Stigma, grief, and depressive symptoms in help-seeking people bereaved through suicide

The study titled “Stigma, grief, and depressive symptoms in help-seeking people bereaved through suicide” by Scocco and collaborators investigates the impact of grief and depression on the perception of stigma among survivors of suicide. The authors hypothesize that the intensity of depressive symptoms and complicated grief is linked to the intensity of perceived stigma against people bereaved through suicide, even after adjusting for sociodemographic confounders and variables related to the suicide event.

The cross-sectional study includes 240 participants who accessed an online support initiative between 2012 and 2017. The sample includes 41 men (17%) and 199 (83%) women aged 18 to 73 years. Descriptive analyses show that women scored higher than men on the Inventory of Complicated Grief (ICG), Beck Depression Inventory (BDI), and Stigma of Suicide Survivor Scale (STOSSS).

The authors find that there is a positive correlation between ICG and BDI scores in both men and women. BDI scores are positively related to STOSSS scores in men, but this correlation is not present in women. The number of days since the suicide is negatively correlated with ICG and BDI scores and positively associated with STOSSS scores.

A cluster analysis of the variables included in the study shows that levels of complicated grief, as measured by the ICG, are not related to levels of perceived stigma against survivors, as measured by the STOSSS. However, levels of depression are positively and significantly related to levels of perceived stigma against survivors, even after controlling for demographic variables and their relationship with suicide.

The study’s limitations include a cross-sectional design, reliance on self-report tools, and a partially representative sample of mostly female suicide survivors seeking help on a specialized website.

The authors conclude that perceived stigma towards people bereaved through suicide positively and significantly correlates with depressive symptomatology and mourning duration but not complicated grief symptoms. They suggest that specific interventions designed for persons bereaved by suicide should consider the qualitative differences between psychological distress and mourning as reactions to a suicide loss. The authors also recommend that healthcare professionals should evaluate and investigate whether a patient has a history of loss by suicide, regardless of the time elapsed. They caution that patients who find it difficult to talk about their experience and minimize its consequences may be experiencing perceived stigma.


Scocco P, Preti A, Totaro S, Corrigan PW, Castriotta C; SOPROXI Team. Stigma, grief and depressive symptoms in help-seeking people bereaved through suicide. J Affect Disord. 2019 Feb 1;244:223-230. doi: 10.1016/j.jad.2018.10.098. Epub 2018 Oct 11. PMID: 30366261.

Prolonged Grief Symptoms among Suicide-Loss Survivors: The Contribution of Intrapersonal and Interpersonal Characteristics

In talking about suicide, it is very important to understand its huge impact: it is a significant public health problem, causing an estimated 700,000 deaths annually, making it the seventeenth leading cause of death worldwide. It impacts not only doctors and medical staff but obviously also relatives and caregivers of those who committed suicide. In this last perspective, we have chosen to search for articles specifically focused on suicide survivors.

Here there are two reading suggestions that we decided to summarize and comment on for you: “Prolonged Grief Symptoms among Suicide-Loss Survivors: The Contribution of Intrapersonal and Interpersonal Characteristics” and “Stigma, Grief and Depressive Symptoms in Help-Seeking People Bereaved through Suicide”, because they seemed to be giving a very new contribution and an innovative point of view on the topic, even though they have been published 5 years apart.

Suicide-loss survivors (SLSs) have unique characteristics that increase their risk of developing prolonged grief symptoms (PGS). According to cumulative evidence, PGS represent a bereavement-specific diagnosis that comprises part of the clinical syndrome of prolonged grief disorder (PGD), a condition recently supplemented to the International Classification of Diseases, 11th Revision (ICD-11). PGD is now included for the first time in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) in the chapter on trauma and stressor-related disorders.

The core element of PGD is intense longing or craving for the deceased or engaging in thoughts or memories of them. Other symptoms include intense emotional pain related to the death, feeling that part of oneself has been lost, difficulty accepting the death, avoiding cues that might trigger thoughts of the deceased and difficulty engaging in social or other activities following the loss. According to the DSM-5 criteria, symptoms should persist for at least 12 months after a loss, whereas ICD diagnostic criteria anticipate symptoms persisting for more than 6 months after the loss.

The aim of this study is to examine the role of intrapersonal characteristics (such as guilt and depression) and Interpersonal characteristics (such as thwarted belongingness (TB), perceived burdensomeness (PB) and self-disclosure (SD))  and the impact of their co-occurrences as potential factors contributing to PGS after suicide loss; in order to facilitate the design of preventive interventions for individuals at increased risk and establish therapeutic measures targeting elements contributing to the onset and severity of PGS.

Study participants were 152 SLSs (80.4% women) aged 22 to 76 who completed questionnaires measuring guilt, depression, perceived burdensomeness, thwarted belongingness, self-disclosure, and PGS using the Prolonged Grief–Revised Inventory. Participants’ demographics and loss-related characteristics, such as the time since suicide and the participant’s age at the time of suicide, were also examined.
Authors evidenced that guilt and depression are critical contributors to the level of PGS among SLSs. Furthermore, they found that interpersonal variables (PB, TB, SD) contributed to PGS beyond intrapersonal, sociodemographic, and loss-related factors. Thus, these results suggest that SLSs’ devastating feelings of lack of belonging, isolation, being a burden to their surroundings, and difficulty disclosing intimate feelings and thoughts may contribute to PGS. This study’s main finding is that PB levels significantly moderate the contribution of guilt to PGS. Thus, it can be inferred from these results that perceived burdensomeness plays a significant role in facilitating PGS among SLSs, especially in those experiencing guilt.

This study has important theoretical and practical implications which could be useful in clinical practice in managing SLSs and SLS relatives searching for help. Concerning the practical implications, it suggests interpersonal variables may serve as buffers against grief complications, particularly among SLSs suffering from painful guilt. Therefore, healthcare professionals, and all the people surrounding the SLS, should monitor the social involvement of the SLS and the extent of social support they receive because it appears that disclosing intimate feelings and thoughts may protect against PGD by enhancing a sense of belonging, relieving harmful cognitions and reducing guilt. Offering primary psychoeducational interventions could help SLSs gain support and get a new perspective on themselves and on the suicide event. In addition, psychotherapy protocols aiming to help people understand their relationships with others may benefit individuals with high TB and PB levels. For example, interpersonal psychotherapy (IPT), which aims to improve interpersonal skills, especially self-disclosure, may prove effective for SLSs. Moreover, psychosocial therapies focusing on activating social support and reducing maladaptive cognitions may benefit SLSs. Another possible treatment may be group therapy, which can help SLSs in sharing and disclosing their feelings of guilt, modifying the meaning of the suicide event, normalizing the grief experience of suicide, and, most importantly, providing them with a sense of belonging. Finally, it appears that there is potential in mindfulness-based interventions as well, as they seem to promote self-compassion, which has been shown to positively impact feelings such as TB and PB and cope with unpleasant emotions such as guilt.

We chose to write about this study because we found it very interesting, complete, useful and extremely recent. In fact, it is very well explained what PGD is, especially since it was only recently added to the DSM-5-TR, and what intrapersonal and interpersonal characteristics include. It also gives an overview of the background knowledge related to suicide and personal factors that can be helpful, especially for those new to the field.

In conclusion, we advise reading this study because it highlights the importance of social and community factors in preventing PGD among suicide-loss survivors. It illustrates the practical implications and suggests that the resilience factors of a sense of belonging and self-disclosure may help SLSs to effectively cope with PGS.


Levi-Belz Y, Ben-Yaish T. Prolonged Grief Symptoms among Suicide-Loss Survivors: The Contribution of Intrapersonal and Interpersonal Characteristics. Int J Environ Res Public Health. 2022 Aug 24;19(17):10545. doi: 10.3390/ijerph191710545. PMID: 36078261; PMCID: PMC9518413.

Recommended papers in suicide research, 2023

By Nathan Risch, PhD student in Montpellier

Research on suicide aims to identify what distinguishes patients who attempt suicide (i.e. suicide attempters) from those who won’t. This systematic review shows that decision-making is impaired in suicidal attempters, especially in social contexts with other human beings. Suicidal attempters are less sensitive to social reward and punishment and can persist longer in the aversive task.

Rzeszutek, M. J., DeFulio, A., & Sylvester, G. E. (2022). A systematic review of behaviour – outcome psychological assessments as correlates of suicidality. Archives of suicide research, 26(4), 1757-1793.

Psychological pain leads to suicide, but not for all patients. In this study, the authors wish to identify which feature of psychological pain distinguishes depressed patients who have attempted suicide (i.e. suicide attempters) from those who haven’t. Depressed suicidal attempters have a stronger motivation for pain avoidance. Pain avoidance could be one of the most important features of psychological pain to predict future suicidal attempt.

Sun, X., Li, H., Song, W., Jiang, S., Shen, C., & Wang, X. (2020). ROC analysis of three-dimensional psychological pain in suicide ideation and suicide attempt among patients with major depressive disorder. Journal of Clinical Psychology, 76(1), 210-227.

Recent European papers from The Journal of Clinical Psychiatry, 2023

By Pr Philippe Courtet, Montpellier

Monitoring suicide attempters with their smartphone could be useful for detecting the short-term risk of reattempt !

Porras-Segovia A et al. Six-Month Clinical and Ecological Momentary Assessment Follow-Up of Patients at  High Risk of Suicide: A Survival Analysis. J Clin Psychiatry. 2022 Dec 14;84(1):22m14411. doi: 10.4088/JCP.22m14411.


In this innovative study, Alejandro Porras-Segovia and colleagues reported that Ecological momentary assessment (daily smartphones questionnaires that are completed by patients) may help to detect the risk of suicide reattempt during the 2 months following the index suicide attempt.

Depressed mood is an important risk factor of imminent suicide !

Fredriksen et al. Imminent and Short-Term Risk of Death by Suicide in 7,000 Acutely Admitted  Psychiatric Inpatients. J Clin Psychiatry. 2022 Dec 12;84(1):22m14460. doi: 10.4088/JCP.22m14460.


Fredriksen et al used a large prospective cohort of Norwegian psychiatric patients to find that during the first week following admission severely depressed mood, including self-blame and guilt was the only predictor of suicide.

How are dreaming our patients may help to identify prodromal signs of suicide !

Geoffroy et al. Bad Dreams and Nightmares Preceding Suicidal Behaviors. J Clin Psychiatry. 2022 Nov 23;84(1):22m14448. doi: 10.4088/JCP.22m14448.


Geoffroy et al. extensively assessed suicidal patients about their dreams and nightmares. A progression in dream content alterations could predict imminent risk of suicide : bad dreams-nightmares-dreaming of suicide.

COVID-19, burnout and suicide

 In February 2020, on Jama Psychiatry, it was published the article “The Loss of Social Connectedness as a Major Contributor to Physician Burnout – Applying Organizational and Teamwork Principles for Prevention and Recovery” (LINK HERE). 

In this period, in which medical teams from all over the world are engaged to fight against COVID-19 pandemic, the necessity for psychological support is a hot topic. 

Physicians are called to work many hours everyday, with a huge number of unknown patients, with individual protections and, when they come back home, they prefer to stay alone to protect their families. All of these factors can produce feelings of loneliness, sadness and tiredness. Moreover, everyday they could face off with death and feelings of impotence against a disease still not well known. All these feelings may enhance the risk of anxiety, depression, burnout and suicide. 

The study published on Jama stresses the association between burnout, loneliness and social isolation; inadequate support from colleagues and leaders, community and so on.  

During this pandemic it is essential not to forget that in order to reduce burnout and permit professionists to give their best it is essential to prioritize human connections and teamwork so they can give optimal patient care. 

  • Southwick SM, Southwick FS. The Loss of Social Connectedness as a Major Contributor to Physician BurnoutApplying Organizational and Teamwork Principles for Prevention and RecoveryJAMA Psychiatry. 2020;77(5):449–450. doi:10.1001/jamapsychiatry.2019.4800

Social Network and Suicide

An increasingly interesting research topic of the recent literature on suicide is about the relationship between use of social network and suicide rates among young people. A recent narrative review published online by Nassir Ghaemi, “Digital Depression: A New Disease of the Millennium?” (Ghaemi, 2020) has reviewed the last data about this subject, finding that in the last decade there has been a rise of suicide rates among teenagers and young adults, correlated with the massive use of smartphones and social networks. Author reports that in this last period depressive symptoms have risen, and suicide has become more frequent especially among teenage girls in the USA. The specific correlation between suicidality and use of social networks has been investigated by studies that tested depressive symptoms in college students and observed a decrease of these symptoms in students that accepted a reduction of social media use. On this track many works identified a correlation between these two phenomena, for example a review published on Current Opinion in Psychiatry in November 2019 titled “Social media, internet use and suicide attempts in adolescents”, found an independent direct association between problematic social media use and suicide attempts in young people. These findings suggest the importance of further studies on this problem, in order to create suicide preventive programs that consider this correlation. Another interesting fact is that the role of social media has shown to be also protective in some cases, because adolescents frequently use this media to communicate suffering and distress as shown by other recent studies (Marchant et al, 2017). 

  • Ghaemi SN (2020) Digital depression: a new disease of the millennium? Acta Psychiatr Scand. 2020 Jan 18. doi: 10.1111/acps.13151.
  • Marchant A, Hawton K, Stewart A, Montgomery P, Singaravelu V, Lloyd K, et al. (2017) A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: The good, the bad and the unknown. PLoS ONE 12(8): e0181722. pmid:28813437

UNICEF: “An open letter to the world’s children”

Henrietta H. Fore, the UNICEF Executive Director, in her recent “An open letter to the world’s children”, described the 8 reasons why she’s worried, and hopeful, about the next generation. In the third place (after the need of clean water, air and safe climate, life in conflict and disaster zone) it is listed the need to talk about mental health and, more specifically, about the vulnerability of young people, the high risk of depression, self harm and suicide. “The World Health Organization (WHO) estimates that 62,000 adolescents died in 2016 because of self-harm, which is now the third leading cause of death for adolescents aged 15 –19. This is not just a rich country problem – WHO estimates that more than 90 per cent of adolescent suicides in 2016 were in low or middle-income countries. And while young people with severe mental disorders in lower-income countries often miss out on treatment and support, there is no country in the world that can claim to have conquered this challenge. To quote the WHO’s mental health expert Shekhar Saxena, “when it comes to mental health, all countries are developing countries.” 

The Kazakhstan experience in suicide prevention is then described: “For example, in Kazakhstan, which has one of the highest suicide rates among adolescents worldwide, UNICEF stepped up efforts to improve the mental well-being of adolescents through a large-scale pilot programme in over 450 schools. The programme raised awareness, trained staff to identify high-risk cases, and ensured referral of vulnerable adolescents to health specialists. Nearly 50,000 young people participated in the pilot with many significant improvements in well-being. The programme has since been scaled up to over 3,000 schools”. 

We are proud to remind that the UNICEF programme involved the EPA-SSSP Chair, Marco Sarchiapone (LINK)

World Mental Health Day

On 10 October 2019, every year, the World Mental Health Day is celebrated to raise awareness about mental health issues around the world and to foster efforts in support of mental health. This year the main theme of the World Mental Health Day is suicide prevention. 

Our section, represented by the Section Chair Marco Sarchiapone, participated in drafting the EPA statement for both the World Suicide Prevention Day and the World Mental Health Day 2019. These statements will be circulated to the NPAs, which will be invited to inform the EPA offices about their activities and initiatives for October 10th, in order to develop a communication strategy to raise visibility and support them.




Scientific News and Reading Suggestion #31

Prof. Zoltan Rihmer shared with us his recent paper published 2 weeks ago on the JOURNAL OF PSYCHOPATHOLOGY

“Suicide in obsessive-compulsive related disorders: prevalence rates and psychopathological risk factors”
U. Albert, L. Pellegrini, G. Maina, A.-R. Atti, D. De Ronchi, Z. Rhimer

The article is a systematic review, stresses that people who suffer from Obsessive-compulsive related disorders (OCRDs) may be at risk for suicide attempts and suicidal ideation independently from comorbid disorders.

Thanks to Prof. Zoltan Rihmer

Scientific News and Reading Suggestion #30

Many interesting articles about suicide have been published during August 2019 on different scientific journals. We talked about high risk of suicide in medical doctors, trainees and specialists, and recently the topic is highlited in many international journals (our previous articles: Scientific News and Reading Suggestion #28Scientific News and Reading Suggestions #22; #CrazySocks4Docs).

Effects of suicide on psychiatry trainees”, published on the BJPsych Bullettin by M.Calcia ( examines the need to support clinicians who deal with suicidal patients, referring to a survey by Gibbons et al. (Gibbons R, Brand F, Carbonnier A, Croft A. Effects of patient suicide on psychiatrists: survey of experiences and support required. BJPsych Bull 2019; doi: 10.1192/bjb.2019.26.). “…having experienced a patient suicide as a trainee had a significant influence on the responder’s choice of subspecialty… we hope that mental health trusts and postgraduate training departments continue working to develop formal and informal support structures for doctors experiencing this difficult event”.

Young doctors are often well trained and skilled in managing organic conditions, but they may have received less training and education in the management of suicidal patients, and may find it difficult to treat them. 

The Journal of Adolescent Health recently published a paper “A Call to Reorient Pediatric Residency Education to Address the Emerging Threat of Suicide”, by M. Townsend Cooper Jr., ( stressing the importance of training pediatric residents to approach suicidality: “As a pediatric community, we are woefully unprepared for this unfolding epidemic”. The article by Schoen et al., Suicide Risk Assessment and Management Training Practices in Pediatric Residency Programs: A Nationwide Needs Assessment Survey (, has highlighted a gap in residents’ training needs that calls for immediate attention: “Although 82% of respondents rated suicide prevention training in residency as “very” or “extremely” important, a minority (18% PDs and 10% CRs) reported adequate preparation relative to need”. 

The most common barrier mentioned to deliver appropriate training about this topic was lack of time:

How do we as a medical community not have time to treat an epidemic that is staring us squarely in the face? Would we accept a similar excuse from ourselves if this was a threat from an infectious disease?”. 

Academic Psychiatry published the article “Preclinical Medical Student Attitudes Toward Use of Psychiatry Residents as Actors in a Suicide and Violence Risk Assessment Simulation Activity” ( stressing the importance of medical students training in suicide prevention “to transform classroom knowledge into clinical skills”; simulation was suggested as a good practice for learning, as it gives students the possibility to get involved in situations resembling clinical practice.

Sources (image)