Grief interventions for people bereaved by suicide: A systematic review

Are we Using the Right Evidence to Inform Suicide Prevention in Low- and Middle-Income Countries? An Umbrella Review

OBJECTIVE

Suicide disproportionately affects low- and middle-income countries and evidence regarding prevention approaches developed in high income countries may not be applicable in these settings. We conducted an umbrella review to assess whether the conclusions of suicide prevention systematic reviews accurately reflect the studies contained within those reviews in terms of setting generalizability.

METHODS

We conducted database searches in PubMed/Medline, Embase, PsycInfo, PsychExtra, OVID global health, and LILACS/BECS. We included systematic reviews with the outcome of suicide, including bereavement studies where suicide death was also the exposure.

RESULTS

Out of the 147 reviews assessed, we found that over 80% of systematic reviews on suicide deaths do not provide an accurate summary of review findings with relation to geographic relevance and ultimately generalizability.

CONCLUSION

Systematic reviews are often the resource used by practitioners and policymakers to guide services. Misleading reviews can detrimentally impact suicide prevention efforts in LMICs. We call for systematic reviewers to be responsible when generalizing the findings of their reviews particularly in the abstracts.

Perceived Effectiveness of Components of Interventions to Support People Bereaved By Suicide

Background: Suicide bereavement increases the probability of adverse outcomes related to grief, social functioning, mental health, and suicidal behavior. While more support for individuals bereaved by suicide has become available, the evidence regarding its effectiveness is not straightforward. The literature suggests that identifying best-practice components is key in designing effective postvention interventions. Aims: This metareview aims to identify components of suicide bereavement interventions perceived to be effective by suicide-bereaved people. Method: The review adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Systematic searches in Medline, PsycINFO, Embase, Emcare, EBM Reviews, Scopus, and Web of Science identified 11 eligible systematic reviews published between 2008 and 2023. The methodological quality was assessed using the Measurement Tool to Assess Systematic Reviews (AMSTAR-2) (PROSPERO registration CRD42023458300). Results: Our narrative synthesis reported the components perceived to be effective in relation to structure and content of interventions, facilitators, and modality (peer, group, community, online). Limitations: The quality of the included reviews varied considerably, and not all reviews reported on perceived effectiveness of interventions' components. Meta-analysis of findings was not possible due to study heterogeneity. Conclusion: The findings provide crucial information for researchers, service providers, and policymakers to enhance the provision of evidence-based support for people bereaved by suicide.

State of the Science: Psychotherapeutic Interventions for Prolonged Grief Disorder

Prolonged grief disorder (PGD) is a distinct diagnostic entity that has recently garnered considerable attention as it describes an intense, enduring, distressing and disabling bereavement reaction experienced by a small minority of community-based mourners. In recent decades, research has exploded to address how best to treat PGD with different psychotherapeutic interventions. In this state-of-the-science review, the strength of the evidence will be discussed regarding common psychotherapeutic interventions used to treat grief. Specifically, we focus on the most commonly used interventions, cognitive behavioral (CB)-based therapies, bereavement and support groups, and brief contact interventions (BCIs), in an effort to summarize the relevant clinical takeaways of the current available research. A discussion of the use of these therapies in specific clinical populations is also included, with a focus on those traumatically bereaved, pediatric populations, communities of color, and underserved communities. Important foci and directions for future research are also discussed.

Qualitative Analysis of Mental Health Stressors Among Pharmacy and Medical Students Between 2009 and 2020

OBJECTIVE

The primary objective of this study was to identify and compare stressors between pharmacy and medical students that may lead to poor mental health outcomes and decreased quality of professional medical care.

METHODS

We used an inductive reflexive thematic analysis to interpret free-text responses from a stress and depression survey administered to pharmacy and medical students between 2009 and 2020 at a single public university. The inductive process involved several steps, including data familiarization, coding, and theme development. Two of the authors independently coded the data and presented their findings to the research team. After reaching a consensus, the data were recoded according to the new interpretation. Theme generation involved grouping codes into overarching ideas that provided a narrative.

RESULTS

Five major themes emerged among both cohorts: constant overwhelming pressure, stressors of an interpersonal relationship, internal battle with oneself, financial burden, and postgraduation anxiety and uncertainty. Constant overwhelming pressure, stresses of an interpersonal relationship, and internal battle with oneself were the 3 most frequent themes identified. One notable stressor observed only among pharmacy students was having an internship during their training years.

CONCLUSION

Addressing the well-being of pharmacy and medical students early in training is crucial. Despite the different pharmacy and medical school curricula, it was evident that both cohorts faced similar stressors. This study identified specific stressors among pharmacy and medical students that can help health professional programs develop initiatives to support student well-being.

Navigating grief in unprecedented times: risk factors in the wake of pandemic loss and end-of-life care

Coronavirus is an infectious disease that has left tens of millions of deaths around the world, and which has had social, economic, emotional, and psychological consequences. To mitigate the spread of the virus, several countries have adopted restrictive measures that impacted the way people experienced the end-of-life and the death of their loved one. This study aimed to identify the variables associated with prolonged grief symptoms in the context of both pandemic-related losses and the unique challenges related to end-of-life care. An anonymous online survey was disseminated widely through various channels including local press, social media, professional networks and hospitals. Socio-demographic information was collected, as well as information related to loss (cause of death, place of end-of-life care and death) and bereavement, and on the impact of the restrictions imposed by the pandemic. The participants were 163 bereaved who lost a loved one who received end-of-life care during the pandemic in Portugal. Most participants were female, married, professionally active and had lost their grandparents. A hierarchical multiple regression was performed to determine the factors associated with prolonged grief symptoms. The results showed that more prolonged grief symptoms were associated with less social support, worsening of the financial situation, greater psychological impact of restrictions on communicating with the deceased, and the deceas having received end-of-life care in a hospital. The early identification based on these factors of individuals at higher risk for more prolonged grief symptoms could allow for targeted interventions and support services.This study unveils crucial factors contributing to heightened grief amid pandemic-related losses and challenges in end-of-life care, which provide practical insights for healthcare practitioners. Highlight the importance of personalized interventions to fortify social connections, address financial challenges, and offer compassionate alternatives to hospital-centric care. Policymakers can leverage this information to optmise grief management during public health crises.

Grief Intervention in Suicide Loss Survivors through Cognitive-Behavioral Therapy: A Systematic Review

Suicide is one of the leading causes of death worldwide, affecting numerous individuals close to the person who died by suicide, including family members, friends, and colleagues. Those affected by the suicide of someone are referred to as "suicide survivors", and the psychological consequences they face are particularly severe. One of these consequences is grief, which is more complicated in survivors of suicide compared with those grieving deaths from other causes, mainly because of the stigma that continues to surround them. Therefore, psychotherapeutic intervention for suicide loss survivors is crucial. This study examines the efficacy of cognitive-behavioral programs for addressing grief and other related variables in suicide loss survivors. The search was conducted in databases including Psycinfo, Academic Search Premier, Medline, APA PsycArticles, E-Journals, Scopus, and PubMed. Five randomized controlled trials were selected, one of which focused exclusively on minors. The results reveal that cognitive-behavioral therapy is effective, although the methodological quality of these studies is not adequate, and the representativeness of the samples is very low. More RCTs are needed on the application of cognitive-behavioral programs to treat grief in suicide loss survivors.

Psychotherapies for prolonged grief disorder in adults: A systematic review and network meta-analysis

BACKGROUND

Prolonged grief disorder (PGD), a condition characterized by severe, persistent, and disabling grief, is newly included in ICD-11 and DSM-5-TR. Psychotherapies are among the most recommended treatments for PGD, but which should be considered as first-line treatment needs to be clarified. The purpose of this systematic review and network meta-analysis was to synthesize the available evidence to compare five outcomes of different psychotherapies on PGD in adults and identify the optimal psychotherapy modality to inform clinical decision-making for the treatment of PGD.

METHOD

A comprehensive search was conducted in 7 databases from inception until March 20th, 2023. In the frequentist framework, pairwise and network meta-analyses using random-effects models were performed for outcomes with 95 % confidence interval (CI).

RESULTS

There were 2962 records found and 55 studies (1,0330 participants) assessing 11 different psychological interventions were included. Compared with the waiting list, behavioral therapy (SMD=-1.05; 95 %CI=-1.71, -0.38), third-wave cognitive behavior therapy (SMD=-1.00; 95 %CI =-1.41, -0.58), family therapy (SMD=-0.87; 95 %CI=-1.59, -0.16), psychodynamic therapy (SMD=-0.88; 95 %CI=-1.67, -0.10) and cognitive therapy (SMD=-0.84; 95 %CI=-1.57, -0.12) were statistically effective in reducing grief symptom. Only cognitive behavior therapy (OR =0.48; 95 %CI = 0.27, 0.85) was more acceptable than waiting list. In terms of secondary outcome, third-wave CBT can statistically significantly reduce depression (SMD= -0.60; 95 %CI =- 0.84, -0.36), PTSD (SMD=-0.99; 95 %CI =- 1.62, -0.36) and anxiety (SMD= -1.44; 95 %CI =-2.63, -0.25) respectively.

CONCLUSIONS

Most psychological interventions are effective, but only cognitive behavior therapy has the highest acceptability. Third-wave CBT with higher efficacy rates may be more beneficial for reducing secondary outcomes. To provide more robust evidence, high-quality trials should be conducted in the future.

The role of depression and use of alcohol and other drugs after partner suicide in the association between suicide bereavement and suicide: cohort study in the Danish population

BACKGROUND

Although suicide bereavement is associated with suicide and self-harm, evidence regarding mechanisms is lacking. We investigated whether depression and substance use (alcohol and/or other drugs) explain the association between partner suicide bereavement and suicide.

METHODS

Linkage of nationwide, longitudinal data from Denmark for the period 1980-2016 facilitated a comparison of 22 668 individuals exposed to bereavement by a partner's suicide with 913 402 individuals bereaved by a partner's death due to other causes. Using causal mediation models, we estimated the degree to which depression and substance use (considered separately) mediated the association between suicide bereavement and suicide.

RESULTS

Suicide-bereaved partners were found to have a higher risk of suicide (HRadj = 1.59, 95% CI 1.36-1.86) and of depression (ORadj 1.16, 95% CI 1.09-1.25) when compared to other-bereaved partners, but a lower risk of substance use (ORadj 0.83; 95% CI 0.78-0.88). An increased risk of suicide was found among any bereaved individuals with a depression diagnosis recorded post-bereavement (ORadj 3.92, 95% CI 3.55-4.34). Mediation analysis revealed that depression mediated 2% (1.68%; 95% CI 0.23%-3.14%; p = 0.024) of the association between suicide bereavement and suicide in partners when using bereaved controls.

CONCLUSIONS

Depression is a partial mediator of the association between suicide bereavement and suicide. Efforts to prevent and optimize the treatment of depression in suicide-bereaved people could reduce their suicide risk. Our findings might be conservative because we did not include cases of depression diagnosed in primary care. Further work is needed to understand this and other mediators.

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

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

Suicide contagion and psychosocial risks among Nepali youth through a near-hanging case study

The phenomenon of suicide contagion: some individuals, especially vulnerable young people, exhibit increased susceptibility to suicidal ideation when exposed to the suicide of other people. Significant research suggests that exposure to media portrayals, suicide groups and peer suicides may lead to suicide contagion. Prevalent psychosocial and cultural factors in Nepal such as interpersonal conflict, domestic violence, gender inequity and social exclusion probably contribute to suicidal behaviour. This case study investigates a high school student in a rural mountainous community in Nepal, who attempted suicide by hanging following his girlfriend's suicide, and demonstrates how peer suicide exposure prompts imitative behaviour in a vulnerable young person and confirms suicide grief as an underrepresented risk factor. Prompt, supportive interventions for high-risk grievers and societal prevention strategies tailored to adolescents are essential to curb imitative deaths.

Possible Mental Health Interventions for Family Members of a Close Relative Who Has Suicidal Thoughts or Committed Suicide: A Pilot Project at a Mental Health Center

Background: Suicides are an actual issue, especially in Lithuania, where, despite significant efforts, the number of suicides remains very high. In cases of suicide, society painfully loses its members, and the relatives of the person who committed suicide, engaged in self-harm, or attempted suicide face many negative experiences. Methods: The purpose of this article is to describe the pilot project applied for 2 years in the Mental Health Center (MHC) in the city of Vilnius, Lithuania, in organizing and providing services to people whose relatives committed suicide or attempted suicide or self-harm. This prevention and early intervention program, organized by an interdisciplinary team at an MHC, appeared appropriate, effective, and well-attended. Program clients could participate anonymously and have the opportunity to choose the time and the right services for themselves from the offered program services package. Results: Providing the possibility for family members to receive flexible mental health services at the primary center increased the attractiveness of the program and reduced stigma. Conclusions: The program results demonstrated the applicability of the implementation of such an initiative as a relevant possibility when providing complex help for the relatives of self-harming and/or suicidal people.

Sudden Infant Death Syndrome (SIDS): State of the Art and Future Directions

Sudden infant death syndrome (SIDS) is a type of death that occurs suddenly and without any apparent explanation, affecting infants between 28 days of life and up to a year. Recognition of this entity includes performing an autopsy to determine if there is another explanation for the event and performing both an external and internal examination of the different tissues to search for possible histopathological findings. Despite the relative success of awareness campaigns and the implementation of prevention measures, SIDS still represents one of the leading causes of death among infants worldwide. In addition, although the development of different techniques has made it possible to make significant progress in the characterization of the etiopathogenic mechanisms underlying SIDS, there are still many unknowns to be resolved in this regard and the integrative consideration of this syndrome represents an enormous challenge to face both from a point of view scientific and medical view as humanitarian. For all these reasons, this paper aims to summarize the most relevant current knowledge of SIDS, exploring from the base the characterization and recognition of this condition, its forensic findings, its risk factors, and the main prevention measures to be implemented. Likewise, an attempt will be made to analyze the causes and pathological mechanisms associated with SIDS, as well as potential approaches and future paths that must be followed to reduce the impact of this condition.

"That feeling of solidarity and not being alone is incredibly, incredibly healing": A qualitative study of participating in suicide bereavement peer support groups

Suicide can have a significant impact on the bereaved. Peer support groups for suicide bereavement have been shown to enhance the wellbeing of those attending. However, research is lacking on the mechanisms that underlie these benefits. Semi-structured interviews were conducted with 12 adults attending peer-facilitated support groups in Ireland and thematic analysis was used. The findings highlighted the enduring emotional impact including guilt and questioning, loss of identity, as well as wider impacts. Mechanisms of the groups included the opportunity to share experiences and feel validated, connection and belongingness and collective processing of grief. Groups were found to have a unique role alongside other informal and formal supports. This study highlights the important role of peer support groups in lessening this burden and adds to the literature through identifying potential mechanisms by which peer support groups contribute to improved wellbeing for the suicide-bereaved and practical steps to facilitate these mechanisms.

Engagement in meaningful activities post suicide loss: A scoping review protocol

RATIONALE

Each day, more than 10 Canadians die by suicide. Each suicide leaves entire communities to manage the traumatic aftermath of this loss. Individuals bereaved by suicide loss are at a higher risk of experiencing negative mental health outcomes. Current research suggests that engagement in meaningful activities may be an avenue to protecting mental health. It is important to understand if this is also the case for those experiencing bereavement post suicide loss. To date, there has not been a synthesis of the literature examining suicide loss and the nature and extent of engagement in meaningful activities post loss.

OBJECTIVES

1) To describe the nature and extent of the peer-reviewed suicide loss and bereavement literature related to engagement in meaningful activities; and 2) to identify facilitators and barriers that may impact engagement in meaningful activities post loss.

METHODS

This paper describes a scoping review protocol that will be completed using stages identified by Arksey and O'Malley and updated by Levac and colleagues. Joanna Briggs Institute framework will also guide this review. Four electronic databases will be searched for suicide bereavement/loss concepts. Two reviewers will apply inclusion and exclusion criteria to identify articles discussing engagement in meaningful activities of everyday living post loss. Data will be descriptively summarized and analyzed using inductive content analysis. Results will be reported following PRISMA Extension for Scoping Reviews.

EXPECTED RESULTS

A descriptive summary and conceptual map describing the current state of the peer-reviewed literature will be constructed.

CONCLUSION

Experiencing a suicide loss increases the risk of negative mental health outcomes. A synthesis of literature is required to map the current available evidence related to suicide bereavement and engagement in meaningful activities, with potential implications for improving supports and services for those bereaved. This protocol is register with Open Science Framework Registries (10.17605/OSF.IO/M2NES).

The Support to Mitigate the Impact of Suicide for Disaster Aid Workers of the 2011 Great East Japan Earthquake

Suicide substantially impacts disaster-affected communities due to pre-existing psychosocial effects caused by the disaster. Following the Great East Japan Earthquake of 2011, local disaster aid workers had overworked for months, and many workers eventually died by suicide. Although many workplaces suffered this dual damage, there is limited literature on psychosocial postvention in this context. This study reports the activities of individual/group postventions provided to these aid workers. The bereaved person expressed grief for the loss of their colleagues and anger for not being protected. The postvention observed unusual and distinctive group dynamics. It was essential for mental health professionals to address 2 types of traumatic exposures in the group programs -trauma from the disaster and their colleagues' deaths due to suicide. These postvention programs might be beneficial in maintaining aid workers' mental health and helping them cope with the loss of their colleagues.

Exploring the phenomenon of intrusive mental imagery after suicide bereavement: A qualitative interview study in a British sample

INTRODUCTION

Each year an estimated 48 million people are bereaved by suicide internationally. Following traumatic events, experiencing intrusive mental imagery relating to the trauma is not uncommon. This phenomenological study aimed to explore the nature, experience and impact of intrusive mental imagery after suicide bereavement.

METHODS

Semi-structured interview transcripts with 18 adults bereaved by the suicide of a close contact were analysed using thematic analysis to explore patterns and themes within the data, with particular consideration of the content of images, how people experience and relate to the imagery, and the impact that the imagery has on the bereaved.

RESULTS

Thematic analysis identified common characteristics in the experience of intrusive mental imagery following suicide loss, summarised under two main themes capturing: 1) the descriptive characteristics and 2) the emotional experience of intrusive mental imagery following suicide loss. The majority of participants found the experience of intrusive imagery distressing, but most also described positive aspects, including help in making sense of the death and retaining memories of the deceased.

CONCLUSION

Findings inform our understanding of the distressing experience of intrusive imagery after suicide loss, also revealing perceived value in processing the death.

Investigating risk of self-harm and suicide on anniversaries after bereavement by suicide and other causes: a Danish population-based self-controlled case series study

AIMS

To investigate mechanisms of suicide risk in people bereaved by suicide, prompted by observations that bereaved people experience higher levels of distress around dates of emotional significance. We hypothesised that suicide-bereaved first-degree relatives and partners experience an increased risk of self-harm and suicide around dates of (i) anniversaries of the death and (ii) the deceased's birthday, compared with intervening periods.

METHODS

We conducted a self-controlled case series study using national register data on all individuals living in Denmark from 1 January 1980 to 31 December 2016 and who were bereaved by the suicide of a first-degree relative or partner (spouse or cohabitee) during that period, and who had the outcome (any episode of self-harm or suicide) within 5 years and 6 weeks of the bereavement. We compared relative incidence of suicidal behaviour in (i) the first 30 days after bereavement and (ii) in the aggregated exposed periods (6 weeks either side of death anniversaries; 6 weeks either side of the deceased's birthdays) to the reference (aggregated unexposed intervening periods). As an indirect comparison, we repeated these models in people bereaved by other causes.

RESULTS

We found no evidence of an elevated risk of suicidal behaviour during periods around anniversaries of a death or the deceased's birthdays in people bereaved by suicide (adjusted incidence rate ratio [IRRadj] = 1.00; 95% confidence interval [CI] = 0.87-1.16) or other causes (IRRadj = 1.04; 95% CI = 1.00-1.08) compared with intervening periods. Rates were elevated in the 30 days immediately after bereavement by other causes (IRRadj: 1.95, 95% CI: 1.77-2.22).

CONCLUSIONS

Although people bereaved by suicide are at elevated risk of self-harm and suicide, our findings do not suggest that this risk is heightened around emotionally significant anniversaries. Bereavement care should be accessible at all points after a traumatic loss as needs will differ over the grief trajectory.

What we know about grief intervention: a bibliometric analysis

Background

Grief is a natural and individualized response to different losses, but if grief persists or becomes pathological, professional interventions are required. Grief and corresponding interventions have received increasing attention, as the related concepts have been incorporated into the DSM-5 and ICD-11. Therefore, we conducted a bibliometric analysis to explore the developments in the field of grief intervention research.

Methods

Articles on grief interventions were systematically searched and screened from the Web of Science Core Collection. The retrieved data were analyzed and visualized using VOSviewer and Bibliometrix software for journals, authors, institutions, countries, references, and keywords.

Results

A total of 9,754 articles were included. The number of articles on grief interventions has increased significantly each year since 1990. Death Studies was the journal that published the most articles in this field. We identified 25,140 authors contributed to this research area and these authors were from 123 countries and 6,630 institutions. Boelen PA secured the first position in article production, Columbia University emerged as the most productive affiliation and the United States was the foremost leading in grief intervention research. The prevalent keywords utilized in this field comprised bereavement, grief, death, depression, and palliative care.

Conclusion

The quantity of publications regarding grief interventions is increasing. Although most prior studies have focused on mortality, grief, and health, emerging themes such as COVID-19, grief among workers, and disfranchised grief have drawn increasing attention in recent years. Future studies may focus on investigating the complexities and challenges of grief, including its underlying mechanisms and impact on mental well-being.

A Longitudinal Study of the Impact of a Suicide Bereavement Service on People Bereaved by Suicide

Whilst the body of research on the impacts of suicide bereavement interventions continues to grow, there is little understanding of the impact over time. This study measured changes in suicidality, levels of loneliness and grief reactions over time between those receiving support from a community-based suicide bereavement service (StandBy) compared with those that did not receive this support. Data were collected through an online survey with participation at baseline being varying times post loss, and three-months post-baseline (StandBy n = 174, Comparison n = 322). Statistical analysis included linear mixed-effects modelling for repeated measures. Results were consistent with earlier studies showing the positive impact of StandBy on participants' grief responses, loneliness and suicidality, specifically within the first 12 months after their loss. However, these outcomes were not retained over time, with the exception of suicidality. Further longitudinal studies consisting of more than two time-points and a greater period between time-points is warranted.

Suicide postvention for staff and students on university campuses: a scoping review

OBJECTIVE

To examine current knowledge about suicide bereavement and postvention interventions for university staff and students.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY

We conducted systematic searches in 12 electronic databases (PubMed, PsycINFO, MEDLINE, CINAHL, Africa-Wide Information, PsycARTICLES, Health Source: Nursing/Academic Edition, Academic Search Premier, SocINDEX through the EBSCOHOST platform; Cochrane Library, Web of Science, SCOPUS), hand searched lists of references of included articles and consulted with library experts during September 2021 and June 2022. Eligible studies were screened against the inclusion criteria independently by two reviewers. Only studies published in English were included.

DATA EXTRACTION AND SYNTHESIS

Screening was conducted by two independent reviewers following a three-step article screening process. Biographical data and study characteristics were extracted using a data extraction form and synthesised.

RESULTS

Our search strategy identified 7691 records from which 3170 abstracts were screened. We assessed 29 full texts and included 17 articles for the scoping review. All studies were from high-income countries (USA, Canada, UK). The review identified no postvention intervention studies on university campuses. Study designs were mostly descriptive quantitative or mixed methods. Data collection and sampling were heterogeneous.

CONCLUSION

Staff and students require support measures due to the impact of suicide bereavement and the unique nature of the university context. There is a need for further research to move from descriptive studies to focus on intervention studies, particularly at universities in low-income and middle-income countries.

Measuring Vulnerability in Grief: The Psychometric Properties of the Italian Adult Attitude to Grief Scale

Although experiences of loss and the consequent grief are natural in human life, some individuals may have difficulty managing these events, to the point of developing significant impairment in their functioning in important life areas. Given this, the present research aimed to explore the psychometric properties of the Italian version of the Adult Attitude to Grief scale (AAG) to facilitate research on adult vulnerability to grief among Italian-speaking populations. A sample of 367 participants (M_age = 30.44, SD = 11.21; 78% females) participated in this research. A back-translation procedure was implemented to develop the Italian AAG. Then, participants completed the Italian AAG alongside a battery of other self-report psychometric scales in order to assess aspects of the construct validity of the AAG: the Forty-Item Defense Style Questionnaire, the Impact of Event Scale-Revised, and the Beck Depression Inventory-II. A bifactor structure was found to have the best fit to the data, supporting the possibility of using both the general factor (i.e., vulnerability) and three dimensions (i.e., overwhelmed, controlled, and resilient). Unlike the original version, the control dimension emerged as a "protective" factor in the Italian population, together with the resilient factor. Furthermore, results provided satisfactory indications of internal consistency and construct validity. In conclusion, the Italian AAG was shown to be a valid, reliable, quick, and easy-to-use scale that can be used both for research and clinical practice in the Italian context.

The relationship between suicide bereavement and suicide ideation: Analysis of the mediating effect of complicated grief

People who have experienced suicide bereavement within social relationships are known to have high risk for suicide, which means that their suicide ideation is high. However, little is known about how suicide bereavement leads to suicide ideation. Therefore, this study aims to understand the pathway of suicide bereavement on suicide ideation by analyzing the mediating effect of complicated grief, which does not abate over time and is known to be highly related to suicide ideation. Data of 1224 people aged 19 or older with bereavement (636 bereaved by suicide and 585 by other causes) were obtained from the Longitudinal study on Suicide Survivors' Mental Health (LoSS) WAVE I [2015-2018], the first nationally-representative longitudinal study in South Korea. Suicide ideation, the dependent variable, was measured by the Scale for Suicide Ideation (SSI), and complicated grief, severe grief that does not abate over time, was measured by the Korean version of the Inventory of Complicated Grief (K-ICG). The results show that suicide bereavement was found to have a significant effect on suicide ideation, and that complicated grief plays a mediating role in the path of suicide bereavement to suicide ideation (Effect = 0.667, [0.387, 0.981]). Based on these findings, clinical and policy suggestions were discussed to understand and prevent suicide ideation of people with suicide bereavement.

Creation and validation of a high-fidelity simulation scenario for suicide postvention

OBJECTIVE

to create and validate a high-fidelity simulation scenario about the initial support to suicide bereaved people.

METHOD

a methodological research study to create and validate a simulation scenario about postvention. Its creation was based on scientific recommendations, the validation process was carried out by experts, based on an instrument developed by the authors; the data were statistically analyzed using the Content Validity Index and Gwet concordance coefficient.

RESULTS

the scenario was created to provide initial support to suicide bereaved people in the Primary Health Care context. As learning objectives, welcoming, health care and organization monitoring were proposed according to technical-scientific recommendations. The scenario was validated by 10 specialists in the themes of postvention (5 judges) and high-fidelity simulation (5 judges). The scenario items met the acceptance and reliability criteria (Content Validity Index = 0.80) and satisfactory concordance (Gwet coefficient = 0.640).

CONCLUSION

the study presented in full a scenario on postvention with innovative potential that can be used free of charge in clinical simulation development during training of different categories of health professionals, to act in support of suicide bereaved people.

Use of Health Services and Support Resources by Immediate Family Members Bereaved by Suicide: A Scoping Review

The knowledge on health service use, systematic follow-up, and support for families bereaved by suicide remains scarce. This scoping review includes studies from 2010 to March 2022 that investigate the follow-up and support offered by health services, peer support services, and other resources available (e.g., internet-based resources) for families bereaved by suicide. We followed the scoping review framework provided by the Johanna Briggs Institute and performed a double-blinded screening process using Covidence. Data were extracted by four researchers and a thematic analysis was performed to summarize the results. The PRISMA Extension for Scoping reviews was used for reporting results. Of 2385 studies screened by title, 190 by abstract, and 93 by full-text reading, we included 63 original articles of which 24, 29 and 10 were quantitative, qualitative, or mixed-methods studies, respectively. The review shows that we have some knowledge about the need for, and experiences with, health services and support resources for immediate family members bereaved by suicide, but a lack of knowledge about their help-seeking behaviour, patient pathways, systematic follow-up, coordination between services, and long-term outcomes. We need more longitudinal observational studies of health service use and patient trajectories for people bereaved by suicide.

Coping with suicide loss: a qualitative study in primary health care

Aim:

To analyze how people cope with suicide loss and the implications for primary health care.

Background:

Previous studies have shown that primary health care will often be an initial source of support for those bereaved by suicide.

Methods:

We included adult persons who were ready to talk about a suicide completed by a person they knew well (family member or close friend). Participants were recruited via mixed media (television, radio, print, social media, etc.). Altogether, we conducted 37 individual interviews, which were recorded using a dictaphone and lasted from 46 to 158 min. The interviews were transcribed verbatim and analyzed using a content analysis method. The interviewees were mostly women (n = 27) and family members (n = 28) of a person who had died by suicide during the years 2012–2018.

Findings:

We identified two main themes in the data: supporters and barriers in support. Coping with suicide takes time, and support was mostly found among friends and family. Support from GPs was mentioned in the context of diagnosing medical problems and prescribing medicines. Respondents indicated that feeling ashamed and a lack of trust impeded their willingness to seek help from their GP. Unmet needs among the bereaved may increase their risk of diminished mental health outcomes. Thus, primary health care practitioners may have a substantial opportunity to support those who are bereaved by suicide.

Conclusion:

Primary care providers have an opportunity to provide bereavement support among their patients. Continuing medical education regarding the needs of the bereaved and a coordinated approach among primary care practitioners may be useful to proactively identifying and supporting those in need.

Silence and Sounds: An Autoethnography of Searching for Spirituality during Suicide Bereavement in Life and Research

In this article, I used autoethnography to describe and analyze my experience of being bereaved by suicide and researching spirituality during suicide bereavement. The culture silenced my grief, and this is congruent with the experiences of my research participants. The religious community, in my case, did not help me and added to my spiritual and psychological pain. The silenced parts of my loss started to make sounds, such as psychological disturbances, but also as unconscious and conscious choices, which led to immersing myself in the research of spirituality during suicide bereavement. Research on the topic goes hand in hand with my search for spirituality during suicide bereavement and reviewing my loss. My story suggests that despite the negative experiences with Catholic priests, spirituality during suicide bereavement can become a vital resource to find meaning for the loss and the pain of grief and can take many different and even unexpected forms.

Efficacy of an online-group intervention after suicide bereavement: A randomized controlled trial

Introduction

People bereaved by suicide are at high-risk for developing mental disorders and suicidal tendencies. Grief after suicide differs from grief after other types of death, and bereaved persons may require support tailored to their situation. In this study, we evaluate an online intervention for individuals bereaved by suicide and its effectiveness on mental health.

Methods

A total of 140 participants were included in the intervention and randomized to either the treatment or the waitlist control group. The intervention consisted of 12 weekly modules, based on cognitive-behavioral methods, and took place as a webinar in a group format. Primary outcomes were depression and suicidality; secondary outcomes were symptoms of prolonged grief, PTSD, posttraumatic cognitions, hopelessness, and grief-specific symptoms.

Results

Symptoms of posttraumatic avoidance improved significantly in the intention-to-treat analyses (d between = 0.43) and in treatment completers (d between = 0.56), posttraumatic intrusion improved in treatment completers (d between = 0.50) compared to the waitlist control group. In the intervention group, psychopathological symptoms decreased significantly from baseline to 6-month follow-up. Furthermore, factors such as higher scores of depression, grief, suicide ideation, and posttraumatic stress symptoms were identified at baseline, which impacted the effectiveness of the intervention.

Conclusions

The results of this study indicate that completing an online group intervention for the suicide bereaved could reduce trauma-related outcomes. However, the waiting control group also improved significantly from pre- to post-measurement in all other outcomes. Future studies with active control groups are needed to further examine the effectiveness.

Psychosocial Outcomes of Individuals Attending a Suicide Bereavement Peer Support Group: A Follow-Up Study

Individuals bereaved by suicide represent an important group in terms of postvention. While peer support groups are often accessed by those bereaved, few studies have examined their impact in terms of physical and mental health wellbeing. The aim of this study was to examine psychosocial outcomes of individuals attending suicide bereavement peer support groups in Ireland. Between August 2020 and June 2021, all members were invited to complete a survey, with new members also surveyed at three- and six-month follow-up, to examine changes in wellbeing, depressive symptoms and grief reactions. Results were analyzed using descriptive statistics and mixed linear regression models. The 75 participants were mostly female, with lower levels of overall wellbeing and a higher prevalence of depressive symptoms and suicidal ideation than the general population. Participants also reported high levels of social adjustment difficulties and grief reactions, which were more pronounced for those more recently bereaved. At follow-up (n = 28), a significant improvement in wellbeing and a reduction in grief reactions were found, adjusting for time since bereavement. Participants identified the groups as creating a safe space and providing a sense of belonging and hope. Notwithstanding the small number of participants at follow-up, these findings underline the enduring mental health challenges for those bereaved by suicide and provide further evidence for the role of peer support in postvention.

Scoping Review of Peer-Led Support for People Bereaved by Suicide

Suicide bereavement support groups are a widely available format of postvention service. Although other reviews have addressed peer-led bereavement interventions, no review has focused specifically on peer-led support for people bereaved by suicide. Informed by a framework for undertaking scoping reviews, we conducted a systematic review according to PRISMA-ScR guidelines. Searches conducted in May 2021 of peer-reviewed literature in MEDLINE (EBSCO), CINAHL Complete (EBSCO), PsycINFO (EBSCO), EMBASE (Elsevier), AMED (EBSCO), ERIC (EBSCO), Web of Science (Core Collection), ASSIA (Proquest), and Global Index Medicus. The search was not limited by language, and all studies were included to full text screening. The search identified 10 studies conducted between 1994 and 2020 in five countries. The selected papers were subjected to quality assessment. The interventions included face-to-face groups, telephone and online groups/forums and were evaluated using a variety of methodologies, which made comparison and synthesis challenging. Thematic analysis resulted in four themes: motivation, impact, aspects of intervention which hindered/enhanced outcomes, and recommendations for the practice of peer support made by the authors. While there were methodological limitations to most studies included in this review; the studies do indicate the potential benefit of peer-led support to those bereaved through suicide. Future studies should provide a definition of 'peer' and a clear description of the intervention being evaluated. As the field matures there is a need for more rigorous evaluation of peer interventions with representative samples, studies that compare the impact of various types of peer interventions, and studies of the peer group processes.

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.

Sobreviventes enlutados por suicídio e as possibilidades para posvenção no contexto da saúde pública brasileira

Resumo Após um suicídio, diversas pessoas são afetadas negativamente. Muitos dos denominados sobreviventes enlutados, em algum momento, precisarão de cuidados e apoio, a conhecida posvenção do suicídio. O objetivo deste estudo é discutir as suas possibilidades no contexto da saúde pública brasileira. Metodologicamente, o texto configura-se como um ensaio teórico apoiado na literatura da área, assim como em documentos institucionais e marcos legais. No cenário internacional, a posvenção do suicídio está mais bem estruturada do que no Brasil que, atualmente, tem o enfoque em grupos de apoio aos sobreviventes enlutados centrados em organizações não governamentais. É preciso lançar o olhar para os serviços de saúde de base territorial e comunitária, a exemplo dos Centros de Atenção Psicossocial, e vislumbrar ações de posvenção acessíveis e resolutivas, como as linhas telefônicas gratuitas de acolhimento, as visitas domiciliares precoces, as escutas terapêuticas e o aconselhamento para o luto.

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.

Spirituality and Religiosity during Suicide Bereavement: A Qualitative Systematic Review

A loved one’s loss to suicide can be a traumatic experience and trigger a difficult grief process, identity changes, a loss of the sense of meaning and a spiritual crisis. Spirituality and/or religiosity (S/R) can be both an important resource and a source of stigmatisation during suicide bereavement. This study aims to synthesise the extant findings about S/R during suicide bereavement in qualitative studies. After an exhaustive selection of articles, the current review utilised a total of 484 citations and seven studies. A thematic synthesis yielded five major themes related to S/R during suicide bereavement: the need to be helped by the religious community without being judged; S/R-related experience of the deceased as a figure who continues to exist; S/R experienced without a conscious choice; conscious reach towards S/R themes; not relating to S/R during suicide bereavement. These findings indicate that the role of S/R during suicide bereavement is complex and varies from providing help to serving as a source of suffering. Hence, practitioners and religious communities should be mindful of the S/R themes during suicide bereavement.

A Narrative Review of Suicide: Aiming at a More Encompassing Understanding

The suicide experience combines despair with the perception of suicide as the last option to alter its suffering effectively and actively. Shneidman’s phenomenology understands the suicidal mind in terms of psychological pain, as opposed to focusing on the individual context. This article aims to meet and review information from articles and books published in the area of the Phenomenology of Suicide, mostly between 2017 and 2021. By integrating and relating the different philosophical perspectives of the patient, his or her family, and the mental health worker, it is intended to identify emotions that are common to different groups affected by suicide, regardless of the context, experiences, and means used to commit suicide. The phenomenological description of self-determination experienced in suicide helps to improve the understanding of the suicidal mind, which can be useful in understanding questions that relate to issues such as assisted suicide and suicide prevention. The management of post-suicide consequences, especially the stigma, a cross-cutting challenge for all these groups, benefits from the specialized support of health professionals, either through psychotherapy and pharmacotherapy or support groups.

Physician Suicide Prevention and the Ethics and Role of a Healing Community: an American College of Physicians Policy Paper

Suicide is a major global public health issue, and in recent years, there has been increasing recognition of the problem of physician suicide. This American College of Physicians policy paper examines, from the perspective of ethics, the issues that arise when individuals and institutions respond to physician suicides and when they engage in broader efforts aimed at physician suicide prevention. Emphasizing the medical profession as a unique moral community characterized by ethical and professional commitments of service to patients, each other, and society, this paper offers guidance regarding physician suicide and the role of a healing community. The response to an individual physician suicide should be characterized by respect and concern for those who are grieving, the creation of a supportive environment for suicide loss survivors, and careful communication about the event. Because suicide is a complex problem, actions aimed at preventing suicide must occur at the individual, interpersonal, community, and societal levels. The medical community has an obligation to foster a culture that supports education, screening, and access to mental health treatment, beginning at the earliest stages of medical training.

From virtual to real healing: a critical overview of the therapeutic use of virtual reality to cope with mourning

In recent years, virtual reality (VR) has been effectively employed in several settings, ranging from health care needs to leisure and gaming activities. A new application of virtual stimuli appeared in social media: in the documentary ‘I met you’ from the South-Korean Munhwa Broadcasting, a mother made the experience of interacting with the avatar of the seven-year-old daughter, who died four years before. We think that this new application of virtual stimuli should open a debate on its possible implications: it represents contents related to grief, a dramatic and yet natural experience, that can have deep psychological impacts on fragile subjects put in virtual environments. In the present work, possible side-effects, as well as hypothetical therapeutical application of VR for the treatment of mourning, are discussed.

Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment

Losing a loved one is one of life's greatest stressors. Although most bereaved individuals navigate through a period of intense acute grief that lessens with time, approximately 10% will develop a prolonged grief condition. This review provides an overview of the course of grief and describes risk factors for developing prolonged grief disorder. The evolution of the prolonged grief disorder diagnosis, including the latest criteria sets for ICD-11 and DSM-5, as well as common comorbid conditions and differential diagnosis are discussed. Clinically useful self-report and clinician-rated measures for assessing symptom constructs and overall prolonged grief disorder severity, evidence-based psychotherapies (such as complicated grief treatment), as well as evidence about pharmacologic approaches are presented. Finally, the authors discuss important future directions, including a potential increase in prolonged grief disorder cases due to the COVID-19 pandemic.

Bearing witness: A grounded theory of the experiences of staff at two United Kingdom Higher Education Institutions following a student death by suicide

Wider networks of people are affected by a suicide death than originally thought, including those whose job-role brings them into contact with a death by suicide of another person. The impact of student suicide within United Kingdom (UK) Higher Education Institutions (HEIs) is unexplored and the experiences of staff members remain unknown. It is not known whether staff members have specific postvention needs following a student death by suicide. Any postvention support currently offered to staff members within UK HEIs lacks a context-specific evidence base. This study asked 'How is a student suicide experienced by staff members within a UK HEI and what are the features of that experience?' Staff members from diverse job-roles in two UK HEIs responded to a qualitative survey (n = 19) and participated in semi-structured interviews (n = 10). Data were transcribed and subjected to a constructivist grounded theory analysis. Participants' experiences informed the development of a core category: 'Bearing witness', which encompassed six further categories: 'Responding to a student suicide'; 'Experiencing a student suicide'; 'Needs and fears'; 'Experiences of support'; 'Human stories'; and 'Cultural stories'. The resulting grounded theory demonstrates how participants' perceptions of impact are informed by their experiences of undertaking tasks following a student suicide within the community of their HEI. Processes of constructing perceptions of closeness to the student who died are evident amongst participants who did not know the student prior to their death. Tailored postvention support is required to respond to the range and complexity of HEI staff needs following a student death by suicide.

Live-Chat Support for People Bereaved by Suicide

Background: People bereaved by suicide often face isolation, complicated grief, and increased suicide risk. Aims: We aimed to explore how live-chat can support survivors in their bereavement process. Method: A thematic analysis was carried out on 30 live-chat conversations through the software ATLAS.ti8. Transcripts were retrieved from a major Italian association providing online support. The users had different ages (18-60 years), degrees of kinship with the deceased (blood-related and not), and time distance from the loss (between 48 hr and 10 years). Results: Five themes were identified: meaning-making, reactions to the loss, resources, needs, and interactions with the operator. Survivors used the live-chat as a safe space in which to disclose nonsocially desirable details and to make sense of suicide through the reconstruction of events and the deceased's motivations. Given the limited social resources and the dissatisfaction with the available formal support, users resorted to justification, rationalization, or faith and found support and reassurance in the live chats. Limitations: Some conversations were fragmented and lacked detailed information on the users. Conclusion: Because of their anonymity and accessibility, live-chats represent a valid first-line form of support, from which survivors may obtain useful information and start a meaning-making process.

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.

A Narrative Evaluation of a Grief Support Camp for Families Affected by a Parent's Suicide

Background: Children of parents who suffer mental ill-health and die by suicide are vulnerable to developing psychological and social problems themselves; they also have a severely elevated risk of dying at a young age - particularly through suicide. This highlights the need to design supportive measures that can counteract such negative developments after a parent's suicide. Aim: This narrative evaluation of a grief support camp for families affected by a parent's suicide arranged by the non-profit organization Children's Rights in Society in Sweden investigates whether children [N = 11] and parents [N = 11] perceived their participation as meaningful and, if so, in what way, and the changes to which the program was said to have contributed. Methods: Family members were invited to reflect on their experiences in narratively structured interviews that took place 18 months after participation. Their narrated experiences were analyzed to examine how the program was integrated into their biographies and with what significance. Narratives of change were identified in particular in order to grasp the self-perceived effects of participation. Results: Both children and parents attributed major significance to their encounters with other suicide bereaved. This led to support exchange and normalization, which countered a perceived "suicide stigma" in everyday life. Help to narratively construct destigmatizing understandings of suicide was also said to have relieved self-blame and shame. Overall, the participants described changes in the form of a better-informed position in grief, increased manageability and enhanced family communication. The parents also reported improved ability to support their children and a more hopeful view of life ahead. Conclusion: The evaluation showcases how this psychoeducational intervention, at a relatively low cost compared to traditional approaches, has great potential to lessen the negative effects of a suicide in the family by assisting families with psychological processing and de-stigmatization. Parental resources are also strengthened, which can serve as continuing support for the children.

Efficacy of an Internet-based cognitive-behavioural grief therapy for people bereaved by suicide: a randomized controlled trial

Background: The loss of a loved one due to suicide can be a traumatic event associated with prolonged grief and psychological distress. Objective: This study examined the efficacy of an Internet-based cognitive-behavioural grief therapy (ICBGT) specifically for people bereaved by suicide. Methods: In a randomized controlled trial, 58 participants with prolonged grief disorder (PGD) symptoms who had lost a close person to suicide were randomly allocated either to the intervention group (IG) or waitlist-control group (WCG). The 5-week intervention comprised ten writing assignments in three phases: self-confrontation, cognitive restructuring, and social sharing. Symptoms of PGD, common grief reactions after suicide, depression, and general psychopathology were assessed at pre-, post-test and follow-up. Results: Between-group effect sizes were large for the improvement of PGD symptoms in treatment completers (d_ppc2 = 1.03) and the intent-to-treat analysis (d_ppc2 = 0.97). Common grief reactions after suicide and depressive symptoms also decreased in the IG compared to the WCG (moderate to large effects). The results are stable over time. Only for general psychopathology, there was no significant time by group interaction effect found. Conclusions: The ICBGT represents an effective treatment approach for people suffering from PGD symptoms after bereavement by suicide. Considering the effect sizes, the small treatment dose, duration, and the stability of the results, the ICBGT constitutes an appropriate alternative to face-to-face grief interventions.

The "men in grief" phenomenon among suicide bereaved Chinese men in Hong Kong

This qualitative study addressed the intersectionality between masculine grief and gender role expectations during the grief process among men. The sample comprised 10 Chinese men in Hong Kong who had lost their wife or child to suicide. The study found that the "men in grief" phenomenon comprised three themes: making sense of hidden grief, processing grief-related guilt, and removing the stigma of masculine grieving. Future research on the masculine grieving process can focus on the association between perceived weaknesses and expected help-seeking behaviors in men who experience multiple losses after a suicide death in the family.

What is known about the health service use and follow-up of immediate family members bereaved by suicide? Scoping review protocol

INTRODUCTION

Suicide remains a major public health issue around the world. People bereaved by suicide are a vulnerable group who are at considerable risk of developing mental and physical health problems, such as complicated grief, post-traumatic stress disorder or cardiovascular disease. Many unanswered questions remain, in particular, in terms of their use of healthcare services. This protocol describes how we aim to systematically scope the existing literature on the professional follow-up and health service use by families bereaved by suicide. The scoping review will help to identify research gaps in the literature and aid in the planning and commission of future research. We will provide a summary of research findings.

METHODS AND ANALYSIS

We will use the scoping review framework provided by the Joanna Briggs Institute. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews will be used as a guide for reporting our results. We plan to conduct an extensive literature search using relevant health-related databases (MEDLINE, Embase, PsycINFO and CINAHL) and Web of Science. Two independent reviewers will screen the articles in a two-stage process: (1) titles and abstracts and (2) full-text documents.

ETHICS AND DISSEMINATION

This scoping review will identify and consider only previously published research. Hence, no ethical approval is considered necessary. We will disseminate the results in a scientific journal and at conferences, as well as through user organisations for people bereaved by suicide and social media.

Being pro-active in meeting the needs of suicide-bereaved survivors: results from a systematic audit in Montréal

BACKGROUND

Suicide is a major public health concern. In 2017, the suicide rate in Canada was 11 per 100,000 inhabitants. According to literature, 1 in 5 people have experienced a death by suicide during their lifetime. The aim of this study was to describe the met and unmet needs of suicide-bereaved survivors and to provide postvention recommendations.

METHODS

Further to an exploratory mixed-method audit of 39 suicides that occurred in Montreal (Canada) in 2016, suicide-bereaved survivors (n = 29) participated in semi-structured interviews and completed instruments to discuss and assess potential pathological grief, depression (PHQ-9), and anxiety (GAD-7), as well as health and social services utilization. A panel then reviewed each case and provided recommendations. The mean age of participants was 57.7 years and 23 were women.

RESULTS

Although help was offered initially, in most cases by a health professional or service provider (16/29), 22 survivors would have liked to be contacted by telephone in the first 2 months post suicide. Four categories of individual unmet needs (medical/pharmacological, information, support, and outreach) and one collective unmet need (suicide pre/postvention training and delivery) emerged.

CONCLUSIONS

Although Quebec provincial services have been developed and offered to suicide-bereaved survivors in the past decade, many dwindled over time and none has been applied systematically. Recommendations for different stakeholders (Ministry of Health and Social Services, coroners, NGOs, and representatives of suicide-bereaved survivors) outlined in this study could be an interesting first step to help develop a suicide pre/postvention strategy.

Online cognitive-behavioural therapy for traumatically bereaved people: study protocol for a randomised waitlist-controlled trial

INTRODUCTION

The traumatic death of a loved one, such as death due to a traffic accident, can precipitate persistent complex bereavement disorder (PCBD) and comorbid post-traumatic stress disorder (PTSD) and depression. Waitlist-controlled trials have shown that grief-specific cognitive-behavioural therapy (CBT) is an effective treatment for such mental health problems. This is the first study that will examine the effectiveness of online CBT (vs waitlist controls) in a sample exclusively comprised of people bereaved by a traumatic death. Our primary hypothesis is that people allocated to the online CBT condition will show larger reductions in PCBD, PTSD and depression symptom levels at post-treatment than people allocated to a waitlist. We further expect that reductions in symptom levels during treatment are associated with reductions of negative cognitions and avoidance behaviours and the experience of fewer accident-related stressors. Moreover, the effect of the quality of the therapeutic alliance on treatment effects and drop-out rates will be explored.

METHODS AND ANALYSIS

A two-arm (online CBT vs waiting list) open-label parallel randomised controlled trial will be conducted. Participants will complete questionnaires at pretreatment and 12 and 20 weeks after study enrolment. Eligible for participation are Dutch adults who lost a loved one at least 1 year earlier due to a traffic accident and report clinically relevant levels of PCBD, PTSD and/or depression. Multilevel modelling will be used.

ETHICS AND DISSEMINATION

Ethics approval has been received by the Medical Ethics Review Board of the University Medical Center Groningen (METc UMCG: M20.252121). This study will provide new insights in the effectiveness of online CBT for traumatically bereaved people. If the treatment is demonstrated to be effective, it will be made publicly accessible. Findings will be disseminated among lay people (eg, through newsletters and media performances), our collaborators (eg, through presentations at support organisations), and clinicians and researchers (eg, through conference presentations and scientific journal articles).

TRIAL REGISTRATION NUMBER

NL7497.

Lived experience peer support programs for suicide prevention: a systematic scoping review

BACKGROUND

Peer-led support models have gained increasing popularity in suicide prevention. While previous reviews show positive effects of peer-led support for people with mental health problems and those bereaved by suicide, little is known about the types of lived experience peer support programs in suicide prevention and whether these are effective in improving the health and wellbeing of people at risk of suicide. The aim of this paper is to provide an overview of peer support programs that aim to reduce suicidality and are led by people with lived experience of suicide.

METHOD

We conducted a systematic scoping review, involving a search of three academic (Medline, PsycINFO, Embase) and selected grey literature databases (Google Scholar, WHO Clinical Trials Registry) for publications between 2000 and 2019. We also contacted suicide prevention experts and relevant internet sites to identify peer support programs that exist but have not been evaluated. The screening of records followed a systematic two-stage process in alignment with PRISMA guidelines.

RESULTS

We identified 8 records accounting for 7 programs focussed on peer-led support programs in suicide prevention. These programs employed a range of different designs and included a variety of settings (schools, communities, rural and online). Only 3 of the 7 programs contained data on effectiveness. With the small number of eligible programs the findings from this review are limited and must be interpreted with caution.

CONCLUSIONS

Despite the increased focus of policymakers on the importance of peer support programs in suicide prevention, our scoping review confirms an evidence gap in research knowledge regarding program design, implementation, and effectiveness. More rigour is required in reporting peer-led support initiatives to clarify the underlying definition of peer support and lived experience and to enhance our understanding of the types of current peer support programs available to those experiencing suicidality. Further, we need formal and high-quality evaluations of peer support suicide prevention programs led by people with lived experience to better understand their effectiveness on participant health across different settings and delivery modalities and to allow for comprehensive systematic reviews and meta-analysis in future.

A systematic review of studies describing the influence of informal social support on psychological wellbeing in people bereaved by sudden or violent causes of death

BACKGROUND

Whilst any type of bereavement can be traumatic, bereavement through violent or sudden causes is associated with more severe negative health and wellbeing outcomes compared to other types of loss. Social support has been found to have a positive impact on wellbeing after traumatic events in general. However, this association appears to be less consistently demonstrated in studies that focus on bereavement, and the literature in this area has not yet been systematically reviewed. This study aimed to review the international literature to examine systematically whether there is an association between informal social support from family and friends after bereavement through sudden and/or violent causes and post-bereavement wellbeing.

METHODS

We conducted a systematic search for quantitative studies that tested for an association between social support and any outcome related to wellbeing after a sudden and/or violent loss. Included studies were assessed for quality, and findings were reported using the approach of narrative synthesis. The review was pre-registered on Prospero (registration number CRD42018093704).

RESULTS

We identified 16 papers that met inclusion criteria, 11 of which we assessed as being of good or fair quality and 5 as poor quality. Fifteen different wellbeing outcomes were measured across all studies. We found consistent evidence for an inverse association between social support and symptoms/presence of depression, predominantly consistent evidence for an inverse association between social support and symptoms/presence of post-traumatic stress disorder (PTSD), and conflicting evidence for an inverse association between social support and symptoms/presence of complicated grief.

CONCLUSIONS

Our systematic review identified evidence to suggest that social support after sudden or violent bereavement is associated with a reduced severity of depressive and PTSD symptoms. Further longitudinal research is needed to explore potential causality in this relationship, widening the focus from common mental disorders to include other mental illnesses, wellbeing outcomes, and suicide-related outcomes after bereavement. There is also a need for consensus on the conceptualisation and measurement of social support. Our findings imply that interventions to improve access to and quality of social support may reduce the burden of mental illness after bereavement, and may therefore be worth investing in.

The Influence of Stigma on Suicide Bereavement: A Systematic Review

Suicide loss affects a significant proportion of the population, and despite its prevalence there remains a stigma surrounding death by suicide. It is important for health professionals to understand the effects of suicide stigma on surviving friends and family members so that they can respond appropriately and provide effective support. A systematic review of the literature was conducted to evaluate the impact of public stigma on bereavement of suicide survivors. A total of 11 qualitative and quantitative studies were reviewed. Suicide survivors reported feeling shamed, blamed, and judged. They perceived a general discomfort and awkwardness surrounding the suicide, which contributed to avoidance and secrecy. Higher perceived stigma levels were associated with global psychological distress, depression, self-harm, and suicidality. Despite the recognized negative impact of suicide stigma on the bereaved, studies on grief interventions for suicide survivors are scarce. There is a critical need for research and evidence-based recommendations on how to best to support this vulnerable population. [Journal of Psychosocial Nursing and Mental Health Services, 58(4), 21-27.].