Complicated Grief After Suicide Bereavement and Other

Causes of Death

Ilanit Tal

Veterans Affairs San Diego Healthcare System, Veterans Medical Research Foundation, San

Diego, CA, USA

Christine Mauro

Department of Biostatistics, Mailman School of Public Health, Columbia University, New York,

NY, USA

Charles F. Reynolds III

Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh

School of Medicine, Pittsburgh, PA, USA

M. Katherine Shear

Columbia School of Social Work, New York, NY, USA

Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York,

NY, USA

Naomi Simon

Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital, Boston,

MA, USA

1
 Harvard Medical School, Boston, MA, USA

Barry Lebowitz

Department of Psychiatry, University of California San Diego, La Jolla, CA, USA

Natalia Skritskaya

Columbia School of Social Work, New York, NY, USA

Yuanjia Wang

Department of Biostatistics, Mailman School of Public Health, Columbia University, New York,

NY, USA

Xin Qiu

Department of Biostatistics, Mailman School of Public Health, Columbia University, New York,

NY, USA

Alana Iglewicz

Veterans Affairs San Diego Healthcare System, Veterans Medical Research Foundation, San

Diego, CA, USA

Department of Psychiatry, University of California San Diego, La Jolla, CA, USA

Danielle Glorioso

Veterans Affairs San Diego Healthcare System, Veterans Medical Research Foundation, San

Diego, CA, USA

Department of Psychiatry, University of California San Diego, La Jolla, CA, USA

2
 Julie Avanzino

Veterans Affairs San Diego Healthcare System, Veterans Medical Research Foundation, San

Diego, CA, USA

Department of Psychiatry, University of California San Diego, La Jolla, CA, USA

Julie Loebach Wetherell

Veterans Affairs San Diego Healthcare System, Veterans Medical Research Foundation, San

Diego, CA, USA

Department of Psychiatry, University of California San Diego, La Jolla, CA, USA

Jordan F. Karp

Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh

School of Medicine, Pittsburgh, PA, USA

Don Robinaugh

Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital, Boston,

MA, USA

Harvard Medical School, Boston, MA, USA

Sidney Zisook

Veterans Affairs San Diego Healthcare System, Veterans Medical Research Foundation, San

Diego, CA, USA

Department of Psychiatry, University of California San Diego, La Jolla, CA, USA

3
Address correspondence to Sidney Zisook, MD 9500 Gilman Dr., La Jolla, CA 92093. Tel.:858-

534-4040. E-mail: szisook@ucsd.edu.

Abstract

We compared baseline demographic characteristics, clinical features, and grief-related thoughts,

feelings and behaviors of individuals bereaved by suicide, accident/homicide and natural causes

participating in a complicated grief (CG) treatment clinical trial. Severity of CG and depression

and current depression diagnosis did not vary by loss type. After adjusting for baseline

demographic features, time since death and relationship to the deceased, those with CG after

suicide had the highest rates of lifetime depression, pre-loss passive suicidal ideation, self-

blaming thoughts, and impaired work and social adjustment. Even among this treatment-seeking

sample of research participants with CG, suicide survivors may face unique challenges.

Keywords: bereavement, complicated grief, prolonged grief disorder, suicide, violent death

Complicated grief (CG) affects about 2–3% of adults worldwide (Kersting, Brähler,

Glaesmer, & Wagner, 2011) and is characterized by prolonged acute grief and complicating

factors such as second-guessing, self-blaming thoughts and excessive avoidance of reminders of

the loss (Prigerson et al., 2009; Shear et al., 2011). CG is a debilitating condition that leads to a

number of negative health outcomes, including increased suicidal ideation (Latham & Prigerson,

2004; Shear et al., 2011). Although CG occurs after the death of a friend or loved one by any

means, it may occur with greater frequency after a death by suicide (de Groot & Kollen, 2013;

Dyregrov, Nordanger, & Dyregrov, 2003; Jordan, 2008; Kristensen, Weisaeth, & Heir, 2012;

Lobb et al., 2010; Mitchell, Kim, Prigerson, & Mortimer-Stephens, 2004; Shear et al., 2011; Tal

4
Young et al., 2012). Yet little is known about whether CG after death by suicide is more severe,

or different in any way, from CG after other causes of death.

One comprehensive review of studies comparing suicide bereaved samples to other

bereaved groups suggested that suicide survivors report higher levels of rejection, shame, stigma,

need for concealing the cause of death, and blaming than all other survivor groups, but found no

significant differences between survivors of suicide and other bereaved groups regarding overall

grief intensity, general mental health, depression, PTSD symptoms, anxiety, and suicidal

behavior (Sveen & Walby, 2008). More recently, another review showed evidence for increased

risk of suicide and certain negative mental health outcomes depending on relationship to the

deceased, and provided further evidence of increased rejection and shame among suicide

survivors compared to those bereaved by other causes, though findings were mixed for

comparisons to those bereaved by other violent means (Pitman, Osborn, King, & Erlangsen,

2014). Research focused solely on suicide bereavement has highlighted high suicidal ideation

among suicide survivors (Crosby & Sacks, 2002; Jordan, 2008), stigma associated with suicide

loss, intense guilt or feelings of responsibility for the death, a ruminative need to explain or make

sense of the death, strong feelings of rejection, abandonment, anger at the deceased, trauma

symptoms, and shame about the manner of death (Jordan, 2008). However, to the best of our

knowledge, only one study has ever focused exclusively on suicide bereaved individuals with

CG (Mitchell, Kim, Prigerson, & Mortimer, 2005; Mitchell et al., 2004). Because suicide risk,

trauma-symptoms and many of these themes are seen in both suicide bereavement and CG, it

would be important to know if they are even more pronounced when suicide bereavement and

CG coexist. This report aims to help fill that gap.

5
 For this report, we utilized baseline data from a multi-site, double-blind, placebo-

controlled, randomized trial designed to evaluate the effectiveness of pharmacotherapy and/or

complicated grief psychotherapy (CGT) for CG (Shear et al., 2016). We divided the larger study

sample into groups, categorized by mode of death, to examine the similarities and differences in

CG patterns, features and trajectories after suicide compared to other deaths. We separated out a

group of accident/homicide bereaved individuals for comparison to help demarcate the effects of

suicide, per se, as opposed to the effects of any violent and unanticipated loss (Kaltman &

Bonanno, 2003), and to eliminate any masking of differences between CG after suicide

compared to after death by natural causes had we included violent loss survivors in the non-

suicide bereaved group. This is the first study to examine CG after suicide, compared to

accident/homicide bereaved and natural death, in a clinical trial treatment seeking sample.

METHOD

Participants

395 bereaved individuals age 18–95, including 58 whose loss was due to suicide and 74

whose loved one died after an accident (n = 58) or homicide (n = 16), were randomized in the

multisite clinical trial (Shear et al., 2016) between March 2010 and September 2014. Participants

were recruited using personal and public outreach, print, broadcast, and internet media. Referrals

were made by health care professionals, non-health care personnel, and by patients or family

members. With support from the American Foundation for Suicide Prevention, study staff made

extra efforts to recruit suicide bereaved participants through targeted online postings,

advertisements and referrals.

6
 Participants who scored >30 on the Inventory of Complicated Grief (ICG) (Prigerson et

al., 1995) were interviewed to confirm the presence and primacy of complicated grief and

confirm study eligibility. Excluded were those with current substance use disorder (past 6

months), lifetime history of psychotic disorder, Bipolar I Disorder, active suicidal plans requiring

hospitalization, Montreal Cognitive Assessment (MoCA)(Nasreddine et al., 2005) score <21,

pending lawsuit or disability claim related to the death, or concurrent psychotherapy or treatment

with an antidepressant. All eligible participants were willing to be randomized to receive

citalopram or placebo with or without Complicated Grief Therapy.

Assessment Procedures

Trained independent evaluators completed the clinician-administered measures described

below.

Structured Clinical Interview for DSM-IV Axis I (SCID-I)

Study staff used the SCID-I (First, Spitzer, Williams, & Gibbon, 2002), to confirm study

eligibility with respect to exclusion criteria and to characterize study participants in terms of

psychiatric comorbidities, including variables used in the present study: current and lifetime

MDD and PTSD.

Columbia Suicide Severity Rating Scale – Revised (C-SSRS-R)

Study staff used a revised version of the C-SSRS (Posner et al., 2011), modified for

bereavement (Shear, Frank, Houck, & Reynolds, 2005), to supplement eligibility decisions

related to acuity of suicidal ideation (SI) and to characterize pre- and post-death passive and

active SI. Passive SI was operationalized by endorsing “did you ever wish that you could go to

sleep and not wake up” and active SI by “have you actually had any thoughts of killing

7
yourself;” each item was repeated referencing SI “before the death” and “since the death” and

these were the only four items used in the current analysis.

Complicated Grief – Clinical Global Impressions Scale - Severity (CG-CGI-S)

Study staff completed a revised version of the CGI-Severity (Guy, 1976), modified for

CG-anchored severity (Shear et al., 2005), to indicate overall severity of complicated grief in the

week leading up to the assessment. Rater agreement was “moderate” for a subsample of ratings

evaluated (weighted kappa = 0.53). In this clinical study sample, for which CG diagnosis was an

eligibility criterion, there were zero instances of participants rated as “normal” or a “borderline

ill” at baseline and very few ratings of “mildly ill” or “among the most extremely ill patients.”

Therefore, for the purpose of this study, we combined CG-CGI-S responses into three categories:

“mildly/moderately ill”, “markedly ill” and “severely/extremely ill” (Shear et al., 2016).Quick

Inventory of Depressive Symptoms – Self-Report (QIDS-SR16). The QIDS-SR16 (Rush et al.,

2003) is a 16-item self-report questionnaire measuring the symptoms of major depression

outlined in the DSM-IV. Response choices are presented on a scale of 0 (no presentation of the

symptom) to 3 (strong presentation of the symptom). A total QIDS-SR16 score of at least 11

indicates moderately severe depression. The QIDS-SR16 demonstrated acceptable internal

consistency in this sample (Cronbach’s α = 0.70).

Inventory of Complicated Grief (ICG)

The ICG (Prigerson et al., 1995) is a 19-item self-report questionnaire designed to

measure the core emotional, behavioral and psychological symptoms of CG. Response choices

are presented on a frequency scale ranging from 0 (never) to 4 (always); total score may range

from 0 to 76. An ICG score of at least 30 at baseline was a requirement for study eligibility. The

8
ICG demonstrated acceptable internal consistency in this sample (Cronbach’s α = 0.76). To

maximize clinical relevance and to be consistent with previous studies (Prigerson et al., 2009),

we dichotomized ICG items, with an item considered endorsed if the item response was a 3

(often) or 4 (always).

Work and Social Adjustment Scale (WSAS)

The WSAS (Mundt, Marks, Shear, & Greist, 2002) is a five-item self-report scale used to

measure different facets of functional impairment attributable to an identified disorder.

Participants endorse their level of impairment on a scale of 0 to 8, with 8 indicating very severe

impairment to the point of being unable to function. The WSAS demonstrated good internal

consistency in this sample (Cronbach’s α = 0.83).

Typical Beliefs Questionnaire (TBQ)

The TBQ (Skritskaya et al., 2016) is a 25-item self-report questionnaire used to evaluate

common CG-related beliefs. Answers range from 0 (not at all agree) to 4 (very strongly agree).

The TBQ demonstrated good internal consistency in this sample (Cronbach’s α = 0.83). As we

did with ICG items, we dichotomized TBQ items; an item was considered endorsed if the item

response was a 3 (strongly agree) or 4 (very strongly agree).

Statistical Analysis

We present summary statistics as number endorsed and frequency for categorical

variables and mean and standard deviation for continuous variables. Our primary analyses tested

for differences across groups using ANOVA and chi-squared tests. For clinical variables with

omnibus tests yielding p-values ≤ .05, we calculated effect sizes (Cohen’s d or h) and also

performed post-hoc regression analyses, adjusting for the demographic variables with omnibus

9
tests yielding p-values ≤ .05. To explore differences across groups of specific CG symptoms and

associated thoughts, we included individual ICG and TBQ items in our analyses. Due to the

exploratory nature of the analyses, we did not adjust for multiple comparisons (Bender & Lange,

2001).

RESULTS

Baseline demographic characteristics, including descriptive statistics, test statistics, p-

values and measures of effect size, are summarized in Table 1. We found significant group

differences in our sample with respect to age, F(2, 392) = 6.80, p = .001, years since loss, F(2,

392) = 3.30, p = .04, marital status, χ2(2, N = 395) = 34.26, p < .001, and relationship to the

deceased, χ2(2, N = 395) = 79.97, p < .001. The suicide bereaved participants were somewhat

younger (M = 47.2, SD = 14.1) than those bereaved by accident/homicide (M = 51.6, SD = 14.8)

and natural causes (M = 54.6, SD = 14.2). More time had passed since the accident/homicide

deaths (M = 6.6 years, SD = 7.1) than the suicide (M = 3.9 years, SD = 4.6) or natural cause

deaths (M = 4.3 years, SD = 7.1). Compared to those bereaved by suicide (SB) or

accident/homicide (AH), a greater number of participants grieving a death by natural causes

(NB) were widowed (SB = 24%, AH = 14%, NB = 43%) and primarily grieving the death of a

partner (SB = 31%, AH = 18%, NB = 43%), or parent (SB = 12%, AH = 13%, NB = 37%), and

fewer were married (SB = 33%, AH = 39%, NB = 17%) and grieving the death of a child (SB =

33%, AH=46%, NB = 10%). We found no significant differences between groups with respect to

gender, race, ethnicity or education.

Clinical features, including descriptive statistics, test statistics, p-values and measures of

effect size, are summarized in Table 2. Pre-loss, the suicide bereaved group had the highest rates

10
of lifetime MDD, χ2(2, N = 395) = 11.33, p = .004 (SB = 97%, AH = 82%, NB = 78%), lifetime

PTSD, χ2(2, N = 395) = 14.63, p < .001 (SB = 64%, AH = 50%, NB = 38%), and passive SI pre-

death, χ2(2, N = 395) = 12.66, p = .002 (SB = 52%, AH = 23%, NB = 32%). Post-loss, we found

no statistically significant differences between groups in severity of CG (as measured by either

CGI-S or ICG total score), intensity of current depressive symptoms (i.e., QIDS-SR16 total

scores), or in rates of current MDD (from SCID) (see Table 2). However, significant findings

indicated that the suicide bereaved group had the highest rates of current PTSD, χ2(2, N = 395) =

8.78, p = .012 (SB = 55%, AH = 42%, NB = 35%) and endorsed non-specific active suicidal

thoughts (active SI) since the death twice as much as those bereaved by natural death, χ2(2, N =

395) = 11.57, p = .003 (SB = 43%, AH = 28%, NB = 22%).

The suicide bereaved reported greater impairment than the accident/homicide and natural

death bereaved in general (as measured by total WSAS score), as well as in all areas of

functioning measured by each WSAS item (see Table 2). Only the work impairment item did not

differ significantly across the three groups (F(2, 391) = 2.11, p = .12). In our exploratory

comparison of complicated grief symptoms, as measured by individual ICG items, we found that

only item 10 (“I’ve lost the ability to care about other people”) differed significantly across the

three groups (χ2 (N = 395) = 10.24, p = .006). Follow-up pair-wise comparisons revealed small

effect sizes for each comparison (see Table 2).

Ten Typical Beliefs Questionnaire (TBQ) items differed significantly across the three

groups (items 1, 2, 3, 4, 6, 9, 10, 12, 16, and 23; see Table 2). Item 2 (“You [the bereaved]

should have done something to prevent the death or make it easier”) was endorsed by 85% of

suicide bereaved, 47% of accident/homicide bereaved and 52% of those bereaved by natural

causes. This was the only TBQ item that differentiated suicide-bereaved from both other

11
bereaved groups with medium effect sizes from the pair-wise comparisons (h = 0.33 compared to

accident/homicide; h = 0.36 compared to natural causes).

Two TBQ items were about twice as likely to be endorsed by the suicide bereaved

compared to the accident/homicide bereaved: item 16, “other people are tired of your endless

grief” (h = 0.26), and item 23, “spending time with other people is hard because you can’t share

your grief with them” (h = 0.27). Conversely, the suicide bereaved differed from the

accident/homicide bereaved groups in being less likely to endorse items 4 (“the world is a

dangerous place”) and 10 (“bad things are uncontrollable). Although the natural-death bereaved

also differed from each of the other two groups with respect to these items, effect sizes were

small in comparison (see Table 2).

Five TBQ items did not distinguish the suicide and accident/homicide bereaved from

each other, but were endorsed more by these groups than the natural-death bereaved (see Table

2). For example, item 12, “your loved one did not have to die in this way,” was endorsed by

almost all of those bereaved by suicide and accident/homicide, but slightly less by the natural-

death bereaved (SB = 97%, AH = 89%, NB = 68%). This same pattern held true for items 1

(“this death should not have happened”), 3 (“someone else should have prevented the death”), 6

(“it isn’t fair that this person died”). For item 9 (“you don’t understand why your grief isn’t

getting better”), there was also no difference between suicide and accident/homicide bereaved,

however, in this case, the natural-death bereaved endorsed the item more, rather than less, than

the other two groups (SB = 52%, AH = 57%, NB = 68%).

Post-hoc regression analyses controlled for age, relationship status, relationship to

deceased and time since death. Clinical features that no longer yielded statistically significant

differences across groups from the adjusted analyses were: lifetime and current PTSD; and active

12
SI since the death. Differences across groups were no longer statistically significant for three

TBQ items: item 3, “someone else should have prevented the death”; item 9, “you don’t

understand why your grief isn’t getting better”; item 23, “spending time with other people is hard

because you can’t share your grief with them.” All other results were consistent with the

bivariate analyses.

DISCUSSION

We found that individuals with CG, regardless of the mode of the deceased’s death,

consistently endorsed intense and protracted grief symptoms; high rates of MDD, PTSD, suicidal

ideation, impairment; and substantial work and social impairment. Our major question, however,

was whether individuals with CG bereaved by suicide had even higher rates of comorbid

disorders and more severe symptoms, or differed on grief-associated features, compared to those

with CG bereaved by other modes of death. We learned that there were many similarities

between groups and that differences, when present, were in degree not kind, with small to

moderate effect sizes. Interestingly, in addition to differences between the suicide and natural

death bereaved groups, there were also a number of features that differed in individuals with CG

after suicide compared to those bereaved after accident/homicide.

Some differences may have been present before the loved one’s death. Those with CG

after a suicide death had higher rates of lifetime MDD and suicidal ideation, and possibly

lifetime PTSD, before the death compared to those bereaved by accident/homicide or natural

causes. These findings were not surprising, as previous studies have found that families in which

suicide occurs often are burdened by psychiatric and psychosocial difficulties even before the

suicide (de Groot & Kollen, 2013; Kissane et al., 1996; Pitman et al., 2014; Qin, Agerbo, &

13
Mortensen, 2002). Suicide survivors may have been living in an environment of constant or

intermittent stress related to their loved one’s vulnerability and the strain of being on “suicide

watch,” and may share genetic risk and familial environments for mental illness and suicidal

behavior (Pitman et al., 2014).

Suicide survivors with CG did not have higher rates of current MDD nor did they exhibit

more severe depression than the other groups. Not only was the severity of CG similar across

groups, but there were no differences between groups on 18 of 19 ICG items, suggesting that

severity of specific CG symptoms is similar among individuals with CG, regardless of the cause

of death. The finding of similar rates of current MDD among individuals with CG bereaved by

suicide compared to other causes of death is consistent with previous reports in mostly

community samples of bereaved individuals (Sveen & Walby, 2008). It is also consistent with

the already established substantial co-occurrence of MDD and CG independent of cause of death

(Simon et al., 2007).

In contrast, compared to those bereaved by other modes of death, we found unique

associations between suicide bereavement and currently meeting criteria for PTSD and active

suicidal ideation. Some evidence suggests that CG predicts suicidal ideation among suicide

survivors (Mitchell et al., 2005) and an increased risk of suicidal thoughts in subsets of

individuals bereaved by suicide (Pitman et al., 2014), however, other studies have not found

differences between suicide survivors and others with respect to PTSD or SI (Sveen & Walby,

2008). Indeed, the post-hoc adjusted analyses we performed suggest that the differences we

found among our participants with CG may be due to factors other than the mode of death.

Perhaps more so than the differences we found for categorical mental health variables,

differences in grief-related thoughts, beliefs and cognitive themes distinguished the suicide

14
bereaved from others in this sample of participants with CG. Suicide bereaved participants were

more likely than others to endorse certain thoughts and beliefs that could be taken to mean that

the bereaved individuals bear some responsibility for their loved ones’ deaths. Specifically, the

idea that they “should have done something to prevent the death” was the most salient and

distinguishing thought that was endorsed. We feel this idea is clearly an indicator of self-blame,

which has been suggested to be associated with suicide bereavement in particular (Jordan, 2008;

Sveen & Walby, 2008; Tal Young et al., 2012). That suicide bereaved endorsed more self-blame

compared to the other groups may relate to the belief many people intuitively feel that suicide is

a “choice” and that a suicide death is preventable (Shear & Zisook, 2014; Tal Young et al.,

2012). Suicide is often viewed as a tragic decision on the part of the deceased rather than as the

terminal consequence of severe distress and mental illness. Others have noted that survivors may

be plagued by the need to make sense of the death and to understand why the suicide completer

chose to end their life (Jordan, 2008). Survivors might recall past disagreements or arguments,

plans not fulfilled, calls not returned or words not said; they may ruminate on how if only they

had done or said something differently, perhaps the outcome would have been different. These

painful recollections open the door to a range of blaming thoughts and feelings, focusing on

counterfactual thinking about how things could have, and should have, gone differently. Many

suicide bereaved people struggle with questions about how they, the deceased person or someone

else, might have acted differently.

In addition, we found that the suicide bereaved were more likely to endorse items related

to their difficulties feeling connected to other people since the death. Specifically, they were

more likely than the other two groups to endorse the ICG item “Ever since he/she died I feel like

I have lost the ability to care about other people or I feel distant from people I care about” and

15
the TBQ item “Other people are tired of your endless grief.” We also found that suicide bereaved

reported more impairment in most aspects of their lives, including socially and interpersonally.

We speculate that these differences could be related to the lack of social connectedness and

support available to suicide survivors, consistent with reports of stigma associated with both

suicide (Feigelman, Gorman, & Jordan, 2009) and suicide bereavement (Cvinar, 2005; Sudak,

Maxim, & Carpenter, 2008). Alternatively, in light of the association with PTSD among suicide

survivors in this sample, these differences might be tapping feelings of detachment or

estrangement from others often present with PTSD or other factors that may have contributed to

the differences we found.

Finally, we distinguished individuals with CG whose loved one died from accidents or

homicides in order to examine whether any differences we found were related specifically to

suicide or were also seen with other deaths perceived as violent or “unnatural”. Frequencies of

lifetime MDD, lifetime and current PTSD and active SI after the death were slightly higher

among suicide bereaved compared to accident/homicide bereaved, with small effect sizes. We

were surprised to find that suicide bereaved had more PTSD than accident/homicide bereaved;

however adjusted post-hoc analyses suggest that this finding may be an artifact of other

differences between the groups.

LIMITATIONS

Several study limitations must be weighed when considering these results. This was not a

community-based epidemiological study, with a representative sample designed to identify

unique features of suicide bereavement. Rather, it was exploratory analysis of baseline data from

an intervention trial targeting complicated grief. As our sample consisted only of help-seeking

16
individuals meeting study inclusion/exclusion criteria and willing to participate in a clinical

research trial, which included both medications and intense, weekly psychotherapy, it may not

represent the general population of bereaved individuals with CG. This sampling bias might also

limit the implications of our findings to only the most distressed patients, as bereaved individuals

with moderate levels of CG might believe their experiences are “normal,” and thus not seek help.

This study is a first of its kind. Therefore, there was insufficient data to enable us to have

any empirically based hypotheses. Rather, we explored potentially meaningful differences that

are inherently interesting, may be helpful to clinicians assessing and treating individuals with CG

and may serve as hypothesis-generating questions for further study. The clinical sample was

relatively small, and it is possible that clinically significant differences were missed.

Furthermore, the sample was too small to fully assess interactions between important

demographic and social differences between the groups. We know, for example, that the death of

a child is a uniquely traumatic loss (Mitchell et al., 2004; Zetumer et al., 2015) and, in our

sample, more of the suicide-bereaved were grieving the death of a child. Although suicide

bereavement may particularly predict negative outcomes depending on kinship (Pitman et al.,

2014), we are unable to pinpoint the role of kinship with respect to the differences we found in

the adjusted analyses presented here. In addition, the natural bereaved group was much larger

than the other two groups and differences in variance across the groups may have affected our

findings.

Although we attempted to divide the sample into three distinct groups, each group was

itself heterogeneous, adding to the difficulty of generalizing results to other populations. Suicide

bereavement, for example, sometimes occurs after a very troubled history of multiple attempts

and serious mental health problems. Sometimes it seems to come out of the blue. At other times,

17
it may occur in a context of recently diagnosed serious medical illness or other severe stressors.

There may be uncertainty about whether the death was accidental or purposeful. Similarly, the

accident/homicide group included those bereaved by homicide, accidental drug overdose, motor

vehicle accident, and other accidents like drownings or falls; future studies might address

whether certain violent deaths lead to patterns more similar to suicide bereavement than the

latter. Additional features unaccounted for in this study and that might contribute to the

heterogeneity of each group and generalizability of the results, include a variety of interpersonal

issues, such as whether and how the bereaved interacted with the deceased in the hours or days

before the death and whether they were the ones to find the body. Also, the relationship to the

deceased person varied within each group, which affect the manifestation of CG (Maccallum &

Bryant, 2013; Mitchell et al., 2004; Shear & Shair, 2005) and the differences seen across groups

in this sample of participants.

Because this is a cross-sectional study, causality cannot be inferred. Future research

should take advantage of prospective, testable hypotheses; larger, more generalizable samples;

inclusion of more potentially relevant moderators and mediators (e.g., measures of stigma, social

support, family interactions, other stresses, biological markers) and longer follow-up. Finally,

although several measures were adapted for studying bereaved participants with CG, the SCID

was not modified to anchor current or past MDD or PTSD diagnoses to the qualifying death.

Indeed, the stressor attributed to a lifetime PTSD diagnosis from the SCID might have occurred

before the death, could be an event since the death, or could be the death itself. Therefore, our

findings must be interpreted with caution and future studies should address this issue.

CONCLUSION

18
 These caveats aside, to our knowledge, this is the first study of help-seeking individuals

with CG to examine clinical characteristics of suicide bereavement relative to non-suicide death,

including other violent deaths. Suicide survivors face acute grief reactions and challenges that

are similar to those encountered by anyone dealing with the death of a loved friend or relative.

However, they also may face unique challenges, including additional vulnerability secondary to a

lifelong struggle with mental health issues, a possible association with current PTSD and suicidal

ideation, greater functional impairment, and a host of potentially maladaptive thoughts and

beliefs, such as believing they could or should have prevented the death. Clinicians should be

especially vigilant for these features among suicide survivors presenting with CG. Confirming

these important preliminary findings in future studies may be useful in breaking the cycle of

suicide and preventing future suicides.

Author Note

This work was supported by grants R01MH60783, R01MH085297, R01MH085288,

R01MH085308, and P30MH90333 from the National Institutes of Health and by grant LSRG-S-

172-12 from the American Foundation for Suicide Prevention.

Acknowledgements

We thank Phillip Lavori for his consultation regarding statistical analyses and we thank

all the study coordinators, independent evaluators, and other study staff for collecting the data

reported here. We especially thank the study participants for their time and trust and willingness

to share the details of their painful losses and emotions with us in order to help others.

References

19
Bender, R., & Lange, S. (2001). Adjusting for multiple testing--when and how? Journal of
Clinical Epidemiology, 54(4), 343–349. doi:10.1016/s0895-4356(00)00314-0
Crosby, A. E., & Sacks, J. J. (2002). Exposure to suicide: Incidence and association with suicidal
ideation and behavior: United States, 1994. Suicide and Life-Threatening Behavior,
32(3), 321–328. doi:10.1521/suli.32.3.321.22170
Cvinar, J. G. (2005). Do suicide survivors suffer social stigma: A review of the literature.
Perspectives in Psychiatric Care, 41(1), 14–21. doi:10.1111/j.0031-5990.2005.00004.x
de Groot, M., & Kollen, B. J. (2013). Course of bereavement over 8-10 years in first degree
relatives and spouses of people who committed suicide: Longitudinal community based
cohort study. BMJ, 347, f5519. doi: 10.1136/bmj.f5519
Dyregrov, K., Nordanger, D., & Dyregrov, A. (2003). Predictors of psychosocial distress after
suicide, SIDS and accidents. Death Studies, 27(2), 143–165.
doi:10.1080/07481180302892
Feigelman, W., Gorman, B. S., & Jordan, J. R. (2009). Stigmatization and suicide bereavement.
Death Studies, 33(7), 591–608. doi:10.1080/07481180902979973
First, M., Spitzer, R., Williams, J., & Gibbon, M. (2002). Structured clinical interview for DSM-
IV-TR (SCID-I)-research version. New York, NY: Biometrics Research, New York State
Psychiatric Institute.
Guy, W. (1976). Clinical global impression scale. The ECDEU Assessment Manual for
Psychopharmacology-Revised Volume DHEW Publ No ADM, 76(338), 218–222.
Jordan, J. R. (2008). Bereavement after Suicide. Psychiatric Annals, 38(10), 679–685.
Kaltman, S., & Bonanno, G. A. (2003). Trauma and bereavement: Examining the impact of
sudden and violent deaths. Journal of Anxiety Disorders, 17(2), 131–147.
Kersting, A., Brähler, E., Glaesmer, H., & Wagner, B. (2011). Prevalence of complicated grief in
a representative population-based sample. Journal of Affective Disorders, 131(1), 339–
343. doi:10.1016/j.jad.2010.11.032
Kissane, D. W., Bloch, S., Onghena, P., McKenzie, D. P., Snyder, R. D., & Dowe, D. L. (1996).
The Melbourne Family Grief Study, II: Psychosocial morbidity and grief in bereaved
families. American Journal of Psychiatry, 153(5), 659–666. doi: 10.1176/ajp.153.5.659
Kristensen, P., Weisaeth, L., & Heir, T. (2012). Bereavement and mental health after sudden and
violent losses: A review. Psychiatry, 75(1), 76–97. doi:10.1521/psyc.2012.75.1.76
Latham, A. E., & Prigerson, H. G. (2004). Suicidality and bereavement: Complicated grief as
psychiatric disorder presenting greatest risk for suicidality. Suicide and Life-Threatening
Behavior, 34(4), 350–362. doi:10.1521/suli.34.4.350.53737
Lobb, E. A., Kristjanson, L. J., Aoun, S. M., Monterosso, L., Halkett, G. K., & Davies, A.
(2010). Predictors of complicated grief: A systematic review of empirical studies. Death
Studies, 34(8), 673–698. doi:10.1080/07481187.2010.496686
Maccallum, F., & Bryant, R. A. (2013). A cognitive attachment model of prolonged grief:
Integrating attachments, memory, and identity. Clinical Psychology Review, 33(6), 713–
727. doi:10.1016/j.cpr.2013.05.001
Mitchell, A. M., Kim, Y., Prigerson, H. G., & Mortimer, M. K. (2005). Complicated grief and
suicidal ideation in adult survivors of suicide. Suicide and Life-Threatening Behavior,
35(5), 498–506. doi:10.1521/suli.2005.35.5.498
Mitchell, A. M., Kim, Y., Prigerson, H. G., & Mortimer-Stephens, M. (2004). Complicated grief
in survivors of suicide. Crisis, 25(1), 12–18. doi:10.1027/0227-5910.25.1.12

20
Mundt, J. C., Marks, I. M., Shear, M. K., & Greist, J. H. (2002). The work and social adjustment
scale: A simple measure of impairment in functioning. The British Journal of Psychiatry,
180, 461–464. doi:10.1192/bjp.180.5.461
Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., 
Chertkow, H. (2005). The Montreal cognitive assessment, MoCA: A brief screening tool
for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695–
699. doi:10.1111/j.1532-5415.2005.53221.x
Pitman, A., Osborn, D., King, M., & Erlangsen, A. (2014). Effects of suicide bereavement on
mental health and suicide risk. Lancet Psychiatry, 1(1), 86–94. doi:10.1016/s2215-
0366(14)70224-x
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A.,  Mann,
J. J. (2011). The Columbia–suicide severity rating scale: Initial validity and internal
consistency findings from three multisite studies with adolescents and adults. American
Journal of Psychiatry, 168, 1266–1277. doi:10.1176/appi.ajp.2011.10111704
Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., 
Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria
proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), e1000121.
doi:10.1371/journal.pmed.1000121
Prigerson, H. G., Maciejewski, P. K., Reynolds, C. F., 3rd, Bierhals, A. J., Newsom, J. T.,
Fasiczka, A.,  Miller, M. (1995). Inventory of complicated grief: A scale to measure
maladaptive symptoms of loss. Psychiatry Research, 59(1–2), 65–79. doi:10.1016/0165-
1781(95)02757-2
Qin, P., Agerbo, E., & Mortensen, P. B. (2002). Suicide risk in relation to family history of
completed suicide and psychiatric disorders: a nested case-control study based on
longitudinal registers. Lancet, 360(9340), 1126–1130. doi:10.1016/S0140-
6736(02)11197-4
Rush, A. J., Trivedi, M. H., Ibrahim, H. M., Carmody, T. J., Arnow, B., Klein, D. N.,  Keller,
M. B. (2003). The 16-item quick inventory of depressive symptomatology (QIDS),
clinician rating (QIDS-C), and self-report (QIDS-SR): A psychometric evaluation in
patients with chronic major depression. Biological Psychiatry, 54(5), 573–583.
doi:10.1016/s0006-3223(02)01866-8
Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F., 3rd. (2005). Treatment of complicated
grief: A randomized controlled trial. JAMA, 293(21), 2601–2608.
doi:10.1001/jama.293.21.2601
Shear, K., & Shair, H. (2005). Attachment, loss, and complicated grief. Developmental
Psychobiology, 47(3), 253–267. doi:10.1002/dev.20091
Shear, M. K., Reynolds, C. F., 3rd, Simon, N. M., Zisook, S., Wang, Y., Mauro, C., 
Skritskaya, N. (2016). Optimizing treatment of complicated grief: A randomized clinical
trial. JAMA Psychiatry, 73(7), 685–694. doi:10.1001/jamapsychiatry.2016.0892
Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N.,  Keshaviah, A. (2011).
Complicated grief and related bereavement issues for DSM-5. Depress Anxiety, 28(2),
103–117. doi:10.1002/da.20780
Shear, M. K., & Zisook, S. (2014). Suicide-related bereavement and grief. In S. H. Koslow, P.
Ruiz, & C. B. Nemeroff (Eds.), A concise guide to understanding suicide: epidemiology,
pathophysiology and prevention (pp. 66–73). Cambridge University Press.

21
Simon, N. M., Shear, K. M., Thompson, E. H., Zalta, A. K., Perlman, C., Reynolds, C. F., 
Silowash, R. (2007). The prevalence and correlates of psychiatric comorbidity in
individuals with complicated grief. Comprehensive Psychiatry, 48(5), 395–399.
doi:10.1016/j.comppsych.2007.05.002
Skritskaya, N. A., Mauro, C., Olonoff, M., Qiu, X., Duncan, S., Wang, Y.,  Shear, K. (2016).
Measuring maladaptive cognitions in complicated grief: Introducing the typical beliefs
questionnaire. The American Journal of Geriatric Psychiatry.
doi:10.1016/j.jagp.2016.09.003
Sudak, H., Maxim, K., & Carpenter, M. (2008). Suicide and stigma: A review of the literature
and personal reflections. Academic Psychiatry, 32(2), 136–142.
doi:10.1176/appi.ap.32.2.136
Sveen, C. A., & Walby, F. A. (2008). Suicide survivors' mental health and grief reactions: A
systematic review of controlled studies. Suicide Life Threat Behav, 38(1), 13–29.
doi:10.1521/suli.2008.38.1.13
Tal Young, I., Iglewicz, A., Glorioso, D., Lanouette, N., Seay, K., Ilapakurti, M., & Zisook, S.
(2012). Suicide bereavement and complicated grief. Dialogues in Clinical Neuroscience,
14(2), 177–186.
Zetumer, S., Young, I., Shear, M. K., Skritskaya, N., Lebowitz, B., Simon, N.,  Zisook, S.
(2015). The impact of losing a child on the clinical presentation of complicated grief.
Journal of Affective Disorders, 170, 15–21. doi:10.1016/j.jad.2014.08.021

22
Table 1. Comparison of demographics and characteristics of death by loss type

Death by Death by Death by χ2 p

suicide accident/homicide natural cause

(n = 58) (n = 74) (n = 263)

n % n % n %

Male 10 17.2% 18 24.3% 59 22.4% 1.03 0.599

Hispanic or Latino 11 19.0% 10 13.5% 24 9.1% 4.96 0.084

Race 3.88 0.423

White 51 87.9% 62 83.8% 212 80.6%

Black 2 3.4% 8 10.8% 29 11.0%

Others 5 8.6% 4 5.4% 22 8.4%

Education 1.22 0.874

≤12 years 7 12.1% 10 13.5% 28 10.6%

Partial college 23 39.7% 25 33.8% 91 34.6%

≥ 4 year college 28 48.3% 39 52.7% 144 54.8%

Marital Status 34.26 <.0001

Never married 14 24.1% 18 24.3% 65 24.7%

Married 19 32.8% 29 39.2% 44 16.7%

Separated/divorced 11 19.0% 17 23.0% 40 15.2%

Widowed (not 14 24.1% 10 13.5% 114 43.3%

remarried)

Person who died 79.97 <.0001

Spouse/partner 18 31.0% 13 17.65% 113 43.0%

23
 Parent 7 12.1% 10 13.55% 96 36.5%

Child 19 32.8% 34 45.95% 27 10.3%

Other 14 24.1% 17 23.0% 27 10.3%

Mean SD Mean SD Mean SD F p

Age 47.2 14.1 51.6 14.8 54.6 14.2 6.80 0.001

Time Since Death 3.9 4.6 6.6 9.1 4.3 7.1 3.30 0.038

24
Table 2. Comparison of clinical features by loss type

Loss type Analysis Pair-wise effect sizes

Death by Death by Death by Suicide Suici Accide

Suicide (n Accident/ Natural vs. de vs. nt/

= 58) Homicide Cause (n = Accide Natur Homici

(n = 74) 263) nt/ al de vs.

Homici Cause Natural

de Cause

n % n % n % χ2 p Cohen’ Cohe Cohen’

sh n’s h sh

Severity of Illness (CG-CGI-S) 6.3 0.1

8 72

Moderately Ill 20 34.5 28 37.8 82 31.2

% % %

Markedly Ill 23 39.7 37 50.0 139 52.9

% % %

Severely/Extre 15 25.9 9 12.2 42 16.0

mely Ill % % %

Me SD Me Me % F p Cohen’ Cohe Cohen’

an an an sd n’s d sd

CG &

Depression

Symptom

25
Scales

Inventory of 43. 7.7 42. 9.3 42. 9.0 0.0 0.9

Complicated 1 5 8 6 39

Grief (ICG)

Typical 57. 15.2 54. 14.4 53. 17.9 1.1 0.3

Beliefs 1 5 4 3 25

Questionnaire

(TBQ)

Quick 14. 4.2 12. 4.2 13. 4.3 2.3 0.1

Inventory for 3 7 4 0 02

Depression

Symptoms-

Self Report

(QIDS-SR)

n % n % n % χ2 p Cohen’ Cohe Cohen’

sh n’s h sh

Psychiatric Comorbidities (SCID)

Lifetime MDD 56 96.6 61 82.4 204 77.6 11. 0.0 0.11* 0.18* 0.04

% % % 33 04

Current MDD 40 69.0 48 64.9 174 66.2 0.2 0.8

% % % 5 80

Lifetime 37 63.8 37 50.0 99 37.6 14. < 0.13* 0.34* 0.16*

PTSDa % % % 63 .00 *

26
 1

Current 32 55.2 31 41.9 91 34.6 8.7 0.0 0.14* 0.28* 0.10*

PTSDa % % % 8 12

Suicidal Ideation (SI; C-SSRS-R)

Passive SI 30 51.7 17 23.0 84 31.9 12. 0.0 0.34** 0.28* 0.13*

before death % % % 66 02

Passive SI 38 65.5 44 59.5 139 52.9 3.5 0.1

since death % % % 5 70

Active SI 14 24.1 9 12.2 50 19.0 3.2 0.1

before death % % % 4 98

Active SI 25 43.1 21 28.4 57 21.7 11. 0.0 0.18* 0.36* 0.11*

since death % % % 57 03 *

Impairment Me SD Me Me % F p Cohen’ Cohe Cohen’

an an an sd n’s d sd

Work and 26. 8.3 19. 9.3 22. 10.0 7.6 < 0.35* 0.25* 0.14

Social 3 7 1 3 .00

Adjustment 1

Scale

Work 4.6 2.6 3.7 2.7 3.9 2.6 2.1 0.1

impaired 1 23

Home 5.1 2.3 3.5 2.4 4.0 2.6 6.3 0.0 0.32* 0.23* 0.12

management 0 02

impaired

27
Private leisure 5.3 2.1 3.8 2.3 4.5 2.5 6.2 0.0 0.33* 0.20* 0.16

impaired 8 02

Social leisure 5.8 2.1 4.5 2.6 5.2 2.5 4.5 0.0 0.26* 0.15 0.15

impaired 5 11

Form and 5.6 2.3 4.2 2.6 4.5 2.5 5.5 0.0 0.28* 0.25* 0.08

maintain 5 04

relationships

impaired

Individual n % n % n % χ2 p Cohen’ Cohe Cohen’

ICG and TBQ sh n’s h sh

items

ICG10. Ever 39 67.2 29 39.2 135 51.3 10. 0.0 0.28* 0.18* 0.14*

since he/she % % % 24 06

died I feel like

I have lost the

ability to care

about other

people or I

feel distant

from people I

care about

TBQ1. This 56 96.6 69 93.2 181 69.1 33. < 0.02 0.27* 0.23*

death should % % % 40 .00

28
not have 1

happened

TBQ2. You 49 84.5 35 47.3 135 51.5 23. < 0.33** 0.36* 0.05

should have % % % 43 .00 *

done 1

something to

prevent the

death or make

it easier

TBQ3. 37 63.8 47 63.5 123 46.9 9.8 0.0 0.00 0.20* 0.19*

Someone else % % % 1 07

should have

prevented a

TBQ4. The 34 58.6 62 83.8 184 70.2 10. 0.0 0.21* 0.12* 0.13*

world is filled % % % 28 06

with

unpredictable

dangers

TBQ6. It isn’t 54 93.1 70 94.6 194 74.0 22. < 0.01 0.18* 0.19*

fair that this % % % 36 .00

person died 1

TBQ9. You 30 51.7 42 56.8 178 67.9 7.1 0.0 0.05 0.17* 0.11*

don’t % % % 4 28

29
understand

why your grief

not getting

better a

TBQ10. Bad 22 37.9 44 59.5 122 46.6 6.4 0.0 0.22* 0.11* 0.15*

things are % % % 6 40

uncontrollable

TBQ12. Your 56 96.6 66 89.2 178 67.9 29. < 0.06 0.28* 0.20*

loved one did % % % 94 .00

not have to die 1

this way

TBQ16. Other 21 36.2 13 17.6 77 29.4 6.1 0.0 0.26* 0.10* 0.19*

people are % % % 5 46

tired of your

endless grief

TBQ23. 30 51.7 21 28.4 100 38.2 7.5 0.0 0.27* 0.18* 0.13*

Spending time % % % 1 24

with other

people is hard

because you

cannot share

your grief with

them a

30
Notes: Effect sizes were only calculated for variables for which omnibus test p-value was <.05. Only ICG and TBQ items for

which omnibus test p-value was <.05 are listed above. Small effect sizes are indicated by an * and medium effect sizes by **; for

categorical variables, Cohen’s h ≥ 0.10 is cut-off for small effect size ≥ 0.30 for medium effect size and for continuous variables,

Cohen’s d ≥ 0.20 is cut-off for small effect size ≥0.50 for medium effect size. a Differences between groups for these variables

were no longer statistically significant at α < .05 in post-hoc logistic regression analyses controlling for demographic variables

that differed across groups (see Table 1).

31