Unpacking the Meaning of Closeness, Reconsidering the Concept of Impact in Suicide Exposure, and Expanding Beyond Bereavement: "Just, I Hope You Don't Forget About Us".

Suicide exposure research has relied on samples of treatment-seeking kin, resulting in an attachment-based model centering bereavement as the most significant form of impact and obscuring other forms of significant and life-altering impact. From a community-based sample (N = 3010) exposed to suicide, we examine a subset (n = 104) with perceived high impact from the death yet low reported closeness to the person who died and analyze qualitative comments (n = 50). On average and out of 5.00, participants rated closeness as 1.56 but impact of death as 4.51. We illustrate dimensions of low closeness and identify themes on the meaning of impact: impact through society and systemic circumstances, impact through history and repeated exposure, impact through other people, impact as a motivator for reflection or change, and impact through shared resonance. Participants reported impact of death as significant or devastating, yet none of their comments reflected experiences typical of bereavement.

Predictors of Caregiver Burden Among Carers of Suicide Attempt Survivors.

Background: Family members often provide informal care following a suicide attempt. Carers may be vulnerable to caregiver burden. Yet, little is known about what contributes to this. Aims: To determine the predictors of caregiver burden in those carers who support people who have attempted suicide. Method: An online survey of 435 participants assessed exposure to suicide, caring behaviors, and psychological variables and caregiver burden. Results: A multivariate model explained 52% of variance in caregiver burden. Being female, closeness to the person, impact of suicide attempt, frequency of contact pre-attempt, and psychological distress were positively associated with caregiver burden. Confidence in supporting the person after suicide attempt, perceived adequacy of healthcare the person received and the support the carer received, and suicidal ideation of the carer were negatively associated with caregiver burden. Moderation analysis suggested that carers with high levels of distress reported negative association between suicidal ideation and caregiver burden. Limitations: The cross-sectional online survey design of self-identified carers is a limitation of the study. Conclusion: Carers are highly distressed, and if unsupported report increased suicide ideation. In their caring roles they may have contact with support services, thus attending to their needs may ameliorate caregiver burden and associated negative outcomes.

Suicide exposure experience screener for use in therapeutic settings: A validation report.

INTRODUCTION: A brief screener assessing experience of exposure to suicide for use in therapeutic settings is warranted. To examine the concurrent validity of such a screening tool, labeled as the Suicide Exposure Experience Screener (SEES), the associations of the two SEES items: (i) reported closeness with the person who died by suicide and (ii) perceived impact of suicide death with psychological distress are presented. METHODS: Five separate datasets comprising surveys from Australia, Canada, and the United States (Ncombined  = 7782) were used to provide evidence of concurrent validity of closeness and impact of suicide exposure. RESULTS: Overall, closeness and impact were significantly correlated with measures of global distress across five different datasets, showing small to medium effect sizes. Closeness and impact were also intercorrelated demonstrating a large effect size across all surveys. This report used cross-sectional data and comprised varied sample sizes across different datasets that influenced statistical significance of obtained effects and did not tease apart the roles of cumulative exposure of suicide and prolonged bereavement in experiencing global distress. CONCLUSION: The SEES has clinical utility in determining psychological distress in bereaved individuals and is recommended for use in therapeutic settings.

A Psychoeducational Support Group Intervention for People Who Have Attempted Suicide: An Open Trial with Promising Preliminary Findings.

Psychoeducational groups have been used to address many health needs. Yet, there are few such options available for people who have attempted suicide. This study presents preliminary findings from an open trial of Eclipse, an 8-week closed, psychoeducational group for people who have attempted suicide. It examined the effectiveness of the Eclipse program in reducing suicidal ideation, depressive symptoms, perceived burdensomeness and thwarted belongingness, and increasing resilience and help-seeking. Results showed statistically significant improvements in depressive symptoms, perceived burdensomeness, resilience and help-seeking from baseline (T1) to immediate post-test (T2), and in perceived burdensomeness from T1 to 1-month follow-up (T3). A pervasiveness analysis showed that over half of the participants reported improvements in key study outcomes, respectively, as a result of participating in the Eclipse group. Psychoeducational support groups could provide broad application for those who have previously attempted suicide in decreasing severity of suicidal thinking by reductions in depressive symptoms, burdensomeness, and thwarted belongingness.

Profiling Suicide Exposure Risk Factors for Psychological Distress: An Empirical Test of the Proposed Continuum of Survivorship Model.

The Continuum of Survivorship proposes a way in which individuals may experience the suicide death of someone known to them along a continuum from being exposed to the death through to long-term bereavement. The present study provides a first empirical testing of the proposed model in an Australian community sample exposed to suicide. Using a Latent Profile Analysis, we tested the suicide exposure risk factors (time since death, frequency of pre-death contact, reported closeness, and perceived impact) to map to the Continuum of Survivorship model. Results revealed identification of five profiles, with four ranging from suicide exposed to suicide bereaved long-term broadly aligning with the proposed model, with one further profile being identified that represented a discordant profile of low closeness and high impact of suicide exposure. Our findings demonstrate that while the proposed model is useful to better understand the psychological distress related to exposure to suicide, it cannot be used as "shorthand" for identifying those who will be most distressed, nor those who may most likely need additional support following a suicide death. Implications and future research directions are discussed.

Workplace exposure to suicide among Australian mental health workers: A mixed-methods study.

Workplace exposure to suicide attempts and deaths has been widely recognized as an occupational hazard for mental health and social care workers, including mental health nurses. Research consistently demonstrates the adverse impact on professionals. This paper explores the results of an online survey examining suicide exposure and impact. Of the 3010 Australian adult participants who identified exposure to suicide attempts and/or deaths in a larger study, 130 indicated that the most impactful suicide attempt and/or death exposure was that of a client or service user. While distress levels were relatively low among participants with workplace exposure, the qualitative content from 53 participants provides illumination into this experience. Themes that emerged in the qualitative responses include impact on the professional, organization response, and lack of adequate resources and supports to prevent suicide. Previous research has examined the impact of suicide exposure among professionals specifically, but this is the first known study of participants in a community sample who identified the most impactful suicide attempt or death exposure they had experienced was that of a client in a mental health setting. Workplace exposure among mental health workers is common and can have both deleterious and positive effects. Bereavement focused outcomes, where the loss of an attachment relationship is the focus, does not capture the full range of experiences in workplace exposure. Systemic issues in mental health care contribute to further distress among exposed workers, and this requires additional investigation and response.

Carers' Motivations for, and Experiences of, Participating in Suicide Research.

(1) Background: First-hand accounts of lived experience of suicide remain rare in the research literature. Increasing interest in the lived experience of suicide is resulting in more opportunities for people to participate in research based on their personal experience. How individuals choose to participate in research, and their experience of doing so, are important considerations in the ethical conduct of research. (2) Methods: To understand the experience of providing care for someone who has previously attempted suicide, a cross-sectional online community survey was conducted. This survey concluded with questions regarding motivation to participate and the experience of doing so. Of the 758 individuals who participated in the survey, 545 provided open-ended text responses to questions regarding motivation and 523 did so for questions regarding the experience of participating. It is these responses that are the focus of this paper. Data were analysed thematically. (3) Results: Motivations to participate were expressed as primarily altruistic in nature, with a future focus on improving the experience of the person who had attempted suicide alongside carers to ease distress. The experience of participating was difficult yet manageable, for all but a few participants. (4) Conclusions: With the increasing interest in first-hand accounts of suicide, how individuals experience participation in research is an important focus that requires further attention.

Suicide exposure and impact within a non-representative Australian community sample.

The impact of exposure to suicide death or attempt remains ill-understood. This article aims to investigate this impact among 3010 community residing Australian adults. An online survey investigated the burden of exposure to suicide, psychological distress, and predictors of distress. The following variables were most significant in predicting distress among those exposed to suicide death: perceived impact of the most impactful death, non-kin relationship to the deceased, number of close suicide attempt exposures, time since the most impactful death, and frequency of contact. Results demonstrate suicide is a highly impactful experience and this impact reaches well beyond kin.

Do Primary Care Physicians Help the Bereaved With Their Suicide Losses: Loss Survivor Perceptions of Helpfulness From Physicians.

Several previous studies suggested that primary care physicians can provide important bereavement assistance to survivors of suicide, yet no study has investigated whether suicide-bereaved patients perceive their physicians as helpful. Contacting bereavement communities on social media, we collected online survey data from 146 bereaved respondents reporting suicides causing them severe emotional distress. Data analysis suggested that nearly half (48%) of the respondents encountered positive, help-offering responses from physicians, compared to 10% whose responses were deemed as negative. Analysis of our data suggested that loss survivors' perceptions of a physician's helping or reproachful responses were associated with differences in grief difficulties and mental health distress.

The Attempt Was My Own! Suicide Attempt Survivors Respond to an Australian Community-Based Suicide Exposure Survey.

Those who attempt suicide have often been overlooked in the suicide prevention literature. Where stories of lived experience have been included, it is often from the perspectives of healthcare professionals who treat the physical and/or psychological impacts following an attempt, rather than firsthand accounts. Yet, the most intimate insights of suicide are lost by not including the voices of those with lived experience of suicide attempt. Through an online, community-based, non-representative survey exploring the impact of exposure to suicide, a sub-sample of 88 participants responded who reported their exposure to suicide as being their own attempt. The survey covered demographic information, questions assessing exposure to suicide attempts and death, current global psychological distress via the Kessler Psychological Distress (K10) Scale, and short qualitative responses provided by 46 participants. The qualitative data was thematically analysed resulting in three themes; the way in which individuals experienced being suicidal; who they were able, or not, to disclose these intentions to-before and after their suicide attempt; and, how these people experienced the formal and informal health care supports available to them to assist with their suicidal crisis. This paper presents important findings from a sample of participants who are highly distressed, and have previously attempted to take their own lives. This adds depth to our understanding of lived experience of suicide attempt, issues associated with seeking appropriate support after suicide attempt, and also demonstrates a willingness of participants to share their stories, even in a study that did not explicitly target those with lived experience of suicide attempt. The need for consistent and compassionate mental health care after a suicide attempt is identified as a vital component of living well after a suicide attempt.

Exposure to suicide in Australia: A representative random digit dial study.

BACKGROUND: Exposure to the suicide death of another may lead to distress and increase the risk of suicide in those connected to the deceased. Yet, the extent of this exposure across the population is ill-defined. This paper utilises representative data to quantify the extent of exposure to suicide in the Australian community and the reported effect of this exposure. METHODS: A random digit dial, computer-assisted telephone interview survey was undertaken to understand how Australian's may assist someone in severe distress or at risk of suicide. Embedded within this survey were questions on exposure to suicide and the impact of this exposure. RESULTS: Among a representative sample of 3002 Australians, 58% reported exposure to the suicide of someone known to them in their lifetime and 18.5% of exposed individuals reported their own suicidal thoughts in the past-year. Higher perceived impact of the suicide and concern for another person were associated with increased likelihood of current suicidal thinking. LIMITATIONS: Survey design limitations resulted in unknown psychological harms beyond past-year suicidal thinking in respondents. CONCLUSIONS: Our findings demonstrate a high level of exposure to suicide death among Australians, with multiple exposures common. How and why suicide manifests in some exposed to suicide and not others remains unknown and requires further research. However, these findings suggest suicide prevention efforts need to expand to include a focus on suicide exposure, and mental health clinicians should consider exposure to suicide in risk assessment to better understand an individual's vulnerability to suicide following exposure.

Suicide Notes: Assessing Their Impact on the Bereaved.

OBJECTIVE: Although suicidologists have devoted great interest toward the importance of suicide notes, scant attention has been paid to their impact upon the suicide bereaved. METHOD: To address this issue we conducted on an online survey querying 146 mostly American suicide bereaved adults who indicated severe emotional distress after their losses, 80% of whom had lost first degree-relatives. RESULTS: We found no significant differences in mental health outcomes between those who received suicide notes and those who had not; nor were differences noted between those whose notes contained helpful or unhelpful information and those who had not received such information. CONCLUSION: We also observed poorer mental health outcomes among the suicide bereaved who expected to receive a suicide note after their loved one died-and did not receive any communication- indicating needs for clinical support among this vulnerable subgroup.

Disclosure in traumatic deaths as correlates of differential mental health outcomes.

This analysis addresses the controversial question of whether disclosure of a significant other's traumatic death cause is associated with mental health outcomes. Consistent with the limited previous research, this data, collected from 131 suicide bereaved, 10 exclusively drug death bereaved, and six other bereaved respondents, showed fewer grief difficulties and better self-rated mental health among those inclined to openly disclose a significant other's death cause, compared to those who feared incurring shame and embarrassment from doing so. Regression analyses suggested that the tendency to openly discuss the death was the single most powerful correlate to explaining variations in grief difficulties.

A Systematic Mapping of Suicide Bereavement and Postvention Research and a Proposed Strategic Research Agenda.

BACKGROUND: Suicide may have disruptive and/or devastating effects on family, friends, and the broader community. Of late, increased interest from suicide researchers has given rise to an upsurge in research productivity addressing suicide bereavement and postvention. At this critical juncture, the establishment of an agenda will help guide the direction of future scholarly research in this field. AIMS: To conduct an exhaustive systematic mapping review and bibliometric analysis of peer-reviewed suicide bereavement and postvention research published over the past 50 years. METHOD: A comprehensive and strategic search of electronic databases and web-based search engines for original research studies was conducted resulting in the identification of 443 articles. RESULTS: Since 1965, the global research activities in the field of suicide bereavement and postvention is approximately 8.86 papers per year. There remains a lack of evaluation studies on the effects of interventions/programs with the majority of papers being explanatory in nature. Several areas of study within this field remain neglected. LIMITATIONS: While the search strategy was rigorous, potential limitations exist due to nonstandardized nomenclature and English language only inclusion, which inherently favors research from high-income countries. CONCLUSION: Suggested topics for a research agenda are proposed from the current limitations in the field.

Is Exposure to Suicide Beyond Kin Associated with Risk for Suicidal Behavior? A Systematic Review of the Evidence.

Suicide bereavement and postvention literature often espouses risk for subsequent suicidal behavior among those previously exposed to a suicide death. Most often risk is discussed in relation to kin; however, many more individuals are exposed to suicide, and the impact of this exposure is important to understand in relation to targeting postvention. This review examined the research literature (1990-2014) to determine the evidence base for risk among those exposed to suicide. The findings demonstrate that risk of suicidal behaviors among those exposed to the suicide is significantly higher than those unexposed. These results are discussed within the context of current research in the field of postvention, and suggestions for future research are suggested.

Suicide Loss Survivors' Experiences with Therapy: Implications for Clinical Practice.

Over two-thirds of suicide loss survivors, those who have lost a loved one to suicide, seek individual therapy following their loss. However, nothing is known about what survivors find helpful about therapy or how therapy impacts their grief. An online survey was conducted June 2012-March 2013 with a convenience sample of 197 survivors primarily from the USA and Australia to develop a better understanding of treatment seeking loss survivors and their experiences in therapy. Questions explored the experience of the suicide death, the therapy received after the loss, and insights about improving therapy for loss survivors. Participants were generally positive about their therapy experiences. However, respondents endorsed symptoms of PTSD, though many did not report a formal diagnosis from a provider, suggesting a discrepancy that could lead to inadequate treatment of symptoms. The findings provide an understanding of treatment seeking loss survivors, along with implications for therapists treating this population.

Methylglyoxal can modify GAPDH activity and structure.

The activity of glyceraldehyde-3-phosphate dehydrogenase (GAPDH) can play an important role in regulating multiple upstream pathways relating to the development of diabetic complications. GAPDH can be modified by a number of metabolic factors, including oxidative and glycation products. To study the effect of glycation on GAPDH we have measured GAPDH structure and activity after exposure of the enzyme to the potent alpha dicarbonyl sugar methylglyoxal (MG). Rabbit GAPDH was incubated with 10-1000 microM MG for 96 hours, and enzyme activity was measured at intervals by a spectrophotometric assay. Isoelectric focusing of purified and cellular GAPDH was performed with a PROTEAN IEF system and the bands visualized by Western blotting. The mass of glycated and native GAPDH was determined by MALDI with a Applied Biosystems Voyager System 6235. GAPDH activity (at 96 h) was decreased by 20% with 1.0 micromolar MG and showed progressively greater suppression of activity with increasing concentrations up to 1 mM, where activity was decreased by 97%. Reduction in GAPDH activity was rapidly decreasing by 69.2% by two hours with 1 mM MG. IEF showed an isoelectric point (IEP) of 8.5 for native GAPDH, while measurable changes were seen with modification by MG levels of 1 mM (IEP 7.5) and 50 microM (IEP 8.0). With MALDI, GAPDH mass increased from 36.012 kDa to 37.071 after exposure to 50 microM MG and to 40.625 following 1 mM MG. This indicates addition of 12.75 and 55.6 MG residues, respectively, to GAPDH. GAPDH can be modified by methylglyoxal intracellular concentrations close to those previously observed in vivo, with measurable changes in isoelectric point and mass. These modifications can lead to decreased enzyme activity, suggesting that conditions associated with elevated intracellular MG could modify GAPDH activity in vivo.

Ketosis leads to increased methylglyoxal production on the Atkins diet.

In the popular and widely used Atkins diet, the body burns fat as its main fuel. This process produces ketosis and hence increased levels of beta-hydroxybutyrate (BOB) acetoacetate (AcAc) and its by-products acetone and acetol. These products are potential precursors of the glycotoxin methylglyoxal. Since methylglyoxal and its byproducts are recognized as a significant cause of blood vessel and tissue damage, we measured methylglyoxal, acetone, and acetol in subjects on the Atkins diet. We found that by 14-28 days, methylghyoxal levels rose 1.67-fold (P = 0.039) and acetol and acetone levels increased 2.7- and 6.12-fold, respectively (P = 0.012 and 0.028). Samples from subjects with ketosis showed even greater increases in methylglyoxal (2.12-fold), as well as acetol and acetone, which increased 4.19- and 7.9-fold, respectively; while no changes were seen in samples from noncompliant, nonketotic subjects. The increase in methylglyoxal implies that potential tissue and vascular damage can occur on the Atkins diet and should be considered when choosing a weight-loss program.