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Research

JAMA Psychiatry |

Original Investigation

Association Between Spousal Suicide and Mental,

Physical, and Social Health Outcomes

A Longitudinal and Nationwide Register-Based Study

Annette Erlangsen, PhD; Bo Runeson, MD, PhD; James M. Bolton, MD; Holly C. Wilcox, PhD; Julie L Forman, PhD;

Jesper Krogh, DMSc; M. Katherine Shear, MD; Merete Nordentoft, DMSc; Yeates Conwell, MD

Editorial

IMPORTANCE

Bereavement after spousal suicide has been linked to mental disorders;

Supplemental content

however, a comprehensive assessment of the effect of spousal suicide is needed.

OBJECTIVE

To determine whether bereavement after spousal suicide was linked to an

excessive risk of mental, physical, and social health outcomes when compared with the

general population and spouses bereaved by other manners.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide, register-based cohort study conducted

in Denmark of 6.7 million individuals aged 18 years and older from 1980 to 2014 covered

more than 136 million person-years and compared people bereaved by spousal suicide with

the general population and people bereaved by other manners of death. Incidence rate ratios

were calculated using Poisson regressions while adjusting for sociodemographic

characteristics and the presence of mental and physical disorders.

MAIN OUTCOMES AND MEASURES

Mental disorders (any disorder, mood, posttraumatic stress

disorder, anxiety, alcohol use disorders, drug use disorders, and self-harm); physical disorders

(cancers, diabetes, sleep disorder, cardiovascular diseases, chronic lower respiratory tract

diseases, liver cirrhosis, and spinal disc herniation); causes of mortality (all-cause, natural,

unintentional, suicide, and homicide); social health outcomes; and health care use.

RESULTS

The total study population included 3 491 939 men, 4814 of whom were bereaved

by spousal suicide, and 3 514 959 women, 10 793 of whom were bereaved by spousal suicide.

Spouses bereaved by a partner’s suicide had higher risks of developing mental disorders

within 5 years of the loss (men: incidence rate ratio, 1.8; 95% CI, 1.6-2.0; women: incidence

rate ratio, 1.7; 95% CI, 1.6-1.8) than the general population. Elevated risks for developing

physical disorders, such as cirrhosis and sleep disorders, were also noted as well as the use

of more municipal support, sick leave benefits, and disability pension funds than the general

population. Compared with spouses bereaved by other manners of death, those bereaved by

suicide had higher risks for developing mental disorders (men: incidence rate ratio, 1.7; 95%

CI, 1.5-1.9; women: incidence rate ratio, 2.0; 95% CI, 1.9-2.2), suicidal behaviors, mortality,

and municipal support. Additionally, a higher level of mental health care use was noted.

CONCLUSIONS AND RELEVANCE

Exposure to suicide is stressful and affects the bereaved

spouse on a broad range of outcomes. The excess risks of mental, physical, and social health

outcomes highlight a need for more support directed toward spouses bereaved by suicide.

Author Affiliations:

Author

affiliations are listed at the end of this

article.

Corresponding Author:

Annette

Erlangsen, PhD, Research Unit,

Mental Health Centre Copenhagen,

Kildegaardsvej 28, DK-2900

Hellerup, Denmark (annette

[email protected]).

JAMA Psychiatry.

doi:10.1001/jamapsychiatry.2017.0226

Published online March 22, 2017.

(Reprinted)

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SUU, Alm.del - 2016-17 - Bilag 314: Henvendelse af 16/5-17 fra Dansk Forskningsinstitut for Selvmordsforebyggelse vedr. hjælp til efterladte efter selvmord

Research

Original Investigation

Association Between Spousal Suicide and Mental, Physical, and Social Health Outcomes

ach year, more than 800 000 people die by suicide,

each person leaving behind up to 60 relatives and

friends directly affected.

The emotional response to

suicide loss may include shock, denial, anger, guilt, shame, or

relief, and complicated grief might arise.

3,4

Support pro-

grams exist but are not broadly available and, to our knowl-

edge, many have not been evaluated.

5,6

Stress has been defined as situations in which “environ-

mental demands tax or exceed the adaptive capacity of an or-

ganism, resulting in psychological and biological changes that

may place persons at risk for disease.”

Psychological stress-

ors, such as bereavement by suicide, might lead to mental dis-

orders such as depression, anxiety, posttraumatic stress dis-

order (PTSD), and psychosis as well as self-harm and death by

suicide.

8-13

Assortative mating might further exacerbate the ef-

fect of a suicide loss.

Through various mechanisms, psycho-

logical stress has been linked to physical disorders,

7,14,15

such

as cardiovascular diseases, cancers, infections, type 2 diabe-

tes, sleep disorders, and disorders related to alcohol misuse,

such as liver cirrohsis.

14,16-19

Furthermore, increased health care

use and higher risks of mortality have been observed.

12,20

Stud-

ies have linked mental health outcomes to spousal suicide and

evidence of an effect on physical and social health outcomes

is lacking.

12,21-23

Also, those bereaved by other causes of sud-

den death experience mental disorders.

To our knowledge,

however, whether any aspects of loss by suicide are worse than

bereavement in general remains unexamined.

The purpose of this study was to examine whether spou-

sal suicide is linked to adverse mental, physical, and social

health outcomes when compared with the general popula-

tion and people bereaved by other manners of death.

Key Points

Question

Does the suicide of a spouse affect the health of the

surviving partner?

Findings

In this nationwide register-based cohort study, an

increased risk of mental and physical disorders, mortality, and

adverse social events were noted among people bereaved by

spousal suicide. Bereavement by suicide differed from

bereavement by other manners of death.

Meaning

Surviving partners are affected on a broad range of

mental, physical, and social health outcomes, suggesting a need

for more proactive outreach.

regardless of civil status, who were not bereaved by suicide

but could be bereaved by other manners of death (group A)

and (2) people bereaved by spousal death because of any

other manner who were identified in similar manners as

described earlier (group B).

Outcomes

The examined outcomes included mental disorders (any dis-

order, mood, PTSD, anxiety, alcohol use disorders, drug use

disorders, and self-harm); physical disorders (cancers, diabe-

tes, sleep disorders, cardiovascular diseases, chronic lower re-

spiratory tract diseases, liver cirrhosis, and spinal disc hernia-

tion); causes of mortality (all causes, natural, unintentional,

suicide, and homicide); social health outcomes (divorce, chil-

dren placed outside the home, a need for municipal family sup-

port, sick leave, unemployment, and disability pension); and

health care utilization. Detailed specifications of the exam-

ined outcomes are listed in eTable 1 in the

Supplement.

Diagnoses from the Psychiatric Central Research Register

and the National Hospital Registry were used as markers of

mental and physical disorders. Additionally, data from the

Prescription Registry were assessed to identify people with

prescriptions for antidepressants. Causes of death were iden-

tified in the Cause of Death register. The examined social out-

comes were based on data from municipal records and in-

come registers. Finally, data on health care use were derived

from hospital and Health Service registers.

Methods

A cohort study design was applied to individual-level data on

all people aged 18 years or older living in Denmark during 1980

to 2014 (n = 7 006 898). Data from the following registries were

linked using a unique, personal identifier: the Civil Registra-

tion System,

the Cause of Death Registry,

the Psychiatric

Central Research Register,

the National Hospital Registry,

and the Registry of Social Pension and Income.

The unique

identifier is assigned at birth or first entry into the country.

The study was approved by the Danish Data Protection Agency

and informed consent was waived.

Follow-up

All persons aged 18 years or older on January 1, 1980, were fol-

lowed up until December 31, 2014. People who later migrated

into the country or had their 18th birthday after January 1, 1980,

entered the study population on the date of the respective

event. People were considered unexposed until the date of their

spouse’s suicide. Similarly, those bereaved because of other

manners of death were included in group B at the date of spou-

sal death. The follow-up period ended at date of the outcome

of interest, emigration, death, or the end of the study.

Exposed

People who died by suicide since 1970 were identified in the

Cause of Death Registry using the

International Classification

of Diseases, Eighth

and

Tenth Revision (ICD-8

and

ICD-10).

31,32

Data were linked to surviving spouses, defined as those mar-

ried, cohabiting, or living in a registered partnership as of Janu-

ary 1 of the calendar year when the death took place, to iden-

tify those bereaved by suicide.

Statistical Analyses

We used a Poisson regression analysis to compare the inci-

dence rates among the exposed relatives with those of groups

A and B. Results were expressed as incidence rate ratios (IRRs)

with 95% confidence intervals.

jamapsychiatry.com

Unexposed

Two comparison groups were formed: (1) the general popu-

lation consisting of all people in the study population,

JAMA Psychiatry

Published online March 22, 2017

(Reprinted)

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SUU, Alm.del - 2016-17 - Bilag 314: Henvendelse af 16/5-17 fra Dansk Forskningsinstitut for Selvmordsforebyggelse vedr. hjælp til efterladte efter selvmord

Association Between Spousal Suicide and Mental, Physical, and Social Health Outcomes

Original Investigation

Research

Only the first onset of any outcome was considered. Long-

term models assessed the effect of spousal suicide from the

date of bereavement until the end of observation while mod-

els with a 5-year follow-up measured more immediate ef-

fects. Multivariate regression models were adjusted for calen-

dar period, country of birth, age, civil status, household income

level, presence of chronic physical disorders,

mental disor-

ders, and self-harm. Time-varying covariates were used while

the presence of mental disorders and self-harm were mea-

sured at baseline. The unit of measurement was person-days

expressed as person-years.

The distribution in risk over time was assessed by calcu-

lating Kaplan-Meier survival curves for a subset of outcomes.

The statistical analyses were carried out using SAS ver-

sion 9.4 (SAS Global).

After a spouse’s suicide, people who later remarried

were less likely to get a divorce than members of the general

population after adjusting for civil status. People bereaved

by suicide were more likely to require municipal-directed

family support and have a child placed outside the home by

authorities. Additionally, extended periods of sick leave

from work, unemployment, and the use of disability pen-

sions were observed.

People bereaved by a spouse’s suicide were more likely to

be admitted to psychiatric hospitals and attend therapy ses-

sions with privately practicing psychologists or psychiatrists.

Women bereaved by suicide were less likely to be hospital-

ized for somatic disorders and see general practitioners.

Comparison With People Bereaved by Other Manners

of Death (Group B)

When comparing spouses bereaved by a partner’s suicide with

spouses bereaved by other outcomes in

Figure 1

and

a higher

risk of mental disorders was observed (men: IRR, 1.7; 95% CI,

1.5-1.9; women: IRR, 2.0; 95% CI, 1.8-2.2). There was an ex-

cess risk for the following disorders after bereavement by a

spouse’s suicide: mood disorders (men: IRR, 1.7; 95% CI, 1.4-

2.1; women: IRR, 1.3; 95% CI, 1.2-1.5), PTSD (men: IRR, 5.6; 95%

CI, 2.7-11.4; women: IRR, 3.6; 95% CI, 2.3-5.5), anxiety (men:

IRR, 1.4; 95% CI, 1.0-1.9; women: IRR, 1.1; 95% CI, 0.9-1.3), drug

use disorders (men: IRR, 1.4; 95% CI, 1.0-2.1; women: IRR, 1.0;

95% CI, 0.8-1.3), and deliberate self-harm (men: IRR, 1.3; 95%

CI, 1.0-1.8; women: IRR, 1.5; 95% CI, 1.2-1.8).

Spousal suicide was linked to a lower risk of spouses re-

ceiving a subsequent diagnosis of cancers (men: IRR, 0.8; 95%

CI, 0.7-0.9; women: IRR, 0.8; 95% CI, 0.7-0.9), diabetes (men:

IRR, 0.6; 95% CI, 0.4-0.7; women: IRR, 0.6; 95% CI, 0.5-0.8),

cardiovascular (men: IRR, 0.9; 95% CI, 0.8-0.9; women: IRR,

0.9; 95% CI, 0.8-1.0), and chronic lower respiratory tract dis-

orders (men: IRR, 0.8; 95% CI, 0.7-1.0; women: IRR, 0.7; 95%

CI, 0.6-0.8). Those recently bereaved by a spouse’s suicide had

elevated risks 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 ac-

centuated for suicide (men: IRR, 3.5; 95% CI, 2.8-4.3; wom-

en: IRR, 4.2; 95% CI, 3.3-5.2) and women faced an increased

risk of dying by homicide (IRR, 33.8; 95% CI, 22.0 to 51.8).

While women bereaved by suicide were less likely to get

a divorce after remarrying than those bereaved by other dis-

orders (IRR, 0.7; 95% CI, 0.6-0.9), they were somewhat more

likely to require municipal intervention (IRR, 1.3; 95% CI, 1.1-

1.5). People bereaved by 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).

An increased use of psychiatric in patient care was noted

among people bereaved by a spouse’s suicide (men: IRR, 1.5;

95% CI, 1.1-2.0; women: IRR, 1.6; 95% CI, 1.3-1.9) as well as 1

or more appointments with private psychiatrists or psycholo-

gists (men: IRR, 2.0; 95% CI, 1.5-2.5; women: IRR, 1.7; 95% CI,

1.5-1.9). Somatic hospital use was less for women (IRR, 0.9; 95%

CI, 0.8 to 1.0), while men were less likely to see a general prac-

titioner than those bereaved by other manners of death (IRR,

0.9; 95% CI, 0.8-1.0).

(Reprinted)

JAMA Psychiatry

Published online March 22, 2017

Results

The total study population consisted of 3 491 939 men and

3 514 959 women who were observed over 79 050 358 and

81 033 322 person-years, respectively. In all, 4814 men (mean

age [SD], 54.0 [14.2]) and 10 793 women (mean age [SD], 49.6

[15.2]) bereaved by a spouse’s suicide were followed up over

75 683 and 184 863 person-years.

The general population, group A, was followed up over

79 126 041 person-years for men and 81 218 1853 for women.

Group B, people bereaved by spousal deaths other than suicide,

covered 251 863 men (mean age [SD], 70.1 [12.8]) and 536 915

women (mean age [SD], 67.9 years [12.1]) observed over 2 285 907

and 6 396 101 person-years, respectively. Characteristics for the

participants are detailed in eTable 2 in the

Supplement.

Comparison With the General Population (Group A)

Multivariate regressions showed that people bereaved by spou-

sal suicide had an elevated risk of a mental disorder (IRR: men,

1.8; 95% CI, 1.6-2.0; IRR: women, 1.7; 95% CI, 1.6-1.8) when

compared with the general population (Table

and

2).

Excess

risks were noted for mood disorders, PTSD, anxiety disor-

ders, alcohol use disorders, drug use disorders, receiving pre-

scriptions for antidepressants, and self-harm.

Those bereaved by spousal suicide had an increased risk

of cancer, cirrhosis, and spinal disc herniation. Over the 5-year

follow-up, diabetes, cardiovascular diseases, and chronic lower

respiratory tract diseases were observed significantly less fre-

quently among those bereaved by suicide. Over the long-

term follow-up, increased risks of sleep disorders were noted

as well as an increased risk of chronic lower respiratory tract

diseases among women.

Among those bereaved by a partner’s suicide, men had

higher risks of dying by any cause (men: IRR, 1.3; 95% CI, 1.2-

1.4; women: IRR, 1.3; 95% CI, 1.2-1.3) and men had higher risks

of dying by natural causes (men: IRR, 1.1; 95% CI, 1.0-1.2; wom-

en: IRR, 1.0; 95% CI, 0.9-1.1) than the general population. A 6-

to 8-fold (men: IRR, 6.4; 95% CI, 5.3-7.8; women: IRR, 8.5; 95%

CI, 7.0-10.5) higher risk of suicide was also noted in the first 5

years as well as a higher risk of death by homicide for women,

while few events were observed for men.

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Research

Original Investigation

Association Between Spousal Suicide and Mental, Physical, and Social Health Outcomes

Table 1. Men Bereaved by Suicide Compared With the General Population (Group A) in Denmark Aged 18 Years and Over During 1980 to 2014

5-y Follow-up

Spouses Bereaved

by Suicide

Outcome

Mental disorders

Any mental disorder

Mood disorders

PTSD

Anxiety disorders

Alcohol use disorder

Drug use disorder

Prescribed antidepressants

Deliberate self-harm

Physical disorders

Cancer

Diabetes

Long-term

Follow-up

General Population

No.

324 524

109 563

9569

43 623

175 325

65 501

593 486

52 507

419 249

194 828

54 427

1 076 658

245 790

44 142

170 396

996 735

930 886

42 083

22 910

1883

407 837

88 654

84 250

990 053

1 177 152

19 533

640 224

56 159

2 045 002

58 581

IRR (95% CI)

Unadjusted

2.7 (2.3-3.0)

3.2 (2.6-3.8)

3.5 (1.9-6.5)

2.7 (2.0-3.8)

2.0 (1.6-2.4)

1.4 (1.0-2.0)

1.5 (1.3-1.7)

2.9 (2.1-3.9)

1.6 (1.4-1.9)

1.0 (0.8-1.3)

0.7 (0.4-1.3)

1.6 (1.4-1.7)

1.6 (1.3-1.9)

2.1 (1.5-3.1)

1.2 (1.0-1.6)

2.3 (2.1-2.5)

2.0 (1.8-2.2)

1.9 (1.3-2.9)

15.1 (12.4-18.3)

0.3 (0.2-0.4)

3.3 (2.7-4.1)

2.0 (1.5-2.7)

1.4 (1.3-1.6)

1.0 (0.9-1.1)

2.8 (1.7-4.5)

1.9 (1.8-2.2)

2.9 (2.2-3.8)

1.0 (1.0-1.1)

4.1 (3.2-5.2)

Adjusted

1.8 (1.6-2.0)

2.2 (1.8-2.7)

12.1 (6.4-22.7)

2.5 (1.8-3.4)

1.5 (1.2-1.8)

1.7 (1.2-2.5)

1.3 (1.2-1.5)

2.0 (1.5-2.7)

1.2 (1.0-1.4)

0.8 (0.6-1.1)

1.4 (0.8-2.5)

1.0 (0.9-1.1)

1.0 (0.8-1.2)

1.6 (1.1-2.3)

1.5 (1.2-1.9)

1.3 (1.2-1.4)

1.1 (1.0-1.2)

0.7 (0.5-1.1)

6.4 (5.3-7.8)

0.2 (0.2-0.3)

3.6 (2.9-4.5)

3.7 (2.8-5.0)

2.3 (2.1-2.5)

2.1 (1.9-2.3)

2.9 (1.8-4.8)

1.2 (1.0-1.3)

2.7 (2.1-3.7)

1.1 (1.0-1.1)

5.8 (4.6-7.4)

Adjusted

1.2 (1.1-1.3)

1.2 (1.1-1.4)

2.6 (1.5-4.6)

1.4 (1.1-1.8)

1.4 (1.3-1.6)

1.5 (1.2-1.8)

1.0 (1.0-1.1)

1.6 (1.3-2.0)

1.2 (1.2-1.3)

1.0 (1.0-1.2)

1.4 (1.1-1.7)

1.0 (1.0-1.1)

1.1 (1.0-1.1)

1.5 (1.2-1.8)

1.3 (1.1-1.5)

1.1 (1.0-1.1)

0.7 (0.5-0.8)

3.6 (3.1-4.3)

0.6 (0.6-0.7)

2.5 (2.1-2.9)

1.8 (1.5-2.2)

1.5 (1.4-1.6)

1.7 (1.6-1.8)

1.8 (1.3-2.6)

1.0 (1.0-1.1)

2.0 (1.6-2.5)

1.1 (1.1-1.1)

2.4 (2.0-2.8)

No.

243

101

100

257

199

467

113

687

557

103

411

357

362

730

IR per

100 000 PY

1163

444

151

448

116

1174

192

878

257

2468

496

120

276

2915

2363

102

437

165

379

217

2202

1990

1711

207

4407

306

IR per

100 000 PY

437

140

229

798

543

252

1569

320

222

1260

1177

559

115

108

1556

2061

881

4211

Sleep disorder

Cardiovascular diseases

Chronic lower respiratory tract

diseases

Liver cirrhosis

Spinal disc herniation

Mortality

Any death

Natural death

Unintentional

Suicide

Homicide

Social and work-related events

Divorce

Children placed outside home

Municipal family support

Sick leave

Unemployed

Disability pension

Service usage

Somatic hospitalization

Psychiatric hospitalization

GP contact

Psychological/psychiatric

therapy

Abbreviations: GP, general practitioner; IR, incidence rate; IRR, incidence rate

ratio; NA, not applicable; PTSD, posttraumatic stress disorder; PY, person-years.

Multivariate models were adjusted for calendar period, country of birth, age

groups, civil status, household income level, presence of chronic physical

disorders (measured using the Charlson Index), previous psychiatric

hospitalization, and previous records of self-harm.

As a person could have been diagnosed with more than 1 mental disorder, the

total number of people with any mental disorders is smaller than the sum of

people with specific disorders.

The examined physical disorder is included in the Charlson Index, so an

adaptation of the Charlson Index without the specific physical disorder was

used for the multivariate model.

The Kaplan-Meier plots revealed several group differences

between the examined groups (eFigure in the

Supplement).

Discussion

To our knowledge, this is the largest and most comprehensive

study of spouses bereaved by a partner’s suicide. Using nation-

JAMA Psychiatry

Published online March 22, 2017

(Reprinted)

wide data, exposure to spousal suicide was linked to higher risks

for developing mental disorders, suicidal behavior, specific

physical disorders, any cause of mortality, suicide, dying by ho-

micide, adverse social events, and mental health care use when

compared with the general population. Those bereaved by a

spouse’s suicide were more affected by mental disorders, mor-

tality, select social outcomes, and mental health care use than

those bereaved by other manners of death.

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SUU, Alm.del - 2016-17 - Bilag 314: Henvendelse af 16/5-17 fra Dansk Forskningsinstitut for Selvmordsforebyggelse vedr. hjælp til efterladte efter selvmord

Association Between Spousal Suicide and Mental, Physical, and Social Health Outcomes

Original Investigation

Research

Table 2. Women Bereaved by Suicide Compared With the General Population (Group A) in Denmark Aged 18 Years and Over During 1980 to 2014

5-y Follow-up

Spouses Bereaved

by Suicide

No.

Mental disorders

Any psychiatric diagnosis

Mood disorders

PTSD

Anxiety disorders

Alcohol use disorder

Drug use disorder

Prescribed antidepressants

Deliberate self-harm

Physical disorders

Cancer

Diabetes

Long-term

Follow-up

General Population

No.

386 846

184 072

9678

87 962

81 809

57 724

876 917

62 753

IR per

100 000 PY

512

233

110

102

1197

IRR (95% CI)

Unadjusted

2.4 (2.2-2.6)

1.9 (1.7-2.2)

4.5 (3.1-6.5)

1.6 (1.3-2.0)

2.6 (2.2-3.1)

1.6 (1.3-2.1)

1.4 (1.3-1.5)

2.8 (2.3-3.3)

Adjusted

1.7 (1.6-1.8)

1.5 (1.3-1.7)

8.7 (6.0-12.5)

1.4 (1.1-1.7)

2.3 (1.9-2.7)

1.6 (1.2-2.1)

1.3 (1.2-1.3)

2.1 (1.8-2.6)

Adjusted

1.1 (1.0-1.1)

2.6 (1.9-3.6)

1.1 (1.0-1.2)

2.0 (1.8-2.2)

1.6 (1.4-1.8)

1.1 (1.0-1.1)

1.6 (1.4-1.8)

IR per

100 000 PY

1235

445

180

266

116

1665

218

587

231

140

803

114

334

749

172

151

643

167

1632

326

288

445 274

166 151

21 821

1 116 171

253 059

26 043

176 892

570

209

1595

321

224

1.1 (1.0-1.3)

0.8 (0.6-1.0)

0.8 (0.5-1.4)

1.0 (1.0-1.1)

1.0 (0.9-1.2)

2.1 (1.5-2.9)

1.3 (1.1-1.5)

1.2 (1.0-1.3)

0.7 (0.6-0.9)

1.4 (0.7-2.8)

0.9 (0.8-1.0)

0.9 (0.7-1.0)

2.1 (1.5-2.9)

1.5 (1.3-1.8)

1.2 (1.2-1.3)

1.0 (0.9-1.1)

1.4 (1.0-1.8)

1.0 (1.0-1.1)

1.2 (1.1-1.2)

2.0 (1.6-2.3)

1.4 (1.3-1.5)

Sleep disorder

Cardiovascular diseases

Chronic lower respiratory tract

diseases

Liver cirrhosis

Spinal disc herniation

Mortality

Any death

Natural death

Unintentional

Suicide

Homicide

Social and work-related events

Divorce

Children placed outside home

Municipal family support

Sick leave

Unemployed

Disability pension

Service usage

Somatic hospitalization

Psychiatric hospitalization

GP contact

Psychological/psychiatric

therapy

796

596

1465

1097

175

144

988 209

935 957

40 047

11 085

1126

1218

1153

1.2 (1.1-1.3)

1.0 (0.9-1.0)

1.0 (0.7-1.5)

12.8 (10.5-15.7)

103.5 (82.2-130.1)

1.3 (1.2-1.3)

1.0 (0.9-1.1)

0.9 (0.6-1.3)

8.5 (7.0-10.5)

62.7 (48.5-81.2)

1.1 (1.0-1.1)

1.0 (1.0-1.1)

0.9 (0.8-1.1)

4.5 (3.7-5.4)

30.6 (23.8-39.3)

208

198

1184

1019

129

409

376

2891

2911

420 088

89 175

85 888

1 017 316

1 242 117

24 316

564

113

107

1533

2220

0.2 (0.2-0.3)

3.6 (3.2-4.1)

3.5 (3.0-4.0)

1.9 (1.8-2.0)

1.3 (1.2-1.4)

3.0 (2.2-3.9)

0.2 (0.1-0.2)

4.8 (4.2-5.5)

5.7 (4.9-6.5)

3.5 (3.3-3.7)

2.3 (2.1-2.4)

3.3 (2.5-4.4)

0.5 (0.5-0.6)

3.7 (3.3-4.1)

2.9 (2.6-3.2)

2.2 (2.1-2.3)

1.9 (1.8-2.0)

2.8 (2.3-3.3)

632

136

1,663

310

1332

260

15 327

587

854 221

61 313

2 105 681

107 043

1200

13 220

134

1.1 (1.0-1.2)

3.4 (2.9-4.0)

1.2 (1.1-1.2)

4.4 (3.9-4.9)

0.7 (0.7-0.8)

3.2 (2.8-3.9)

0.9 (0.9-1.0)

5.3 (4.7-5.9)

0.8 (0.8-0.9)

2.2 (2.0-2.5)

1.0 (1.0-1.0)

2.1 (2.0-2.3)

Abbreviations: IR, Incidence rate; IRR, incidence rate ratio; PTSD, posttraumatic

stress disorder; PY, person-years.

Multivariate models were adjusted for calendar period, country of birth, age

groups, civil status, household income level, presence of chronic physical

disorders (measured using the Charlson Index), previous psychiatric

hospitalization, and previous records of self-harm.

As a person could have been diagnosed with more than 1 mental disorder, the

total number of people with any mental disorders is smaller than the sum of

people with specific disorders.

The examined physical disorder is included in the Charlson Index, so an

adaptation of the Charlson Index without the specific physical disorder was

used for the multivariate model.

Mental Health

Spouses bereaved by suicide had higher risks for all exam-

ined mental disorders, including deliberate self-harm, when

compared with the general population. While previous stud-

ies have linked spousal suicide to depression and death by

suicide,

12,22

the current study extends our knowledge of which

mental disorders might arise after the suicide of a spouse.

jamapsychiatry.com

Excess risks of mood disorders and PTSD were found

when comparing spouses bereaved by suicide with those

bereaved by other manners. Previous studies of similar

groups are limited to measuring depression.

22,24

No differ-

ences were noted for alcohol and drug use disorders, which

suggests that these may be pervasive across all types of

bereavement.

(Reprinted)

JAMA Psychiatry

Published online March 22, 2017

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Research

Original Investigation

Association Between Spousal Suicide and Mental, Physical, and Social Health Outcomes

Figure 1. Men Bereaved by Suicide Compared With Men Bereaved by Other Manners of Death

Over a 5-Year Follow-up (Group B)

Any mental disorder

Mood disorders

Posttraumatic stress disorder

Anxiety disorders

Alcohol use disorder

Drug use disorder

Prescribed antidepressants

Deliberate self-harm

Cancer

Diabetes

Sleep disorder

Cardiovascular diseases

Chronic lower respiratory tract diseases

Liver cirrhosis

Spinal disc herniation

Any death

Natural death

Unintentional

Suicide

Homicide

Divorce

Children placed outside home

Municipal family support

Sick leave

Unemployed

Disability pension

Somatic hospitalization

Psychiatric hospitalization

General practitioner contact

Psych/psychiatric consultation

Rate Ratio

Multivariate models were adjusted

for the calendar period, country of

birth, age group, civil status,

household income level, presence of

physical disorder (measured using

the Charlson Index), previous

psychiatric hospitalization, and

previous records of self-harm.

Physical Health

Spousal suicide has, to our knowledge, not previously been

linked to physical disorders. The excess risks of cancer and cir-

rhosis, as well as sleep disorders and chronic lower respira-

tory tract diseases (long-term), might be attributed to un-

healthy coping styles, such as alcohol use disorder, or a

weakening of the immune system, both related to psychoso-

cial stress.

14,37

A spouse’s death by any cause has previously

been linked to smoking and alcohol consumption.

The elevated risk of spinal disc herniation could be spu-

rious, however, the association remained significant across sex

and follow-up periods. Although conflicting evidence exists,

an association between levels of stress, pain pressure sensi-

tivity, and depressive symptoms could indicate an increased

pain sensitivity among bereaved people.

39,40

Additionally, be-

reavement is associated with weight loss, and unexpected

weight loss may precede back pain.

41,42

A lower risk of some physical diagnoses was noted for

spouses bereaved by a partner’s suicide, particularly within the

first 5 years, although there was an excess in overall mortal-

ity. People bereaved by a spouse’s suicide might be less in-

clined to seek medical attention for health concerns (eg, being

distracted by their grief to a degree of self-neglect),

and the

partially lower use of somatic hospitals supports this notion.

Competing risks, as reflected in the elevated risk of mortality,

is another possible explanation.

JAMA Psychiatry

Published online March 22, 2017

(Reprinted)

Mortality

Those bereaved by suicide had higher rate ratios of overall mor-

tality than the general population and those bereaved by other

manners. To our knowledge, excess mortality has not been

studied among spouses bereaved by suicide, but has been

shown to exist among bereaved spouses generally.

Most of

these deaths were natural deaths (men: 81%; women: 75%);

thus, a person’s neglect of his or her health could be a poten-

tial explanation.

The excess risk of suicide is supported by previous

studies.

12,24

Exposure to a loss by suicide might lessen barri-

ers to engage in suicidal behavior.

Assortative mating is an-

other option,

which is supported by higher suicide risks

among spouses bereaved by suicide than other family

members.

The increased risk of dying by homicide is, to our knowl-

edge, a new observation. Although homicides recorded on the

same or following day after a spouse’s suicide were not in-

cluded, some of these cases might be dyadic suicides.

Social Health

Increased risks of having a single marital status, low income, and

criminal conduct have been reported for parents and children

bereaved by suicide, but we have no information on the social

health of spouses.

11,20

The observed lower risk of getting a di-

vorce could imply a more precautious partner selection. The

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Association Between Spousal Suicide and Mental, Physical, and Social Health Outcomes

Original Investigation

Research

Figure 2. Women Bereaved by Suicide Compared With Women Bereaved by Other Manners of Death

Over a 5-Year Follow-up (Group B)

Any mental disorder

Mood disorders

Posttraumatic stress disorder

Anxiety disorders

Alcohol use disorder

Drug use disorder

Prescribed antidepressants

Deliberate self-harm

Cancer

Diabetes

Sleep disorder

Cardiovascular diseases

Chronic lower respiratory tract diseases

Liver cirrhosis

Spinal disc herniation

Any death

Natural death

Unintentional

Suicide

Homicide

Divorce

Children placed outside home

Municipal family support

Sick leave

Unemployed

Disability pension

Somatic hospitalization

Psychiatric hospitalization

General practitioner contact

Psych/psychiatric consultation

Rate Ratio

Multivariate models were adjusted

for the calendar period, country of

birth, age group, civil status,

household income level, presence of

physical disorder (measured using

the Charlson Index), previous

psychiatric hospitalization, and

previous record of self-harm.

The rate ratio for homicide was

33.8; 95% CI, 22.0-51.8.

fewer episodes of taking sick leave days or experiencing unem-

ployment when compared with people bereaved by other man-

ners might relate to the social stigmatization of suicide.

The

mean age (>67 years) for those bereaved by other manners of

death implies that only a subsample were working and assor-

tative mating might have increased their rate of absence.

Health Care Use

Increased mental health care use was noted. The reduced

use of somatic hospitals is contradictive to the excess mor-

tality among spouses bereaved by suicide and raises con-

cerns regarding the identification and the treatment of

health conditions.

Clinical Implications

It is important to note that most people bereaved by suicide

do not experience health complications; 1 in 200 spouses be-

reaved by suicide received a diagnosis of a mood disorder com-

pared with 1 in 500 among the general population.

Women bereaved by suicide had less contact with their

general practitioners than the general population, and men be-

reaved by suicide had less primary care contact than those be-

reaved by other manners of death. This is concerning, as pri-

mary care could provide an access point for support and

suggests the need for more aggressive outreach following be-

reavement by suicide.

jamapsychiatry.com

Studies have linked spousal bereavement to compli-

cated grief.

Furthermore, this association could be medi-

ated through other mental disorders.

An elevated risk of

misuse disorders was noted for people bereaved by suicide.

Future research might address whether mental disorders

following bereavement could be an indication of a compli-

cated grief.

Short-term interventions have shown promising results re-

garding treating complicated grief.

5,47

In Denmark, people be-

reaved by suicide are entitled to state-subsidized treatment with

a psychologist or psychiatrist.

5,48

Although bereaved spouses

used mental health care, the elevated risks of adverse social out-

comes illustrates the high societal costs and need for profes-

sional help. Still, most support for those bereaved by suicide is

left for volunteer organizations.

Strengths and Limitations

Nationwide register data were collected on a uniform basis for

both exposed and unexposed people, which improved inter-

nal validity and avoided recall bias. By including all spouses

bereaved by suicide, the selection bias noted in previous stud-

ies was avoided.

Longitudinal data on civil statuses and

household identifiers let us identify those living together at

the time of bereavement. Additionally, the large sample size,

the long observation period, and no loss to follow-up were other

strengths.

(Reprinted)

JAMA Psychiatry

Published online March 22, 2017

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SUU, Alm.del - 2016-17 - Bilag 314: Henvendelse af 16/5-17 fra Dansk Forskningsinstitut for Selvmordsforebyggelse vedr. hjælp til efterladte efter selvmord

Research

Original Investigation

Association Between Spousal Suicide and Mental, Physical, and Social Health Outcomes

Limitations include that only people who had entered

a formal union or cohabitation were considered. Danish

suicide records might underestimate the actual figure,

although a recent study noted a good reliability.

Also,

hospital diagnoses might represent underestimates of actual

incidences.

5 1

The effect of stressful exposures might

be modified through personality traits, individual coping

strategies, the presence of children and social support or

intensified though multimorbidity.

Although the analysis

was adjusted for relevant covariates, unmeasured con-

founders cannot be excluded. Similarly, type I errors are

possible. The findings are representative of Scandinavia but

might also apply to other countries with different social

structures and cultural values, or different ethnic or racial

composition.

Conclusions

Bereavement following suicide constitutes a psychological

stressor and remains a public health burden. The excess risk

of mental disorders, select physical disorders, mortality, and

adverse social events illustrate the breadth of consequences

of bereavement by spousal suicide. Furthermore, we find in-

dications that people bereaved by spousal suicide had higher

risks of mental disorders, mortality, and mental health care use

than people bereaved by other manners of death. Higher risks

of drug and alcohol use disorder were noted for people be-

reaved by suicide. More proactive outreach and linkage to sup-

port mechanisms is needed for people bereaved by spousal

suicide to help them navigate their grief.

ARTICLE INFORMATION

Accepted for Publication:

January 31, 2017.

Published Online:

March 22, 2017.

doi:10.1001/jamapsychiatry.2017.0226

Author Affiliations:

Danish Research Institute for

Suicide Prevention, Mental Health Centre,

Copenhagen, Denmark (Erlangsen, Krogh,

Nordentoft); Department of Mental Health, Johns

Hopkins Bloomberg School of Public Health,

Baltimore, Maryland (Erlangsen, Wilcox); iPSYCH,

Lundbeck Foundation Initiative for Integrative

Psychiatric Research, Copenhagen, Denmark

(Erlangsen, Nordentoft); Institute of Regional

Health Research, University of Southern Denmark,

Odense, Denmark (Erlangsen); Centre for

Psychiatry Research, Department of Clinical

Neuroscience, Karolinska Institutet, Stockholm,

Sweden (Runeson); Department of Psychiatry,

University of Manitoba, Winnipeg, Manitoba,

Canada (Bolton); Department of Psychiatry and

Behavioral Sciences, Johns Hopkins School of

Medicine, Baltimore, Maryland (Wilcox); Section of

Biostatistics, Department of Public Health,

University of Copenhagen, Copenhagen, Denmark

(Forman); Columbia School of Social Work,

Columbia University College of Physicians and

Surgeons, New York, New York (Shear); Center for

the Study and Prevention of Suicide, Department

of Psychiatry, and Office for Aging, University of

Rochester Medical Center, Rochester, New York

(Conwell).

Author Contributions:

Dr Erlangsen had full access

to all the data in the study and takes responsibility

for the integrity of the data and the accuracy of the

data analysis.

Study concept and design:

Erlangsen, Runeson,

Bolton, Wilcox, Forman, Shear, Conwell.

Acquisition, analysis, or interpretation of data:

Erlangsen, Runeson, Bolton, Wilcox, Forman,

Krogh, Nordentoft, Conwell.

Drafting of the manuscript:

Erlangsen.

Critical revision of the manuscript for important

intellectual content:

All authors.

Statistical analysis:

Erlangsen, Runeson, Wilcox,

Forman.

Obtained funding:

Erlangsen, Nordentoft, Conwell.

Administrative, technical, or material support:

Nordentoft.

Supervision:

Runeson, Wilcox, Forman, Krogh,

Nordentoft, Conwell.

Conflict of Interest Disclosures:

None reported.

Funding/Support:

The study was supported by

American Foundation for Suicide Prevention and

the Danish Health Insurance Foundation.

Role of the Funder/Sponsor:

The American

Foundation for Suicide Prevention and the Danish

Health Insurance Foundation had no role in the

design and conduct of the study; collection,

management, analysis, and interpretation of the

data; preparation, review, or approval of the

manuscript; and decision to submit the manuscript

for publication

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