Bereavement has been shown to be associated with adverse health outcomes, including increased alcohol and tobacco consumption [1
] and impairments in physical health, including increased risk of cardiovascular events [2
] and heightened risk of mortality [3
]. Bereavement also poses risk of adverse mental health outcomes (e.g., anxiety, depression, and prolonged grief disorder (PGD)) [4
]. Elevated risk of suicidal ideation, attempts [7
], and suicide [8
] may be associated with bereavement as well. For many family members, bereavement may be preceded by a period of informal caregiving for the deceased. Several factors related to informal caregiving have been shown to heighten risk of psychological distress and suicidal ideation among this population. For example, place of death of a family member was associated with post-traumatic stress disorder (PTSD) and PGD in a bereaved sample (specifically among patients with cancer who die in a hospital or ICU) [9
]. Additionally, PGD and quality of life/quality of death of the patient may affect bereaved informal caregivers’ mental health [10
] and even their degree of suicidal ideation [11
]. What remains less well-known and studied is the relationship between the deceased’s cause of death and the bereaved family caregiver’s risk of suicidal ideation.
In addition, stigma has been suggested as a factor implicated in the onset or exacerbation of suicidal thoughts among bereaved survivors of a significant other’s death. Bereaved individuals who reported greater perceived stigma surrounding their loss were more likely to report suicidal ideation [12
]. Additionally, stigma and accompanying suicidality may be associated with cause of death, specifically among deaths considered “traumatic” [13
The aim of this literature review is to compare the evidence and identify gaps in knowledge with respect to the incidence of suicidal ideation among the bereaved based on whether the deceased died by suicide, accidental overdose, cancer, dementia, cardiovascular disease (CVD), or human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDs), causes of death that collectively represent approximately 50% of all mortality in the United States [14
]. These specific causes of death were chosen for two reasons. First, family members bereaved by chronic diseases such as cancer, dementia, and CVD, and HIV/AIDS may have served as informal caregivers before death, while other groups did not, allowing the opportunity to illuminate potential differences between suicidal ideation among caregiving and non-caregiving populations in bereavement. Second, comparing natural causes of death not traditionally associated with stigma (cancer, dementia, CVD) with causes of death historically associated with stigma (accidental overdose, HIV/AIDS, suicide) may elucidate potential effects of stigma on suicidal ideation in bereavement as well. The goal of this review is to identify which bereaved populations are at the greatest need for additional research and intervention to reduce the risk of suicidal thoughts in bereavement.
Given the limited number of articles comparing SI of people bereaved from different causes of death, a meta-analysis was not appropriate to summarize risk of SI for different types of loss. Overall, articles included in this review found rates of SI from 16.5% to 31.4% in individuals bereaved by cancer, 13.7% of individuals bereaved by dementia, and 9% to 49% in individuals bereaved by suicide. Rates of SI were not reported for HIV/AIDs, accidental overdose, and CVD-bereaved groups. High rates found in the suicide-bereaved group suggest this is a salient issue to consider in efforts to improve their well-being. It is possible that this is a higher rate than other causes of death, and we believe this may be a result of both inherited and environmental risks for suicide among bereaved survivors to the extent they share the genetic or household risks. Although Song et al. found 31.4% of their bereaved sample of South Korean family caregivers of cancer patients reported SI [28
], these results may be related to higher rates of suicide in Korea in general (2.4 times higher than the average suicide rates of other countries) [35
] and cultural differences in family caregiving [36
] rather than as a function of cancer bereavement, per se.
Suicide-bereaved individuals may grieve differently compared to individuals bereaved by other causes of death [37
]. This may be at least partially a function of stigma associated with deaths from suicide. Due to the stigmatization of suicide [38
], suicide-bereaved individuals often report feelings of shame, guilt (feeling responsible for the suicide), and rejection [21
]; an experience that individuals bereaved by other causes of death have been found to report at lower rates [37
]. Data collected from a community sample showed suicide-bereaved families were viewed as contributing to the death of their loved on [40
] through neglect and failure to provide help to the deceased, suggesting both stigma and blame. In addition to public perceptions of the role families may have in the death of a loved one by suicide, families may also feel a sense of shame and guilt. In a study comparing families bereaved by suicide and accidental death, it was found that families bereaved by suicide experienced guilt, shame, and rejection at higher rates than those bereaved by accidental deaths [41
]. Similarly, Pitman and colleagues found that suicide-bereaved individuals experienced more stigma compared to people bereaved by sudden natural death and people bereaved by sudden unnatural death [42
]. Furthermore, high perceived stigma in bereavement has shown to be associated with higher likelihood of suicidal thoughts and suicide attempts, compared to bereaved individuals with lower scores of perceived stigma [12
]. Results from our search indicate that family members bereaved by HIV/AIDs [31
] and accidental overdose also report high rates of stigmatization [26
]. Future research should examine how risk factors interact in bereaved populations where cause of death is highly stigmatized, to create and implement appropriate interventions for suicide prevention.
While beyond the scope of this review, families bereaved by suicide have been found to attempt [16
] and die by suicide [43
] at higher rates than families bereaved by other causes of death. Current theories of suicide support feelings of isolation and burdensomeness, combined with the capability and access to lethal means, will increase an individual’s risk of suicide [46
]. Thus, the perceived stigma and isolation felt by suicide-bereaved family members, in addition to genetic risks for suicide [47
], may help explain these findings.
Eight studies included in our review included informal caregiving populations [11
]. These articles found rates of SI from 16.5% to 31.4% in informal caregivers bereaved by cancer [11
] and 13.7% in informal caregivers bereaved by dementia [33
]. Informal caregiving is well-established as an independent risk factor for poor mental health [48
] and SI [11
] and the limited results of this literature search show that these risks may continue into bereavement. Dementia-bereaved individuals, however, exhibited higher rates of SI pre-loss compared with post-loss [33
]. These results suggest that changes in SI from active caregiving to bereavement may be linked with cause of death, and possibly confounders such as the age, gender, and kinship relationship between family caregiver and deceased as well. More research is needed to understand how factors specific to the caregiving process, such as medical care, financial burden, or cultural beliefs, contribute to SI in family member bereavement.
Results from our review indicated several gaps in the literature. First, far greater standardization is needed for quantifying SI and behavior for more accurate comparison across studies. In 19 studies, 10 different measures of SI were used (see Table 2
). Additionally, many of the studies were conducted on primarily white/Caucasian race samples. More research is needed on ethnically and racially diverse populations. Studies retrieved in our review were also overwhelmingly treatment-seeking bereaved family members. There is a need for studies that include bereaved populations who do not seek help. Caregivers were underrepresented in the results generated by our systematic review. Given the risk associated with caregiving, further research is needed to investigate the presence of SI in this population. Lastly, women were also over-represented in studies; although women are at higher risk of SI and historically more likely to be informal caregivers [49
], men are overwhelmingly more likely to die by suicide [50
]. Future research should attend to adequate inclusion of men in study sampling.