The association of loneliness after sudden bereavement with risk of suicide attempt: a nationwide survey of bereaved adults.

PURPOSE: We aimed to test the hypothesis that among people who experience sudden bereavement, loneliness is associated with post-bereavement suicide attempt and post-bereavement suicidal ideation, even when adjusting for network size. METHODS: We analysed cross-sectional data collected in the 2010 UCL Bereavement Study, to identify 3193 respondents who had experienced sudden bereavement. We used multivariable logistic regression to test for an association between loneliness (using a newly-developed eight-item loneliness measure) and post-bereavement suicide attempt and suicidal ideation, adjusting for socio-demographic factors, pre-bereavement depression and self-harm, and network size. RESULTS: Among bereaved adults, loneliness was significantly associated with probability of post-bereavement suicide attempt (AOR 1.19; 95% CI 1.14-1.25) and of post-bereavement suicidal ideation (AOR 1.24; 95% CI 1.20-1.28), with estimates unchanged by adding perceived stigma of the bereavement to adjusted models. There was no association between suicide bereavement and loneliness (adjusted coefficient 0.22; 95% CI - 0.12 to 0.45; p = 0.063). The association of loneliness and suicide attempt risk was similar whether participants were bereaved by suicide or not. CONCLUSIONS: People who report feeling lonely after sudden bereavement are more likely to make a suicide attempt after their loss, even when taking into account their network size and the perceived stigma of the sudden bereavement. There is no evidence that the effects of loneliness on suicidality are specific to suicide bereavement. This work identifies loneliness as a potential target for suicide prevention interventions among bereaved people. It also fuels interest in longitudinal research investigating loneliness as a putative mediator of suicide risk.

Characteristics and risk of repeat suicidal ideation and self-harm in patients who present to emergency departments with suicidal ideation or self-harm: A prospective cohort study.

BACKGROUND: Characteristics and outcomes of patients presenting to Emergency Departments (EDs) have been under-examined. This paper describes the characteristics and risk of repeat suicidality amongst patients presenting to EDs with (1) suicidal ideation and (2) self-harm, compared to (3) controls in mental health crisis. METHODS: The Clinical Record Interactive Search tool identified 2211 patients who presented to three London EDs with suicidal ideation or self-harm, and 1108 control patients. All patients received a full psychosocial assessment. Chi-squared tests examined group characteristics. Cox regression models assessed the risk of re-presentation with suicidal ideation or self-harm within one year. RESULTS: There were a higher proportion of females and individuals under the age of 25 in the self-harm group. Patients presenting with suicidal ideation or self-harm were more likely to be white, live in more deprived areas, and less likely to receive a psychiatric diagnosis within one year compared to controls. Risk of repeat suicidality within one year was 3-4 times higher in those with baseline suicidal ideation (adjusted HR = 3.66, 95% CI 2.44-5.48) or self-harm (HR = 3.53 95% CI 2.47-5.04) compared to controls. LIMITATIONS: To be included patients needed to have a full psychosocial assessment. Incomplete records meant 21.4% of the sample was excluded. This will have introduced bias which might confound observed associations. CONCLUSION: Individuals presenting with either suicidal ideation or self-harm have similar risk for re-presentation within one year. Both groups would benefit from personalised risk management plans and active follow-up to reduce the risk of repeat suicidal behaviour.

The stigma associated with bereavement by suicide and other sudden deaths: A qualitative interview study.

Quantitative studies have found that suicide bereavement is associated with suicide attempt, and is perceived as the most stigmatising of sudden losses. Their findings also suggest that perceived stigma may explain the excess suicidality. There is a need to understand the nature of this stigma and address suicide risk in this group. We aimed to describe and compare the nature of the experiences of stigma reported by people bereaved by suicide, sudden unnatural death, and sudden natural death, and identify any commonalities and unique experiences. We conducted a population-based cross-sectional survey of 659,572 staff and students at 37 British higher educational institutions in 2010, inviting those aged 18-40 who had experienced sudden bereavement of a close contact since the age of 10 to take part in an on-line survey and to volunteer for an interview to discuss their experiences. We used maximum variation sampling from 1398 volunteer interviewees to capture a range of experiences, and conducted individual face-to-face semi-structured interviews to explore perceptions of stigma and support. We continued sampling until no new themes were forthcoming, reaching saturation at n = 27 interviews (11 participants bereaved by suicide). We employed thematic analysis to identify any distinct dimensions of reported stigma, and any commonalities across the three groups. We identified two key themes: specific negative attitudes of others, and social awkwardness. Both themes were common to interviewees bereaved by suicide, sudden unnatural death, and sudden natural death. All interviewees reported the experience of stigmatising social awkwardness, but this may have been experienced more acutely by those bereaved by suicide due to self-stigma. This study provides evidence of a persistent death taboo in relation to sudden deaths. There is potential for anti-stigma interventions to reduce the isolation and social awkwardness perceived by people bereaved suddenly, particularly after suicide loss.

Support received after bereavement by suicide and other sudden deaths: a cross-sectional UK study of 3432 young bereaved adults.

OBJECTIVE: To test the hypothesis that people bereaved by suicide are less likely to receive formal or informal support than people bereaved by other causes of sudden death. DESIGN: National cross-sectional study. SETTING: Adults working or studying at any UK higher education institution (HEI) in 2010. PARTICIPANTS: A total of 3432 eligible respondents aged 18-40 years bereaved by the sudden death of a close friend or relative, sampled from approximately 659 572 bereaved and non-bereaved staff and students at 37 of 164 UK HEIs invited to participate. EXPOSURES: Bereavement by suicide (n=614; 18%), by sudden unnatural causes (n=712; 21%) and by sudden natural causes (n=2106; 61%). MAIN OUTCOME MEASURES: Receipt of formal and informal support postbereavement; timing of valued support. RESULTS: 21% (725/3432) of our sample of bereaved adults reported receiving no formal or informal bereavement support, with no evidence for group differences. People bereaved by suicide were less likely to have received informal support than those bereaved by sudden natural causes (adjusted OR (AOR)=0.79; 95% CI 0.64 to 0.98) or unnatural causes (AOR=0.74; 95% CI 0.58 to 0.96) but did not differ from either comparison group on receipt of formal support. People bereaved by suicide were less likely to have received immediate support (AOR=0.73; 95% CI 0.59 to 0.90) and more likely to report delayed receipt of support (AOR=1.33; 95% CI 1.08 to 1.64) than people bereaved by sudden natural causes. Associations were not modified by gender, or age bereaved, but became non-significant when adjusting for stigma. CONCLUSIONS: People bereaved by suicide are less likely to receive informal support than people bereaved by other causes of sudden death and are more likely to perceive delays in accessing any support. This is concerning given their higher risk of suicide attempt and the recommendations within suicide prevention strategies regarding their need for support. STUDY REGISTRATION: http://www.ucl.ac.uk/psychiatry/bereavementstudy/.

Support for Relatives Bereaved by Psychiatric Patient Suicide: National Confidential Inquiry Into Suicide and Homicide Findings.

OBJECTIVES: International suicide prevention strategies recommend providing support to families bereaved by suicide. The study objectives were to measure the proportion of cases in which psychiatric professionals contact next of kin after a patient's suicide and to investigate whether specific, potentially stigmatizing patient characteristics influence whether the family is contacted. METHODS: Annual survey data from England and Wales (2003-2012) were used to identify 11,572 suicide cases among psychiatric patients. Multivariate regression analysis was used to describe the association between specific covariates (chosen on the basis of clinical judgment and the published literature) and the probability that psychiatric staff would contact bereaved relatives of the deceased. RESULTS: Relatives were not contacted after the death in 33% of cases. Contrary to the hypothesis, a violent method of suicide was independently associated with greater likelihood of contact with relatives (adjusted odds ratio=1.67). Four patient factors (forensic history, unemployment, and primary diagnosis of alcohol or drug dependence or misuse) were independently associated with less likelihood of contact with relatives. Patients' race-ethnicity and recent alcohol or drug misuse were not associated with contact with relatives. CONCLUSIONS: Four stigmatizing patient-related factors reduced the likelihood of contacting next of kin after patient suicide, suggesting inequitable access to support after a potentially traumatic bereavement. Given the association of suicide bereavement with suicide attempt, and the possibility of relatives' shared risk factors for suicide, British psychiatric services should provide more support to relatives after patient suicide.

The stigma perceived by people bereaved by suicide and other sudden deaths: A cross-sectional UK study of 3432 bereaved adults.

OBJECTIVE: To test the hypothesis that perceived stigma scores in young adults bereaved by suicide are significantly higher than in young adults bereaved by other sudden deaths, whether blood-related to the deceased or not. METHODS: We conducted a cross-sectional study of all staff and students aged 18-40 at 37 UK higher educational institutions in 2010, and identified 3432 respondents who had experienced a sudden bereavement of a close contact since reaching the age of 10, either due to sudden natural causes, sudden unnatural causes, or suicide. We used multivariable regression to compare scores on the stigma, shame, responsibility and guilt subscales of the Grief Experience Questionnaire, adjusting for socio-demographic factors and pre-bereavement psychopathology. RESULTS: People bereaved by suicide (n=614) had higher stigma scores than people bereaved by sudden natural death (n=2106; adjusted coefficient=2.52; 95% CI=2.13-2.90; p=<0.001) and people bereaved by sudden unnatural death (n=712; adjusted coefficient=1.69; 95% CI=1.25-2.13; p=<0.001). Shame, responsibility and guilt scores were also significantly higher in people bereaved by suicide, whether compared with bereavement by sudden natural death or sudden unnatural death. Associations were not modified by whether the bereaved was blood-related to the deceased or not. CONCLUSIONS: Stigma was perceived more acutely by the relatives and friends of those who died by suicide than those bereaved by other causes of sudden natural or sudden unnatural death. Their high levels of perceived stigma, shame, responsibility and guilt require qualitative investigation to identify whether these grief dimensions limit social functioning, help-seeking behaviour and/or support offered.

Bereavement by suicide as a risk factor for suicide attempt: a cross-sectional national UK-wide study of 3432 young bereaved adults.

OBJECTIVES: US and UK suicide prevention strategies suggest that bereavement by the suicide of a relative or friend is a risk factor for suicide. However, evidence is lacking that the risk exceeds that of any sudden bereavement, is specific to suicide, or applies to peer suicide. We conducted the first controlled UK-wide study to test the hypothesis that young adults bereaved by suicide have an increased risk of suicidal ideation and suicide attempt compared with young adults bereaved by other sudden deaths. DESIGN: National cross-sectional study. SETTING: Staff and students at 37 UK higher educational institutions in 2010. PARTICIPANTS: 3432 eligible respondents aged 18-40 exposed to sudden bereavement of a friend or relative after the age of 10. EXPOSURES: Bereavement by suicide (n=614), by sudden unnatural causes (n=712) and by sudden natural causes (n=2106). PRIMARY OUTCOME MEASURES: Incident suicidal ideation and suicide attempt. FINDINGS: Adults bereaved by suicide had a higher probability of attempting suicide (adjusted OR (AOR)=1.65; 95% CI 1.12 to 2.42; p=0.012) than those bereaved by sudden natural causes. There was no such increased risk in adults bereaved by sudden unnatural causes. There were no group differences in probability of suicidal ideation. The effect of suicide bereavement was similar whether bereaved participants were blood-related to the deceased or not. The significant association between bereavement by suicide and suicide attempt became non-significant when adding perceived stigma (AOR=1.11; 95% CI 0.74 to 1.67; p=0.610). When compared with adults bereaved by sudden unnatural causes, those bereaved by suicide did not show significant differences in suicide attempt (AOR=1.48; 95% CI 0.94 to 2.33; p=0.089). CONCLUSIONS: Bereavement by suicide is a specific risk factor for suicide attempt among young bereaved adults, whether related to the deceased or not. Suicide risk assessment of young adults should involve screening for a history of suicide in blood relatives, non-blood relatives and friends.

Individual and area-level risk factors for suicidal ideation and attempt in people with severe depression.

INTRODUCTION: Previous research has identified several risk factors that are strongly associated with suicidal behavior in patients with severe depression. However, the effects of area-level characteristics on suicidal ideation and attempt in this population remain unclear. METHODS: The Clinical Record Interactive Search (CRIS) database was used to identify 2587 patients with severe depression who received secondary mental health services from the Camden & Islington NHS Foundation Trust. Stepwise multivariable logistic regression models were used to examine associations between socio-demographic characteristics, clinical variables, area-level measures, and suicidal ideation and attempt as separate outcomes. RESULTS: Both suicidal ideation and attempts were common among this cohort of severely depressed individuals (70.5% and 37.7%, respectively). While several individual socio-demographic and clinical characteristics were associated with both outcomes, particularly past psychiatric admission (suicidal ideation: adjusted OR=2.86, 95% CI: 2.26-3.62; suicide attempt: adjusted OR=4.00, 95% CI: 3.30-4.89), neither social deprivation nor ethnic density (measured at the area-level) was associated with risk for either outcome. LIMITATIONS: Data were not collected specifically for research purposes and hence information on some potential confounders was not available. Additionally, information was restricted to individuals who accessed secondary mental health services in a defined catchment area and period. The study therefore does not take into account individuals who did not access mental health services. CONCLUSIONS: The variation in risk for suicidal ideation and attempt among severely depressed individuals is explained by differences in individual socio-demographic and clinical characteristics, most notably past psychiatric admission and substance misuse, and not by area-level measures.

Cardiovascular screening of people with severe mental illness in England: views of service users and providers.

OBJECTIVE: In England national clinical guidelines recommend annual screening for cardiovascular risk factors among individuals with schizophrenia and bipolar disorder within primary care supported by efforts to promote healthy behaviors by secondary psychiatric services. This study elicited the views of primary and specialty mental health care staff and service users about such service arrangements and barriers to implementation. METHODS: Surveys were mailed to a representative cross-section of service users, community mental health team (CMHT) staff, and primary care staff in Western England and London. RESULTS: Surveys were completed by 227 service users, 143 primary care staff, and 166 CMHT staff. A majority of staff stated that cardiovascular disease screening and risk reduction work were important, felt that this work was best accomplished in primary care settings, and anticipated good uptake among service users. More than 80% of service users viewed cardiovascular screening favorably, but 30% had not been screened in the past year. The proportion of service users prepared to make healthy changes in their lifestyle varied from 37% to 51%, depending on the change contemplated, but many cited difficulty traveling (35%), time pressures (28%), and a distaste for courses or group work (23%) as barriers to attending courses in healthy living. CONCLUSIONS: The obstacles to service identified by this study reinforce the importance of providing incentives for both providers and users of services to improve implementation of national clinical guidelines on mental illness.