Spousal Suicide Ups Morbidity, Mortality in Surviving Partner

Batya Swift Yasgur, MA, LSW

March 24, 2017

People bereaved by spousal suicide have a significantly higher risk for physical and mental disorders and mortality compared to the general population and those bereaved by other types of spousal death, new research shows.

Investigators led by Annette Erlangsen, PhD, associate professor and department head, Danish Research Institute for Suicide Prevention, Copenhagen, found that compared with individuals who lose spouses from other causes, survivors of spousal suicide were at higher risks for developing mental disorders and suicidal behaviors. The risk was also higher for all-cause mortality.

"We were surprised that we could see so clearly that people bereaved by a spouse's suicide are affected in so many different parameters from the loss. It is a severely distressing event and can require professional intervention," Dr Erlangsen told Medscape Medical News.

The study was published online March 22 in JAMA Psychiatry.

A Vulnerable Population

Previous research has demonstrated that survivors of spousal suicide experience a range of emotional sequelae and physical disorders, as well as increased healthcare use and higher mortality risk.

Individuals bereaved by the loss of spouses to other causes also experience mental disorders.

"We wanted to investigate whether survivors of spousal suicide experience worse mental, physical, and social health outcomes than members of the general population or spouses bereaved by causes other than suicide," Dr Erlangsen said.

"We hoped that our findings would demonstrate the need for more support for spouses bereaved by suicide," she added.

To investigate the question, the researchers examined a Danish register-based cohort of individuals (aged 18 years or older) from 1980 to 2014.

The total study population included 3,491,939 men and 3,514,959 women, of whom 4814 men (mean age [SD], 54.0 [14.2]) and 10,973 women (mean age [SD], 49.6 [15.2]) were bereaved by spousal suicide.

The researchers divided the population into two groups. Those considered "exposed" were bereaved by spousal suicide. The "unexposed" group was further subdivided into the general population (group A) or people bereaved by nonsuicidal spousal death (group B).

A Poisson regression analysis was used to compare incidence rates among exposed spouses to groups A and B. Long-term models assessed the impact of spousal suicide from the date of bereavement until the end of the observation period; 5-year models measured more immediate effects.

Outcomes included mental disorders, physical disorders, mortality, social health outcomes, and healthcare utilization.

The researchers found that those who had lost spouses to suicide had an elevated risk for a mental disorder (mood disorders, posttraumatic stress disorder, anxiety disorders, alcohol use disorders, drug use disorders, receiving prescriptions for antidepressants, and self-harm [IRR: men, 1.8; 95% confidence interval [CI], 1.6 - 2.0; IRR: women, 1.7; 95% CI, 1.6 - 1.8]), compared to group A. They were also more likely to be admitted to psychiatric hospitals.

Women who were survivors of spousal suicide had increased long-term risk for sleep disorders and chronic lower respiratory tract diseases. They also had an increased risk for cancer, cirrhosis, and spinal disc herniation.

Long-term Impact

Compared to group A, survivors of spousal suicide also had a higher risk for all-cause mortality (IRR, 1.3; 95% CI, 1.2 - 1.4) and mortality by natural causes (men: IRR, 1.1; 95% CI, 1.0 - 1.2). Women had a sixfold to eightfold (IRR, 8.5; 95% CI, 7.0 - 10.5) higher risk for suicide in the first 5 years, as well as a higher risk for death by homicide.

Spousal suicide survivors had a higher risk for mental disorders (men: IRR, 1.7; 95% CI, 1.5 - 1.9; women: IRR, 2.0; 95% CI, 1.8 - 2.2) than those in group B.

Spousal suicide was linked to an elevated risk of dying by any cause (men: IRR, 1.2; 95% CI, 1.1 - 1.3; women: IRR, 1.4; 95% CI, 1.3 - 1.5), but the risk was accentuated for suicide (men: IRR, 3.5; 95% CI, 2.8 - 4.3; women: IRR, 4.2; 95% CI, 3.3 - 5.2). Women had an increased risk of dying by homicide (IRR, 33.8; 95% CI, 22.0 - 51.8).

Survivors of spousal suicide were less likely to take sick leave (men: IRR, 0.8; 95% CI, 0.7 - 0.9; women: IRR, 0.8; 95% CI, 0.7 - 0.8) or experience unemployment (men: IRR, 0.9; 95% CI, 0.8 - 1.0; women: IRR, 0.8; 95% CI, 0.8 - 0.9) than members of group B.

The increase in physical disorders and the higher mortality rates in spousal suicide survivors may be attributable to unhealthy coping styles, self-neglect, or later diagnosis of illness, Dr Erlangsen suggested.

The risk for adverse events did not stop during the period immediately after the loss but remained over time, she added. "Our study shows that the impact of spousal suicide is a long-term problem."

She noted that, despite the high risk, "not all people bereaved by spousal suicide go on to have a mental disorder. Only 1 in 200 develop mental disorders, in contrast to 1 in 500 in the general population."

But those who do become symptomatic require additional support and professional intervention, especially since many do not voluntarily seek help, she emphasized.

"Compared to people bereaved by other causes of spousal death, they were less inclined to take sick leave or be unemployed, which may be related to sense of stigma. It is more socially acceptable to mourn when one loses a partner due to some other cause, so people who have lost spouses to suicide may think they need to simply work it off and keep up with their regular activities."

Proactive Intervention

Commenting on the findings for Medscape Medical News, Eric D. Caine, MD, Injury Control Research Center for Suicide Prevention, Department of Psychiatry, University of Rochester Medical Center, in New York, said the study's very large sample size and its longitudinal design make it a valuable contribution to the literature.

"The study has an elegant design, and what makes it unique is that it looks at the whole nation of Denmark over time, using the remarkable data available to make a more complete picture than one can get from small anecdotal observations," said Dr Caine.

He cautioned that an epidemiologic study only looks at associations in populations, not at each individual, and does not address causation.

Nevertheless, "it does tell us that people who have lost a loved one to suicide will have a substantial burden for many years, and we need to see what we can do to lessen the burden," said Dr Caine, who is also the author of an accompanying editorial. He was not involved in the study.

"As a society, we should offer support," he said, suggesting resources such as the American Foundation for Suicide Prevention.

"Clinicians should ask patients detailed questions," he said. "Asking, 'How are you doing?' may elicit one-syllable answers, such as 'Fine.' Instead, ask whether they are getting out, have friends, are active in church, and whether they are eating and exercising. This will paint a more complete picture and inform whether you need to refer them for professional help or further support."

Dr Erlangsen agreed. "It is normal to go through a grieving phase, but if grief becomes chronic, it is important to get help. Clinicians should be outgoing to identify which patients require help and refer them to appropriate resources, such as specialized professional or suicide-oriented grief support groups when available."

The study was supported by the American Foundation for Suicide Prevention and the Danish Health Insurance Foundation. The authors and Dr Caine report no relevant financial relationships.

JAMA Psychiatry. Published online March 22, 2017. Full text, Editorial

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