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Suicide constitutes a major public health problem with more than , people dying by suicide globally each year [ 1 ]. The societal toll of suicide goes well beyond the human loss. Whereas the act of suicide ends the pain of one, it is a major disruptive and psychosocial stressor for others who are bereaved [ 2 ].

A suicide death can affect a substantial number of people. For example, Berman [ 3 ] found that one suicide can affect between five nuclear family members and 80 relatives, friends and acquaintances. A recent meta-analysis of population-based studies found that approximately one in 20 people 4. Grief is understood as the primarily emotional affective and natural reaction to the loss of a significant other [ 5 ]. It encompasses diverse psychological emotional, cognitive , physical, and behavioural responses to the death.

Acute grief reactions include sadness, crying, yearning, guilt and anger [ 5 ]. The course and duration of the grief process after a suicide death appear to be similar to grief processes following deaths by other causes [ 6 , 7 ]. Nonetheless, people bereaved by suicide may experience more shock or trauma related to the unexpected or violent nature of the death compared to other forms of bereavement [ 7 ].

Suicide bereavement is also a risk factor for adverse outcomes related to complicated grief [ 10 ]. While there may be similarities between some clinical characteristics of complicated grief, depression and posttraumatic stress disorder PTSD , there are a number of specific symptoms i. Compared with the general population, people bereaved by suicide have a higher risk of suicidal behaviour, and psychiatric problems such as depression, anxiety, post-traumatic stress disorder, and substance abuse [ 8 , 14 ]. This is particularly the case for those who have a personal or family history of mental health and suicidal behaviour [ 15 , 16 ].

There is also growing evidence of increased physical disorders among people bereaved by suicide, possibly related to increased unhealthy lifestyles e. More than four decades ago, Shneidman [ 19 ] identified provision of adequate suicide bereavement support i. Currently there seems to be a tension between the need for psychosocial and professional support reported by people bereaved by suicide [ 20 — 23 ] and what is known about its effectiveness [ 24 — 26 ]. At the same time, postvention has become available in an increasing number of countries [ 27 ], and has been recognized as an important suicide prevention strategy [ 1 ].

There has also been an increase in suicide bereavement research [ 28 — 30 ]. However, most of the research has been focused on the experiences of those who have been bereaved and the characteristics of suicide bereavement, whereas the effectiveness of postvention in terms of its impact on the grief process and mental health of bereaved individuals remains unclear [ 8 ].

To date three systematic reviews of interventions for people bereaved by suicide have been published [ 24 — 26 ]. McDaid et al. Six interventions showed some evidence of effectiveness on at least one outcome measure, such as reduced anxiety or depression, and less maladaptive grief reactions. Szumilas and Kutcher [ 25 ] reviewed sixteen postvention programs, including school-based, community-based and family-focused interventions.

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Although some of the reviewed interventions had positive impact on mental health and grief outcomes, the review found no evidence of reduced incidence of non-fatal or fatal suicidal behaviour related to any of the programs. Linde et al. Five studies demonstrated a decrease of intensity of grief on at least one measure. The three systematic reviews conducted to-date found some evidence of effectiveness of postvention interventions [ 24 — 26 ]. They also pointed out the limitations of the field, namely the paucity of intervention research in postvention, the diversity of methodologies used, and the general poor quality of the relevant studies.

However, the systematic reviews used different inclusion and exclusion criteria and reported on different outcomes, ranging from a variety of grief and mental health outcomes [ 24 ] to grief-specific outcomes [ 26 ]. In addition, although McDaid et al. The differences between these reviews i. To redress this gap in the literature and postvention practice, this review aimed to establish the effectiveness of suicide bereavement interventions with regard to grief, psychosocial related to mental health and psychological functioning and suicide-related outcomes using data from controlled studies only.

The review was designed to 1 uncover the research findings regarding the effectiveness of interventions on grief, psychosocial and suicide-related outcomes, 2 assess the quality of the included studies, and 3 consider the implications for practice and further research. The findings of this review will provide crucial information for service providers, both professional and peer support-based, and policy makers, as well as for the bereaved by suicide in need of effective support.

We have used the same search string in the other databases using subject headings and keywords. Any disagreement was resolved through discussion. The methodological quality of the included studies was assessed with the Quality Assessment Tool for Quantitative Studies [ 32 ]. No qualitative study met the inclusion criteria. The instrument comprises six components selection bias, study design, confounders, blinding, data collection methods, and withdrawals and dropouts to be scored as weak, moderate or strong. In addition, the instrument assesses the integrity of the intervention and analyses e.

Two researchers KK, NH independently assessed the quality of the included studies. Discussion with a third researcher KA and the wider team resolved any disagreement. Effectiveness of suicide bereavement interventions: Summary of studies. Battle USA [ 33 ]. Psychosocial functioning incl. Problems, feelings, goals self-constructed questions.

Constantino et al. De Groot et al. Farberow USA [ 36 ]. Health, impact of loss, coping, major changes, feelings self-constructed questions. Control group: decreased scores from T1 to T2; only in anxiety for T2 to T3. Intervention group at T3 significant higher on depression and puzzlement compared to Control group. Students selected by school staff on basis of close friendship with deceased student. Facilitated by child psychiatrist or trainee psychiatrist with assistance of senior school staff. Pfeffer et al. Manual based bereavement group intervention for children grouped by age.

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Significantly greater reduction in anxiety and depressive symptoms in intervention vs. Sandor et al. Greater social acceptance and job competence at T2 in SG vs. SG vs CG group not compared on problem-solving appraisal, scholastic competence, and global self-worth. Wittouck et al. Intervention 9. Zisook et al. Exclusion: Being suicidal, other psychiatric disorders except depression, other treatments. Most studies involved interventions that targeted adult populations, but three tested interventions aimed at children or adolescents [ 38 , 39 , 43 ].

Studies varied in terms of the types of participants targeted. The time since the bereavement varied across studies, with some reporting a few days [ 43 ] and others several years Zisook et al. However, about half of the studies reported either a time range or a mean within or just over one year since the bereavement [ 35 , 37 , 38 , 41 , 42 , 44 ]. Three studies evaluated family-oriented interventions [ 38 , 41 , 42 , 44 ], and two examined individual interventions [ 37 , 40 ]. One intervention was based on an individual writing task but also involved interaction with the researchers [ 37 ].

Several studies involved manualised interventions [ 37 , 38 , 40 — 42 ]. As presented in Table 1 , studies also varied in terms of the outcomes they assessed, and how they assessed them. Some studies assessed grief, using measures like the Inventory of Traumatic Grief [ 45 ], the Grief Cognitions Questionnaire [ 46 ], and the Grief Experience Inventory [ 47 ]. Other studies assessed mental health outcomes like levels of depressive symptoms Beck Depression Inventory [ 48 ], Centre for Epidemiological Studies Depression Scale [ 49 ] , psychological distress Brief Symptom Inventory [ 50 ] or social adjustment Social Adjustment Scale [ 51 ].

Still other studies assessed suicide-related outcomes, using measures like the Columbia Suicide Severity Rating Scale [ 52 ]. USA [ 33 ]. USA [ 34 ]. USA [ 35 ]. The Netherlands [ 41 , 42 ]. Australia [ 43 ]. USA [ 37 ]. USA [ 38 ]. USA [ 39 ].

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Belgium [ 44 ]. USA [ 40 ]. One study comparing an intervention with a passive control group provided some evidence of positive effects on grief outcomes. An 8-week support group program facilitated by a mental health professional and a trained volunteer found a greater decrease in grief feelings in the intervention group than in the control group [ 36 ].

Six studies with an active control group or a treatment-as-usual condition reported mixed findings. A secondary analysis of the same sample comparing participants with suicidal ideation with those who reported no ideation found a non-significant decrease in complicated grief in the former group [ 42 ].

Although grief reduced in the intervention group, no differences were found on the development of complicated grief eight months after the intervention. Complicated grief therapy resulted in similar reduction of complicated grief symptoms in the three bereaved samples, though the sample sizes may have been too small for detecting statistically significant differences [ 40 ]. A study comparing effects of a professionally led group psychotherapy and a social group program for widows bereaved through suicide [ 34 , 35 ] found that grief symptoms reduced in the therapy group [ 34 ], although a repetition of the study with a larger sample failed to replicate this effect [ 35 ].

A study comparing the effects of a death-related writing task intervention with a control condition involving trivial writing tasks yielded mixed findings [ 37 ]. Both groups experienced a significant reduction in grief levels, but the suicide-related grief aspects were more reduced in the intervention group than in the control group [ 37 ].

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  • Three studies with passive control groups focused on psychosocial outcomes, such as depression, anxiety, self-efficacy, social acceptance, and alcohol and drug use, in young people bereaved through suicide. A psycho-educational component for parents may have contributed to the positive effects. Modest positive effects were found in the intervention group in terms of greater self-efficacy, social acceptance and job competency, up to two months after the intervention. No effect on internalization, externalization, depression, risk behavior or drug and alcohol consumption was found in the only school-based intervention included in the current review [ 43 ].

    Studies assessing the effects of an intervention for adults against an active control group found little evidence of effectiveness regarding psychosocial outcomes, including depression, distress, problem solving, and social adjustment.

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    Participants in a weekly, 4-month, support group program with an educational component reported less painful emotions, and more positive emotions, insights, and problem-solving skills compared to non-help-seeking people bereaved by suicide and help-seeking individuals in psychotherapy [ 33 ]. However, a suicide and an attempted suicide occurred in the intervention group, and the study quality is unclear. The above-mentioned study by Constantino and Bricker [ 34 ] also looked at depression, distress and social adjustment and found significant reduction in depression and distress in both groups, whereas social adjustment improved in the social group only [ 34 ].

    However, a repetition of the study with a larger sample did not find any difference between the two groups [ 35 ]. A study assessing the effects of an intervention based on CBT and psycho-education on complicated grief found reduced depression and passive coping styles in the intervention group, although no differences were found regarding depression at eight-month follow-up [ 44 ]. No study reported on non-fatal or fatal suicidal behaviour, still, three previously mentioned studies reported on suicidal ideation as an intervention outcome.

    However, Zisook et al. This systematic review aimed to establish the evidence for the effectiveness of suicide bereavement interventions. Unlike previous reviews, it only included controlled studies, and reported on grief, psychosocial and suicide-related outcomes. Almost three quarters of the studies 8 out of 11 studies were conducted in the USA, and the remaining three in Western Europe.

    It is not clear whether their results would be replicated in other cultural settings and mental health care systems [ 53 ]. Most intervention studies included more female participants than male participants. As there are gender differences in the experience of suicide loss and coping strategies between females and males [ 55 ], the unintended focus on effectiveness of interventions in female-dominated samples [ 56 ] creates a significant gap in the literature and postvention practice.

    Studies identified in this review examined a wide range of outcomes related to grief, psychosocial functioning, and suicidal ideation.

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    Given the diversity of outcomes across studies, the wide range of measures employed, and the methodological limitations, at this stage it is not possible to univocally indicate effective interventions targeting issues related to bereavement through suicide. Two studies that tested CBT-based interventions targeting complicated grief, such as an intervention with psycho-education [ 44 ] and targeted complicated grief therapy [ 40 ], yielded some positive short-term results. Nonetheless, De Groot et al. Clinical studies can take place in many locations, including hospitals, universities, doctors' offices, and community clinics.

    The location depends on who is conducting the study. The length of a clinical study varies, depending on what is being studied. Participants are told how long the study will last before they enroll. In general, clinical studies are designed to add to medical knowledge related to the treatment, diagnosis, and prevention of diseases or conditions.

    Some common reasons for conducting clinical studies include:. A clinical study is conducted according to a research plan known as the protocol. The protocol is designed to answer specific research questions and safeguard the health of participants. It contains the following information:. Clinical studies have standards outlining who can participate. These standards are called eligibility criteria and are listed in the protocol.

    Some research studies seek participants who have the illnesses or conditions that will be studied, other studies are looking for healthy participants, and some studies are limited to a predetermined group of people who are asked by researchers to enroll. The factors that allow someone to participate in a clinical study are called inclusion criteria, and the factors that disqualify someone from participating are called exclusion criteria. They are based on characteristics such as age, gender, the type and stage of a disease, previous treatment history, and other medical conditions.

    Informed consent is a process used by researchers to provide potential and enrolled participants with information about a clinical study. This information helps people decide whether they want to enroll or continue to participate in the study. The informed consent process is intended to protect participants and should provide enough information for a person to understand the risks of, potential benefits of, and alternatives to the study. In addition to the informed consent document, the process may involve recruitment materials, verbal instructions, question-and-answer sessions, and activities to measure participant understanding.

    In general, a person must sign an informed consent document before joining a study to show that he or she was given information on the risks, potential benefits, and alternatives and that he or she understands it.

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    Signing the document and providing consent is not a contract. Participants may withdraw from a study at any time, even if the study is not over. See the Questions to Ask section on this page for questions to ask a health care provider or researcher about participating in a clinical study. Institutional review boards. Each federally supported or conducted clinical study and each study of a drug, biological product, or medical device regulated by FDA must be reviewed, approved, and monitored by an institutional review board IRB.

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