Suicide is a major public health concern. In 2017, the suicide rate in Canada was 11 per 100 000 inhabitants (1). According to literature, 1 in 5 people have experienced a death by suicide during their lifetime (2–4).
The grief experienced by suicide-bereaved survivors (SBS) is very specific. Dealing with a loved one’s suicide can be extremely challenging for SBS, to the point that they may become more vulnerable to an array of problems (5). The majority of SBS will not develop pathological bereavement or other problems. However, it is important to recognize those who do and to bear in mind that this may occur even 18 to 24 months post suicide (6). Bailley et al. (7) found that, compared with bereaved individuals in other contexts, SBS were more likely to experience feelings of rejection and guilt, suggesting that they also felt higher levels of shame and stigma. This context of death can have an impact on the bereavement process, the development of somatic or mental health disorders and, ultimately, suicide risk (8-11). McMenamy and al. (12) found that SBS had a high level of psychological distress, guilt, anxiety, depression and trauma signs.
Studies have found that SBS needs for help were met in different ways. SBS received help from friends and family, general or suicide grief support groups, individual psychotherapy, information and referral services, talking one to one with another suicide survivor, and psychotropic medication (12-14).
Bereavement programs do exist and some have been assessed. However, there is little knowledge relating to the content and effectiveness of these programs (15). Some evidence of benefits has emerged from a few intervention studies (15-17). For example, Andriessen et al. (2) carried out a systematic review of controlled studies to assess evidence of the effectiveness of interventions for SBS and simultaneously appraise research quality. Their results showed that interventions targeting support, therapy and education seemed to work best when they included the social environment of the bereaved and when the therapy sessions were led by professionals. In another systematic review, Linde et al. (16) found that bereavement groups had positive effects on uncomplicated grief and that cognitive-behavioral programs had positive effects on individuals at risk for suicide. However, as pointed out by Andriessen et al. (2) and Linde et al. (16), the overall quality of research in the field of SBS postvention remains very weak. That being said, the current available evidence on the effectiveness of these interventions is neither strong nor reliable. For example, the results of a systematic review of the literature by Szumilas and Kutcher showed that only 16 of 49 studies of suicide postvention programs met their inclusion criteria regarding quality and evidence of effectiveness (17). Outcomes and measures varied widely from one study to another. Given the absence of any evidence-based suicide postvention program, further research is required into the exact form and structure of these programs. Furthermore, if these programs are proved ineffective, it could be because they were not based on the actual needs of bereaved adults to begin with. As shown by Wilson and Marshall (18), less than half of individuals bereaved by suicide who expressed needing help with their grief process actually received help and only 40% of these were satisfied with the help received. In a study exploring the needs of SBS in Ontario (Canada), Gall, Henneberry, and Eyre (19) described and compared the perspectives of SBS and of mental health workers and found that they complemented each other and helped identify best practices for SBS postvention. Pitman et al. (20), too, demonstrated the importance of addressing support needs from the perspective of SBS. Finally, Castelli-Dransart and Séguin (21) recommended that the help offered to SBS follows a specific progression according to needs: family support in the first weeks, support group if necessary, and therapy for difficult or pathological bereavement.
Finally, SBS often have difficulty seeking help because of depression or lack of energy. They may also have lost confidence in the health and social services systems that failed their loved one or because they feel shame over what happened (7,9,12,22–24). SBS have also underlined in some studies that there was a lack of information about where to find resources and that resources were not always available (13).
The above studies and findings argue in favor of approaching SBS needs proactively (25-27) and of developing specific programs to address these needs. Moreover, it is reassuring to know that programs exist that have proved effective in the very specific situations of complicated bereavement (28,29).
In Canada, health and social services are provincial responsibilities. In the province of Quebec, suicide prevention centers often offer help in the form of support groups to the community. But it seems that SBS are not systematically referred to these centers. This is why it is important to assess social and health service needs and to understand why such needs go unmet. Grieving difficulties, service utilization, and unmet needs should be assessed systematically.
Against this background, we undertook an exploratory cross-sectional and retrospective mixed-method study to describe the met and unmet needs of SBS two years after the event and to formulate specific suicide postvention recommendations over this two-year period.