498 Suicide and Life-Threatening Behavior 35(5) October 2005

 2005 The American Association of Suicidology

Complicated Grief and Suicidal Ideation

in Adult Survivors of Suicide
Ann M. Mitchell, PhD, RN, Yookyung Kim, PhD, Holly G. Prigerson, PhD,
and Mary Kay Mortimer, PhD, RN

While the prevalence of complicated grief has been demonstrated to be

elevated in survivors of suicide, the association between complicated grief and
suicidal ideation among adult suvivors of suicide has not been explored. The pur-
pose of the present study is to examine the association between complicated grief
and suicidal ideation in suicide survivors. The Inventory of Complicated Grief
and the Beck Depression Inventory were administered to 60 adult survivors within
1 month of a death by suicide of a family member or significant other. Compli-
cated grief was associated with a 9.68 (CI: 1.036, 90.417) times greater likelihood
of suicidal ideation after controlling for depression, suggesting that syndromal
complicated grief heightens vulnerability to suicidal ideation. Clinicians may pro-
vide more comprehensive assessments by recognizing the possibility of suicidal
ideation in those with complicated grief.

Suicide, a major public health problem, oc-
curs most frequently as a consequence of a
mental disorder (National Institute of Mental
Health [NIMH], 2003; U.S. Department of
Health and Human Services [DHHS], 1999).
Suicide is the third leading cause of death in
young people between the ages of 15 and 24,
and the eleventh leading cause of death in the
United States (American Association of Sui-
cidology, 2001; DHHS, 2000), accounting
for about 30,000 deaths annually. For each
person who commits suicide, as many as six
to ten survivors (persons close to the suicide
victim) remain to cope with the loss (Ameri-
can Association of Suicidology, 1999; Colt,
1991), resulting in 180,000 to 300,000 newly

Ann M. Mitchell is Assistant Professor of Nursing and Psychiatry in the Health and Community
Systems Department at the University of Pittsburgh School of Nursing. Yookyung Kim is Assistant
Professor of Biostatistics, Center for Nursing Research, at the University of Pittsburgh School of Nurs-
ing. Holly G. Prigerson is Associate Professor of Psychiatry at Brigham and Women’s Hospital, Har-
vard Medical School, and the Division of Psychosocial Oncology and Palliative Care at Dana-Farber
Cancer Institute in Boston. Mary Kay Mortimer is Associate Professor of Nursing at the Franciscan
University of Steubenville in Ohio.
This work was made possible by the generous support of the American Foundation for Suicide
Prevention, New York, NY, and the University of Pittsburgh Central Research Development Fund,
Pittsburgh, PA. The authors wish to acknowledge the contributions of David Brent, MD, Department
of Psychiatry, Pediatrics, and Epidemiology at the University of Pittsburgh School of Medicine and
Graduate School of Public Health; Karen Evanczuk, PhD, CRNP, Family Nurse Practitioner, Depart-
ment of Community Outreach, University of Pittsburgh Medical Center, UPMC McKeesport; and Susan
Wesner, MSN, RN, Clinical Nurse Specialist, Services for Teens at Risk, Western Psychiatric Institute
and Clinic, Pittsburgh, PA.
Address correspondence to Ann M. Mitchell, PhD, RN, University of Pittsburgh, School of Nurs-
ing, 415 Victoria Building, Pittsburgh, PA 15261; E-mail: ammi@pitt.edu
Mitchell et al.
bereaved suicide survivors annually. From a
public health perspective, suicide is a major
problem (DHHS, 1999, 2000) and for survi-
vors of suicide, their bereavement can nega-
tively influence their functioning and mental
health, including their risk of complicated
grief reactions.
Recent studies have identified compli-
cated grief as an important distinct reaction
to bereavement that is separate from normal
grief and other psychiatric disorders, such as
bereavement-related depression and anxiety
disorders (Prigerson, Frank, et al., 1995; Prig-
erson et al., 1997; Jacobs, Mazure, & Priger-
son, 2000). To develop complicated grief
symptom criteria empirically, data were de-
rived from a study group of 82 recently wid-
owed elderly individuals recruited for an in-
vestigation of physiological changes in bereaved
persons. Baseline data were collected 3 to 6
months after the deaths of the subjects’
spouses, with follow-up data collected from
56 subjects 18 months after the baseline as-
sessments. Principal-components analysis re-
vealed a complicated grief factor and a be-
reavement-depression factor. The concept of
complicated grief as a new diagnostic cate-
gory requires that certain criteria be met.
The proposed criteria, based on the work of
Prigerson, Shear, et al. (1999), requires that
survivors of a significant loss have an intru-
sive and a distressing set of core symptoms
which includes: yearning and longing for the
deceased, a sense of purposelessness, feelings
of futility, difficulty imagining a life without
the deceased, numbness, detachment, feeling
stunned, dazed or shocked, feeling that life is
empty or meaningless, feeling disbelief over
the loss, and excessive anger or bitterness re-
lated to the death.
Complicated grief has been found to
be associated with a heightened risk of sui-
cidal thoughts and actions among young
adult friends of adolescents who died by sui-
cide (Prigerson, Bridge, et al., 1999). Priger-
son, Bridge, et al. (1999) examined the influ-
ence of complicated grief on suicidal ideation
in 76 young adults who had a fried who died
by suicide at an average of 6.3 years after
their friend’s suicide. Results indicated that
499
complicated grief was associated with a 5.08
times greater likelihood of suicidal ideation
after controlling for depression. Comorbid
complicated grief and depression were not
associated with a greater likelihood of sui-
cidal ideation. Recently, Melhem and col-
leagues (2004) reported in a sample of 146
friends and acquaintances of 26 individuals
who died by suicide, the occurrence of trau-
matic grief symptoms was independent from
that of depression and Posttraumatic stress
disorder (PTSD), and that traumatic grief at
6 months predicted the onset or course of de-
pression and PTSD at subsequent assess-
ments. These results suggest a long-lasting
effect of complicated grief on suicidality.
Complicated grief also has been found
to be associated with a heightened risk of sui-
cidal ideation and thoughts among bereaved
older persons. Szanto, Prigerson, Houck,
Ehrenpreis, and Reynolds (1997) examined
whether complicated grief predicted suicidal
ideation during a depressive episode in 130
elderly bereaved individuals who had lost
their spouses within the past 2 years. They
found that 57% of the patients with high
complicated grief scores were found to be
ideators during the follow-up time period
versus 24% of the patients with low compli-
cated grief scores. Latham and Prigerson
(2004) also examined the influence of com-
plicated grief on suicidal thoughts or behav-
iors in 281 bereaved elders at an average of
6.3 months post-loss. They found the risk of
any suicidal thoughts or behaviors was 10.80
times greater for subjects with complicated
grief and 7.10 times greater for subjects with
a major depressive disorder compared to those
who did not meet criteria for these disorders.
There is an increased risk for suicidal
ideation and behavior in families where there
has been a completed suicide (DHHS, 1999).
While complicated grief has been demon-
strated to be high in survivors of suicide
(Mitchell, Kim, Prigerson & Mortimer-
Stephens, 2004), the influence of compli-
cated grief symptoms on suicidal ideation
among adult survivors of suicide has not been
explored. The purpose of the present study
is to examine the main and interactive effects
500
of complicated grief and depression on sui-
cidal ideation in this group of individuals.
METHODS
Subjects and Design of the Study
A cross-sectional design was used for
this exploratory, descriptive pilot study. Data
were obtained from 60 adult survivors of sui-
cide (18 years of age or older) who completed
baseline measures as part of a crisis interven-
tion study during the acute phase of bereave-
ment. That study, which was conducted over
a 3-year period, examined the efficacy of a
modified, family-focused critical incident
stress debriefing intervention for survivors
within 1 month of a death by suicide. Sub-
jects were recruited with the assistance of lo-
cal coroners’ offices, funeral homes, commu-
nity mental health centers, and other social
service agencies within a 100 mile radius of a
tri-state area that included Southwestern
Pennsylvania, Ohio, and West Virginia.
All data reported had been collected
before any intervention was administered.
The study received Institutional Review Board
(IRB) approval from a university-designated
committee comprised of members with mul-
tidisciplinary backgrounds and expertise es-
tablished to protect the rights and welfare of
human subjects participating in research ac-
tivities. All subjects consented to participate
in the study.
Measures
The 60 subjects completed the follow-
ing self-report measures at baseline, within 1
month of the death by suicide of a family
member or significant other.
The Beck Depression Inventory (BDI),
Version I. The BDI is composed of 21 self-
administered, Likert-type items. Each of the
21 items is rated on a 4-point scale ranging
from 0–3. The total BDI score (0–66) is ob-
tained by adding the score of all categories
and is matched with established degrees of
depression: minimal, 0–9; mild to moderate,
Complicated Grief
10–19; moderate to severe, 20–29; and se-
vere, 30–66. Concurrent validity of the BDI
to depression ratings by clinicians is well es-
tablished in the literature. Test-retest reli-
ability over 6 to 21 days was 0.86 for de-
pressed, and 0.76 for nondepressed samples
(Beck, Ward, Mendelson, Mock, & Erbaugh,
1961; Metcalfe & Goldman, 1965; Schwab,
Pialow, & Holzer, 1967). The BDI demon-
strated high internal consistency in the pres-
ent sample (Cronbach’s alpha = 0.95).
Suicidal Ideation. Suicidal ideation
was determined by No = 0 on question 9 of
the BDI and Yes = 1, 2, or 3 on question 9 of
the BDI. In this sample, 16.7% (n = 10)
scored Yes on question 9 of the BDI. The in-
ventory’s item assessing suicidal ideation
(question 9) was then omitted from the sum-
mary score. A BDI score greater than 10 was
selected as the cutoff point for “caseness” of
depression in this study because this is the
established start point for the mild to moder-
ate level of depression. In this sample, 50%
(n = 30) scored above 10 on the BDI.
The Inventory of Complicated Grief (ICG).
The ICG is an instrument developed to as-
sess certain symptoms of grief known to pre-
dict long-term functional impairments (Prig-
erson, Maciejewski, et al., 1995). It was
designed to measure symptoms that have
been termed complicated grief. Subjects are
asked to report the frequency (Never = 0 to
Always = 4) with which they currently experi-
ence each of the behavioral, cognitive, and
emotional symptoms described in the ICG.
Respondents with ICG scores >25 were found
to be significantly more impaired in social,
mental, and physical health functioning than
those with ICG score ≤25. The instrument
has been shown to have adequate psychomet-
ric properties. Concurrent validity of the
ICG was assessed in relation to other scales
and showed a fairly high association with the
BDI (r = 0.67, p < 0.001) and the Grief Mea-
surement Scale (r = 0.70, p < .0001). The in-
ternal consistency of the 19-item ICG was
high (Cronbach’s alpha = 0.94). Test-retest
reliability was 0.80 when used with conju-
gally bereaved elderly (Prigerson, Maciejew-
ski, et al., 1995). The 19-item ICG demon-
Mitchell et al.
strated modest internal consistency in the
present sample (Cronbach’s alpha = 0.66).
The cutoff point for “caseness” of
complicated grief was an ICG score greater
than 25 given the prior work demonstrating
the criterion validity of this cutpoint (Priger-
son, Maciejewski, et al., 1995). In this sample,
43.3% (n = 26) scored above 25 on the ICG.
Data Analyses
Preliminary descriptive analyses on de-
mographic and clinical variables and psycho-
metric analyses on the BDI and ICG were
conducted. Relationships between demo-
graphic variables (age, gender, religion, and
education) and suicidal ideation were exam-
ined to identify significant covariates. Logis-
tic regression analyses (Agresti, 1990) were
performed using the ICG scores, as well as
BDI scores as independent variables, and sui-
cidal ideation as the dependent variable. Vari-
ables were examined to determine that there
was not a problem with multicollinearity.
Multicollinearity is usually regarded as a
problem if bivariate correlation coefficients
between each pair of independent variables
are greater than .80. Our results showed that
bivariate correlation between independent
variables was .471, indicating that multicol-
linearity is unlikely. The collinearity statistic
(e.g., tolerance) of .778 further supports our
justification of using the current models for
data analysis.
We employed binary logistic regres-
sion models to estimate the probability of an
individual reporting suicidal ideation (Yes vs.
No). Logistic regression models estimated
the main effect of syndromal complicated
grief on the likelihood of suicidal ideation,
controlling for depression.
RESULTS
Sample Characteristics
A brief description of the investiga-
tion’s subjects follows. The sample was com-
prised of 43 Caucasian females (72%) and 17
501
Caucasian males (28%), with a mean age of
43.3 years (range: 18–78 years) and was pre-
dominately Catholic (67%) or Protestant
(23%). In general, the subjects had a high
school education (40%), technical/vocational
diploma (13%), or bachelor’s degree (32%)
and worked fulltime (65%) or parttime (33%).
The sample consisted of 60 subjects
recently bereaved (within 1 month) by the
suicide of a family member, significant other,
friend, or coworker. Each subject belonged
to one of 16 family networks, with the num-
ber of subjects per family network ranging
from 1 to 22. A family network consisted of
those bereaved subjects who were survivors
of a particular individual’s suicide. Each fam-
ily network included at least one spouse, par-
ent, child, or sibling while the larger net-
works also included in-laws, nieces/nephew,
friends and/or co-workers. Although the
family networks varied in size, the largest
network had members representing each of
the relationship categories examined.
Of the 16 deaths by suicide, 7 (44%)
were by gunshot, 4 (25%) were by hanging,
3 (19%) were by carbon monoxide, followed
by 1 overdose (6%) and 1 suffocation (6%).
However, of the 60 subjects associated with
each of the 16 deaths, most subjects (n = 32,
53%) were exposed to a death by hanging,
with the next most frequent category being
death by gunshot (n = 15, 25%).
The demographic characteristics of
the 60 subjects in terms of the two subgroups
of suicidal ideation (Yes vs. No) are presented
in Table 1. The groups were comparable with
regard to age, gender, race, religion, and edu-
cation with no significant statistical differ-
ences found between the two groups.
Complicated Grief and Likelihood
of Suicidal Ideation
Multivariate logistic regression models
were employed to estimate the probability of
an individual reporting suicidal ideation (Yes
vs. No) with two dichotomized grouping vari-
ables of complicated grief (Yes vs. No) and
depression (Yes vs. No), with cutoff scores
described in a previous section of this paper.
502 Complicated Grief

TABLE 1
Sample Demographics by Suicidal Ideation (SI) Group
SI Yes SI No
(n = 10) (n = 50) t or χ2 P

Age .402 .689

Mean ± SD 41.70 [12.63] 43.62 [13.99]
Gender .410 .522
Male, n (%) 8 (80%) 35 (70%)
Female, n (%) 2 (20%) 15 (30%)
Race — —
White, n (%) 10 (100%) 50 (100%)
Religion 1.929 .381
Catholic, n (%) 5 (50%) 35 (70%)
Protestant, n (%) 4 (40%) 10 (20%)
Other, n (%) 1 (10%) 5 (10%)
Education 5.862 .210
Elem Sch, n (%) 1 (10%) 0 (0%)
High Sch, n (%) 4 (40%) 20 (40.8%)
Voc Sch, n (%) 2 (20%) 6 (12.2%)
Undergrad, n (%) 2 (20%) 17 (34.7%)
Graduate, n (%) 1 (10%) 6 (12.2%)

Table 2 depicts the multivariate logistic re-
gression models for predicting suicide ide-
ation (predictor variable, unstandardized
regression coefficient, standard error, Wald-
test statistic, p value, adjusted odds ratio
[OR], and 95% confidence interval for OR).
In step 1, a logistic regression model first
tested the effect of depression on suicidal ide-
ation. The results showed that depression had
a significant effect on suicidal ideation (OR =
12.429, 95% CI = 1.461–105.737, p = .021).
In step 2, an additional logistic regres-
sion model was used to estimate the unique
effect of syndromal complicated grief on the
likelihood of suicidal ideation, controlling for
the effects of depression. As shown in Table
2, complicated grief was significantly associ-
ated with suicidal ideation even after adjust-
ing for the effect of depression in the model.
Subjects with syndromal levels of compli-
cated grief were found to be approximately
ten times more likely to report suicidal ide-
ation than were subjects with nonsyndromal
levels of complicated grief (OR = 9.680, 95%
CI = 1.036–90.417, p = .046) when depres-
sion was in the model. The broad 95% confi-

TABLE 2
Depression and Complicated Grief as Predictors of Suicidal Ideation in Survivors of Suicide
95% CI for OR

Step Predictor Variable B SE Wald df p OR Lower Upper

1 Depression 2.520 1.092 5.322 1 .021 12.429 1.461 105.737

2 Depression 1.709 1.156 2.186 1 .139 5.524 .573 53.230
Complicated Grief 2.270 1.140 3.965 1 .046 9.680 1.036 90.417

Note. B = Unstandardized Regression Coefficient; SE = Standard Error; Wald = Wald-test

Statistic; OR = Adjusted Odds Ratio.
Mitchell et al.
dence intervals for ORs indicate the effect
was small, although significant.
The model was statistically reliable
(Chi-squared for model = 14.3, df = 2, p =
.001) and demonstrated a good fit to the data
(Chi-squared for Hosmer-Lemeshow test
statistic = 3.11, df = 2, p = .211). The overall
predictive success (correct classification) of
the model was 83.3%, indicating that com-
plicated grief was highly predictive of suicide
ideation in survivors of suicide, over and
above the effects of depression.
DISCUSSION
Syndromal levels of complicated grief
significantly increased the likelihood of sui-
cidal ideation in this sample of adult survi-
vors of suicide. The significant effect of com-
plicated grief on suicidal ideation remained
even after depression was entered into the
model, suggesting that it is an independent
clinical correlate of suicidal ideation. Even
though there were no completed suicides re-
ported among the survivors of suicide within
the study observation period, prior suicidal
thoughts and gestures have been identified as
a leading predictor of subsequent suicide (Shaf-
fer, Garland, Gould, Fisher, & Trautman,
1988). The results of the present study indi-
cate that complicated grief and depressive
symptoms independently heighten the risk of
suicidal ideation which may pose a risk for
subsequent suicide.
Although the present assessment of
complicated grief was done within 1 month
of the death, when time from loss to mea-
surement of complicated grief has been con-
trolled, it has not had significant effects on
levels of complicated grief. Furthermore,
Prigerson and others have found that the
presence of complicated grief is higher and
more persistent in suicide bereavement than
in other forms of death. Dyregrov, Nor-
danger, and Dyregrov (2003) have found the
prevalence of complicated grief to be signifi-
cantly higher in parents bereaved by suicidal
and accidental deaths than by deaths from
SIDS. Recently, Rynearson, Favell, Belluo-
503
mini, Gold, and Prigerson (2002) found that
in a 208-bed correctional facility for boys and
girls, 60% of the detainees had experienced
the violent death of a friend or family mem-
ber approximately 21⁄2 years earlier, and that
complicated grief was higher in those be-
reaved by suicide (Prigerson, November 2004,
personal communication). Rynearson et al. were
evaluating a treatment group intervention,
and although the pre- and post-intervention
decrease in measures of distress (including
complicated grief) could have been associ-
ated with change over time, it would seem
unlikely that, given the high levels of death-
related distress at 30 months since the violent
death, a significant decrease would occur
spontaneously.
Although the present study utilized
cross-sectional data, longitudinal data has
demonstrated that complicated grief and de-
pression are preludes to suicidal ideation in
the spousally bereaved (Szanto et al., 1997).
In a larger, community-based sample of re-
cently bereaved blood relatives of the de-
ceased, Latham and Prigerson (2004) found
that bereaved elders who met criteria for
complicated grief were at a significantly
heightened risk of suicidality that remained
after controlling for depression. This sug-
gests that complicated grief is an indepen-
dent and important clinical correlate of sui-
cidality, apart from a major depressive disorder.
An important finding in the Latham
and Prigerson (2004) study involved the ex-
amination of the prevalence of a prior psychi-
atric diagnosis. It could be postulated that
those with a prior psychiatric history might
tend to be less successful at grieving the loss
of a loved one. However, baseline character-
istics in their sample demonstrated that prior
psychiatric history and complicated grief sta-
tus at baseline were not related. That is, the
death of a loved one is an event that can
cause great mental distress in persons both
with and without a prior psychiatric history,
making both populations vulnerable for suf-
fering from complicated grief.
Furthermore, symptoms of compli-
cated grief are not only associated with sui-
cidal ideation but also with a number of other
504
negative physical and mental health outcomes.
Prigerson, Bierhals, et al. (1997) followed a
group of 150 widows and widowers at the
time of their spouses hospitalization and at
6, 13, and 25-month follow-up time periods.
Using survival analysis and linear and logistic
regressions, the risk for adverse physical and
mental health outcomes posed by the pres-
ence of complicated grief were assessed. The
presence of complicated grief at 6 months
after the death of their spouse predicted neg-
ative health outcomes including cancer, heart
trouble, high blood pressure, changes in
eating habits, and suicidal ideation at 13- or
25-month follow-up time periods. These re-
sults indicate that psychiatric sequelae, such
as complicated grief, may be of critical im-
portance in determining which individuals
will be at risk for long-term mental and phys-
ical health problems, rather than simply the
stress of bereavement (Prigerson, Bierhals, et
al., 1997).
More recently, Dyregrov and colleagues
(2003) compared the predictors of psychoso-
cial distress after a death by youth suicide,
SIDS, and child accidents. Data were col-
lected from 140 families, representing 232
parents. One and one-half years post-loss,
57–78% of the survivors scored above cut-
off levels for complicated grief. Although
they found no significant differences between
survivors of suicide and accidents, both groups
had significantly greater subjective distress
than the survivors of SIDS. These results
suggest that to lose a child suddenly and in
traumatic circumstances can have a long-last-
ing impact. It may be that sudden and trau-
matic death is a factor associated with com-
plicated grief and other posttraumatic reactions.
It will be important to assess if the resultant
risks of suicidal ideation in these bereaved
adults are similar to what we have found in
survivors of suicide.
Furthermore, Callahan (2000) found
that in a group of 210 survivors participating
in suicide support groups, one of the factors
affecting their overall level of grief was post-
traumatic reactions which increased their dis-
tress. Latham and Prigerson (2004) found
that 38.2% of those with complicated grief
Complicated Grief
met criteria for PTSD, indicating the overlap
was not extremely high. When Silverman,
Johnson, and Prigerson (2001) compared the
influence of childhood and adulthood adver-
sities on current diagnoses of major depres-
sion, PTSD, and complicated grief among 85
recently widowed older adults, they found
adversities occurring in childhood were sig-
nificantly associated with complicated grief,
and secondarily to depression, while adversi-
ties occurring in adulthood were associated
with PTSD. The tendency of childhood ad-
versity to predict complicated grief and adult
adversities to predict PTSD remained signifi-
cant even after the clustering of adversity and
comorbidiy among psychiatric disorders was
taken into account. The distinct etiological
risks for bereavement-related depression,
PTSD, and complicated grief suggest that
therapeutic interventions should be devel-
oped and tailored to the particular symptoms
and syndromes that are present.
Limitations
There are a number of limitations of
the current study, including a small and ho-
mogeneous sample (e.g., all Caucasian and
primarily Catholic subjects from Western
Pennsylvania). There also may be sample se-
lection bias using participants who were will-
ing to take part in a crisis intervention study.
We continue to need longitudinal analyses to
draw conclusions about causality; and a larger
and more ethnically and geographically di-
verse sample to draw conclusions that are
more generalizable. Finally, family network
effects (including the varying sizes of the net-
works) were not fully examined in this study
because of the small sample size.
CONCLUSIONS AND
RECOMMENDATIONS
This study builds on previous work
that has been conducted on complicated grief
with adolescents and the elderly, and broad-
ens the subjects to include numerous other
relationship categories (e.g., spouses, parents,
Mitchell et al.
children, siblings, in-laws, nieces/nephews,
and friends or coworkers). The findings indi-
cate that survivors of suicide are vulnerable
not only to complicated grief, but also to sui-
cidal ideation and possibly to suicide. Health
care providers should be positioned to re-
sponsibly assess these areas and make appro-
priate follow-up referrals to prevent further
complications of grief and potentially self-
harm in these populations.
Future research is needed to address
current limitations, including a larger and
more diverse sample. A larger and less self-
selected into treatment sample will make
conclusions more generalizable to the target
group of survivors of suicide. Once we have a
larger sample we can then apply hierarchical
linear modeling (HLM) or multi-level analy-
ses to address the issue of interdependence of
subjects. Longitudinal studies will also allow
us to determine if long-term associations
exist in suicide survivors as they do in non-
suicide survivors and to examine other factors
that may influence complicated grief and sui-
cidal ideation. Future studies with survivors
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Manuscript Received: May 18, 2004
Revision Accepted: December 20, 2004