Parents who have lost a son or daughter through suicide : towards improved care and restored psychological health

Background Parents that have lost a son or daughter through suicide are at risk of developing psychological morbidity that may become long-lasting and even life-threatening. Despite this the aftermath of a suicidal loss is yet to be carefully studied. One reason for the lack of studies is that trauma-related surveys may be hindered when the risks of asking participants are overestimated and the benefits not considered. Another reason is methodological difficulties. The goal of our studies is to provide knowledge that may be used to improve the professional care of suicide-bereaved parents. This thesis describes the first steps towards the goal. Methods We developed hypotheses, questionnaires and an ethical protocol in a qualitative preparatory study with 46 suicide-bereaved parents (paper I). In a population-based survey we then collected data from parents who lost a child (15 to 30 years of age) to suicide, two to five years earlier. In all, 666 of 915 (73%) bereaved and 508 of 666 (74%) non-bereaved (matched 2:1) parents participated. Results We found that 633 (95%) of the bereaved parents thought the study was valuable and that 604 (91%) would recommend another parent to participate. Among the bereaved 334 (50%) reported being positively affected by their participation, whereas 70 (11%) reported being temporary negatively affected (most referring to sadness). The bereaved parents’ need for sharing their experiences regarding the suicide of their child was widely expressed and 639 (96%) thought the healthcare should contact parents bereaved through suicide to offer information and support (paper II). In all, 167 (25%) of the bereaved parents were currently taking antidepressants or were moderate-to severely depressed according to PHQ-9 versus 35 (9%) of the non-bereaved (RR 2.7). Fourteen percent of the bereaved reported they had had psychological morbidity more than 10 years earlier, versus 14% among the non-bereaved (RR 1.0). The highest levels of current psychological morbidity were found among the group of bereaved parents with psychological premorbidity (paper III). Of the bereaved parents 460 had (69%) viewed the body at a formal setting, among these parents 430 of 446 (96%) answered “no” to the question “Do you regret that you viewed your child after the death”. Among the parents that had not viewed 99 of 159 (62%) answered “no” to the question “Do you wish that you had viewed your child after the death” (paper IV). Conclusions We found that most parents perceived the research participation as something positive and that the contact was welcomed. Bereavement was associated with high prevalence of psychological morbidity two to five years after the loss. We found no difference in prevalence of premorbidity between the bereaved and the non-bereaved parents. The significant minority that had premorbidity before the loss did however report the highest levels of current psychological morbidity. By and large everyone that had viewed their deceased child in a formal setting did not regret the viewing. Of equal importance, more than half of those who did not view the body did not wish that they had

Psychological morbidity among suicide-bereaved and non-bereaved parents: a nationwide population survey.

OBJECTIVE: To determine how psychological premorbidity affects the risk of depression in parents who lost a child through suicide. DESIGN: Population-based survey. SETTING: Sweden, between 2009 and 2010. PARTICIPANTS: All parents who lost a child, age 15-30, through suicide between 2004 and 2007 according to National population registries. Non-bereaved parents matched for age, sex, living area, marital status, number of children. EXCLUSION CRITERIA: born outside a Nordic country, not Swedish speaking, contact details missing. Participants: 666 of 915 (73%) suicide-bereaved and 377 of 508 (74%) non-bereaved parents. MAIN OUTCOME MEASURES: Depression measured by the nine-item depression scale of the Patient Health Questionnaire (PHQ-9) and study-specific questions to assess psychological premorbidity and experience of the child's presuicidal morbidity. RESULTS: In all, 94 (14%) suicide-bereaved and 51 (14%) non-bereaved parents (relative risk 1.0; 95% CI 0.8 to 1.4) had received their first treatment for psychological problems or had been given a psychiatric diagnosis more than 10 years earlier. The prevalence of moderate-to-severe depression was 115 (18%) in suicide-bereaved versus 28 (7%) in non-bereaved parents (RR 2.3; 95% CI 1.6 to 3.5). For those without psychological premorbidity, the relative risk was 2.3 (95% CI 1.4 to 3.6). 339 (51%) suicide-bereaved parents expressed worry over the child's psychological health during the month preceding the suicide and 259 (39%) had anticipated the suicide. CONCLUSIONS: In parents who lost a child through suicide in Sweden we did not find a higher prevalence of long-term psychological premorbidity than among parents who had not lost a child; the more than twofold risk of depression among the bereaved can probably be explained by the suicide and the stressful time preceding the suicide

Viewing the body after bereavement due to suicide: a population-based survey in Sweden.

BACKGROUND: Research on the assumed, positive and negative, psychological effects of viewing the body after a suicide loss is sparse. We hypothesized that suicide-bereaved parents that viewed their childs body in a formal setting seldom regretted the experience, and that viewing the body was associated with lower levels of psychological morbidity two to five years after the loss. METHODS AND FINDINGS: We identified 915 suicide-bereaved parents by linkage of nationwide population-based registries and collected data by a questionnaire. The outcome measures included the Patient Health Questionnaire (PHQ-9). In total, 666 (73%) parents participated. Of the 460 parents (69%) that viewed the body, 96% answered that they did not regret the experience. The viewing was associated with a higher risk of reliving the child's death through nightmares (RR 1.61, 95% CI 1.13 to 2.32) and intrusive memories (RR 1.20, 95% CI 1.04 to 1.38), but not with anxiety (RR 1.02, 95% CI 0.74 to 1.40) and depression (RR 1.25, 95% CI 0.85 to 1.83). One limitation of our study is that we lack data on the informants' personality and coping strategies. CONCLUSIONS: In this Swedish population-based survey of suicide-bereaved parents, we found that by and large everyone that had viewed their deceased child in a formal setting did not report regretting the viewing when asked two to five years after the loss. Our findings suggest that most bereaved parents are capable of deciding if they want to view the body or not. Officials may assist by giving careful information about the child's appearance and other details concerning the viewing, thus facilitating mental preparation for the bereaved person. This is the first large-scale study on the effects of viewing the body after a suicide and additional studies are needed before clinical recommendations can be made

Depression among Parents Two to Six Years Following the Loss of a Child by Suicide: A Novel Prediction Model.

BACKGROUND: Parents who lose a child by suicide have elevated risks of depression. No clinical prediction tools exist to identify which suicide-bereaved parents will be particularly vulnerable; we aimed to create a prediction model for long-term depression for this purpose. METHOD: During 2009 and 2010 we collected data using a nationwide study-specific questionnaire among parents in Sweden who had lost a child aged 15-30 by suicide in years 2004-2007. Current depression was assessed with the Patient Health Questionnaire (PHQ-9) and a single question on antidepressant use. We considered 26 potential predictors assumed clinically assessable at the time of loss, including socio-economics, relationship status, history of psychological stress and morbidity, and suicide-related circumstances. We developed a novel prediction model using logistic regression with all subsets selection and stratified cross-validation. The model was assessed for classification performance and calibration, overall and stratified by time since loss. RESULTS: In total 666/915 (73%) participated. The model showed acceptable classification performance (adjusted area under the curve [AUC] = 0.720, 95% confidence interval [CI] 0.673-0.766), but performed classification best for those at shortest time since loss. Agreement between model-predicted and observed risks was fair, but with a tendency for underestimation and overestimation for individuals with shortest and longest time since loss, respectively. The identified predictors include female sex (odds ratio [OR] = 1.84); sick-leave (OR = 2.81) or unemployment (OR = 1.64); psychological premorbidity debuting during the last 10 years, before loss (OR = 3.64), or more than 10 years ago (OR = 4.96); suicide in biological relatives (OR = 1.54); with non-legal guardianship during the child's upbringing (OR = 0.48); and non-biological parenthood (OR = 0.22) found as protective. CONCLUSIONS: Our prediction model shows promising internal validity, but should be externally validated before application. Psychological premorbidity seems to be a prominent predictor of long-term depression among suicide-bereaved parents, and thus important for healthcare providers to assess

Caring for patients with eating deficiencies in palliative care-Registered nurses' experiences : A qualitative study.

AIMS AND OBJECTIVES: The aim was to explore RNs' experiences of caring for patients with eating deficiencies in palliative care. BACKGROUND: Food and mealtimes are fundamental aspects for wellbeing and social interactions. The worldwide trajectory of ageing populations may result in increased need for palliative care. Everyday life with chronic life limiting illness and eating deficiencies is challenging for patients and families. RNs are key care providers at end-of-life. DESIGN: A qualitative study with an inductive approach was used. METHODS: Nineteen experienced RNs in palliative care were interviewed through telephone; interviews were audio recorded and transcribed verbatim. Inductive qualitative content analysis was performed, and the COREQ checklist was used to guide proceedings. RESULTS: The overarching theme, Supporting persons with eating deficiencies in-between palliative care and end-of-life care, is represented by three sub-themes: Easy to stick with doing, Just being, without doing, is hard and Letting go. Near end-of-life, eating symbolized social belonging and quality of life for RNs, whereas for patients and families, eating symbolized life. RNs tried practical solutions, however, not always according to patients' and families' preferences. CONCLUSIONS: RNs were well prepared to tackle physical inconveniences and provide support, however, less prepared to encounter existential, psychological and social issues in relation to eating deficiencies. Although RNs stated that human beings stop eating when they are about to die, letting nature run its' course and facilitating patients' transition to end-of-life care was challenging. RELEVANCE TO CLINICAL PRACTICE: Food and mealtimes represent fundamental aspects of human life and denote central parts in RNs clinical practice in palliative care. The findings can inspire development of a comprehensive palliative care approach to support patients and families. Structured reflection in relation to clinical practice may support and encourage RNs, caring for patients with eating deficiencies, in mastering both doing and being

Experiences of food and mealtime from the perspective of patients with chronic life-limiting disease : A mixed-method systematic review

Aim To describe and synthesise experiences of food and mealtimes from the perspective of patients with chronic life-limiting disease. Design A mixed-method systematic review. Data Sources The databases Academic Search Complete, CINAHL, Nursing and Allied Health Database, PsycINFO, PubMed, Soc Index and Web of Science Core Collection were searched (January 2000 to March 2019). Review Methods Out of 3151 identified articles, 24 were included for appraisal and synthesis, using a data based convergent design. Results Four themes were derived: ‘understanding hampered eating—perhaps it is best to let nature run its course’; ‘food and meals evoke distress—reducing joy, testing interim ways’; ‘struggling with food and meals—eating to please others and to postpone death’; and ‘food and meals as caring and love—flanked by social disconnecting’. Conclusion For patients with chronic life-limiting disease, food entailed potential to remain healthy, improve well-being and prolong life. Meanwhile, eating difficulties were experienced as fundamentally affecting social life and interactions; consequently, joy around food and meals was lost

Suicide-bereaved parents experience of viewing the body at formal settings.

<p>^* “Emergency department or ward”, “Hospital church”, “Department of forensic medicine”, and “Funeral parlour”. Viewing also includes viewing the contour of the body or part of the body.</p>†<p>The most unfavourable value ranging from “No”; “Yes, a little”; “Yes, moderate”; “Yes, much” at any of the formal settings.</p

Circumstances related to the suicide.

<p>^* Poisoning for example by medication, chemicals or some kind of gas”.</p>†<p>Of the 40 parents that stated “Other way” 17 wrote that they were present at the time of death; 11 at the hospital and 6 had witnessed the suicide, 23 parents wrote that they received the death notice from someone else and two did not comment on the question.</p

Classification performance.

<p>Receiver operating characteristic (ROC) curves, and corresponding areas under the curves (AUC) with 95% confidence intervals (CI), for (a) entire cohort, unadjusted and for 100 repetitions of ten-fold stratified cross-validation (SCV), and (b) for each of the four time-frames after cross-validation against a model derived from data in the other three time-frames. The ten-fold SCV adjusted values of AUC and CI limits are the corresponding mean values among the 100 repetitions, and the solid black line is a LOESS smoothed curve for the 100 SCV adjusted ROC curves outlined in gray.</p

Characteristics of the participating suicide-bereaved parents.

<p>Characteristics of the participating suicide-bereaved parents.</p