Psychiatric morbidity, violent crime, and suicide among children and adolescents exposed to parental death

Negative and positive urgency as pathways in the intergenerational transmission of suicide risk in childhood

Introduction

Parental suicide attempts and suicide death increase suicide risk in their offspring. High levels of impulsivity have been observed in families at high risk for suicide. Impulsivity, a highly heritable trait that is especially elevated in childhood, is frequently measured with the UPPS-P Impulsive Behavior Scale, which includes negative urgency, positive urgency, sensation seeking, premeditation, and perseverance. Our study examined the association between the UPPS-P facets and suicide ideation (without suicide attempts) and suicide attempts at baseline and first-time endorsement within the next two years in childhood. We also examined how the UPPS-P facets mediated the association between parental suicide attempts and suicide death and offspring first-time suicide ideation and attempts at follow-up.

Methods

The sample was 9,194 children (48.4% female; 9-10 years old) from the Adolescent Brain Cognitive Development (ABCD) study, assessed yearly three times. At Time 1 (T1), caregivers reported on suicide attempts and suicide deaths (combined) of the biological parents. Caregivers and children reported on suicide ideation and attempts in the KSADS-PL DSM-5 at each time point, T1 and follow-up (T2 and/or T3). The Short UPPS-P Scale (child-report) assessed the impulsivity facets at T1, which were computed as latent variables.

Results

At T1, 6.7% of children had a parent who had attempted or died by suicide. Most UPPS-P facets were associated with suicide ideation and attempts at T1 and T2/T3. In adjusted models, parental suicide attempts and suicide death were associated with offspring negative and positive urgency. In mediation models, parental suicide attempts and suicide death had an indirect effect on offspring first-time suicide ideation at T2/T3 through negative urgency (OR = 1.04; 95% CI, 1.01-1.08) and positive urgency (OR = 1.03, 95% CI, 1.01-1.05). Similar results were found for first-time suicide attempts at T2/T3.

Discussion

Our findings support an impulsive pathway in the familial transmission of suicide risk. For all youth, interventions that target multiple UPPS-P facets may help prevent or reduce suicide risk. For offspring whose parents have attempted or died by suicide, clinicians should pay particular attention to children who impulsively act on extreme emotions, as they may be at higher suicide risk.

Maternal experienced bereavement and offspring mental health in early adulthood: the role of modifiable parental factors

BACKGROUND

It is estimated that 78% of children experience the death of a close friend or family member by 16 years of age, yet longitudinal research examining the mental health outcomes of wider experiences of bereavement is scarce. We conducted a longitudinal investigation of the association between maternal experienced bereavement before the age of 11 years and offspring depressive and anxiety disorders at age 18 and examined moderation of this association by modifiable parental factors.

METHODS

We analysed data from the Avon Longitudinal Study of Parents and Children, a UK-based birth cohort, including 9,088 child participants with data available on bereavement. Bereavement was measured via maternal report at eight timepoints until children were 11 years. Offspring depressive and anxiety-related disorders were self-reported at 18 years old using the Clinical Interview Schedule-Revised (CIS-R). The potential moderating roles of maternal anxiety, maternal depression, parental monitoring, positive parenting and negative parenting practices were examined.

RESULTS

Maternal experienced bereavement was not associated with depression or anxiety-related disorders in early adulthood among offspring. In addition, no support was found for negative parenting practices, parental monitoring or maternal anxiety and depression as moderators of the relationship between maternal experienced bereavement and offspring mental health problems at 18 years old. Findings in relation to the moderating role of positive parenting practices were inconsistent.

CONCLUSIONS

Findings suggest that a large number of children are exposed to maternal experienced bereavement. We found no evidence that maternal experienced bereavement during childhood increases the risk for offspring psychiatric disorders in early adulthood. Several methodological considerations prudent to bereavement research are discussed.

Childhood Factors Associated With Unnatural Death Through Midadulthood

Importance

Life expectancy is decreasing in the US. Without national efforts to address factors that support policies and programs directed at children living in areas of concentrated poverty, life expectancy will likely continue to decline while costs and suffering associated with unnatural deaths will increase.

Objective

To identify which childhood factors are associated with death from unnatural causes through midadulthood.

Design, Setting, and Participants

For this cohort study, longitudinal data on childhood characteristics came from a group-randomized intervention trial implemented in Baltimore City Public Schools, Baltimore, Maryland (baseline 1985-1986; all students entering first grade were selected to participate at age 6 years). Participants were followed up to midadulthood with a National Death Index search through December 31, 2020. Data analysis was performed from February to May 2023.

Exposures

Exposures included individual factors (ie, sociodemographic characteristics, teacher-reported aggressive behavior, self-reported depression, anxiety, early alcohol and cannabis use, and assaultive violence exposure), family and peer factors (ie, household structure and education level, deviant peer affiliation, and parental monitoring), and neighborhood factors (ie, rates of neighborhood assault and public assistance).

Main Outcomes and Measures

The main outcome was unnatural death, defined as death due to unintentional injury, suicide, and homicide. A National Death Index search ascertained participants who died by age 41 to 42 years and cause of death. Multivariable Cox proportional hazards models were used to identify whether the exposures were independently associated with future mortality by unnatural causes.

Results

The initial trial included 2311 children, and longitudinal data were available for 2180 participants (median [IQR] age in first grade, 6.3 [6.0-6.5] years; 1090 female [50.0%]; 1461 Black [67.0%]; 1168 received free or reduced lunch in first grade [53.6%]). A total of 111 male participants (10.2%) and 29 female participants (2.7%) died; among those who died, 96 male participants (86.5%) and 14 female participants (48.3%) died of unnatural causes. Two factors remained significantly associated with mortality from unnatural causes: female sex was associated with reduced risk (hazard ratio, 0.13; 95% CI, 0.08-0.22), and neighborhood public assistance was associated with increased risk (hazard ratio, 1.89; 95% CI, 1.09-3.30).

Conclusions and Relevance

In this urban population-based cohort study, no modifiable risk factors of mortality at the level of the individual (eg, depression or anxiety and substance use) or the family (eg, household education level) were identified. However, the degree of neighborhood poverty in early childhood was significantly associated with death by unnatural causes in early adulthood, suggesting that economic policies are needed to advance health equity in relation to premature mortality.

Adolescents' primary care consultations before and after parental suicide: evidence from population-wide data

Parental bereavement is associated with distress and poorer long-term outcomes among adolescents. Adolescents who lose a parent to suicide fare worse than their peers even before bereavement. Based on the current literature, we cannot distinguish such initial differences from the medium and long-term effect of parental suicide. We study the impact of parental suicide on adolescents' General Practitioner visits for mental health or psychosocial reasons. Within-individual models account for time-invariant differences between the bereaved and non-bereaved. We investigate if effects differ from the impact of parental death from other causes, and vary with sex and socioeconomic background. Full population data on Norwegian residents aged 10-19 in the period 2006-2015 are drawn from registers (N = 1 405 suicide bereaved, 12 982 bereaved by other causes, and 1 182 819 non-bereaved controls). Records include data on use of health services, parental mortality, and sociodemographic characteristics of parent and child. Mental health consultations increase gradually in the quarters leading up to the parental suicide, significantly more for girls than for boys. Two years prior to bereavement, 2.4% of the subsequently suicide bereaved have a mental health consultation in any given quarter. In the year of bereavement, this increases with 6% points. Health care workers should be aware that boys are less likely to turn to their GP for support before parental bereavement from suicide.

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.

Association of parental death and illness with offspring suicidal ideation: cross-sectional study in a large cohort of university students

PURPOSE

The aim of this study was to (1) investigate the association of parental death and illness with suicidal ideation using a large sample of university students and (2) test whether associations were moderated by perceived family support.

METHODS

We used data from N = 15,008 French university students enrolled in the i-Share cohort (mean age, 20.5 years; 77% women). Students self-reported information on parental death, including the cause, parental illness (cardiovascular, stroke, cancer, depression/anxiety, alcohol abuse), and perceived family support during childhood/adolescence. Twelve-month suicidal ideation was self-reported and categorized into no, occasional, and frequent ideation.

RESULTS

Occasional and frequent suicidal ideation were, respectively, reported by 2692 (17.5%) and 699 (4.6%) students. After adjustment for age, gender, and parental education, we found associations between parental death and risk of occasional and frequent suicidal ideation (respectively, RR = 1.98 [1.81-2.17] and RR = 2.73 [2.30-3.24]). Parental deaths from illness, accidents, and suicides had the strongest associations. We also found associations for parental depression/anxiety (occasional, RR = 1.98 [1.81-2.17]; frequent, RR = 2.73 [2.30-3.24]), alcohol use problems (occasional, RR = 1.71 [1.5-1.94]; frequent, RR = 2.33 [1.89-2.87]), and cardiovascular diseases (occasional, RR = 1.22 [1.06-1.40]; frequent, RR = 1.83 [1.47-2.27]). For participants who experienced parental death and stroke, associations with occasional and frequent suicidal ideation (respectively) increased as perceived family support increased (Ps_interaction ≤ 0.005).

CONCLUSIONS

Students who experienced parental death and common parental illnesses were at risk of reporting suicidal ideation, especially if their family were perceived as an important source of support. As information on parental death or illness can be routinely collected during health visits, attention should be paid to students reporting such experiences.

Parental death by external causes during childhood and risk of psychiatric disorders in bereaved offspring

BACKGROUND

Previous studies have reported increased risks of psychiatric disorders in offspring who have lost a parent, but knowledge is lacking on the risks of several specific disorders and comorbidity. The present study investigated the influence of parental death by external causes during childhood and adolescence on risk of a range of psychiatric disorders and comorbidity.

METHOD

The study cohort comprised 655,477 individuals born 1970-2012 with a link to both parents. Data on deceased parent's cause and date of death between 1970 and 2012 and offspring's psychiatric disorders between 2008 and 2012 were retrieved from four longitudinal Norwegian registers. Data were analyzed with Cox regression.

RESULTS

Compared to nonexposed offspring, offspring exposed to parental death by external causes had a significantly increased risk of depressive disorders, reactions to stress, anxiety disorders, substance use disorders, developmental disorders, childhood behavioral and emotional disorders, psychotic disorders, bipolar disorder, personality disorders, and psychiatric comorbidity, but not eating disorders. These increased risks were especially evident following parental suicide and accidental falls and poisoning. No differences were evident depending on gender of the deceased or age at bereavement, and generally no significant interactions with gender of the bereaved offspring were evident.

CONCLUSIONS

The improved insight into several different psychiatric disorders and psychiatric comorbidity should guide postvention measures aimed at children and adolescents at greatest risk of future sequelae.

Grief as a predictor of long-term risk for suicidal ideation and attempts of parentally bereaved children and adolescents

Although children who experience the death of a parent have a heightened risk of suicidality, the long-term associations between grief and suicidality among bereaved youth have yet to be examined. Research is needed to test the specific aspects of grief associated with suicidality, after controlling for other risk factors, in this population. Grief and covariates, including age, gender, parental cause of death, time since parental death, depression, anxiety, internalizing problems, posttraumatic stress symptoms, and child treatment involvement, were assessed at baseline, 6-year, and 15-year follow-ups in a sample of 244 parentally bereaved youth aged 8-16 years. Utilizing multiple grief measures, a bifactor approach was used to identify a general factor and two uncorrelated specific factors: Intrusive Grief Thoughts and Social Detachment/Insecurity. Suicidal thoughts and attempts were assessed at both follow-ups. The Intrusive Grief Thoughts specific factor had a prospective nonlinear association with suicidality at both follow-ups after controlling for all baseline covariates. The nonlinear relation consisted of a large effect, OR > 73 (using the rescaled scores), on the increased risk of suicidality from low to moderate levels of intrusive grief, with no association from moderate to high levels. At 6-year follow-up, the specific Social Detachment/Insecurity factor was significantly associated with suicidality after controlling for covariates. Specific grief factors assessed at different points were associated with suicidal thoughts or attempts among parentally bereaved youth. These findings highlight the significance of specific aspects of child and adolescent grief that have implications for the development of upstream suicide prevention services.

A systematic review of controlled studies of suicidal and self-harming behaviours in adolescents following bereavement by suicide

BACKGROUND

Research suggests that being exposed to the suicide of others increases risk of subsequent suicidal or self-harming thoughts or behaviours. What is less clear is whether this applies to adolescents, and if the risk exceeds that following other causes of death, which has implications on suicide prevention approaches. This study aimed to systematically review the evidence on adolescent bereavement experiences by different causes to address this gap.

METHODS

A comprehensive literature search using four databases (MEDLINE, PsycInfo, Web of Science, and Embase) identified 21 studies which measured suicidal or self-harm outcomes among bereaved adolescents aged between 12 to 18 years old. The literature was screened, data was extracted using pre-piloted forms, and risk of bias was assessed using versions of the Newcastle-Ottawa Scale; a proportion of papers were double extracted and assessed for bias. The review has been registered with PROSPERO (CRD42016051125).

RESULTS

A narrative synthesis of the literature demonstrated divergent findings depending on the outcome being measured. Suicide bereavement appears to be strongly associated with suicide mortality among parentally bereaved youth, while self-harm or non-fatal suicide attempts (either presenting to hospital or self-reported) showed mixed evidence. Suicidal ideation was not uniquely associated with suicide bereavement. An exploration of circumstances surrounding the death, characteristics of the person who died, and characteristics of the young person across each outcome measure suggested that earlier experiences of loss, shorter timeframes following the death, and maternal death are associated with particularly elevated risk of suicidal outcomes.

CONCLUSIONS

Findings suggest that suicide loss is associated with subsequent suicide, and may be associated with non-fatal self-harm. A detailed account of the risk and protective factors surrounding suicide bereavement among young people is crucial to understand the pathways through which suicidal behaviours develop. Researchers, policy makers and practitioners with an interest in suicide prevention will benefit from clarity around the needs of young bereaved individuals.

Characteristics and Precipitating Circumstances of Suicide Among Children Aged 5 to 11 Years in the United States, 2013-2017

IMPORTANCE

Suicide is the eighth leading cause of death among children aged 5 to 11 years, with rates increasing during the past decade. A better understanding of factors associated with childhood suicide can inform developmentally appropriate prevention strategies.

OBJECTIVE

To examine characteristics and precipitating circumstances of childhood suicide.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study examined restricted-use data from the National Violent Death Reporting System (NVDRS) regarding child suicide decedents aged 5 to 11 years in the US from 2013 to 2017. The NVDRS is a state-based surveillance system that collects data on suicide and violent deaths in 50 states, with restricted-use data available from 37 states. Details and context related to suicide deaths were identified through a content analysis of case narratives from coroner or medical examiner and law enforcement reports associated with each incident.

EXPOSURES

Characteristics and precipitating circumstances associated with suicide cited in the coroner, medical examiner, and law enforcement case narratives.

MAIN OUTCOMES AND MEASURES

Suicide incidence and risk factors for suicide including mental health, prior suicidal behavior, trauma, and peer, school, or family-related problems.

RESULTS

Analyses included 134 child decedents (101 [75.4%] males; 79 [59.0%] White individuals; 109 [81.3%] non-Hispanic individuals; mean [SD] age, 10.6 [0.8] years). Most suicides occurred in the child's home (95.5% [n = 128]), and more specifically in the child's bedroom. Suicide by hanging or suffocation (78.4% [n = 105]) was the most frequent method, followed by firearms (18.7% [n = 25]). Details on gun access were noted in 88.0% (n = 22) of suicides by firearm, and in every case, the child obtained a firearm stored unsafely in the home. Findings revealed childhood suicide was associated with numerous risk factors accumulated over time, and suggest a progression toward suicidal behavior, especially for youth with a history of psychopathology and suicidal behavior. An argument between the child and a family member and/or disciplinary action was often a precipitating circumstance of the suicide.

CONCLUSIONS AND RELEVANCE

This qualitative study found that childhood suicide was associated with multiple risk factors and commonly preceded by a negative precipitating event. Potential prevention strategies include improvements in suicide risk assessment, family relations, and lethal means restriction, particularly safe firearm storage. Future research examining the myriad aspects of childhood suicide, including racial/ethnic and sex differences, is needed.

Environmental Risk Factors for Schizophrenia and Bipolar Disorder and Their Relationship to Genetic Risk: Current Knowledge and Future Directions

Schizophrenia (SZ) and bipolar disorder (BD) are severe psychiatric disorders which result from complex interplay between genetic and environmental factors. It is well-established that they are highly heritable disorders, and considerable progress has been made identifying their shared and distinct genetic risk factors. However, the 15-40% of risk that is derived from environmental sources is less definitively known. Environmental factors that have been repeatedly investigated and often associated with SZ include: obstetric complications, infections, winter or spring birth, migration, urban living, childhood adversity, and cannabis use. There is evidence that childhood adversity and some types of infections are also associated with BD. Evidence for other risk factors in BD is weaker due to fewer studies and often smaller sample sizes. Relatively few environmental exposures have ever been examined for SZ or BD, and additional ones likely remain to be discovered. A complete picture of how genetic and environmental risk factors confer risk for these disorders requires an understanding of how they interact. Early gene-by-environment interaction studies for both SZ and BD often involved candidate genes and were underpowered. Larger samples with genome-wide data and polygenic risk scores now offer enhanced prospects to reveal genetic interactions with environmental exposures that contribute to risk for these disorders. Overall, although some environmental risk factors have been identified for SZ, few have been for BD, and the extent to which these account for the total risk from environmental sources remains unknown. For both disorders, interactions between genetic and environmental risk factors are also not well understood and merit further investigation. Questions remain regarding the mechanisms by which risk factors exert their effects, and the ways in which environmental factors differ by sex. Concurrent investigations of environmental and genetic risk factors in SZ and BD are needed as we work toward a more comprehensive understanding of the ways in which these disorders arise.

A meta-analysis of the relationship between parental death in childhood and subsequent psychiatric disorder

OBJECTIVE

To systematically review evidence for an association between parental death in childhood, and the subsequent development of an anxiety, affective or psychotic disorder.

METHODS

Electronic databases (Scopus, Medline (for Ovid), EMBASE and PsychINFO) were searched for peer-reviewed, cohort studies in the English language. Meta-analyses were performed for studies reporting hazard ratios, incidence rate ratios and odds ratios. Two studies reported risk ratios, and these were included in an overall pool of odds, risk and incidence rate ratios. Sensitivity analyses were performed (removal of one study at a time) for all meta-analyses, and study quality assessed using the Newcastle-Ottawa Scale.

RESULTS

Fifteen studies were retained, and where required, data were averaged in advance of pooling. Significant results were observed in studies reporting hazard ratios (k = 4, 1.48 [95% CI = 1.32-1.66]), incidence rate ratios (k = 3, 1.37 [95% CI = 1.01-1.85]), but not odds ratios (k = 4, 0.87 [95% CI = 0.72, 1.05]). However, the overall pooled effect (using odds, incidence rate and risk ratios) was statistically significant (k = 9, 1.22 [95% CI = 1.03-1.44]).

CONCLUSION

Overall, the evidence suggests that there is a positive association between the death of a parent before age 18, and the subsequent development of an anxiety, affective or psychotic disorder. The lack of a significant pooled effect in studies reporting results as odds ratios is likely an artefact of study design.

LIMITATIONS

Data were clustered in four countries making generalizability uncertain. Studies adjusted for a variety of possible confounders, and follow-up after death varied considerably.

People exposed to suicide attempts: Frequency, impact, and the support received

OBJECTIVE

Little is known about people who have been exposed to a suicide attempt by someone they know. The purpose of this study was to examine how many people have been exposed to a suicide attempt by someone they knew and whether the exposure was associated with general well-being and suicidal ideation.

METHOD

A population-based online survey was conducted during 2019 in Denmark (n = 6,191). The associations between exposures to suicide attempt and general well-being (WHO-5) and suicidal ideation (Suicidal Ideation Attributes Scale) were examined using linear regression analyses.

RESULTS

Overall, 24.6% reported having experienced a suicide attempt by someone they knew. Of those, 46.5% had experienced a suicide attempt of a close relation and this group reported having been more affected by the event. Those exposed scored lower on general well-being (b: -3.0; 95% CI: -4.2 to -1.8; p > 0.001) and higher on suicidal ideation (b: 1.6; 95% CI: 1.3 - 1.9; p = 0.001) than those not exposed. Half of the exposed reported not having received sufficient support after the event.

CONCLUSION

Suicide attempt affects a substantial share of the population, and it might be relevant to ensure that support is available for those exposed perceived to be in need of support.

Parental death by external causes and risk of hospital-treated deliberate self-harm in bereaved offspring

Previous studies have reported an increased risk of hospital-treated deliberate self-harm (DSH) in offspring who have lost a parent, but inconclusive findings regarding differences between loss from suicide and accidents. The present study aimed to investigate the association between parental death by external causes before age 18 and hospital-treated DSH, and potential differences between different accidents and suicide. This nested-case-control study was based on data from longitudinal Norwegian registers. Subjects comprised 12,526 people born between 1970 and 2003 who received acute somatic treatment because of DSH at hospitals and associated services between 2008 and 2013 (cases), and 222,362 controls matched for gender and date of birth with no recorded DSH treatment. Information concerning deceased parent's death and offspring's DSH treatment and socioeconomic data was merged. Data were analysed with conditional logistic regression. Results indicated that offspring who had lost a parent to suicide (OR 2.32, 95% CI 1.92-2.80) and death by accidents such as falls, poisoning, and drowning (OR 1.79, 95% CI 1.38-2.33) had a significantly increased risk of hospital-treated DSH compared to offspring who had not experienced such loss. Parental bereavement from transport accidents and other external causes were not associated with significantly increased risks. No differences were evident for different genders of deceased, ages at bereavement, or genders of bereaved. The improved identification of bereaved offspring at particular risk of hospital-treated DSH should be utilized to implement effective prevention and treatment programs in specialist healthcare aimed at the individuals at highest risk.

Association between family history of suicide attempt and neurocognitive functioning in community youth

BACKGROUND

Suicidal behavior is highly familial. Neurocognitive deficits have been proposed as an endophenotype for suicide risk that may contribute to the familial transmission of suicide. Yet, there is a lack of research on the neurocognitive functioning of first-degree biological relatives of suicide attempters. The aim of the present study is to conduct the largest investigation to date of neurocognitive functioning in community youth with a family history of a fatal or nonfatal suicide attempt (FH).

METHODS

Participants aged 8-21 years from the Philadelphia Neurodevelopmental Cohort completed detailed clinical and neurocognitive evaluations. A subsample of 501 participants with a FH was matched to a comparison group of 3,006 participants without a family history of suicide attempt (no-FH) on age, sex, race, and lifetime depression.

RESULTS

After adjusting for multiple comparisons and including relevant clinical and demographic covariates, youth with a FH had significantly lower executive function factor scores (F[1,3432] = 6.63, p = .010) and performed worse on individual tests of attention (F[1,3382] = 7.08, p = .008) and language reasoning (F[1,3387] = 5.12, p = .024) than no-FH youth.

CONCLUSIONS

Youth with a FH show small differences in executive function, attention, and language reasoning compared to youth without a FH. Further research is warranted to investigate neurocognitive functioning as an endophenotype for suicide risk. Implications for the prevention and treatment of suicidal behaviors are discussed.

"It Changes Your Orbit": The Impact of Suicide and Traumatic Death on Adolescents as Experienced by Adolescents and Parents

BACKGROUND

Having someone close die through suicide or another form of traumatic death is a distressing event in the lives of adolescents, putting them at risk of grief and mental health ramifications. As most research in this field has been focused on intrapersonal grief reactions, this study aimed to broaden the perspective by exploring the impact of the death through an interpersonal lens.

METHODS

The study involved individual and group interviews with bereaved adolescents (n = 20) and parents of bereaved adolescents (n = 18), and thematic analysis of the data.

RESULTS

The analysis yielded three themes: (i) the death is a life-changing experience, (ii) the death differentiates you from your peers, and (iii) the death impacts on the family system.

CONCLUSIONS

The study revealed the devastating impact of the deaths on adolescents, their relationships with peers and the family system. Adolescents' grief must be understood within the context of their agency and their immediate social environment. The findings clearly indicate that support for bereaved adolescents should incorporate the familial context.

The Impact of Referral to Mental Health Services on Suicide Death Risk in Adolescent Suicide Survivors

Objectives

This study aims to examine the effect of adolescent suicide survivors' experience on suicide death risk, and the effect of referral to mental health services (hereafter referral) in this regard.

Methods

This study used the data of 878 suicide-deceased and suicide-attempted adolescents aged 8-19 years, managed by the Suicide and School Mental Health Institute from 2016 to 2018.

Results

Regression analysis for main effects showed that although suicide experience had no direct effect on suicide death, non-referral status was associated with a greater risk of death by suicide. While the "non-suicide survivor with non-referral" and "suicide survivor with non-referral" groups showed 1.87 [adjusted odds ratio=1.87, 95% confidence interval (CI)=1.21-2.89] and 4.59 (adjusted odds ratio= 4.59, 95% CI=2.02-10.42) times higher odds of suicide death, respectively, the "suicide survivor with referral" group showed no difference compared to the "non-suicide survivor with referral" group.

Conclusion

From these findings, there is a need to strengthen referral to mental health services and apply complicated grief treatment to improve the mental health of adolescent suicide survivors.

Suicidal Thoughts and Behaviors Among Swedish Suicide-Bereaved Women: Increased Risk Associated With the Loss of a Child, Feelings of Guilt and Shame, and Perceived Avoidance From Family Members

Previous studies have shown that suicide-bereaved individuals may suffer increased risk of suicidal thoughts and behaviors (STBs) due to traumatic grief. In this paper, we present the self-reported rate of STB among Swedish suicide-bereaved women (N = 293). Data was collected in a cross-sectional anonymous survey on the homepages of Sweden’s leading suicide survivor organization, SPES. We used logistic regression to evaluate risks (of any STB event) related to losing a child compared to other relatives and the experience of social avoidance from family members, as well as feelings of shame and guilt. The self-reported rate of suicidal thoughts, plans, and attempts was 60, 24, and 5 percent, respectively, considerably higher than in the general population. Results showed that all of the investigated variables were independent risk factors for STB (ORs ranged between 1.29 and 2.69). Women who had both lost a child and experienced family avoidance reported the highest STB rate (87.5%), and we found an interaction effect between these two risk factors (OR = 3.45; 95% CI = 1.05–11.32) that was related to self-reported shame. It is concluded that perceived responsibility for someone else’s suicide, and the social avoidance associated with it, may play an important role for suicide survivors and should be targeted by postvention activities.

A Theory-Based Longitudinal Investigation Examining Predictors of Self-Harm in Adolescents With and Without Bereavement Experiences

BACKGROUND

Research has demonstrated that exposure to suicide can lead to increased vulnerability for self-harm or suicide. As a result, ideation-to-action models of suicide (e.g., the Integrated Motivational-Volitional Model of Suicide; IMV) recognise exposure as a significant risk factor which may be implicated in the translation of thoughts into actions. However, few studies have tested this theoretical link explicitly within an adolescent population, and examined how it compares to other types of bereavements.

METHODS

A 6-month prospective questionnaire study was conducted with 185 Scottish adolescents aged 11-17 (113 adolescents also completed the questionnaire at follow-up). The questionnaire included measures on experiences with bereavement and lifetime engagement in self-harm, as well as measures of defeat, entrapment, social support, coping, and other psychological variables.

RESULTS

At baseline, 12% of young people reported exposure to a suicide death, and 61% to a non-suicide death. In addition, 21% of pupils reported ever engaging in self-harm, while 23% had experienced self-harm ideation without engaging in it. Cross-sectional multivariate logistic regressions showed that family social support, glorifying/normalising beliefs about suicide, and family self-harm were significantly associated with self-harm group membership (control, ideation, or enactment groups). At follow-up, 10% of pupils reported exposure to a suicide death and 16% to a non-suicide death for the first time. A total of 26% of the sample reported self-harm at T2 (11% of participants for the first time), and 24% reported self-harm ideation without engaging in it. Multivariate analyses found that self-harm ideation and family self-harm at baseline were the only variables to predict self-harm group membership prospectively, in the expected directions. Bereavement experiences, whether by suicide or non-suicide, did not predict self-harm group status at baseline nor at follow-up.

CONCLUSIONS

This study provides support for the validity of a theoretical model of suicide, even though predictive ability over the 6-months period was limited. Although difficulties with recruitment may have limited the statistical power, this study provides insight into the prevalence and experiences of suicide bereavement among adolescents and the factors related to the onset and maintenance of self-harm.

Educational attainment in offspring bereaved by sudden parental death from external causes: a national cohort study from birth and throughout adulthood

PURPOSE

Previous research has linked loss of a parent during childhood to reduced educational aspirations, school performance, and educational attainment later in life. The potential effect of maternal and paternal bereavement on attainment at all educational levels is, however, unknown. The present study aimed to investigate the potential influence of parental death by external causes on completion of compulsory education, high school, vocational education, and University or College education.

METHODS

The study was based on data from three national longitudinal registers in Norway. The study population comprised 373,104 individuals born between January 1st 1970 and December 31st 1994. Information concerning deceased parents' cause and date of death and offspring's education and sociodemographic data were retrieved. Data were analysed with Cox regression.

RESULTS

Children who had experienced parental death by external causes had a significantly reduced hazard ratio (HR) of completing all educational levels compared to children who did not have such experiences. The largest effects were evident for completion of high school (HR 0.68, 95% CI 0.65-0.71) and University or College education (HR 0.75, 95% CI 0.70-0.80). No differences were evident for different causes of death, genders of deceased or ages at bereavement, and generally no significant interactions between gender of the bereaved offspring and predictor variables were evident for completion of all educational levels.

CONCLUSION

Parental death by external causes has vast and long-lasting impacts on offspring's educational attainment at all levels. Health care interventions aimed at supporting bereaved children and adolescents should focus on challenges related to educational progress.

JAACAP's Role in Advancing the Science of Pediatric Mental Health and Promoting the Care of Youth and Families During the COVID-19 Pandemic

As we pen these words, the COVID-19 pandemic is having profound impacts on human society. Based on decades of research, we know that the accompanying illness,¹ death,² social isolation,^3,4 and malnutrition⁵ will have deep and lasting impacts on our children and adolescents, their families, and the communities in which they develop. The pandemic is exposing, with terrible clarity, the disparities in human society-racism,⁶ poverty,^7,8 domestic violence,^9,10 and child maltreatment and neglect¹¹-and tragically will likely amplify the negative impacts that each has on child development and mental health.

The intergenerational transmission of suicidal behavior: an offspring of siblings study

We examined the extent to which genetic factors shared across generations, measured covariates, and environmental factors associated with parental suicidal behavior (suicide attempt or suicide) account for the association between parental and offspring suicidal behavior. We used a Swedish cohort of 2,762,883 offspring born 1973-2001. We conducted two sets of analyses with offspring of half- and full-siblings: (1) quantitative behavior genetic models analyzing maternal suicidal behavior and (2) fixed-effects Cox proportional hazard models analyzing maternal and paternal suicidal behavior. The analyses also adjusted for numerous measured covariates (e.g., parental severe mental illness). Quantitative behavior genetic analyses found that 29.2% (95% confidence interval [CI], 5.29, 53.12%) of the intergenerational association was due to environmental factors associated with exposure to maternal suicidal behavior, with the remainder due to genetic factors. Statistical adjustment for parental behavioral health problems partially attenuated the environmental association; however, the results were no longer statistically significant. Cox hazard models similarly found that offspring were at a 2.74-fold increased risk [95% CI, 2.67, 2.83]) of suicidal behavior if their mothers attempted/died by suicide. After adjustment for familial factors and measured covariates, associations attenuated but remained elevated for offspring of discordant half-siblings (HR, 1.57 [95% CI, 1.45, 1.71]) and full-siblings (HR, 1.62 [95% CI, 1.57, 1.67]). Cox hazard models demonstrated a similar pattern between paternal and offspring suicidal behavior. This study found that the intergenerational transmission of suicidal behavior is largely due to shared genetic factors, as well as factors associated with parental behavioral health problems and environmental factors associated with parental suicidal behavior.

Self-harm and violent criminality linked with parental death during childhood

BACKGROUND

Adverse health and social outcomes are known to occur more frequently following parental death during childhood, but evidence is lacking for comparing long-term risks of internalised v. externalised harm.

METHODS

This national register-based cohort study consisted of Danish persons born 1970-2000. The Civil Registration System and National Causes of Death Register were linked to ascertain parental deaths by cause before cohort members' 15th birthdays. From age 15 years, hospital-treated self-harm episodes were ascertained through linkage to the National Patient Register and the Psychiatric Central Research Register, and violent crimes were identified via linkage to the National Crime Register. Hazard ratio and cumulative incidence values were estimated.

RESULTS

Self-harm and violent criminality risks were elevated following parental death during childhood. Covariate adjustment for gender, birth year and first-degree relatives' mental illnesses attenuated these associations, although significantly heightened risks persisted. The estimated hazard ratios did not differ greatly according to which parent died, but losing both parents conferred particularly large risk increases. Risks for both adverse outcomes were higher in relation to unnatural v. natural parental death; violent criminality risk was especially raised among individuals exposed to parental death by unnatural causes other than suicide. The association was strongest when pre-school age children experienced parental death.

CONCLUSIONS

Effective early intervention is needed to help youngsters who have experienced the death of one or both parents to develop immediate and sustained coping strategies. Enhanced cooperation between health and social services and criminal justice agencies may mitigate risks for these two destructive behaviours.

Theoretical frameworks informing the relationship between parental death and suicidal behaviour: A scoping review

BACKGROUND

Exposure to parental death in childhood has been strongly associated with offspring suicide although few studies have applied theoretical models to conceptualise this relationship.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Scoping Reviews guidelines, we conducted a scoping review of primary studies that identified a theory/framework explaining the aetiology of suicidal behaviour in adulthood, following childhood exposure to external-cause parental death, including suicide.

RESULTS

The search yielded 1598 articles. Following full-text screening, 23 studies were identified as meeting inclusion criteria. Data extraction was then completed and found that the studies collectively referenced nine theories. The specific theories identified covered a range of biopsychosocial frameworks and included attachment theory, familial transmission of suicide, conservation of resources framework, diathesis-stress model, social integration theory, socio-ecological model, social learning theory, critical period hypothesis or life course approach and the developmental model of antisocial behaviour.

LIMITATIONS

It was beyond the scope of this review to conduct rigorous testing and evaluation of the theories identified. Future research could extend on this study by developing criteria to assess the range of theories and frameworks on suicide exposure, as well as the studies providing evidence for these theories, in order to guide more advanced theory development as well as policies, programs and interventions.

CONCLUSIONS

Based on these theories, the authors proposed that using an integrated biopsychosocial model will provide a more comprehensive understanding of the diverse risk and protective factors for suicidal behaviour following parental death.

Suicide

Throughout the world, approximately 800,000 people die by suicide every year, accounting for 1.5% of all deaths. Suicide is the 10th leading cause of death in North America and the foremost cause of death worldwide among persons 15 to 24 years of age.

Use of Alcohol and Unprescribed Drugs after Suicide Bereavement: Qualitative Study

Studies describing the impact of suicide bereavement report an excess risk of suicide, suicide attempt, psychiatric illness, and drug and alcohol use disorders compared with the general population. However, the nature of patterns of drug and alcohol use after suicide bereavement is unclear. We used an online survey to collect qualitative data to understand whether and how drug and alcohol use changes after suicide bereavement. We conducted thematic analysis of free-text responses to a question capturing their use of alcohol and drugs after the suicide of a family member or a close friend. Analysing data from 346 adults in Britain aged 18-40, we identified three main themes describing the relationship of suicide bereavement to alcohol or drug use: (1) control over drug or alcohol use, (2) the perceived purpose of using drugs or alcohol, and (3) the attribution of drug or alcohol misuse to external factors. Overlying these themes were dimensions of control and of awareness of potential harms. This study highlights that increased use of drugs and alcohol after suicide bereavement may form part of a bereaved person's coping strategies, and that sensitive approaches are needed when judging whether and when to intervene.

Risk of childhood mortality associated with death of a mother in low-and-middle-income countries: a systematic review and meta-analysis

Background

Death of a mother at an early age of the child may result in an increased risk of childhood mortality, especially in low-and-middle-income countries. This study aims to synthesize estimates of the association between a mother’s death and the risk of childhood mortality at different age ranges from birth to 18 years in these settings.

Methods

Various MEDLINE databases, EMBASE, and Global Health databases were searched for population-based cohort and case-control studies published from 1980 to 2017. Studies were included if they reported the risk of childhood mortality for children whose mother had died relative to those whose mothers were alive. Random-effects meta-analyses were used to pool effect estimates, stratified by various exposures (child’s age when mother died, time since mother’s death) and outcomes (child’s age at risk of child death).

Results

A total of 62 stratified risk estimates were extracted from 12 original studies. Childhood mortality was associated with child’s age at time of death of a mother and time since a mother’s death. For children whose mother died when they were ≤ 42 days, the relative risk (RR) of dying within the first 1–6 months of the child’s life was 35.5(95%CI:9.7–130.5, p [het] = 0.05) compared to children whose mother did not die; by 6–12 months this risk dropped to 2.8(95%CI:0.7–10.7). For children whose mother died when they were ≤ 1 year, the subsequent RR of dying in that year was 15.9(95%CI:2.2–116.1,p [het] = 0.02), compared to children whose mother lived. For children whose mother died when they were ≤ 5 years of age, the RR of dying before aged 12 was 4.1(95%CI:3.0–5.7),p [het] = 0.83. Mortality was also elevated in specific analysis  among children whose mother died when child was older than 42 days. Overall, for children whose mother died < 6 and 6+ months ago, RRs of dying before reaching adulthood (≤18 years) were 4.7(95%CI:2.6–8.7,p [het] = 0.2) and 2.1(95%CI:1.3–3.4,p [het] = 0.7), respectively, compared to children whose mother lived.

Conclusions

There is evidence of an association between the death of a mother and childhood mortality in lower resource settings. These findings emphasize the critical importance of women in family outcomes and the importance of health care for women during the intrapartum and postpartum periods and throughout their child rearing years.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7316-x) contains supplementary material, which is available to authorized users.

The Impact of Parental Death in Childhood on Sons' and Daughters' Status Attainment in Young Adulthood in the Netherlands, 1850-1952

Previous research on the impact of parental loss on labor market outcomes in adulthood has often suffered from low sample sizes. To generate further insights into the long-term consequences of parental death, I use the Historical Sample of the Netherlands (HSN). The HSN contains occupational information on life courses of a sample of more than 8,000 males and almost 7,000 females born between 1850 and 1922, a period of important labor market transformations. Roughly 20 % of the sample population experienced parental death before age 16. Linear regression models show that maternal loss is significantly associated with lower occupational position in adulthood for both men and women, which points to the crucial importance of maternal care in childhood for socioeconomic outcomes in later life. This interpretation is supported by the finding that a stepmother's entry into the family is positively related with sons' occupational position later in life. In contrast to expectations, the loss of economic resources related to the father's death is generally not associated with lower status attainment in adulthood for men or for women. The results indicate, however, that the negative consequences of paternal death on men's socioeconomic outcomes decreased over time, illustrating the complex interaction between individual life courses and surrounding labor market transformations.

Early Parental Death and Risk of Psychosis in Offspring: A Six-Country Case-Control Study

Evidence for early parental death as a risk factor for psychosis in offspring is inconclusive. We analyzed data from a six-country, case-control study to examine the associations of early parental death, type of death (maternal, paternal, both), and child’s age at death with psychosis, both overall and by ethnic group. In fully adjusted multivariable mixed-effects logistic regression models, experiencing early parental death was associated with 1.54-fold greater odds of psychosis (95% confidence interval (CI): 1.23, 1.92). Experiencing maternal death had 2.27-fold greater odds (95% CI: 1.18, 4.37), paternal death had 1.14-fold greater odds (95% CI: 0.79, 1.64), and both deaths had 4.42-fold greater odds (95% CI: 2.57, 7.60) of psychosis compared with no early parental death. Experiencing parental death between 11 and 16 years of age had 2.03-fold greater odds of psychosis than experiencing it before five years of age (95% CI: 1.02, 4.04). In stratified analyses, experiencing the death of both parents had 9.22-fold greater odds of psychosis among minority ethnic groups (95% CI: 2.02–28.02) and no elevated odds among the ethnic majority (odds ratio (OR): 0.96; 95% CI: 0.10–8.97), which could be due in part to the higher prevalence of early parental death among minority ethnic groups but should be interpreted cautiously given the wide confidence intervals.

Suicidal Ideation in Bereavement: A Systematic Review

Background: Bereavement is associated with impaired mental health, increases in adverse health behaviors, and heightened risk of suicidal ideation, attempts, and death by suicide. The purpose of this literature review was to explore associations between cause of death and suicidal thoughts among bereaved individuals. Our aim was to compare incidence of suicidal ideation by cause of death and identify gaps in this literature to guide future research and clinical intervention. Methods: PRISMA-P guidelines were used to structure an electronic literature search in the PsycINFO, MEDLINE, and Web of Science databases. The search focused on English language studies that were published before February 2019 and sought to compare rates of suicidal ideation among bereaved people who lost a loved one to suicide, accidental overdose, cancer, dementia, cardiovascular disease, and HIV/AIDs. Results: Ten articles were identified with suicide as cause of death, zero articles for accidental overdose, zero articles for cardiovascular disease, eight articles for cancer, one article for dementia, and one article for HIV/AIDs. Given the limited number of articles generated by our search, a formal meta-analysis was not appropriate. However, a comparison of results did suggest that suicide bereavement was associated with the highest rates of suicide ideation (14.1% to 49%). Stigma, isolation, avoidance behaviors, and psychological distress were associated with suicidal thoughts among bereaved individuals, regardless of the deceased's cause of death. Conclusions: Findings of this literature search revealed significant gaps in the literature, especially regarding thoughts of suicide in bereaved survivors of accidental overdose and cardiovascular disease. Results suggest that multiple causes of death are associated with suicidal ideation in bereavement, but that suicide bereavement may be the cause of death associated with the highest risk of suicidal ideation. More research is needed to understand the ways in which cause of death influences prevalence, risk, and protective factors associated with suicidal thoughts among bereaved individuals.

The Burden of Bereavement: Early-Onset Depression and Impairment in Youths Bereaved by Sudden Parental Death in a 7-Year Prospective Study

OBJECTIVE

The authors sought to determine the long-term impact of sudden parental death on youths and pathways between youth bereavement and impairment.

METHODS

Youths (N=216) who lost a parent to suicide, accident, or sudden natural death and nonbereaved youths (N=172) were followed periodically for up to 7 years. The incidence and prevalence of disorder and of functional impairment, as well as pathways to impairment, were assessed using Cox and mixed-effects logistic regression and structural equation modeling.

RESULTS

Prior to parental death, bereaved youths had higher rates of psychiatric disorder, parental psychiatric disorder, and maltreatment. Even after adjustment for predeath risk factors, bereavement was associated with an increased incidence of depression, posttraumatic stress disorder, and functional impairment. The peak incidence of depression was in the first 2 years postbereavement, with incident depression occurring mainly in those who lost a parent at age 12 or younger. Youths bereaved by all three causes of death showed higher rates of impairment at all time points. Structural equation modeling found that bereavement had a direct effect on impairment and was also linked to impairment via its effects on early and later depression and through negative life events. Child psychiatric disorder prior to parental loss also contributed to functional impairment.

CONCLUSIONS

Parental death increased the incidence of depression in offspring early in the course of bereavement. Early identification and treatment of depression in bereaved youths and augmentation of family resilience may protect against later sequelae of functional impairment.

Does childhood trauma influence offspring's birth characteristics?

Background

: A recent epigenetic hypothesis postulates that 'a sex-specific male-line transgenerational effect exists in humans', which can be triggered by childhood trauma during 'the slow growth period' just before puberty. The evidence is based on a few rather small epidemiological studies. We examine what response childhood trauma predicts, if any, in the birth size and prematurity risk of almost 800 000 offspring.

Methods

Children of parity 1, 2 or 3, born 1976-2002 in Sweden, for whom we could trace both parents and all four grandparents, constituted generation 3 (G3, n = 764 569). Around 5% of their parents, G2, suffered parental (G1) death during their own childhood. The association of such trauma in G2 with G3 prematurity and birthweight was analysed, while controlling for confounders in G1 and G2. We examined whether the slow growth period was extra sensitive to parental loss.

Results

Parental (G1) death during (G2) childhood predicts premature birth and lower birthweight in the offspring generation (G3). This response is dependent on G2 gender, G2 age at exposure and G3 parity, but not G3 gender.

Conclusions

The results are compatible with the Pembrey-Bygren hypothesis that trauma exposure during boys' slow growth period may trigger a transgenerational response; age at trauma exposure among girls seems less important, suggesting a different set of pathways for any transgenerational response. Finally, parental death during childhood was not important for the reproduction of social inequalities in birthweight and premature birth.

Association of Cumulative Childhood Adversity and Adolescent Violent Offending With Suicide in Early Adulthood

IMPORTANCE

Childhood adversity (CA) is associated with an increased risk of suicide in young adulthood that might be explained by maladaptive trajectories during adolescence. Although adolescent violent offending is linked with suicide, little is known about its role in the association between CA and suicide.

OBJECTIVE

To examine whether adolescent violent offending mediates the association between CA and suicide in early adulthood.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, longitudinal cohort study with a follow-up time spanning 5 to 9 years included 476 103 individuals born in Sweden between 1984 and 1988. The study population was prospectively followed up from 20 years of age until December 31, 2013, with respect to suicide. Data analysis was performed from January 1, 1984, to December 31, 2013.

EXPOSURES

Register-based CAs included parental death, parental substance abuse and psychiatric disorder, parental criminal offending, parental separation, public assistance recipiency, child welfare intervention, and residential instability. Adolescent violent offending was defined as being convicted of a violent crime between the ages of 15 and 19 years.

MAIN OUTCOMES AND MEASURES

Estimates of risk of suicide after 20 years of age (from 2004 if born in 1984 and from 2008 if born in 1988) until the end of 2013 were calculated as incidence rate ratios (IRRs) with 95% CIs using Poisson regression analysis. Adjustments were made for demographics and psychiatric disorder. In addition, binary mediation analysis with logistic regression was used.

RESULTS

A total of 476 103 individuals (231 699 [48.7%] female) were included in the study. Those with a conviction for violent offending had been exposed to all CAs to a greater extent than those with no violent offending. Cumulative CA was associated with risk of suicide in nonconvicted (adjusted IRR, 2.4; 95% CI, 1.5-3.9) and convicted youths, who had a higher risk of suicide (adjusted IRR, 8.5; 95% CI, 4.6-15.7). Adolescent violent offending partly mediated the association between CA and suicide.

CONCLUSIONS AND RELEVANCE

Individuals with a history of CA who also engage in violent offending in adolescence have a high risk of suicide. Interventions to prevent externalizing behavior during childhood and increased support to youths with delinquent behavior may have the potential to prevent suicide related to CA.

What are the physical and psychological health effects of suicide bereavement on family members? An observational and interview mixed-methods study in Ireland

OBJECTIVES

Research focussing on the impact of suicide bereavement on family members' physical and psychological health is scarce. The aim of this study was to examine how family members have been physically and psychologically affected following suicide bereavement. A secondary objective of the study was to describe the needs of family members bereaved by suicide.

DESIGN

A mixed-methods study was conducted, using qualitative semistructured interviews and additional quantitative self-report measures of depression, anxiety and stress (DASS-21).

SETTING

Consecutive suicide cases and next-of-kin were identified by examining coroner's records in Cork City and County, Ireland from October 2014 to May 2016.

PARTICIPANTS

Eighteen family members bereaved by suicide took part in a qualitative interview. They were recruited from the Suicide Support and Information System: A Case-Control Study (SSIS-ACE), where family members bereaved by suicide (n=33) completed structured measures of their well-being.

RESULTS

Qualitative findings indicated three superordinate themes in relation to experiences following suicide bereavement: (1) co-occurrence of grief and health reactions; (2) disparity in supports after suicide and (3) reconstructing life after deceased's suicide. Initial feelings of guilt, blame, shame and anger often manifested in enduring physical, psychological and psychosomatic difficulties. Support needs were diverse and were often related to the availability or absence of informal support by family or friends. Quantitative results indicated that the proportion of respondents above the DASS-21 cut-offs respectively were 24% for depression, 18% for anxiety and 27% for stress.

CONCLUSIONS

Healthcare professionals' awareness of the adverse physical and psychosomatic health difficulties experienced by family members bereaved by suicide is essential. Proactively facilitating support for this group could help to reduce the negative health sequelae. The effects of suicide bereavement are wide-ranging, including high levels of stress, depression, anxiety and physical health difficulties.

Maternal suicide - Register based study of all suicides occurring after delivery in Sweden 1974-2009

Background

Recent research suggests that having a newborn child is associated with substantially reduced risk for maternal suicide. We studied postpartum suicides in a national cohort of mothers and the role of mental disorder, self-harm and delivery related factors.

Methods

We used a nested case-control design with data from Swedish registries. The cohort consisted of all women given birth in Sweden 1974–2009. Mothers who died by suicide during follow-up were considered cases (n = 1,786) and risk of suicide was estimated with proximity to delivery as the explanatory variable. In a second step, association between suicide during the first year following delivery (n = 145) and mental disorder, self-harm and delivery related variables risk factors were analyzed.

Results

The first postpartum year was associated with a lower risk of suicide, compared to later (RR 0.80, 95%CI 0.66–0.96), which was unaltered after adjustment for socio-economic status and history of self-harm (aRR 0.82, 95%CI 0.68–0.99). Compared to living mothers, suicide victims of the postpartum year more often had affective disorders (aRR 133.94, 95%CI 45.93–390.61), psychotic disorders (aRR 83.69, 95%CI 36.99–189.31) and history of self-harm (aRR 47.56, 95%CI 18.24–124.02). The aRR of stillbirth was 2.66 (95%CI 0.63–11.30).

Conclusions

We found only a weak negative association between childbirth during the preceding year and suicide, when using mothers as controls. A severe mental disorder after delivery and a history of self-harm was strongly associated with increased risk of suicide in the postpartum year and may inform the clinical assessment postpartum.

Support received after bereavement by suicide and other sudden deaths: a cross-sectional UK study of 3432 young bereaved adults

OBJECTIVE

To test the hypothesis that people bereaved by suicide are less likely to receive formal or informal support than people bereaved by other causes of sudden death.

DESIGN

National cross-sectional study.

SETTING

Adults working or studying at any UK higher education institution (HEI) in 2010.

PARTICIPANTS

A total of 3432 eligible respondents aged 18-40 years bereaved by the sudden death of a close friend or relative, sampled from approximately 659 572 bereaved and non-bereaved staff and students at 37 of 164 UK HEIs invited to participate.

EXPOSURES

Bereavement by suicide (n=614; 18%), by sudden unnatural causes (n=712; 21%) and by sudden natural causes (n=2106; 61%).

MAIN OUTCOME MEASURES

Receipt of formal and informal support postbereavement; timing of valued support.

RESULTS

21% (725/3432) of our sample of bereaved adults reported receiving no formal or informal bereavement support, with no evidence for group differences. People bereaved by suicide were less likely to have received informal support than those bereaved by sudden natural causes (adjusted OR (AOR)=0.79; 95% CI 0.64 to 0.98) or unnatural causes (AOR=0.74; 95% CI 0.58 to 0.96) but did not differ from either comparison group on receipt of formal support. People bereaved by suicide were less likely to have received immediate support (AOR=0.73; 95% CI 0.59 to 0.90) and more likely to report delayed receipt of support (AOR=1.33; 95% CI 1.08 to 1.64) than people bereaved by sudden natural causes. Associations were not modified by gender, or age bereaved, but became non-significant when adjusting for stigma.

CONCLUSIONS

People bereaved by suicide are less likely to receive informal support than people bereaved by other causes of sudden death and are more likely to perceive delays in accessing any support. This is concerning given their higher risk of suicide attempt and the recommendations within suicide prevention strategies regarding their need for support.

STUDY REGISTRATION

http://www.ucl.ac.uk/psychiatry/bereavementstudy/.

Association Between Spousal Suicide and Mental, Physical, and Social Health Outcomes: A Longitudinal and Nationwide Register-Based Study

IMPORTANCE

Bereavement after spousal suicide has been linked to mental disorders; however, a comprehensive assessment of the effect of spousal suicide is needed.

OBJECTIVE

To determine whether bereavement after spousal suicide was linked to an excessive risk of mental, physical, and social health outcomes when compared with the general population and spouses bereaved by other manners.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide, register-based cohort study conducted in Denmark of 6.7 million individuals aged 18 years and older from 1980 to 2014 covered more than 136 million person-years and compared people bereaved by spousal suicide with the general population and people bereaved by other manners of death. Incidence rate ratios were calculated using Poisson regressions while adjusting for sociodemographic characteristics and the presence of mental and physical disorders.

MAIN OUTCOMES AND MEASURES

Mental disorders (any disorder, mood, posttraumatic stress disorder, anxiety, alcohol use disorders, drug use disorders, and self-harm); physical disorders (cancers, diabetes, sleep disorder, cardiovascular diseases, chronic lower respiratory tract diseases, liver cirrhosis, and spinal disc herniation); causes of mortality (all-cause, natural, unintentional, suicide, and homicide); social health outcomes; and health care use.

RESULTS

The total study population included 3 491 939 men, 4814 of whom were bereaved by spousal suicide, and 3 514 959 women, 10 793 of whom were bereaved by spousal suicide. Spouses bereaved by a partner's suicide had higher risks of developing mental disorders within 5 years of the loss (men: incidence rate ratio, 1.8; 95% CI, 1.6-2.0; women: incidence rate ratio, 1.7; 95% CI, 1.6-1.8) than the general population. Elevated risks for developing physical disorders, such as cirrhosis and sleep disorders, were also noted as well as the use of more municipal support, sick leave benefits, and disability pension funds than the general population. Compared with spouses bereaved by other manners of death, those bereaved by suicide had higher risks for developing mental disorders (men: incidence rate ratio, 1.7; 95% CI, 1.5-1.9; women: incidence rate ratio, 2.0; 95% CI, 1.9-2.2), suicidal behaviors, mortality, and municipal support. Additionally, a higher level of mental health care use was noted.

CONCLUSIONS AND RELEVANCE

Exposure to suicide is stressful and affects the bereaved spouse on a broad range of outcomes. The excess risks of mental, physical, and social health outcomes highlight a need for more support directed toward spouses bereaved by suicide.

Examining longer-term effects of parental death in adolescents and young adults: Evidence from the national longitudinal survey of adolescent to adult health

Using longitudinal data spanning a 7-year period, we investigated the behavioral and psycho-social effects resulting from a parent's death during early childhood or teenage years on adolescent and early adulthood functioning. Findings confirmed previous work demonstrating various behavioral problems and social-psychological adjustment deficits during adolescence. Results suggested that most detrimental adjustment behaviors among parentally bereaved youth fade as they entered into young adulthood. Yet, premature school withdrawals and diminished interests in college attendance at Wave 1 left many of these young adults with diminished academic accomplishments, lingering economic disadvantages and for females a hesitancy to marry as their lives progressed into adulthood.

Parental Psychiatric Disease and Risks of Attempted Suicide and Violent Criminal Offending in Offspring: A Population-Based Cohort Study

IMPORTANCE

Self-directed and interpersonal violence share some common risk factors such as a parental history of mental illness. However, relationships between the full spectrum of parental psychiatric disease and these 2 related outcomes are unclear.

OBJECTIVE

To examine associations between the full spectrum of parental psychiatric disease and risks of attempted suicide and violent offending among offspring.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cohort study of all persons born in Denmark 1967 through 1997, followed up from their 15th birthday until occurrence of adverse outcome or December 31, 2012, whichever came first.

EXPOSURES

Array of parental psychiatric disorders and parental suicide attempt, delineated from records of secondary care treatments.

MAIN OUTCOMES AND MEASURES

Using survival analyses techniques, incidence rate ratios were estimated for offspring suicide attempt and violent offending.

RESULTS

We examined 1 743 525 cohort members (48.7% female; total follow-up, 27.2 million person-years). Risks for offspring suicide attempt and violent offending were elevated across virtually the full spectrum of parental psychiatric disease. Incidence rate ratios were the most elevated for parental diagnoses of antisocial personality disorder (suicide attempt, 3.96; 95% CI, 3.72-4.21; violent offending, 3.62; 95% CI, 3.41-3.84) and cannabis misuse (suicide attempt, 3.57; 95% CI, 3.25-3.92; violent offending, 4.05; 95% CI, 3.72-4.39), and for parental suicide attempt (suicide attempt, 3.42; 95% CI, 3.29-3.55; violent offending, 3.31; 95% CI, 3.19-3.44). Parental mood disorders (and bipolar disorder in particular) conferred more modest risk increases. A history of mental illness or suicide attempt in both parents was associated with double the risks compared with having just 1 affected parent. Associations between parental psychiatric disease and offspring violent offending were stronger for female than for male offspring, whereas little sex difference in risk was found for offspring suicide attempt.

CONCLUSIONS AND RELEVANCE

The similarities in risk patterns observed between the 2 outcomes may evidence a shared etiology. Early interventions to tackle parental mental disorders may be beneficial to both parents and children.

Triggers for Violent Criminality in Patients With Psychotic Disorders

IMPORTANCE

Absolute and relative risks of violence are increased in patients with psychotic disorders, but the contribution of triggers for violent acts to these risks is uncertain.

OBJECTIVE

To examine whether a range of triggers for violent acts are associated with risks of violence in patients diagnosed with psychotic disorders and in individuals without a psychiatric diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

Using a sample of all individuals born in Sweden between 1958 and 1988 (N = 3 123 724), we identified patients in the National Patient Register who were diagnosed with schizophrenia spectrum disorders (n = 34 903) and bipolar disorder (n = 29 692), as well as unaffected controls (n = 2 763 012). We then identified, within each subsample, persons who had experienced any of the following triggers for violent acts between January 1, 2001, and December 15, 2013: exposure to violence, parental bereavement, self-harm, traumatic brain injury, unintentional injuries, and substance intoxication. By using within-individual models, we conducted conditional logistic regression to compare the risk of the individual engaging in violent acts in the week following the exposure to a trigger with the risk during earlier periods of equivalent length. All time-invariant confounders (eg, genetic and early environmental influences) were controlled for by this research design and we further adjusted for time-varying sociodemographic factors.

MAIN OUTCOMES AND MEASURES

Adjusted odds ratios (aORs) of violent crime occurring in the week following the exposure to a trigger event compared with earlier periods.

RESULTS

Among the sample of 2 827 607 individuals (1 492 186 male and 1 335 421 female), all of the examined trigger events were associated with increased risk of violent crime in the week following exposure. The largest 1-week absolute risk of violent crime was observed following exposure to violence (70-177 violent crimes per 10 000 persons). For most triggers, the relative risks did not vary significantly by diagnosis, including unintentional injuries (aOR range, 3.5-4.8), self-harm (aOR range, 3.9-4.2), and substance intoxication (aOR range, 3.0-4.0). Differences by diagnosis included parental bereavement, which was significantly higher in patients with schizophrenia spectrum disorders (aOR, 5.0; 95% CI, 3.0-8.1) compared with controls (aOR, 1.7; 95% CI, 1.3-2.2).

CONCLUSIONS AND RELEVANCE

In addition to identifying risk factors for violence, clarifying the timing of the triggers may provide opportunities to improve risk assessment and management in individuals with psychotic disorders.

Pre- and postloss features of adolescent suicide bereavement: A systematic review

Despite increasing clinical and research interest in suicide bereavement the impact of suicide on adolescents is still poorly understood. This systematic review aims to disentangle pre- and postloss features that affect response to grief in this age group. The literature was analyzed after a systematic search and hand-check of retrieved articles. The impact of suicide is affected by (a) preloss features related to personal/family history of mental health, family life, suicidal behavior, and type and emotional closeness of relationship; and (b) postloss issues such as quality of remaining relationships. Future research and bereavement support should consider these broader contexts.

Life adversities and suicidal behavior in young individuals: a systematic review

Suicidal behavior in young people is a significant public health problem. However, it is not yet clear whether adversities (adverse life events) may be related to suicidality in adolescence and early adulthood. This paper aimed to investigate systematically the association between the type/number of adverse life events and experiences and suicidal behavior in young people. We developed a detailed strategy to search relevant articles in Pubmed, Scopus, PsycInfo, and Science Direct (January 1980-January 2015) about adverse life events and suicidal behavior. Adverse life events and experiences included maltreatment and violence, loss events, intra-familial problems, school and interpersonal problems. Studies were restricted to suicidal behavior in young people aged 10-25 years. The search yielded 245 articles, of which 28 met our inclusion criteria. Most studies reported a strong association between adversities and suicidality (both suicidal ideation and attempts). Based on the main results, the number of adversities or negative life events experienced seemed to have a positive dose-response relationship with youth suicidal behavior. However, the type of event experienced also appeared to matter: one of the most consistent findings was the association between suicidal behavior and experience of sexual abuse. More prospective studies are needed to elucidate the relative importance of risk accumulation and risk specificity for youth suicide.

Childhood exposure to a parental suicide attempt and risk for substance use disorders

Childhood exposure to parental suicidal behavior has been linked to a variety of adverse behavioral and health outcomes. However, relatively little is known about the degree to which such exposure may place individuals at risk for a substance use disorder (SUD). Employing data from the National Epidemiologic Survey on Alcohol and Related Conditions, we compared the prevalence of SUDs among those who experienced childhood exposure to parental suicide attempts. Childhood exposure to parental suicide attempts was not associated with increased risk for the development of alcohol, cannabis, or cocaine use disorders. However, individuals who were exposed to a parental suicide attempt as children were significantly more likely to have met criteria for stimulant (AOR=1.40, 95% CI=1.18-1.67), sedative (AOR=1.24, 95% CI=1.04-1.47), tranquilizer (AOR=1.78, 95% CI=1.45-2.20), and opioid (AOR=1.41, 95% CI=1.19-1.67) use disorders in their lifetime. No significant gender differences were identified with respect to the magnitude of the relationship between exposure to parental suicide attempts and SUD risk among men and women. Findings suggest that, controlling for an array of sociodemographic, parental, mental health, and childhood adversity confounds, childhood exposure to parental suicide attempts is a vulnerability factor for low prevalence illicit drugs (i.e. stimulants, sedatives, tranquilizers, opioids), but not for more commonly used substances.

Long term mental health outcomes of Finnish children evacuated to Swedish families during the second world war and their non-evacuated siblings: cohort study

OBJECTIVES

To compare the risks of admission to hospital for any type of psychiatric disorder and for four specific psychiatric disorders among adults who as children were evacuated to Swedish foster families during the second world war and their non-evacuated siblings, and to evaluate whether these risks differ between the sexes.

DESIGN

Cohort study.

SETTING

National child evacuation scheme in Finland during the second world war.

PARTICIPANTS

Children born in Finland between 1933 and 1944 who were later included in a 10% sample of the 1950 Finnish census ascertained in 1997 (n = 45,463; women: n = 22,021; men: n = 23,442). Evacuees in the sample were identified from war time government records.

MAIN OUTCOME MEASURE

Adults admitted to hospital for psychiatric disorders recorded between 1971 and 2011 in the Finnish hospital discharge register.

METHODS

We used Cox proportional hazards models to estimate the association between evacuation to temporary foster care in Sweden during the second world war and admission to hospital for a psychiatric disorder between ages 38 and 78 years. Fixed effects methods were employed to control for all unobserved social and genetic characteristics shared among siblings.

RESULTS

Among men and women combined, the risk of admission to hospital for a psychiatric disorder did not differ between Finnish adults evacuated to Swedish foster families and their non-evacuated siblings (hazard ratio 0.89, 95% confidence interval 0.64 to 1.26). Evidence suggested a lower risk of admission for any mental disorder (0.67, 0.44 to 1.03) among evacuated men, whereas for women there was no association between evacuation and the overall risk of admission for a psychiatric disorder (1.21, 0.80 to 1.83). When admissions for individual psychiatric disorders were analyzed, evacuated girls were significantly more likely than their non-evacuated sisters to be admitted to hospital for a mood disorder as an adult (2.19, 1.10 to 4.33).

CONCLUSIONS

The Finnish evacuation policy was not associated with an increased overall risk of admission to hospital for a psychiatric disorder in adulthood among former evacuees. In fact, evacuation was associated with a marginally reduced risk of admission for any psychiatric disorder among men. Among women who had been evacuated, however, the risk of being admitted to hospital for a mood disorder was increased.

Unaccompanied evacuation and adult mortality: evaluating the finnish policy of evacuating children to foster care during World War II

OBJECTIVES

I examined associations between evacuation of Finnish children to temporary foster care in Sweden during World War II and all-cause mortality between ages 38 and 78 years.

METHODS

I used a Cox proportional hazards model to estimate mortality risk according to whether the individual was evacuated during childhood or not. I used within-sibling analysis to control for all unobserved socioeconomic and genetic characteristics shared among siblings. Individual-level data for Finnish cohorts born in 1933 to 1944 were derived from wartime government records, Finnish census data from 1950 and 1970, and death cause registry from 1971 to 2011.

RESULTS

I found no statistically significant association between evacuation and all-cause mortality when all exposed individuals were included in the analysis. However, subgroup analysis showed that men evacuated before age 4 years had a 1.31 higher mortality risk (95% confidence interval = 1.01, 1.69) than their nonevacuated counterparts.

CONCLUSIONS

In the aggregate, individuals do not have elevated mortality risk as a consequence of foster care during early childhood owing to the onset of sudden external shocks (e.g., wars).

Mortality after parental death in childhood: a nationwide cohort study from three Nordic countries

BACKGROUND

Bereavement by spousal death and child death in adulthood has been shown to lead to an increased risk of mortality. Maternal death in infancy or parental death in early childhood may have an impact on mortality but evidence has been limited to short-term or selected causes of death. Little is known about long-term or cause-specific mortality after parental death in childhood.

METHODS AND FINDINGS

This cohort study included all persons born in Denmark from 1968 to 2008 (n = 2,789,807) and in Sweden from 1973 to 2006 (n = 3,380,301), and a random sample of 89.3% of all born in Finland from 1987 to 2007 (n = 1,131,905). A total of 189,094 persons were included in the exposed cohort when they lost a parent before 18 years old. Log-linear Poisson regression was used to estimate mortality rate ratio (MRR). Parental death was associated with a 50% increased all-cause mortality (MRR = 1.50, 95% CI 1.43-1.58). The risks were increased for most specific cause groups and the highest MRRs were observed when the cause of child death and the cause of parental death were in the same category. Parental unnatural death was associated with a higher mortality risk (MRR = 1.84, 95% CI 1.71-2.00) than parental natural death (MRR = 1.33, 95% CI 1.24-1.41). The magnitude of the associations varied according to type of death and age at bereavement over different follow-up periods. The main limitation of the study is the lack of data on post-bereavement information on the quality of the parent-child relationship, lifestyles, and common physical environment.

CONCLUSIONS

Parental death in childhood or adolescence is associated with increased all-cause mortality into early adulthood. Since an increased mortality reflects both genetic susceptibility and long-term impacts of parental death on health and social well-being, our findings have implications in clinical responses and public health strategies. Please see later in the article for the Editors' Summary.

An introduction to sensitivity analysis for unobserved confounding in nonexperimental prevention research

Despite the fact that randomization is the gold standard for estimating causal relationships, many questions in prevention science are often left to be answered through nonexperimental studies because randomization is either infeasible or unethical. While methods such as propensity score matching can adjust for observed confounding, unobserved confounding is the Achilles heel of most nonexperimental studies. This paper describes and illustrates seven sensitivity analysis techniques that assess the sensitivity of study results to an unobserved confounder. These methods were categorized into two groups to reflect differences in their conceptualization of sensitivity analysis, as well as their targets of interest. As a motivating example, we examine the sensitivity of the association between maternal suicide and offspring's risk for suicide attempt hospitalization. While inferences differed slightly depending on the type of sensitivity analysis conducted, overall, the association between maternal suicide and offspring's hospitalization for suicide attempt was found to be relatively robust to an unobserved confounder. The ease of implementation and the insight these analyses provide underscores sensitivity analysis techniques as an important tool for nonexperimental studies. The implementation of sensitivity analysis can help increase confidence in results from nonexperimental studies and better inform prevention researchers and policy makers regarding potential intervention targets.

Severe bereavement stress during the prenatal and childhood periods and risk of psychosis in later life: population based cohort study

OBJECTIVE

To examine the risk of psychosis associated with severe bereavement stress during the antenatal and postnatal period, between conception to adolescence, and with different causes of death.

DESIGN

Population based cohort study.

SETTING

Swedish national registers including births between 1973 and 1985 and followed-up to 2006.

PARTICIPANTS

In a cohort of 1,045,336 Swedish births (1973-85), offspring born to mothers exposed to severe maternal bereavement stress six months before conception or during pregnancy, or exposed to loss of a close family member subsequently from birth to 13 years of age were followed until 2006. Admissions were identified by linkage to national patient registers.

MAIN OUTCOME MEASURES

Crude and adjusted odds ratios for all psychosis, non-affective psychosis, and affective psychosis.

RESULTS

Maternal bereavement stress occurring preconception or during the prenatal period was not associated with a significant excess risk of psychosis in offspring (adjusted odds ratio, preconception 1.24, 95% confidence interval 0.96 to 1.62; first trimester 0.95, 0.58 to 1.56; second trimester 0.79, 0.46 to 1.33; third trimester 1.14, 0.78 to 1.66). Risks increased modestly after exposure to the loss of a close family member from birth to adolescence for all psychoses (adjusted odds ratio 1.17, 1.04 to 1.32). The pattern of risk was generally similar for non-affective and affective psychosis. Thus estimates were higher after death in the nuclear compared with extended family but remained non-significant for prenatal exposure; the earlier the exposure to death in the nuclear family occurred in childhood (all psychoses: adjusted odds ratio, birth to 2.9 years 1.84, 1.41 to 2.41; 3-6.9 years 1.47, 1.16 to 1.85; 7-12.9 years 1.32, 1.10 to 1.58) and after suicide. Following suicide, risks were especially higher for affective psychosis (birth to 2.9 years 3.33, 2.00 to 5.56; 6.9 years 1.84, 1.04 to 3.25; 7-12.9 years 2.68, 1.84 to 3.92). Adjustment for key confounders attenuated but did not explain associations with risk.

CONCLUSIONS

Postnatal but not prenatal bereavement stress in mothers is associated with an increased risk of psychosis in offspring. Risks are especially high for affective psychosis after suicide in the nuclear family, an effect that is not explained by family psychiatric history. Future studies are needed to understand possible sources of risk and resilience so that structures can be put in place to support vulnerable children and their families.

Alcohol and substance abuse in parentally bereaved youth

OBJECTIVE

Little is known about the role of parental bereavement regarding alcohol and substance abuse. Our aim was to examine whether the incidence of alcohol and substance abuse is higher in parentally bereaved youth and, if so, what might explain this increased incidence.

METHOD

In a longitudinal population-based study conducted between November 2002 and December 2012, the incidence of alcohol and substance abuse or dependence (ASAD) during a period of 5 years was examined (using DSM-IV criteria) in 235 youth whose parents died of suicide, accident, or sudden natural death and 178 demographically similar nonbereaved youth.

RESULTS

In a period that covered 5 years subsequent to the death, bereaved youth had an increased incidence and earlier time to onset of ASAD relative to nonbereaved controls (incident rate ratio = 2.44; 95% CI, 1.17-5.56). Additionally, youth over the age of 13 years (hazard ratio [HR] = 6.68; 95% CI, 3.22-13.89; P < .001), those who developed a disruptive behavior disorder (HR = 7.55; 95% CI, 1.83-31.22; P = .005), and those who had greater functional impairment (HR = 0.93; 95% CI, 0.90-0.95; P < .001) were at increased risk for ASAD. However, after adjusting for the above-noted variables, the relationship between parental bereavement and pathological youth alcohol and substance use was not statistically significant (HR = 1.73; 95% CI, 0.79-3.81; P = .17).

CONCLUSIONS

Bereaved youth are at greater risk for ASAD than their nonbereaved counterparts, especially adolescent boys with disruptive behavior disorders. The effect of bereavement was explained by its overall impact on greater functional impairment in bereaved offspring. Interventions that help to improve offspring functioning and that prevent or attenuate the development of disruptive behavior disorders have the potential to prevent ASAD in bereaved youth.