The Symptoms of Suicide Survivors

Marilyn W. Edmunds, PhD, CRNP; Laurie Scudder, MS, NP


April 21, 2009

Depression, Anxiety and Quality of Life in Suicide Survivors: A Comparison of Close and Distant Relationships

Mitchell AM, Sakraida TJ, Kim Y, Bullian L, Chiappetta L
Arch Psychiatr Nurs. 2009;23:2-10


Suicide is the ninth leading cause of death in the United States, accounting for approximately 30,000 to 32,000 deaths annually. Suicide is particularly high in the 15- to 24-year-old age group. For each person who commits suicide, it is estimated conservatively that as many as 6 to10 survivors (persons close to the suicide victim or "suicide survivors") remain alive to cope with the loss. This would increase the number of newly bereaved survivors by as much as 300,000 every year. For suicide survivors, their bereavement can alter functioning and quality of life and may be associated with depression, anxiety, complicated grief, perceived stress, posttraumatic stress symptoms, and psychological distress.

The sudden, unnatural death of a family member or significant other may be ranked as a one of life's most stressful events. Critical incidents such as suicide occur suddenly, and severely disrupt a person's feelings of control and security in his or her surroundings. For survivors, death by suicide is often shattering and alters their functional ability through associated affective, behavioral, and cognitive consequences. Observation suggests that bereavement following suicide is very different from bereavement following other types of death.

The purpose of this study was to describe and compare depression, anxiety, and quality of life, by degree of relationship, between 60 closely related and distantly related survivors (persons close to the suicide victim, or suicide survivors) during the first month or acute phase of bereavement. Relationships were classified as close (spouses, parents, children, and siblings) or distant (in-laws, aunts/uncles, and nieces/nephews). Analysis of covariance was used to examine differences between the 2 groups on the symptom measures.

Results indicate that, after controlling for age and gender effects, closely related survivors had significantly higher mean levels of depression and anxiety and had lower levels of mental health quality of life than more distantly related survivors. There were no statistically significant differences between these groups on the physical health quality of life subscale.

The results of this study are consistent with findings demonstrating that close relationships may predispose one to complicated bereavement reactions following suicide. After controlling for depression, survivors are also more likely to have suicidal ideation. Complicated grief and depressive symptoms independently heighten the risk for suicidal ideation, which may pose a risk for subsequent suicide in survivors. Healthcare providers should be positioned to assess and make appropriate follow-up referrals to prevent further complications and self-harm in people who are survivors of a loved one's death by suicide.


The field of psychiatry has recognized that relational health involves a process of forming an intimate circle of persons who respond to the presence of unmet needs and provide social support. The authors suggest that first-degree relatives, because of primary socialization that stresses a value of being responsive to immediate family members, are most likely to have been invested in a relationship with the suicide victim. It seems logical that the abrupt end of that relationship may send the closely related survivor into a period of self-questioning guilt and complex grief.

Other research has also documented the clustering of completed suicides in families where suicide may be seen as a solution to the pain experienced by survivors. This article paints a stark picture of the need for clinicians to be more sensitive to proactively offer help to suicide-bereaved families.



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