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Australasian Psychiatry21(6) 545 –549

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Suicide in Australia accounts for more than 24% of all male deaths and 15% of all female deaths in the 15- to 24-year age group compared to 1.6% of

deaths among all age groups.1 This means there is a dis-proportionate representation of suicide in an age group that should reflect the best and most productive years of health and quality of life. Mental health problems in this age group account for 49% of the burden of disease2 and therefore identifying risks to mental health for young people is also an important strategy to reduce suicidal behaviour throughout the lifespan.

To date the focus of work in youth suicide prevention has been to ameliorate known risk factors to attempt to reduce the number of young people dying.3 Over the last ten years, suicide in the age group 15–24 years has decreased from a rate of 20.4 to 13.4 per 100,000 for males and the rate for females has risen slightly from 4.8 to 5.2 per 100,000.4 Despite an overall reduction, suicide continues to occur, and with each death people are left grieving. These individuals bereaved by suicide have largely been ignored in the literature and are those inti-mately affected by the suicide death of a young person,

including parents, family and friends. The mechanisms of bereavement following suicide are empirically under-studied and yet personal vulnerability factors, such as a previous or recent significant loss, are major contribu-tors to suicide in young Australians.5

Suicide is statistically a rare event but is a human tragedy with far-reaching effects on families, friends and com-munities. Attempts to quantify those bereaved by sui-cide have estimated that those directly and intimately affected by the suicide death of a sibling and friend is in the range of 45 to 50 people.6 Applying this estimate to the suicide rate for 15- to 24-year-olds in Australia (296 deaths in 2010)4 equates to over 13,000 new survivors in any one calendar year adding to those bereaved previ-ously (as suicide bereavement is known to affect some-one for a long time, perhaps a lifetime).

The psychological impact of losing a friend to suicide

Warren Bartik Clinical Psychologist and PhD student, CRN for Mental Health and Wellbeing in Rural and Regional Communities, University of New England, Armidale, NSW, Australia

Myfanwy Maple Associate Professor, CRN for Mental Health and Wellbeing in Rural and Regional Communities, University of New England, Armidale, NSW, Australia

Helen Edwards Lecturer, School of Education, University of New England, Armidale, NSW, Australia

Michael Kiernan Associate Professor, School of Psychology, Charles Sturt University, Bathurst, NSW, Australia

Abstract Objective: Suicide bereavement research can help facilitate greater understanding of the impact of suicide and potential risks for others. As there is limited research on the experience of young people who lose a friend to suicide, the aim of this exploratory study was to consider specific psychological factors for such bereaved young people.Methods: Ten young people who had experienced the suicide death of a friend completed self-report measures to assess levels of depression, anxiety, coping and prolonged grief.Results: Participants reported increased levels of stress, depression, reduced coping capacity and prolonged grief symptoms that have continued considerably beyond the death of their friend.Conclusions: Psychological distress for young people bereaved by a friend’s suicide is of concern given the develop-mental changes and life transitions associated with this age group. Implications include the significant health and wellbeing challenges associated with suicide bereavement for young people. The outcomes support a more proactive response from mental health and support services.

Keywords: bereavement, coping, depression, grief, suicide, young people

Correspondence:Warren Bartik, School of Health, University of New England, Armidale, NSW 2351, Australia. Email: [email protected]

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People bereaved by suicide often experience a range of psychological and social difficulties7,8 and are them-selves at elevated risk of suicide.9,10 People experiencing bereavement may also be at risk of Prolonged Grief Disorder (PGD), which comprises grief-related symp-toms that continue beyond that which is considered adaptive. This includes separation distress such as long-ing and searching for the deceased, preoccupation with thoughts of the deceased, and traumatic distress such as feelings of disbelief, mistrust, anger, shock, detachment and experiencing somatic symptoms of the deceased.11 PGD is estimated to be experienced by between 10% and 20% of bereaved people,12 with studies demonstrating its validity and distinctiveness from bereavement-related depression and anxiety disorders.13

In the suicide literature, there are a small number of studies that consider the impact on friends of young people who die by suicide. Increased risk of recurrent depression in non-related peers was found in a longitu-dinal study comparing siblings to friends of young peo-ple who had died by suicide.14 Young adults who had experienced the suicide of a friend on average six years previously and who had symptomatic levels of compli-cated grief (now termed PGD) were five times more likely to report suicidal ideation than participants with non-symptomatic levels. These levels remained high after controlling for depression, gender and time since death.15

In a sample of 146 friends of 26 individuals who died by suicide, the occurrence of traumatic grief symptoms was reported to be independent from depression and post-traumatic stress disorder (PTSD), and traumatic grief at six months predicted the onset of depression and PTSD at subsequent assessment.16 Australian studies17,18 reported that secondary school students were at risk of imitative suicidal behaviour following the suicide death of a peer. These studies indicated the need for further research of mechanisms to identify at-risk students and what constituted effective interventions. They docu-mented that friends of suicide attempters had higher levels of depression and suicidal behaviour. There are similar findings from a large-scale study,19 with peers of suicide attempters at higher risk of suicidal behaviour than peers of those who died by suicide although mem-bers of the latter group were at higher risk of internalis-ing problems. Both groups were reported to be high-risk for psychiatric disturbance and suicidal behaviours, with the authors concluding that the closer the relationship, and possibly the greater the impact of exposure, the higher the risk of suicidal behaviours.19

Young people are recommended as a priority for future suicide research,20 and adolescence and young adult-hood is a time of significant physical, cognitive and psy-chosocial change.21 Better understanding of the effect of suicide during this key transition period has the poten-tial to inform the direction and delivery of both suicide prevention activities and suicide support services. There has been very little recent empirical research that

explores the bereavement experience of young people following the suicide death of a friend. The aim of this current exploratory study was to investigate the psycho-logical impact of grief and coping for young people who had lost a friend to suicide. It was hypothesised that young people who experience the suicide death of a friend would be at increased risk for mental health prob-lems, such as depression and anxiety, but also experi-ence prolonged grief and exhibit reduced coping skills.

MethodParticipants

The study comprised 10 participants (eight females and two males) with an average age at interview of 24 years (standard deviation (SD) = 3.43). The age of the partici-pants when they first experienced the suicide death of a friend ranged from 16 to 24 years (M =19.3 years, SD = 2.58). The time period between the suicide death and the interview ranged from one year to eight years (M = 4.7 years). The 10 participants had experienced 24 sui-cide deaths comprising friends (22) and family members (two).

Measures

Participants completed the following measures in the order listed.

The Depression Anxiety Stress Scales (DASS-21)22 is a short form self-report measure of depression, anxiety and stress for ages 14 years and up. Studies23 have dem-onstrated that the DASS-21 has considerable validity and adequate reliability for use as a measure of general psy-chological distress.

The State Trait Inventory for Adults (STAI)24 consists of two 20-item self-report scales designed to assess the present feelings of the individual (e.g. ‘I feel calm’) and how the individual generally feels (e.g. ‘I lack self-confidence’). The STAI is reported to have good construct validity and its reliability is high with median coefficients of the S-Anxiety scale and T-Anxiety scale .93 and .90, respectively.

The Coping Inventory for Stressful Situations (CISS)25 is a 48-item self-report inventory that assesses task- oriented coping, emotion-oriented coping and avoid-ance-oriented coping. The avoidance-oriented scale has two sub-scales, distraction and social diversion. Respondents rate each item on a five-point frequency scale ranging from (1) ‘Not at all’ to (5) ‘Very much’. The CISS is reported as having very high internal consistency, reliability and good validity as a multidimensional instru-ment that independently assesses coping responses.26

The Beck Depression Inventory (BDI-II)27 is a 21-item self-report measure that assesses the severity of depres-sion symptoms that the respondent has been feeling for the previous two weeks. Items are assessed on a four-point Likert scale, ranging from 0 to 3, and summed to



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give a total score range of 0–63, where high scores indi-cate a greater level of depressive symptoms. The BDI-II has high reliability, validity and internal consistency.27,28

The Prolonged Grief Disorder-13 (PG-13)29 is a 13-item self-report measure of prolonged grief symptoms, such as longing and yearning for the person who died (sepa-ration distress) that must persist for at least six months after the loss (duration criteria) and be associated with feelings of confusion, trouble accepting loss and emo-tional numbness (symptoms) with significant impair-ment in social and occupational related areas of functioning (impairment criteria).

Procedure

The research was approved by the University of New England’s Human Research Ethics Committee. The study was advertised in local and regional media. Participants were provided with information that outlined a face-to-face interview and completion of self-report question-naires. Interview dates and locations were then set with participants and these ranged from university meeting rooms, cafes and participants’ homes. Participants signed consent forms prior to completion of the self-report measures. A semi-structured interviewed fol-lowed. The qualitative component of the study is reported elsewhere.30

Analytic approach

Participants’ results on the self-report measures were compared by t tests to normative samples as described in the respective test manuals for the DASS-21, STAI and CISS. The means and standard deviations for the PG-13 were derived from a sample of caregivers pre- and post-loss following cancer illness.31 The means and SDs for the BDI-II were derived from a primary-care popula-tion.28 Because of the exploratory nature of the study, a per-comparison error rate of .05 was used for the analy-sis, controlling the Type II error rate at the level of the test only.

Results

Details of the results are presented in Table 1. Young peo-ple reported significant levels of depression t(9) = 2.70, p < .05 and stress t(9) = 2.27, p < .05. They also experienced higher levels of grief symptoms at pre-loss but compara-ble to post-loss. Depression scores as measured by the BDI-II were in the ‘mild range’ (M = 15.70, SD = 9.45). Anxiety levels were not found to be significant, but were elevated for trait anxiety (M = 41.90, SD = 11.38), with those participants who scored higher on the depression measures also reporting higher levels of both state and particularly trait anxiety. Reduced coping was significant for task-oriented coping t(9) = −3.80 p < .05, avoidance t(9) = 3.84 p < .05 and distraction t(9) = 3.22

p < .05. Participants were less able to apply structured solutions (planning and problem solving) to help them cope with stressful situations. They were also signifi-cantly more likely to use avoidant strategies and attempt to distract themselves to avoid dealing with stressful sit-uations. They also were less likely to use social diversion strategies (being with other people or talking to friends) to help them cope in stressful situations. The full criteria for prolonged grief disorder were not met by partici-pants; however, two participants met all criteria other than either duration or the full number of criteria symp-toms. Eight participants reported cognitive, emotional and behavioural grief symptoms. The hypothesis that young people who lose a friend to suicide during adoles-cence or young adulthood would be significantly more likely to report increased psychological distress and reduced coping capacity was supported for stress, depres-sion, task-oriented and avoidant coping, plus prolonged grief.

Discussion

Previous research with people bereaved by suicide has confirmed this group are at risk for a variety of psycho-logical concerns including depression, prolonged grief and in some cases self-harm and suicide.32 The results of this study confirmed that young people who had lost a friend to suicide share levels of increased stress, depres-sion, prolonged grief symptoms and reduced coping skills consistent with other suicide bereaved populations described in the literature.8 Stress and depression symp-toms were in the mild range and although the full crite-ria for PGD were not met, the majority of participants had elevated symptoms with social and functional impairment. Participants also reported lower levels of task-oriented coping, suggesting they were less able to find solutions to difficult or upsetting situations. They were also more avoidant in their coping style, using dis-traction activities rather than social engagement. This supports other findings that young people with depres-sion often adopt maladaptive coping strategies,33 and avoidance through social isolation can occur because the person is less emotionally equipped to reach out to old friends or make new friends.34

The participants were all aged in their late teens to early 20s when they experienced their friend’s suicide. This is a significant time in terms of life transitions with the end of formal secondary education and the commencement of tertiary education and/or full-time employment. This also usually coincides with changed living situations: moving away from the family to independent accommodation; changes to relationships and intimate relationships; plus new friendships and social networks often related to edu-cational, vocational and accommodation changes. Normal development in this transitional period is charac-terised by consistent and dependable relationships with significant others, and social networks are critical to engagement and growth.35 Disruption and psychological



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issues resulting from the suicide of a friend at a time of these major life transitions can have a large impact on the normal developmental experiences of young people with potentially long-lasting consequences.36 For those in this study, the length of time since the suicide death did not mediate or lessen the grief, suggesting that these behav-iours can continue for a period of years, meaning that young people’s potential for increased risk of poor health outcomes can be ongoing.

Limitations

The small number of participants limited the statistical power in this exploratory study and as such the results

and their generalisation to others bereaved by suicide need to be considered with some caution. The results, however, were consistent with similar studies of other suicide-bereaved people. There was also considerable variation in the time since the death occurred and this could have influenced the results, as might have the seemingly high number of suicide deaths this small group of young people were exposed to.

Conclusion and recommendations

There is limited research with Australian youth popula-tions that considers the impact of losing a friend to suicide. The results suggested higher levels of psychological issues

Table 1. Self-report measures

DASS Normative sample Study sample t(df=9) Sig. (two-tailed)

Mean SD Mean SD

Depression 3.18 4.16 3.30 2.84 .134 .90Anxiety 2.25 3.34 1.90 2.02 −.547 .60Stress 5.16 4.44 7.60 3.41 2.27 .05Total 10.59 10.61 12.80 4.96 1.41 .19

STAI Normative sample Study sample t(df=9) Sig. (two-tailed)

Mean SD Mean SD

State 36.36 10.96 34.30 7.86 −.83 .43Trait 35.86 9.53 41.90 11.38 1.68 .13

CISS Normative sample Study sample t(df=9) Sig. (two-tailed)

Mean SD Mean SD

Task 58.58a 8.65 49.20 7.81 −3.80 .01Emotion 40.89a 11.35 45.40 11.49 1.24 .25Avoidance 41.41a 10.24 51.80 8.55 3.84 .01Distraction 19.01a 5.90 24.80 5.69 3.22 .01Social Diversion 14.97a 4.47 17.70 5.81 1.49 .17acombined gender mean

BDI-II Normative sample Study sample t(df=9) Sig. (two-tailed)

Mean SD Mean SD

7.65 5.90 15.70 9.45 2.70 .03

PG-13 Normative sample Study sample t(df=9) Sig. (two-tailed)

Mean SD Mean SD

Grief pre-loss 23.03 7.97 29.90 8.50 2.56 .03Grief post-loss 28.57 12.66 29.90 8.50 .50 .63

DASS: Depression Anxiety Stress Scales; STAI: State Trait Inventory for Adults; CISS: Coping Inventory for Stressful Situations; BDI-II: Beck Depression Inventory; PG-13: Prolonged Grief Disorder-13; SD: standard deviation.



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that manifest at a critical time of development. Friends need to be better considered within the potential extent of people who might be identified as bereaved by suicide and perhaps a priority for response or intervention at this time. Given the small scale of this study, replication with larger participant numbers is required and consideration might also be given to the potential differences between rural and urban populations. Replication could also examine whether the extent of suicides experienced by the young people in this study is representative of normal experience.

FundingAn internal grant awarded to Maple, Edwards and Bartik from the Faculty of the Professions, University of New England, contributed to the financial support for the research.

DisclosureThere are no conflict of interest. The authors alone are responsible for the content and writing of the paper.

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