Support for Relatives Bereaved by Psychiatric Patient Suicide: National Confidential Inquiry Into Suicide and Homicide Findings

Over the study period (January 1, 2003, to December 31, 2012), NCISH received notifications of 47,824 suicides in England and Wales, including 35,091 cases in which the coroner's verdict was suicide and 12,733 open verdicts or deaths from undetermined cause. Of these, 13,243 (28%) cases were confirmed to be patients who had been in contact with NHS psychiatric services in the year prior to death. Completed questionnaires were received for 13,033 cases, a response rate of 98% (Figure 1). Details of whether postsuicide contact had been made with relatives were lacking for 1,461 (11%) cases, which were excluded from this analysis. We included the remaining 11,572 suicide cases in the analyses. Levels of missing data were minimal, ranging from 0% to 9%.

The sample was primarily male (66%) and white (92%), and most patients had used a violent suicide method (72%) (Table 1). Approximately half the sample had lived alone (46%), whereas 52% had cohabited with family (spouse or partner, parents, or children) or friends.

No contact had been made with relatives after 3,790 suicides (33%). Of the 7,782 suicides (67%) following which relatives were contacted, 61% (N=4,755) of contacts were made face-to-face, 28% (N=2,177) by telephone call, and 11% (N=843) by letter. During 2003–2012, the annual proportion of suicide cases for which relatives were contacted ranged from 63% to 70%, and there were no significant temporal changes over time (likelihood-ratio χ² test for linear trend) (Figure 2).

The results of our univariate logistic regression analyses showed that several potentially stigmatizing patient characteristics (forensic history, unemployment, recent alcohol misuse, recent drug misuse, primary diagnosis of alcohol dependence or misuse, and primary diagnosis of drug dependence or misuse) were associated with a lesser likelihood that psychiatric staff contacted relatives of a patient after the patient’s suicide (Table 2). Violent method of suicide was associated with a significantly greater probability that staff contacted relatives, as was living with a partner or dependent who also was a psychiatric patient.

Results from our multivariate logistic regression analyses showed that, contrary to our hypothesis, a violent method of suicide was independently associated with a greater likelihood of contacting relatives (adjusted OR [AOR]=1.67) (Table 3). Patient characteristics independently associated with not contacting relatives were unemployment (AOR=.80), forensic history (AOR=.69), primary diagnosis of alcohol dependence or misuse (AOR=.46), and primary diagnosis of drug dependence or misuse (AOR=.48). No other potentially stigmatizing patient characteristics were significantly associated with probability of staff’s making contact with relatives.

Multivariate analysis for our secondary outcome showed that only primary diagnosis of alcohol dependence or misuse was associated with lower odds of being contacted face-to-face versus by letter or telephone (AOR=.62) (Table 3). Again, contrary to our hypothesis, use of a violent method was associated with an increased likelihood of face-to-face contact (AOR=1.28).

In an analysis excluding patients who were not as likely to have listed next of kin, the magnitude of the ORs for our outcomes were only marginally changed. In analyses that excluded patients with an open verdict and included patients with missing values for contact (recoded as no contact), our findings were unchanged.

In an analysis adjusted for recent patient contact, recent alcohol misuse was significantly associated with lower odds of contacting relatives (AOR=.85, CI=.75–.96), unlike the findings of our main analysis. [Tables presenting the results of the sensitivity analyses are available as an online supplement to this article.]

For a third of cases in our national sample, relatives bereaved by patient suicide had not been contacted by the psychiatric team involved, even for the third of those patients who were living with a partner, family, or friends. This pattern occurred despite clear NHS recommendations that providers of psychiatric services should contact relatives after all cases of patient suicide (16). Whereas some of those patients may have chosen not to provide next-of-kin details, this figure raises concerns about inequalities in the support offered to psychiatric patients’ relatives after a potentially traumatic bereavement. Unless there were clear circumstances in which contacting household members was inadvisable, such as breaching confidentiality, our findings suggest a need for more proactive outreach after patient suicide. Furthermore, our hypothesis-based analysis demonstrated that these inequalities constituted inequities, given that potentially stigmatizing characteristics of the deceased were associated with a reduced likelihood of contacting relatives, including a forensic history, unemployment, and a primary diagnosis of alcohol dependence or misuse or drug dependence or misuse. These results suggest that such patients’ families are being avoided because of generalized stigma, resulting in the neglect of their needs and raising concerns about the likelihood of neglecting patients’ needs (34).

Above and beyond these clinical governance issues, our findings are concerning because such characteristics are likely to be shared with bereaved relatives, and many of these characteristics are regarded themselves as risk factors for suicide (11). These and other shared familial and environmental risk factors for mental illness and suicidal behavior (35,36), together with the additional risk conferred by suicide bereavement (4,5), identifies this group of relatives as being at higher risk of suicidal behavior. Their help-seeking behavior is likely to have been conditioned by the stigma associated with their relative’s mental illness (37) and further influenced by the stigma of suicide (6–9). Consequently, such patient characteristics should alert staff to a greater need to support such relatives after suicide rather than as reasons to marginalize them in this way.

Contrary to our prediction that a violent method of suicide would dissuade staff from contacting relatives, a violent mode of suicide increased the probability of contact, primarily in person. This finding suggests that staff responded appropriately to the anticipated distress of a violent suicide, in contrast to the lay public, who tend to withdraw through social distaste or embarrassment (7–10). Because violent suicide is associated with more severe and comorbid mental illness (38), this finding may also reflect a tendency by staff to contact relatives who were well known to the service.

The strengths of this study were that it used a national, comprehensive sample of all suicides among patients with recent contact with psychiatric services, benchmarking expected standards of postsuicide support against national guidelines (16). Only one other published study in the United Kingdom has described support offered to those bereaved by suicide, recruiting a sample of 85 friends and relatives of older adults (39). Our use of routine data reduced the risk that bias might explain the findings, which were robust to sensitivity analyses. We prespecified predictor variables, reducing the likelihood that chance might account for associations identified. Alternative explanations for the negative associations between patient characteristics and contact with relatives are that these factors might themselves reduce the likelihood of a patient’s providing details of next of kin. In some cases they could be markers of disrupted family and social networks, influencing professionals’ relationships with relatives before the suicide and their anticipation of the families’ reaction if contacted.

The study’s main limitation lay in using routine data. The data set lacked a variable describing presence or absence of next-of-kin details, beyond the six cases in which the availability of next-of-kin data was specifically documented. However, our main findings were robust to a sensitivity analysis that excluded cases with a higher likelihood of not having next-of-kin data. We excluded cases (11%) in which it was unknown whether contact with relatives had taken place. In some cases in which completing psychiatrists endorsed none, they may have omitted mentioning that there were no next-of-kin details or may have been unaware of colleagues’ communications. Our analysis used employment status as a proxy for deprivation but did not capture area-level deprivation or describe geographic variation in outcomes. Understanding the influence of these variables would assist service improvements.

Our secondary outcome captured the mode of contact after patient suicide but not its therapeutic quality. In some cases, contact may have been made to notify relatives of the death rather than to offer condolences or sources of support. The routine data set lacked a variable describing whether staff had met relatives before the death, which might influence postsuicide contact, as well as any sociodemographic characteristics of the next of kin. It also lacked information on which individuals in the sample had been formally discharged from psychiatric care within 12 months of their deaths and how soon after the discharge the suicide occurred. In some cases, teams may have been unaware of the patient’s death. However, our findings were robust to adjustment for recent contact with the patient, suggesting that the timing of the most recent contact did not strongly influence postsuicide support. Moreover, all such cases require postsuicide review involving relatives, even if discharge had been a year before death, and therefore represent missed opportunities to learn lessons, particularly for patients affected by unemployment, criminality, and substance misuse. Improving recording of next-of-kin details and involving families in case review should open up communication channels, providing a natural context in which to offer information and support.

Educating psychiatric professionals about the vulnerabilities of people bereaved by suicide is important (40) and has the potential to address the inequities uncovered in this study. Directing relatives of patients who die by suicide to support services (15) is recommended (40), but no United Kingdom studies have described the use of NHS and voluntary-sector services for this purpose. Qualitative interviews with British general practitioners indicate that although the majority feel a responsibility to contact bereaved patients, particularly after traumatic bereavement (41), many feel unprepared to deal with the specific effects of suicide, welcoming guidance on what approach to take (42). Their uncertainty is compounded by a lack of evidence for effective interventions to reduce the risk of suicide and psychopathology (13). Each suicide affects a network of relatives, former partners, and friends (3) that extends well beyond registered next of kin. Even if immediate family are offered professional support, other members of the patient’s network may be overlooked. National marketing of bereavement support available by self-referral would help address the needs of the “hidden” bereaved and reduce the barriers to help seeking created by the stigma of suicide bereavement (7–9).

Future studies describing national patterns of postsuicide support in primary care and voluntary sector services would complement this analysis, particularly because the majority of suicides in high-income countries involve people who were not in psychiatric care (1,43). Qualitative work would permit a deeper exploration of the acceptability and quality of support received. Given the limited evidence base, further trials are required of interventions for people bereaved by suicide (13), particularly proactive outreach, for which there is an expressed need (44). Primary care and psychiatric professionals are in unique positions to offer such outreach and to counter reluctance to seek help. Health services and academic partners must evaluate such work as part of local and national initiatives to prevent suicide.

Our study showed that the relatives of over 30% of psychiatric patients who died by suicide in the United Kingdom did not receive postsuicide support from the patients’ psychiatric teams, even if the presence of next of kin could be inferred from living situation. We demonstrated clear inequities in the provision of support for families of unemployed patients, those with a forensic history, and those with a primary diagnosis of alcohol or drug dependence or misuse. Such characteristics, themselves risk factors for suicidal behavior, are often shared with bereaved relatives, for whom suicide bereavement additionally confers an increased risk of suicidality. Improved outreach to relatives after a patient’s suicide has the potential to improve outcomes in a group regarded as having a high risk of suicide, although this possibility requires careful evaluation.