designing their studies and to ensure the safety of their participants. The findings can also be used in clarifying the decisions made to a research ethics board, thus contributing to the quality of the research in this field. Future reviews may examine how the ethical issues reported in this review are similar or different to those reported in research with minors in other fields and expand to include more experimental research.

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.

The Reactions of Adolescents, Parents and Clinicians to Participating in Qualitative Research Interviews Regarding Adolescents Bereaved by Suicide and Other Traumatic Death

There are concerns that involving adolescents bereaved by suicide and other traumatic death in research may cause distress and harm. However, no study has investigated such bereaved adolescents’ research experiences. In addition, no study has looked at the experiences of parents and clinicians as participants in adolescent suicide and traumatic death bereavement research. This study aimed to explore the short-term impact of research participation experienced by adolescents, parents, and clinicians. A total of 61 participants (adolescents, n = 17; parents, n = 12; clinicians, n = 32) filled out a short survey within two weeks of having taken part in a qualitative interview study. Data were analyzed descriptively. Most participants had experienced no distress while participating and no negative effects of participating; rather, participation was experienced as helpful for them and they would highly recommend participating in a study like this to others. A few adolescents and parents reported some distress, related to anxiety about participation and the unpleasantness of grief memories. The study clearly indicates that bereaved adolescents, parents and clinicians can safely participate in research interviews regarding their experiences of grief and help after suicide, generally valuing the opportunity to share their experience. To prevent and mitigate potential distress, training of research staff and implementation of appropriate participant distress protocols are imperative. Future studies could include longitudinal follow-up of participants to assess any longer-term consequences.

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.

Vulnerability and Resilience in Sensitive Research: The Case of the Quantitative Researcher

The emotional experiences of quantitative researchers, particularly while conducting sensitive research, are largely neglected. This article aims to advance the awareness of possible emotional strains for quantitative researchers engaged in sensitive research. It qualitatively assesses the ethical and emotional experiences of quantitative researchers conducting a study on aging of bereaved parents and people with a physical disability. Based on the detailed minutes of 66 weekly research meetings held during 2015-2017, a thematic analysis of the researchers' experiences was performed. Our analysis identified two main themes: vulnerability and resilience. We delineate these themes, along with their subthemes and affinity to vicarious traumatization, moral stress, and vicarious posttraumatic growth. The current study is among the first to introduce the emotional and ethical experiences of the quantitative researcher. Tentative recommendations for the advancement of the researcher's safety and well-being by training, institutional support, self-care skills, and policy development are provided.

A Qualitative Analysis of Motivators to Participation in Suicide-Focused Research from a Community-Based Australian Sample

Suicide prevention strategies internationally appear to be falling short of making a meaningful impact on global suicide deaths. Increasing the rates of general community participation in suicide research may improve knowledge generalisability as it relates to suicidal behaviour and leads to new suicide prevention approaches. This study aims to explore the motivations of a community-based sample to participate in suicide research. A subsample of the Australian general population took part in an online survey which is part of a multilevel suicide prevention trial. The survey concluded with an optional open-text question asking about peoples’ motivations for participating in the study; 532 participants left a response to this question. These responses were qualitatively analysed using Thematic Network Analysis. Motivations to participate in suicide research were represented by four global themes: altruism, solve systemic problems, lived experience, and personal benefit. Of these themes, three were focused on the benefit of others, while only the final theme articulated motivation to participate that was self-focused. The impact of suicide is felt throughout the wider community. This new understanding of the motivations of community-based samples to participate in suicide research should be used to increase participation rates and reach people who would not normally contribute their voice to suicide research.

Using my Demons to Make Good: The Short- and Long-Term Impact of Participating in Suicide-Related Research

Participation in suicide-related research is generally associated with more positive than negative outcomes. However, sparse research has examined the longevity of any effects of participation. Here, we report the first qualitative examination of both the immediate and long-term views of participating in suicide-related research interviews. Thematic analysis indicated that participants had positive experiences, including increased altruism and self-understanding. For some participants, these benefits remained in the months post-participation. Follow-up data revealed that participants can be susceptible to short-term dips in mood, which may not emerge until a few hours/days post-participation. However, any negative effects of participation were confined to the days immediately following the study. Participant-informed recommendations were developed to support researchers in optimizing the well-being of participants in suicide-related research.

Acceptability, Safety, and Resonance of the Pilot Digital Suicide Prevention Campaign "Better Off With You": Qualitative Study

Background

The Interpersonal Theory of Suicide posits that there are three key elements of suicidal behavior: perceived burdensomeness, thwarted belongingness, and the acquired capability for suicide. The digital campaign Better Off With You was developed to directly challenge the idea of perceived burdensomeness among people who are contemplating suicide in 2 communities within Australia.

Objective

The aim of this study is to explore the needs and preferences of people with lived experience of suicidal thoughts and actions to inform the development of Better Off With You.

Methods

This study involved a series of focus groups that aimed to discuss campaign messaging, scope, and approach. People with lived experience of suicidal thoughts and actions attended the focus groups. After the completion of initial focus groups, the results informed the creation of campaign collateral by creative agencies. Early versions of the campaign collateral were then presented in the user testing sessions. Transcriptions were analyzed via thematic analysis.

Results

In total, 13 participants attended the focus groups and 14 attended the user testing sessions. The following three overarching themes were presented: acceptability, safety, and resonance. Participants believed that suicide is a serious and ongoing issue in their communities and welcomed a localized suicide prevention focus via peer-to-peer storytelling. The idea of perceived burdensomeness required clarification but was perceived as acceptable and relevant. Participants seemed drawn toward peer narratives that they perceived to be authentic, genuine, and believable as given by real people with lived experience. Campaign messaging needs to be clear and empathetic while directly talking about suicide. Participants did not anticipate any significant negative or harmful impact from any campaign videos and highlighted the importance of providing appropriate help-seeking information.

Conclusions

This iterative study provided important insights and knowledge about peer-to-peer storytelling in suicide prevention campaigns. Future campaigns should involve simple messaging, be validating and empathetic, and consider including a lived experience perspective.

Development of an Online Resource for People Bereaved by Suicide: A Mixed-Method User-Centered Study Protocol

Introduction: Suicide bereavement is known to be highly distressing and is frequently associated with mental health problems. Despite high-level of need regarding mental and physical health, people bereaved by suicide display low level of help-seeking and perceived support in the aftermath of the loss. The lack of accessibility and reliability of face-to-face counseling resources is notably reported by suicide survivors. Online resources can enhance early access to help and support for people bereaved by suicide. The primary objective of the study is to design and implement an innovative and adaptive online resource for people bereaved by suicide according to their needs and expectation regarding online solutions dedicated to suicide bereavement. Methods: The ESPOIR₂S study is a mixed-method user-centered study. ESPOIR₂S seeks to build the resource from the perspectives and needs of both people bereaved by suicide and professionals or volunteers working in the field of postvention. The Information System Research (ISR) Framework is used to guide the design of the study through a 3-step research cycle. The structure of the ESPOIR₂S study relies on a simultaneous collection of qualitative and quantitative data which will be collected and analyzed during (a) the Relevance cycle through an online questionnaire and focus groups; (b) the Design cycle through focus groups; and (c) and the Rigor cycle through an online questionnaire and semi-structured interviews. The user-centeredness will be ensured by the active participation of people bereaved by suicide, members of associations for bereaved people and professionals of postvention. Discussion: The mixed-method and user-centered design of the ESPOIR₂S study will offer an in-depth collection of the needs and expectation of suicide survivors regarding online resources. Through the implementation of an adaptive online solution, we aim to enhance the access to help and support for suicide survivors which are highly correlated with well-being and recovery.

The Experience of Adults Bereaved by the Suicide of a Close Elderly Relative: A Qualitative Pilot Study

Suicide in older persons is a serious issue in many countries. The act of intentionally causing one’s own death is often associated with lack of social support, thwarted belongingness, or chronic interpersonal difficulties. Therefore, suicide has a significant interpersonal dimension that can influence those left behind. However, studies that have investigated the impact of older adults’ suicide on their family are scarce. The objective of this pilot study was to assess the feasibility of a qualitative research on the psychosocial experience of adults bereaved by the suicide of an elderly relative. This research could recruit three participants (daughter, grand-son, and grand-niece) who had lost to suicide a close family member aged between 75 and 90. The analysis of the content of the semi-structured interviews revealed seven main themes: (1) finding an explanation to the suicide, (2) give meaning to the loss, (3) the emotional processes of mourning, (4) the repercussions of the suicide on the individual and the family, (5) looking for support, (6) the taboo and secrecy of suicide, and (7) perceptions of aging and the end of life. To explain the suicide of their loved one, the bereaved mentioned various factors related to aging, such as loss of autonomy, illness, and fear of placement. Although the older relative was perceived to be approaching death because of his/her age, the suicide was still unexpected and shocking and led to various emotions (shock, anger, and guilt) and to family conflicts. Suicide remains a taboo subject, but the newly legalized medical assistance in dying is seen as a potential solution to suffering in old age. Further investigation is clearly needed on this topic and this pilot study indicates that the main difficulties will lie in the choice of selection criteria for participants and in the recruitment process.

Carers' Motivations for, and Experiences of, Participating in Suicide Research

(1) Background: First-hand accounts of lived experience of suicide remain rare in the research literature. Increasing interest in the lived experience of suicide is resulting in more opportunities for people to participate in research based on their personal experience. How individuals choose to participate in research, and their experience of doing so, are important considerations in the ethical conduct of research. (2) Methods: To understand the experience of providing care for someone who has previously attempted suicide, a cross-sectional online community survey was conducted. This survey concluded with questions regarding motivation to participate and the experience of doing so. Of the 758 individuals who participated in the survey, 545 provided open-ended text responses to questions regarding motivation and 523 did so for questions regarding the experience of participating. It is these responses that are the focus of this paper. Data were analysed thematically. (3) Results: Motivations to participate were expressed as primarily altruistic in nature, with a future focus on improving the experience of the person who had attempted suicide alongside carers to ease distress. The experience of participating was difficult yet manageable, for all but a few participants. (4) Conclusions: With the increasing interest in first-hand accounts of suicide, how individuals experience participation in research is an important focus that requires further attention.

The case for case-control studies in the field of suicide prevention

Much of our knowledge about the risk factors for suicide comes from case-control studies that either use a psychological autopsy approach or are nested within large register-based cohort studies. We would argue that case-control studies are appropriate in the context of a rare outcome like suicide, but there are issues with using this design. Some of these issues are common in psychological autopsy studies and relate to the selection of controls (e.g. selection bias caused by the use of controls who have died by other causes, rather than live controls) and the reliance on interviewing informants (e.g. recall bias caused by the loved ones of cases having thought about the events leading up to the suicide in considerable detail). Register-based studies can overcome some of these problems because they draw upon contain information that is routinely collected for administrative purposes and gathered in the same way for cases and controls. However, they face issues that mean that psychological autopsy studies will still sometimes be the study design of choice for investigating risk factors for suicide. Some countries, particularly low and middle income countries, don't have sophisticated population-based registers. Even where they do exist, there will be variable of interest that are not captured by them (e.g. acute stressful life events that may immediately precede a suicide death), or not captured in a comprehensive way (e.g. suicide attempts and mental illness that do not result in hospital admissions). Future studies of risk factors should be designed to progress knowledge in the field and overcome the problems with the existing studies, particularly those using a case-control design. The priority should be pinning down the risk factors that are amenable to modification or mitigation through interventions that can successfully be rolled out at scale.

Ethical Concerns in Suicide Research: Results of an International Researcher Survey

Researchers and research ethics committees share a common goal of conducting ethically sound research. However, little is known of researchers' experiences in obtaining ethics approval for suicide-related studies. This study aimed to investigate what concerns researchers have received on suicide-related ethics applications and how they dealt with it. Thirty-four respondents, recruited through the International Association for Suicide Prevention, filled out an online survey. The study found that researchers have received important concerns regarding potential harm and researchers' responsibilities to participants. Researchers modified their application and/or consulted their research ethics committee in response to the concerns, which had a positive/neutral impact on their given study. Anticipating concerns and improved collaboration between researchers and research ethics committees should protect the quality of suicide prevention research.

Dealing with Ethical Concerns in Suicide Research: A Survey of Australian Researchers

Given the increasing trend in suicide mortality and its burden on individuals, families and communities, ethically sound research is crucial to improve the prevention of suicidal behaviour. However, few studies have looked at the experiences of researchers in obtaining ethics approval for their studies. This study addressed this gap by investigating researchers’ experiences in obtaining ethics approval and how they dealt with the concerns raised by ethics committees. Respondents were recruited from September to November 2018 through the Australian Suicide Prevention Research Leaders Network, and 33 respondents (35%) completed the study survey, comprising forced-choice and open-ended questions. Respondents most commonly reported concerns from ethics committees regarding potential harm to participants and researchers’ responsibilities to participants within the context of intervention and evaluation studies. Most researchers modified their ethics application and/or consulted with their ethics committee to reply to the concerns raised. Most respondents perceived the impact of the modification as positive or neutral. The study concludes that researchers may anticipate potential concerns of ethics committees. Improved understanding of how ethics committees work and dialogue between researchers and ethics committees should sustain the quality in suicide-related research.