Having decided to investigate suicide bereavement as a putative risk factor for suicidality, I wished to define the socio-demographic characteristics of the population in which to test for an association. A focus on delineating risk factors for suicide in specific age-groups has been encouraged as a means of informing the development of any subsequent tailored treatment approaches and prevention strategies (144). For example, a study that found an association between suicide bereavement and risk of suicide attempt in a sample of UK adults aged >18 might use additional qualitative data to develop a psychosocial intervention for reducing such a risk. The resulting blanket intervention would be unlikely to have universal positive outcomes if it had differential effectiveness and/or acceptability in different age-groups (2). In the following section I describe the factors influencing my decision to focus my study on young men and women bereaved suddenly by any close contact. This included a review of suicide epidemiology; the high-risk status of young men in UK suicide prevention policy at that time (12); the relative paucity of research on individual risk factors for suicide in this age group; concerns over vertical (intergenerational) and horizontal (peer-to-peer) social modelling effects;
and the high economic cost to the nation of suicide in this group (145).
1.3.1 Epidemiology of suicide in different age-groups
At the time of planning this research project in 2007, the groups identified by the 2002 national suicide prevention policy as highest risk for suicide were people under the care of mental health services, people who had self-harmed, young men, prisoners, and those in high-risk occupational groups (12). The inclusion of young men reflected falls in suicide rates among older men, traditionally understood to be the group at highest risk, coupled with rises in rates for young men (146) who had supplanted older men as highest risk (147). This identified young adults as a potential sub-group of interest.
33 To better understand the risk factors for suicide in young men, I conducted a systematic review of international studies describing the epidemiology of suicide in men aged 19-30, which was published in The Lancet (145) (see Appendix 4). This review found that suicide ranks second only to accidental death as a cause of mortality in young men internationally, accounting for a substantial proportion of the economic costs of suicide. Individual-level risk factors for suicide identified in young men included psychiatric illness, substance misuse, lower socio-economic status, and single status. Population-level risk factors included unemployment levels, social deprivation levels, and irresponsible media reporting of suicide. I found very few studies assessing the effectiveness of interventions to reduce suicide risk in young men, but the most promising appeared to be efforts to encourage help-seeking behaviour and to limit access to frequently-used methods. My other finding was that in some parts of the world, young women and middle-aged men were also groups at high risk of suicide (145).
Since planning my research study, epidemiological findings regarding suicide have changed, with a fall in rates for young men (148) and a rise in those for men aged 35-49, who have now become the group at highest risk (149) (150). By 2011, adult men under 50 accounted for approximately half of all suicides in England and Wales (151). This changing demographic was reflected in the shifted focus of the 2012 suicide prevention strategy for England (110); from young men to young and middle-aged men up to the age of 50. Although interpretation of more recent trends in suicide rates are problematic due to the growing popularity of narrative verdicts by coroners (152), these shifts are suggestive of a cohort effect (153). Contributions from the sociological literature describe social factors such as relationship breakdown or job loss as likely contributors to the risk of suicide in middle-aged men (154), as well as the differential impact of the economic downturn on traditionally male industries (155). The difficulties of engaging young (156) and middle-aged suicidal men with services (157) may also contribute to their risk of suicidal behaviour.
1.3.2 Impact of peer suicide
Whilst planning this research project, a series of young people died by suicide in Bridgend, South Wales throughout 2007 and 2008. This was later demonstrated to
34 have been a suicide cluster, albeit more circumscribed than that reported in the media (158). Press reports on Bridgend indicated that many of the deceased had been known to each other, either personally or through social networking sites, suggesting the role of suicide contagion (63). The irresponsible style of media reporting was condemned by politicians and academics (159), further justifying the existence of media guidelines (93).
Public concern over the deaths in Bridgend highlighted the psychological vulnerabilities of young bereaved adults, and raised questions about the influences of social networking and internet sites (160) on social modelling of a friend’s suicidal behaviour. Accidental deaths and suicide are the leading causes of death in young adults (161), therefore peer losses are primarily violent. Young people may lack the emotional resources to deal with grief, and family members may not understand how strong the bond with the deceased had been. Adolescents and young adults who perceive intergenerational misunderstanding or feel alienated from family may be particularly vulnerable to the effects of loss after peer death if bonds with friends were stronger than those with family. The events in Bridgend reinforced the importance of measuring the effect of suicide bereavement on family members and close friends of the deceased.
Few studies have investigated how kinship or quality of attachment moderates the impact of suicide bereavement, and these have tended to focus on family and in-laws rather than friends. Findings have shown either few differences (162) or worse outcomes in first- than second-degree relatives (163). Amongst closest relatives, worst outcomes have been observed in spouses compared with children or siblings (164). In US survey data on the impact of adolescent suicide on friends and acquaintances, there is mixed evidence that closeness predicts worse outcomes, depending on the outcome considered: highest levels of grief were seen in close friends of the deceased (165), while acquaintances were most vulnerable to suicide contagion (108). A high degree of closeness did predict increased risk of PTSD (166) and incident depression (167). Together these factors highlight a need for further research on the public health impact of suicide bereavement in the young; not only among relatives but also among friends of varying degrees of closeness.
35 1.3.3 Perspective of the bereaved
In planning this study I consulted with members of the public who had experienced a sudden bereavement, bereavement counsellors, voluntary sector organisations representing bereaved people, and clinicians with a special interest in bereavement. It was clear that there was strong support for a study that might be able to clarify the specific impacts of sudden bereavement on both family and friends, and to document views on unmet needs in this population. One point emphasised was that the recovery period is often longer than clinicians and the public might appreciate (91).
This informed a decision to include exposure to bereavements occurring years previously, but to include a measure of time elapsed.