Course of Bereavement in Relatives and Spouses of Suicides
Course of Bereavement in Relatives and Spouses of Suicides
Complicated grief, depression, and suicide ideation are strongly associated in the long term course of bereavement after the suicide of a first degree relative or spouse. A history of clinical depression and/or anxiety and/or previous suicide attempts do not predict long term psychological and psychiatric difficulties after a loss through suicide. Depression is more likely to be predicted by individual factors generally associated with an increased risk of depression than by complicated grief. No help resources were significantly associated with long term symptoms of complicated grief, depression, or suicide ideation, except for mutual support, which was associated with an increased risk of complicated grief. In general, relatives bereaved after suicide recover from their bereavement in the course of time, whereas the magnitude of the change at 13 months is small for both depression and complicated grief.
This study has several limitations. Firstly, because it was performed to investigate the effects of family based cognitive behavioural therapy on the one year course of bereavement, participants who felt a need for help immediately after the loss might be over-represented. This could have introduced selection bias as bereaved people who seek help generally have poorer psychological wellbeing. Help seeking was self reported (yes or no), and, because the number of sessions and the type of therapy administered by help resources (psychiatrist, psychologist, mental health nurse, social worker) remained unknown, this could have introduced some bias. Also the specific contents of mutual support (quantity, timing, group or individual, type of group, active or passive, and type of leadership) have not been assessed. In addition, it should be taken into account that data on mutual support in the first year of bereavement were collected in a period of time before online (mutual) support became generally available. Therefore, it is uncertain whether web based mutual support (the availability of which has accelerated in recent years) also predicts an increased risk of complicated grief. The findings, however, probably concern relatives involved in help seeking, thereby supporting the external validity of these findings. It is unclear whether the dichotomisation of suicide ideation affected the outcome. However, we elected to dichotomise Paykel suicide items, because the distribution of the data of this variable was highly skewed. To facilitate interpretation of this variable, we preferred dichotomisation of this variable rather than transforming it. Consequently, the cut-off point was set at scores >8, indicating considerable suicide ideation. It is unknown whether or how the families who dropped out might have introduced response bias.
Outcomes from our study confirm previous findings of an increased risk of suicidal behaviour in relatives of individuals who kill themselves. Outcomes confirm that depression is more likely to be predicted by individual factors generally associated with an increased risk of depression, such as female sex and lower self efficacy, than by complicated grief. In addition, spouses show higher levels of depression than parents and siblings. This could be explained by difficulties that might arise when a spouse dies, such as financial and/or housing problems and becoming a single parent. Also, participants who lost a spouse might suffer from the loss of support and intimacy of the one they usually share their grief with. Family factors might also have played a role in the onset or maintenance of depression because suicide is known to be strongly associated with mental disorder. Therefore, participants might genetically share a vulnerability for the development of depression with the dead person. Clinical observations between T0 and T1 showed that families in which suicide occurred are sometimes burdened by psychiatric and psychosocial difficulties as well as high conflict, poor cohesion, and poor expressiveness even before the index suicide. These family features are associated with a more adverse bereavement outcome. This hypothesis is compatible with the observed changes in depression scores in our population that are explained by changes within participants, whereas changes in complicated grief are explained by changes within and between participants. Complicated grief seems to be more likely to be predicted by the trauma of losing a child, as also reported by others. Clinical observations showed that parents and siblings receive more social support than spouses, possibly moderating the risk of depression in parents and siblings.
We earlier suggested that a history of psychiatric (co)morbidity before the index suicide increases the risk of psychiatric (co)morbidity after the suicide. We also found that family based cognitive behavioural therapy reduced maladaptive grief reactions, particularly in relatives who had suicide ideation. Given the lack of effect of this therapy on long term complicated grief, this effect seems to be transient. On the other hand, family based cognitive behavioural therapy might provide considerable relief in the initial period of intense grief without causing harm.
Mutual support, sought by 4/153 (6%) at T0 to 26/68 (38%) at T2 throughout the course of bereavement, was associated with an increased risk of complicated grief. In the catchment area, mutual support consisted mainly of small voluntary peer led or clergy led groups and/or individual contacts with peer leaders. We cannot rule out that general practitioners were more likely to include relatives who are at increased risk of complicated grief, and this could explain the positive association between mutual support and complicated grief, whereas relatives who benefited from mutual support might have eluded our view. Compared with relatives with lower symptom levels, those with high symptom levels of complicated grief might be more likely to seek contact with other bereaved relatives to share their grief. Alternatively, individuals who seek mutual support might be inclined to ruminative coping, placing them at risk of avoidance rather than of recovery and thereby increasing the risk of complicated grief. Recovery from bereavement is ultimately considered to be a process of restoration and coming to sense with the reality of the loss. Suicide ideation is characterised by feelings of hopelessness and perceptions that life is not worth living. These feelings and thoughts can inhibit adjustment, which is considered necessary to recover from bereavement. Suicide ideation can interfere with effective emotional processing and therefore increase the risk of complicated grief. It should be emphasised, however, that the outcomes of the prediction models do not allow us to draw conclusions about causal associations between the use of help resources and long term complicated grief and depression. As help seeking is measured on a yes/no scale, it lacks nuance. In particular, the positive association observed between mutual support and an increased risk of complicated grief might suggest that mutual support is iatrogenic; however, this assumption might not be valid. Therefore, the observed positive association between help seeking and complicated grief should be interpreted with caution.
No evidence is available for any interventions in prevention of complicated grief. Negative beliefs about the self and the future are said to be responsible for the onset and maintenance of complicated grief and suicide ideation. One study found that cognitions like "the future holds no meaning or purpose" and "life cannot be fulfilling without the lost" discriminated best between low and high complicated grief, suggesting that similar negative cognitions play a role in the onset of both complicated grief and suicide ideation. This idea might be examined in future research. It would also be useful to determine whether the onset of complicated grief can be prevented by cognitive behavioural treatment of suicide ideation and to study whether suicide ideation is a consequence or a cause of complicated grief. This could be explored in a prospective study among relatives of people who attempt suicide. Possible outcomes could then be generalised to relatives bereaved by causes other than suicide, such as from natural causes, unintentional injury, or homicide.
The association between previous suicide attempts and long term suicide ideation provides support for the stress-diathesis model for suicidal behaviour, proposing that suicidal behaviour is not only determined by a stressor (such as mental disorder, experience of loss), but also by a constitutional predisposition to this type of behaviour. Unfortunately, because low power does not allow us to adjust suicide ideation at 8-10 year follow-up for other variables, the findings should be interpreted with caution.
Our findings support the necessity of assessing the history of suicide attempts in individuals bereaved by suicide to determine the risk of complicated grief and depression in the long term. Over the years, mutual support is associated with an increased risk of complicated grief, suggesting that shortly after a suicide, healthcare providers should be cautious about indiscriminately recommending mutual support to bereaved relatives in case of emerging symptoms of depression, complicated grief, and suicide ideation.
Discussion
Complicated grief, depression, and suicide ideation are strongly associated in the long term course of bereavement after the suicide of a first degree relative or spouse. A history of clinical depression and/or anxiety and/or previous suicide attempts do not predict long term psychological and psychiatric difficulties after a loss through suicide. Depression is more likely to be predicted by individual factors generally associated with an increased risk of depression than by complicated grief. No help resources were significantly associated with long term symptoms of complicated grief, depression, or suicide ideation, except for mutual support, which was associated with an increased risk of complicated grief. In general, relatives bereaved after suicide recover from their bereavement in the course of time, whereas the magnitude of the change at 13 months is small for both depression and complicated grief.
Limitations
This study has several limitations. Firstly, because it was performed to investigate the effects of family based cognitive behavioural therapy on the one year course of bereavement, participants who felt a need for help immediately after the loss might be over-represented. This could have introduced selection bias as bereaved people who seek help generally have poorer psychological wellbeing. Help seeking was self reported (yes or no), and, because the number of sessions and the type of therapy administered by help resources (psychiatrist, psychologist, mental health nurse, social worker) remained unknown, this could have introduced some bias. Also the specific contents of mutual support (quantity, timing, group or individual, type of group, active or passive, and type of leadership) have not been assessed. In addition, it should be taken into account that data on mutual support in the first year of bereavement were collected in a period of time before online (mutual) support became generally available. Therefore, it is uncertain whether web based mutual support (the availability of which has accelerated in recent years) also predicts an increased risk of complicated grief. The findings, however, probably concern relatives involved in help seeking, thereby supporting the external validity of these findings. It is unclear whether the dichotomisation of suicide ideation affected the outcome. However, we elected to dichotomise Paykel suicide items, because the distribution of the data of this variable was highly skewed. To facilitate interpretation of this variable, we preferred dichotomisation of this variable rather than transforming it. Consequently, the cut-off point was set at scores >8, indicating considerable suicide ideation. It is unknown whether or how the families who dropped out might have introduced response bias.
Comparison With Other Studies
Outcomes from our study confirm previous findings of an increased risk of suicidal behaviour in relatives of individuals who kill themselves. Outcomes confirm that depression is more likely to be predicted by individual factors generally associated with an increased risk of depression, such as female sex and lower self efficacy, than by complicated grief. In addition, spouses show higher levels of depression than parents and siblings. This could be explained by difficulties that might arise when a spouse dies, such as financial and/or housing problems and becoming a single parent. Also, participants who lost a spouse might suffer from the loss of support and intimacy of the one they usually share their grief with. Family factors might also have played a role in the onset or maintenance of depression because suicide is known to be strongly associated with mental disorder. Therefore, participants might genetically share a vulnerability for the development of depression with the dead person. Clinical observations between T0 and T1 showed that families in which suicide occurred are sometimes burdened by psychiatric and psychosocial difficulties as well as high conflict, poor cohesion, and poor expressiveness even before the index suicide. These family features are associated with a more adverse bereavement outcome. This hypothesis is compatible with the observed changes in depression scores in our population that are explained by changes within participants, whereas changes in complicated grief are explained by changes within and between participants. Complicated grief seems to be more likely to be predicted by the trauma of losing a child, as also reported by others. Clinical observations showed that parents and siblings receive more social support than spouses, possibly moderating the risk of depression in parents and siblings.
We earlier suggested that a history of psychiatric (co)morbidity before the index suicide increases the risk of psychiatric (co)morbidity after the suicide. We also found that family based cognitive behavioural therapy reduced maladaptive grief reactions, particularly in relatives who had suicide ideation. Given the lack of effect of this therapy on long term complicated grief, this effect seems to be transient. On the other hand, family based cognitive behavioural therapy might provide considerable relief in the initial period of intense grief without causing harm.
Mutual support, sought by 4/153 (6%) at T0 to 26/68 (38%) at T2 throughout the course of bereavement, was associated with an increased risk of complicated grief. In the catchment area, mutual support consisted mainly of small voluntary peer led or clergy led groups and/or individual contacts with peer leaders. We cannot rule out that general practitioners were more likely to include relatives who are at increased risk of complicated grief, and this could explain the positive association between mutual support and complicated grief, whereas relatives who benefited from mutual support might have eluded our view. Compared with relatives with lower symptom levels, those with high symptom levels of complicated grief might be more likely to seek contact with other bereaved relatives to share their grief. Alternatively, individuals who seek mutual support might be inclined to ruminative coping, placing them at risk of avoidance rather than of recovery and thereby increasing the risk of complicated grief. Recovery from bereavement is ultimately considered to be a process of restoration and coming to sense with the reality of the loss. Suicide ideation is characterised by feelings of hopelessness and perceptions that life is not worth living. These feelings and thoughts can inhibit adjustment, which is considered necessary to recover from bereavement. Suicide ideation can interfere with effective emotional processing and therefore increase the risk of complicated grief. It should be emphasised, however, that the outcomes of the prediction models do not allow us to draw conclusions about causal associations between the use of help resources and long term complicated grief and depression. As help seeking is measured on a yes/no scale, it lacks nuance. In particular, the positive association observed between mutual support and an increased risk of complicated grief might suggest that mutual support is iatrogenic; however, this assumption might not be valid. Therefore, the observed positive association between help seeking and complicated grief should be interpreted with caution.
No evidence is available for any interventions in prevention of complicated grief. Negative beliefs about the self and the future are said to be responsible for the onset and maintenance of complicated grief and suicide ideation. One study found that cognitions like "the future holds no meaning or purpose" and "life cannot be fulfilling without the lost" discriminated best between low and high complicated grief, suggesting that similar negative cognitions play a role in the onset of both complicated grief and suicide ideation. This idea might be examined in future research. It would also be useful to determine whether the onset of complicated grief can be prevented by cognitive behavioural treatment of suicide ideation and to study whether suicide ideation is a consequence or a cause of complicated grief. This could be explored in a prospective study among relatives of people who attempt suicide. Possible outcomes could then be generalised to relatives bereaved by causes other than suicide, such as from natural causes, unintentional injury, or homicide.
The association between previous suicide attempts and long term suicide ideation provides support for the stress-diathesis model for suicidal behaviour, proposing that suicidal behaviour is not only determined by a stressor (such as mental disorder, experience of loss), but also by a constitutional predisposition to this type of behaviour. Unfortunately, because low power does not allow us to adjust suicide ideation at 8-10 year follow-up for other variables, the findings should be interpreted with caution.
Conclusions and Policy Implications
Our findings support the necessity of assessing the history of suicide attempts in individuals bereaved by suicide to determine the risk of complicated grief and depression in the long term. Over the years, mutual support is associated with an increased risk of complicated grief, suggesting that shortly after a suicide, healthcare providers should be cautious about indiscriminately recommending mutual support to bereaved relatives in case of emerging symptoms of depression, complicated grief, and suicide ideation.