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Impact of sudden bereavement on mental well-being and social functioning: results of the UCL Bereavement Study
Results of our national survey
We have analysed quantitative (fixed choice or tick box) data from over 3,400 people and qualitative (free text) data from over 2,700 people.
Overall our respondents had a mean age of 25, and a male:female gender ratio of 1:4. The average time elapsed since bereavement was 4·9 years, but this ranged from 1 day to 30 years. We divided our sample into people bereaved by sudden natural causes, sudden unnatural causes, and suicide. The death of a friend was the loss most commonly reported in the groups bereaved by sudden unnatural causes (38%) and suicide (41%), compared with 10% in the group bereaved by sudden natural causes. The most common loss reported in the group bereaved by sudden natural causes was that of a grandparent: 31% compared with 4% for the group bereaved by sudden unnatural causes and 2% for the group bereaved by suicide. Parental deaths accounted for 39% of losses in the group bereaved by sudden natural causes, compared with less than 20% in each of the other two groups.
Publications
Suicide attempt risk
The first findings from the UCL Bereavement Study were published in the BMJ Open in 2016:
Pitman A, Osborn D, Rantell K, King M. (2016) Bereavement by suicide as a risk factor for suicide attempt: a cross-sectional national UK-wide study of 3,432 young bereaved adults. BMJ Open 6:e009948. doi:10.1136/bmjopen-2015-009948 http://bmjopen.bmj.com/content/6/1/e009948.full
In this study we found that 31% of our sample had experienced symptoms suggestive of a depressive episode since the bereavement, and 6% had had to drop out from a course or from a job. We also found that 45% of this sample reported suicidal thoughts since the bereavement, and 6% had made a suicide attempt since the loss. To give a rough comparison with the general population in England, a 2007 survey showed that 21% of people in this age group had ever had suicidal thoughts in their whole life, and 7% had ever attempted suicide in their life. Our figures of 45% and 6%, respectively, only related to the period since the bereavement - an average of only 4 years.
When we conducted statistical comparisons between the groups we found that there were no differences between the groups in terms of their likelihood of becoming depressed after the loss. People bereaved by suicide were at higher probability of suicide attempt than people bereaved by sudden natural causes, but there were no differences between the groups in relation to suicidal thoughts. We also found that people bereaved by suicide were more likely to have dropped out of a course or job than people bereaved by sudden natural causes. The only differences we observed between people bereaved by sudden unnatural causes and the other two groups, were that people bereaved by suicide were more likely to describe poor social functioning. This suggests that there are many similarities between people bereaved by suicide and by other unnatural causes of death. All the group differences we found applied whether the bereaved person was related to the deceased or not. We also found that the differences disappeared when we took into account high stigma scores - in other words, that those reporting suicide attempts, poor social functioning, and occupational drop-out also tended to be those who felt the most stigmatised. This suggests that stigma explains the increased probability of suicide attempt and of occupational and social difficulties, although we plan to investigate this further.
Voluntary sector organisations joined us in publicising the study's findings.
Stigma
To investigate which groups reported the greatest degree of stigma, we published a further study in 2016: Pitman AL, Osborn DPJ, Rantell K, King MB. (2016) The stigma perceived by people bereaved by suicide and other sudden deaths: A cross-sectional UK study of 3432 bereaved adults Journal of Psychosomatic Research 87:22-29 doi:10.1016/j.jpsychores.2016.05.009
This study found that people bereaved by suicide reported significantly higher scores on measures of perceived stigma, shame, responsibility and guilt than people bereaved by sudden natural death or sudden unnatural death. This applied whether they were a blood relative of the person who had died or not. As stigma appeared to be implicated in the association between suicide bereavement and poor mental health outcomes, we tested whether the stigma of any sudden bereavement was associated with suicide attempt and other related outcomes.
Our study was published in 2017: Pitman A. Rantell K. Marston M. King M, Osborn D. (2017) Perceived stigma of sudden bereavement as a risk factor for suicidal thoughts and suicide attempt: analysis of British cross-sectional survey data on 3,387 young bereaved adults Int J Environ Res Public Health 14(3). pii: E286. doi: 10.3390/ijerph14030286 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369122/
In a related study we found that anyone who feels stigmatised by a sudden bereavement, regardless of the cause of death, is at increased risk of suicidal thoughts and suicide attempt, even taking into account prior suicidal behaviour.
Pitman A. Rantell K. Marston M. King M, Osborn D. (2017) Perceived stigma of sudden bereavement as a risk factor for suicidal thoughts and suicide attempt: analysis of British cross-sectional survey data on 3,387 young bereaved adults Int J Environ Res Public Health 14(3). pii: E286. doi: 10.3390/ijerph14030286 http://www.mdpi.com/1660-4601/14/3/286
Support received
To investigate whether groups bereaved by different causes differed in the amount of support they received after their loss, we conducted a study comparing reported levels of formal support (from professionals) and informal support (from family and friends). This was published in 2017: Pitman A. Rantell K. Moran P. Sireling L. Marston M. King M, Osborn D. (2017) Support received after bereavement by suicide and other sudden deaths: a cross-sectional UK study of 3432 young bereaved adults BMJ Open 2017;7:e014487. doi: 10.1136/bmjopen-2016-014487 http://bmjopen.bmj.com/content/7/5/e014487
This study found that 1 in 5 people in our sample had not received any formal or informal support after their bereavement. People bereaved by suicide were significantly less likely to have received informal support than people bereaved by sudden natural death and sudden unnatural death, and also more likely to describe delays in receiving any formal or informal support, and a lack of support immediately after the death. Again, we found that the differences disappeared when we took into account high stigma scores. That suggested that those reporting delays in support and lack of support also tended to be those who felt the most stigmatised, highlighting the link between the two.
In a linked study we analysed qualitative data from the 27 interviews with bereaved adults conducted as part of our national survey to explore what it meant to feel stigmatised. We found that all interviewees, whether bereaved by suicide, other unnatural causes, or sudden natural causes of death, reported the experience of stigmatising social awkwardness. However, this appeared to be experienced more acutely by those bereaved by suicide due to self-stigma. This was published in early 2018: Pitman A, Stevenson F, King M, Osborn D (2018) The stigma associated with bereavement by suicide and other sudden deaths: a qualitative interview study Soc Sci Med 198; 121-129 doi: https://doi.org/10.1016/j.socscimed.2017.12.035
Suicide suggestion
One possible explanation for the increased risk of suicide attempt and suicide in people bereaved by suicide is that knowing someone who dies by suicide modifies one's own attitudes to suicide. This is used as an explanation for so-called copycat suicides, also described as suicide contagion, imitative suicide, or suicide suggestion. We analysed qualitative data from our survey to explore the attitudes of young adults bereaved by suicide towards their own likelihood of dying by suicide. We found that although the majority described having become determined never to choose suicide themselves, primarily because they had become aware of the potentially devastating impact on others, a minority described their experiences as having normalised suicide for them. This seemed to suggest that knowing someone who dies by suicide can influence attitudes to suicide in ways that could implies an imitative effect. This study was published in 2017: Pitman A, Nesse H, Morant N, Azorina V, Stevenson F, King M, Osborn D (2017) Attitudes to suicide following the suicide of a friend or relative: a qualitative study of the views of 429 young bereaved adults in the UK. BMC Psychiatry BMC Psychiatry. 2017; 17: 400. doi: 10.1186/s12888-017-1560-3
Further collaborations
As part of this project we decided to focus on the aftermath of suicide among patients under the care of mental health services. For this project we collaborated with the University of Manchester on an analysis of data from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Our paper was published in 2017: Pitman A, Hunt I, McDonnell S, Appleby L, Kapur N. (2017) Support for Relatives Bereaved by Psychiatric Patient Suicide: National Confidential Inquiry Into Suicide and Homicide Findings. Psychiatric Services 68(4); 337-344 doi: http://dx.doi.org/10.1176/appi.ps.201600004
This study found that in a third of cases of the suicide of a patient under the care of psychiatric services, the patient's relatives were not contacted after the death by a member of the mental health team. This was despite clear NHS recommendations that providers of psychiatric services should contact relatives after all cases of patient suicide. Furthermore, as predicted, specific and potentially stigmatising characteristics of patients were associated with a reduced likelihood of relatives being contacted after a suicide. These factors were the patient having a history of criminality or unemployment, or a primary diagnosis of alcohol or drug dependence or misuse. Our study therefore raises concerns about inequalities in the support offered to psychiatric patients' relatives after a potentially traumatic bereavement. Those relatives least likely to be offered support were those with the greatest number of risk factors for suicide.
We presented this study at the Royal College of Psychiatrists Joint Child and Adolescent and General Adult Psychiatry Faculties Annual Conference in Birmingham (October 2016), where it won first prize in the oral presentations.
Patient and public involvement
In 2006 we were granted funding by the NIHR Enabling Involvement Fund to conduct a focus group with people bereaved by suicide. The purpose of this discussion was for service users to identify priority areas for future research to design interventions to benefit people bereaved by suicide. Our discussion was attended by 10 individuals from the South East of England, and an account of our findings was published in Bereavement Care in 2016: Pitman A, Krisna Putri A, Kennedy N, De Souza T, Osborn D, King M (2016)Priorities for the development and evaluation of support after suicide bereavement in the UK: results of a discussion group Bereavement Care 35(3): 109-116 doi: http://dx.doi.org/10.1080/02682621.2016.1254457
Participants identified a need to develop and evaluate interventions in three key areas: immediate outreach after suicide; diversification and development of peer support services; and individual psychological support for those who feel suicidal.
In 2017 we were funded by the Judi Meadows Memorial Fund to develop a co-produced leaflet describing how best to support someone after a suicide loss. This was based on the advice provided by the 27 bereaved people we interviewed, and the personal experiences of someone bereaved by suicide who co-authored the leaflet. Support After Suicide Partnership (2018) Finding the words: How to support someone who has been affected by suicide (PDF)
Future qualitative studies
Forthcoming qualitative analyses of this dataset will cover:
- Experiences of sources of support accessed after suicide bereavement, and · views on what support was helpful, unhelpful or lacking after their loss (co-authored with Tanisha De Souza)
- Views on the impact of a sudden bereavement on relationships with family and friends (co-authored with Valeriya Azorina)
- Experiences of any difficulties at work or in education after the loss (co-authored with Adelia Khrisna Putri)
- Views on how the press reported the suicide of a close contact (co-authored with Phil Gregory)
Some of these studies have focussed specifically on the experience of people bereaved by suicide, to help explain why their likelihood of suicide attempt appears to be increased.
We have presented findings from three of these papers at recent research conferences. Co-authors include Alexandra Pitman, Valeriya Azorina, Hedvig Nesse, Tanisha De Souza, Adelia Khrisna Putri, Nicola Morant, Fiona Stevenson, Michael King, and David Osborn.
- The impact of suicide bereavement on interpersonal relationships: national qualitative study of young adults - poster presentation at the 50th Congress of the German Psychological Society (DGP)
- Attitudes to suicide following a friend or relative's suicide: a qualitative study of the views of 429 young bereaved adults in the UK - poster presentation at the Royal College of Psychiatrists Liaison Faculty conference May 2017
- Experiences of support and perceived needs of people bereaved by suicide: qualitative findings from a cross-sectional UK study of bereaved young adults - poster presentation at the North East London NHS Foundation Trust 16th Annual Research and Development Open Day May 2017
Clinical and policy relevance of this work
Our work has highlighted the range of problems experienced by people who lose a relative or friend unexpectedly, and has been welcomed by voluntary sector bereavement organisations. It has also highlighted the increased probability of suicide attempt in people bereaved by suicide, whether or not they are related to the person who died. This represents a step change in our understanding of suicide risk. Until now, clinicians had understood a suicide in the family to represent a heritable risk. Now we realise that the personal impact of losing a friend or relative to suicide can also be a key influence.
In disseminating the results of our study via our peer-reviewed publications, Twitter, our UCL press release, and our UCL blog we have drawn attention to the difficulties people have in knowing what to say to someone who has recently been bereaved.
We have contributed these insights to a Public Health England expert reference group on suicide bereavement, resulting in the following guidance for local commissioners: Public Health England (2017) Support after a suicide: a guide to providing local services. PHE publications gateway number: 2016392
We are keen to use the results of this study to understand how we can help people who experience sudden loss. We are aware of a number of resources that may be helpful, and these are listed on our Sources of support link. However, our research findings suggest that there is scope to improve the accessibility of support, in collaboration with the voluntary sector, public health agencies, and the NHS.