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: email@example.com
497986 APY21610.1177/1039856213497986Australasian PsychiatryBartik et al.2013
at ROCHESTER INST OF TECHNOLOGY on December 22, 2014apy.sagepub.comDownloaded from
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