Bereavement by suicide

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Presentation from the International Congress of the Royal College of Psychiatrists 24-27 June 2014, London

Transcript of Bereavement by suicide

  • 1. Bereavement by suicide: an emergent risk factor for suicide & mental health problems Wednesday 25th June 2014 International Congress of the Royal College of Psychiatrists Barbican Centre, London Dr Alexandra Pitman Clinical Research Fellow UCL Division of Psychiatry

2. Policy-making & evidence 2008 systematic review 2014 systematic review first clinical concerns published DH 2002 DH 2012 paper paper paper paper paper paper paper 3. Clinical background clinical impression that suicide bereavement has more damaging psychosocial impact task of grieving a loss extra burden of: horror of a violent death agonizing self-questioning blaming oneself & others concealing the cause stigma (Cvinar, 2005) 4. Cultural background cultural taboo around violent deaths stigma associated with suicide (Harwood et al, 2002) people crossing the road to avoid the bereaved few sympathy cards blaming attitudes embarrassment disgust fear of violating social rules 5. Theoretical basis Factors thought to elevate risk of suicidality in SB: heritability self-fulfilling prophecy assortative mating & relating shared environments social modelling depression lack of support reduced helpseeking 6. Exposure to suicide bereavement 6 - 425 people affected by each suicide best estimate: 20 family, 20 friends, 20 colleagues = 60 total (Berman, 2011) UK incidence: 350,000 4.5 million people Worldwide incidence: 48-500 million people 7. Suicide prevention strategy since 2002 Department of Health, 2002 U.S. Department of Health & Human Services, 2001 8. Featured risk factors for suicide past suicide attempt & NSSI male gender age specific occupational groups bereavement by suicide psychiatric illness substance misuse recent psychiatric discharge prisoners specific ethnic groups 9. International suicide prevention strategies support for people bereaved by suicide 10. 1st systematic review (2008) few differences between people bereaved by suicide & other causes in relation to: general mental health depression, PTSD, anxiety suicidal ideation suicide-bereaved group reported: stigma blame rejection (Sveen & Walby, 2008) 11. Problems with the evidence base many have methodological problems small convenience samples not hypothesis-driven numerous unstandardized measures mainly US and Canada ?generalisability 12. October 2013 systematic review (Pitman et al, 2014) 13. Method inclusion criteria: bereavement by suicide (confirmed relationship) bereaved control group primary data, any recorded outcomes English language 4 databases: Medline, CINAHL, PsycINFO, EMBASE secondary searching of references cited identified 7,504 records n = 57 studies eligible for inclusion 14. Results Partners Parents Offspring Siblings Peers Mixed kinship groups Strong evidence Weak evidence 15. Partners bereaved by suicide risk suicide in SB women and men vs partners death by other causes (Agerbo 2005) 9 studies found no apparent differences in: depression psychopathology grief 16. Parents bereaved by offspring suicide: Europe risk suicide in SB mothers vs other causes (Qin & Mortensen, 2003) no differences in suicide risk in SB parents vs other causes (Agerbo 2005) no differences in risk of grief or distress between SB parents & those bereaved by accidental death (Dyregrov et al 2003) 17. Parents bereaved by offspring suicide: Canada no differences between SB parents & those bereaved by accidental death in risk of: suicide attempts specific mental disorders relationship breakdown hardship risk psychiatric admission in SB parents risk depression in SB parents (Bolton et al 2013) 18. Adults bereaved by parental suicide possible risk depression in adults bereaved by maternal suicide compared with maternal non- suicide bereavement (Kessing et al 2003) no apparent differences in depression in offspring bereaved by paternal suicide compared with paternal non-suicide bereavement (Kessing et al 2003) 19. Children bereaved by parental suicide possible severity of depression in SB schoolchildren compared with schoolchildren bereaved by parental cancer death (Pfeffer et al, 2000) 20. Sibling suicide no apparent differences in depression in adults bereaved by sibling suicide compared with sibling non-suicide deaths (Kessing et al 2003) 21. Peer suicide no studies using bereaved controls 22. Mixed kinship groups compared with bereavement by natural and unnatural causes, SB groups had: self-perceived stigma responsibility shame rejection compared with bereavement by violent causes: rejection shame 23. Similarities between bereavement by suicide and by accidental death n=21 studies found no differences between people bereaved by suicide and those bereaved by sudden violent deaths on measures of: grief intensity stress reactions psychopathology Canadian study found risk depression in parents bereaved by childs RTA death compared with SB (Bolton et al 2013) 24. More recent findings: China Setting: rural China Compared: family members bereaved by suicide to those bereaved by accidental death Primary outcome: Chinese version of SCL-90-R Finding: no sig differences (Xu & Li, 2014) 25. Summary findings risk suicide in partners and mothers risk psychiatric hospitalisation in parents risk of rejection and shame compared to other violent bereavements many similarities to non-suicide violent risk depression in parents 26. Policy implications clear risk of suicide in specific kinship groups justifies inclusion in suicide prevention strategy ? include people bereaved by accidental deaths need to identify best means of offering support 27. Interventions following suicide bereavement heterogeneous group needs vary over time Interventions for the SB: poor evidence base reliance on voluntary sector (Hawton & Simkin, 2003; McDaid et al, 2008; DH, 2010) 28. Research implications: gaps in evidence peer suicide comparing outcomes in specific kinship groups: FSA investigated only in relation to deceased partners & children NFSA investigated only in relation to deceased children specific cultural settings interventional studies focussed on specific groups: bereaved by suicide bereaved by other violent causes 29. Acceptable interventions GP screening peer support voluntary sector