Survivors of Suicide

More than 29,000 people in the United States die by suicide every year, leaving behind thousands of loved ones. Referred to as "survivors of suicide," family and friends grieving a suicide death often struggle with their own feelings in relation to the loss as well as the stigma that suicide confers. On May 13th and 14th, 2003, the American Foundation for Suicide Prevention (AFSP) and the National Institute of Mental Health (NIMH) brought together a panel of scientists and clinicians from diverse disciplinary backgrounds to participate in a workshop to assess existing research on suicide survivors, and to identify research to be conducted so that the population of suicide survivors can be served effectively and appropriately. Workshop topics were informed by input from the suicide survivors’ community. Six areas in which significant gaps in research knowledge exist were identified:

1. Defining and identifying "survivors of suicide." There is no standard definition of "survivor" which limits ways of estimating the potential burden of this condition nationwide. Studies are needed to determine whether the status of survivor is best defined by kinship ties, by the nature and quality of the relationship one has shared with the deceased, and/or by other specific characteristics. Epidemiological studies are needed to determine how many survivors there are, what their characteristics are, and what they need.

2. Individual vulnerability to distress after suicide. Suicide survivors have not been found to suffer any greater psychiatric disability than individuals bereaved by the unexpected and violent loss of a loved one, but they are more apt to feel guilt, experience social discomfort, and struggle with understanding why it happened. It is not known if survivors experience any adverse physical health effects. To learn why some people are more or less vulnerable/resilient to severe and persistent distress after a loss due to suicide, the following dimensions should be considered: the nature and quality of the relationship with the deceased; prior mental health vulnerability; the role of social support and “connectedness” within one’s cultural groups; and whether the survivor has been blamed by others for the death.

3. Impact of suicide on family functioning and suicide risk. Little is known about how a suicide affects family stability and functioning, and how this is related to stability and functioning prior to the suicide. What is the role of cultural values and religious and work institutions in this process? People who have had a suicide in their family also appear to be at greater risk for suicide. It is not known whether this is a result of genetic factors, environmental influences, or some combination of both.

4. Interventions for survivors of suicide. What is "treatment as usual" for survivors of suicide, specifically who seeks treatment, how is it accessed, and how effective is it? While promising interventions have been developed, there is scant evidence about the impact of such efforts. Likewise, little is known about the impact of "first responders," including emergency room providers, clergy and funeral directors, on survivors’ emotional responses and adjustment.

5. Special populations. There is insufficient research on suicide survivors from different cultural, racial or ethnic backgrounds to draw conclusions regarding possible differences in responses or experiences of survivorship. And virtually no research has been conducted on the impact of suicide among gay and lesbian survivors, nor families who have lost more than one member to suicide.

6. Methodological and ethical challenges. Methodological challenges included: identifying representative samples associated with a rare (low base rate) event; selecting appropriate comparison groups; and utilizing valid and reliable measures of specified outcomes. Ethical considerations include privacy limits and the risk of re-traumatization.

The workshop was supported by funds provided by the National Institutes of Health Office of Rare Diseases to NIMH, and by unrestricted educational grants from Forest Laboratories and the Stephen D. Lelewer Memorial Fund.