After suicide


A resource for GPs

Who are the bereaved?

☰ Table of contents


An early pioneer in suicidology, Edwin Shneidman, estimated that for every person who completes suicide, there are six people who suffer from a significant grief reaction.37 Over time, this figure has become stated as fact, however the actual number of people affected is unknown.8,38 Not all suicides have the same impact and the degree of impact is not just a function of ‘closeness’.38
 


When a person dies by suicide, those affected include:

  • family and friends
  • colleagues
  • those involved in his/her clinical care
  • people who appear quite removed from the deceased (eg a person in the community with depression and suicidal thoughts).38
     

 

Therefore, the term ‘bereaved’ may apply to ‘anyone who experiences a high level of self-perceived psychological, physical, and/or social distress for a considerable length of time after exposure to the suicide of another person’.38

If you were involved in the care of the person who has suicided, you might also be affected by suicide bereavement. In this case, you face managing your emotions (eg sense of loss, personal or professional failure), often while needing to provide support to the bereaved family and community members.8

  1. Mindframe National Media Initiative. Facts and stats about suicide in Australia. Australia: Mindframe National Media Initiative, 2016.  [Accessed 1 February 2016].
  2. headspace. School support suicide postvention toolkit. Melbourne: headspace, 2012.
  3. McDowell AK, Lineberry TW, Bostwick JM. Practical suicide-risk management for the busy primary care physician. Mayo Clin Proc 2011;86(8):792–800.
  4. Gutin N, McGann V, Jordan J. The impact of suicide on professional caregivers. In: Jordan J, McIntosh J, editors. Grief after suicide: Understanding the consequences and caring for the survivors. New York: Routledge, 2011.
  5. Public Health England and the National Suicide Prevention Alliance. Help is at Hand: Support after someone may have died by suicide. England: Public Health England and the National Suicide Prevention Alliance, 2010.
  6. Aguirre RT, Slater H. Suicide postvention as suicide prevention: Improvement and expansion in the United States. Death Stud 2010;34(6):529–40.
  7. Andriessen K, Krysinska K. Essential questions on suicide bereavement and postvention. Int J Environ Res Public Health 2012;9(1):24–32.
  8. Suicide Prevention Australia. Position statement: Suicide bereavement and postvention. Leichhardt, NSW: Suicide Prevention Australia, 2009.
  9. Berkowitz L, McCauley J, Schuurman D, Jordan J. Organizational postvention after suicide death. In: Jordan J, McIntosh J, editors. Grief after suicide: Understanding the consequences and caring for the survivors. New York: Routledge, 2011.
  10. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: A review of the evidence. Am J Psychiatry 2002;159(6):909–16.
  11. Denneson LM, Williams HB, Kaplan MS, McFarland BH, Dobscha SK. Treatment of veterans with mental health symptoms in VA primary care prior to suicide. Gen Hosp Psychiatry 2016;38:65–70.
  12. O'Connor M, Breen LJ. General practitioners' experiences of bereavement care and their educational support needs: A qualitative study. BMC Med Educ 2014;14:59.
  13. Krysinska K, Batterham PJ, Tye M, et al. Best strategies for reducing the suicide rate in Australia. Aust N Z J Psychiatry, 2015;50(2):386. doi:10.1177/0004867415620024.
  14. Ghesquiere AR, Patel SR, Kaplan DB, Bruce ML. Primary care providers' bereavement care practices: Recommendations for research directions. Int J Geriatr Psychiatry 2014;29(12):1221–29.
  15. Jordan J, McIntosh J. Is suicide bereavement different? A framework for rethinking the question. In: Jordan J, McIntosh J, editors. 
    Grief after suicide. New York: Roitledge, 2011.
  16. Australian Bureau of Statistics. Causes of death, Australia 2014. Catalogue No. 3303.0. Canberra: Commonwealth of Australia, 2016. [updated 10 March 2016]  [Accessed 1 February 2016].
  17. Australian Bureau of Statistics. Causes of death, Australia 2014. Catalogue No. 3303.0 Canberra: Commonwealth of Australia, 2016 [updated 8 March 2016]. [Accessed 1 February 2016].
  18. Australian Institute of Health and Welfare. Australia's health 2014. Australia's health series no. 14, cat. no. AUS 178. Canberra: AIHW, 2014.
  19. Alston M. Rural male suicide in Australia. Soc Sci Med 2012;74(4):515–22.
  20. Kõlves K, Milner A, McKay K, De Leo D. Suicide in rural and remote areas of Australia. Brisbane: Australian Institute for Suicide Research and Prevention, 2012.
  21. Bridge S. Suicide prevention – Targeting the patient at risk. Aust Fam Physician 2006;35(5):335–38.
  22. Snowdon J. Why have Australian suicide rates decreased? Aust N Z J Psychiatry 2016;50(1):13–15.
  23. Suicide Prevention Australia. Position statement: Responding to suicide in rural Australia. Leichgardt: SPA, 2008 [reviewed 2010].
  24. World Health Organization (WHO). Preventing suicide: A global imperative (World suicide report). Geneva: WHO, 2014.
  25. Schrieber J, Culpepper L. Suicide ideation and behavior in adults. UpToDate, 2016.  [Accessed 17 January 2016].
  26. Haukka J, Suominen K, Partonen T, Lonnqvist J. Determinants and outcomes of serious attempted suicide: A nationwide study in Finland, 1996-2003. Am J Epidemiol 2008;167(10):1155–63.
  27. Tidemalm D, Langstrom N, Lichtenstein P, Runeson B. Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up. BMJ 2008;337:a2205.
  28. Gardner J. General practitioners: The frontline in suicide prevention. Health Issues 2009(98):20–22.
  29. Shand FL, Proudfoot J, Player MJ, et al. What might interrupt men's suicide? Results from an online survey of men. BMJ Open 2015;5(10):e008172.
  30. Buron P, Jimenez-Trevino L, Saiz PA, et al. Reasons for attempted suicide in Europe: Prevalence, associated factors, and risk of repetition. Arch Suicide Res 2016 20(1):45–58. doi:10.1080/13811118.2015.1004481.
  31. Webb RT, Kontopantelis E, Doran T, Qin P, Creed F, Kapur N. Suicide risk in primary care patients with major physical diseases: A case-control study. Arch Gen Psychiatry 2012;69(3):256–64.
  32. Cheavens JS, Cukrowicz KC, Hansen R, Mitchell SM. Incorporating resilience factors into the interpersonal theory of suicide: The role of hope and self-forgiveness in an older adult sample. J Clin Psychol 2016;72(1):58–69.
  33. Coupland C, Hill T, Morriss R, Arthur A, Moore M, Hippisley-Cox J. Antidepressant use and risk of suicide and attempted suicide or self harm in people aged 20 to 64: Cohort study using a primary care database. BMJ 2015;350:h517.
  34. Zisook S, Shear K. Grief and bereavement: What psychiatrists need to know. World Psychiatry 2009;8(2):67–74.
  35. Shear MK, Reynolds CF, Simon N, Zisook S. Grief and bereavement in adults: Clinical features. UpToDate, 2015.  [Accessed 10 February 2016].
  36. Sveen CA, Walby FA. Suicide survivors' mental health and grief reactions: A systematic review of controlled studies. Suicide Life Threat Behav 2008;38(1):13–29.
  37. Shneidman E. Forward. In: Cain C, editor. Survivors of suicide. Oxford: Charles C Thomas, 1972. p. ix–xi.
  38. Jordan J, McIntosh J. Suicide bereavement: Why study survivors of suicide loss. In: Jordan J, McIntosh J, editors. Grief after suicide: Understanding the consquences and caring for the survivors. New York: Routledge, 2011.
  39. Wittouck C, Van Autreve S, Portzky G, van Heeringen K. A CBT-based psychoeducational intervention for suicide survivors: A cluster randomized controlled study. Crisis 2014;35(3):193–201.
  40. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edn (DSM-5). Arlington: American Psychiatric Association, 2013.
  41. Hedström P, Liu K-Y, Nordvik MK. Interaction domains and suicide: A population-based panel study of suicides in Stockholm, 1991–1999. Social Forces 2008;87(2):713–40.
  42. Cerel J, Aldrich R. The impact of suicide on children and adolescents. In: Jordan J, McIntosh J, editors. Grief after suicide: Understanding the consequences and caring for survivors. New York: Routelegde, 2011.
  43. deAngelis T. Surviving a patient's suicide. Washington: American Psychological Association, 2001. [Accessed 24 February 2016].
  44. Vannoy SD, Tai-Seale M, Duberstein P, Eaton LJ, Cook MA. Now what should I do? Primary care physicians' responses to older adults expressing thoughts of suicide. J Gen Intern Med 2011;26(9):1005–11.
  45. Foley SR, Kelly BD. When a patient dies by suicide: Incidence, implications and coping strategies. Advances in Psychiatric Treatment 2007;13(2):134–38.
  46. Jordan J, Feigelman W, McMenamy J, Mitchell A. Research on the needs of survivors. In: Jordan J, McIntosh J, editors. Grief after suicide: Understanding the consequences and caring for the survivors. New York: Routledge, 2011.
  47. McGann V, Gutin N, Jordan J. Guidelines for postvention care with survivor families after the suicide of a client. In: Jordan J, McIntosh J, editors. Grief after suicide: Understanding the consequences and caring for the survivor. New York: Routledge, 2011.
  48. Clifford AC, Doran CM, Tsey K. A systematic review of suicide prevention interventions targeting indigenous peoples in Australia, United States, Canada and New Zealand. BMC Public Health 2013;13:463.
  49. Coleman D, Del Quest A. Science from evaluation: Testing hypotheses about differential effects of three youth-focused suicide prevention trainings. Soc Work Public Health 2015;30(2):117–28.
  50. Forte AL, Hill M, Pazder R, Feudtner C. Bereavement care interventions: A systematic review. BMC Palliat Care 2004;3.
  51. Shear MK. Complicated grief treatment: The theory, practice and outcomes. Bereave Care 2010;29(3):10–14.
  52. Jordan A, Litz B. Prolonged grief disorder: Diagnostic, assessment, and treatment considerations. Prof Psychol Res Pr 2014;45(3):180–87.
  53. O'Connor M, Lasgaard M, Shevlin M, Guldin MB. A confirmatory factor analysis of combined models of the Harvard Trauma Questionnaire and the Inventory of Complicated Grief-Revised: Are we measuring complicated grief or posttraumatic stress? J Anxiety Disord 2010;24(7):672–79.
  54. Ehlers A. Understanding and treating complicated grief: What can we learn from posttraumatic stress disorder? Clin Psychol (New York) 2006;13.
  55. Prigerson HG, Maciejewski PK, Reynolds CF 3rd, et al. Inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Res 1995;59(1-2):65–79.
  56. Glickman K, Shear MK, Wall M. Exploring outcomes related to anxiety and depression in completers of a randomized controlled trial of complicated grief treatment. Clin Psychol Psychother 2016 Mar;23(2):118–24.
  57. Wetherell JL. Complicated grief therapy as a new treatment approach. Dialogues Clin Neurosci 2012;14(2):159–66.
  58. Shear K, Frank E, Houck PR, Reynolds CF. Treatment of complicated grief – A randomized controlled trial. JAMA 2005;293(21):2601–08.
  59. Wittouck C, Van Autreve S, De Jaegere E, Portzky G, van Heeringen K. The prevention and treatment of complicated grief: A meta-analysis. Clin Psychol Rev 2011;31(1):69–78.
  60. American Psychiatric Publishing. Major depressive disorder and the "bereavement exclusion" [press release]. American Psychiatric Publishing, 2013.
  61. Carey M, Jones K, Meadows G, et al. Accuracy of general practitioner unassisted detection of depression. Aust N Z J Psychiatry 2014;48(6):571–78.
  62. Kessler RC, Rose S, Koenen KC, et al. How well can post-traumatic stress disorder be predicted from pre-trauma risk factors? An exploratory study in the WHO World Mental Health Surveys. World Psychiatry 2014;13(3):265–74.
  63. Sareen J. Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis. UpToDate, 2015.  [Accessed 3 March 2016].
  64. Wilson JF. Posttraumatic stress disorder needs to be recognized in primary care. Ann Intern Med 2007;146(8):617–20.
  65. Zatzick D, Roy-Byrne P, Russo J, et al. A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Arch Gen Psychiatry 2004;61(5):498–506.
  66. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The posttraumatic stress disorder checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. J Trauma Stress 2015;28(6):489–98.
  67. Rothbaum BO. Pharmacotherapy for posttraumatic stress disorder in adults. UpToDate, 2015. [Accessed 7 March 2016].
  68. Rothbaum BO. Psychotherapy for posttraumatic stress disorder in adults. UpToDate, 2015. [Accessed 7 March 2016].
  69. U.S. Preventive Services Task Force. Summaries for patients: Screening for suicide risk in adolescents, adults, and older adults in primary care. Ann Intern Med 2014;160(10):I–22.
  70. Burke TA, Hamilton JL, Cohen JN, Stange JP, Alloy LB. Identifying a physical indicator of suicide risk: Non-suicidal self-injury scars predict suicidal ideation and suicide attempts. Compr Psychiatry 2016;65:79–87.
  71. Hunter Institute of Mental Health. Summary of the literature for discussing suicide. Newcastle: HIMH, 2012.

Download

After suicide (PDF 1 MB)