The psychological impact of losing a friend to suicide
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Australasian Psychiatry21(6) 545 549
The Royal Australian and New Zealand College of Psychiatrists 2013
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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 1524 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, AustraliaMichael 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 friends 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: firstname.lastname@example.org
497986 APY21610.1177/1039856213497986Australasian PsychiatryBartik et al.2013
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Australasian Psychiatry 21(6)
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.
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).
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 063, 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).
The research was approved by the University of New Englands 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
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.
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.
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 o...