When Tragedy Strikes: Understanding the Health Impact of Suicide Loss
During Suicide Prevention Month, Boston University’s A.J. Rosellini discusses his current research on the mental and physical health of suicide loss survivors, supported by a $2.95M grant from the National Institute of Mental Health.
By Joela Goga
As we observe Suicide Prevention Month this September, it’s crucial to not only focus on preventing suicide but also on understanding the profound and often overlooked impact it has on those left behind. Suicide loss survivors — family, friends, and loved ones — face unique mental and physical health challenges that can last for years. Dr. A.J. Rosellini, a Boston University School of Public Health associate professor of epidemiology, is working to shed light on these consequences through an innovative new study.
Rosellini, along with co-principal investigator Dr. Jaimie Gradus, was recently awarded a $2.95 million grant from the National Institute of Mental Health (NIMH) to explore the health outcomes of suicide loss survivors. Leveraging Denmark’s comprehensive national health registries, Rosellini’s team will analyze 30 years of data to track the mental and physical health impacts experienced by those affected by suicide, compared to survivors of accidental deaths and the general population. The study, which will span four years, aims to provide crucial insights into how suicide uniquely affects its survivors and identify potential pathways for future suicide postventions.
In this Q&A, Rosellini discusses the goals of his study, the trauma surrounding suicide loss, and how he hopes this research will contribute to a better understanding of the ripple effects of suicide. Drawing from his extensive background in trauma and mental health research, Rosellini offers a compelling look at what it means to support those who have endured such a devastating loss.
Your work spans anxiety, mood disorders, and internalizing psychopathology, with a focus on understanding factors like stress and trauma. What initially drew you to this line of research, particularly in studying suicide and its broader impact on mental health? How has your background shaped your approach to this current project on suicide loss survivors?
My curiosity about anxiety and mood disorders started as an undergraduate here at BU. As I learned about these conditions in undergrad courses, I recognized how they are characterized by feelings and behaviors that most people experience on a near daily basis — fear, worry, sadness, guilt, over-preparation, avoidance, etc. My interests in stress, trauma, and suicide developed during my graduate and post-doctoral training, once diving deeper into the scientific literature. I recognized how common these experiences are, and how broad the impact on mental and physical health could be.
My interest in suicide loss bridges many of these areas and evolved in a similar way — recognizing that it is a common form of stress that may have a broad adverse impact on mental and physical health. Research indicates that for each suicide death, an estimated 135 people are exposed to suicide loss. Exposure to suicide loss is linked to poor mental and physical health outcomes, including increased risk of depression and suicidal behaviors. Although the public health significance of suicide loss is clear, additional work is needed to determine the full scope of adverse health sequalae. This is the overarching goal of the NIMH-funded project being led by myself and Dr. Gradus.
Could you elaborate on the significance of using Denmark’s national data registries for this study? What advantages does this data offer compared to other datasets?
Denmark has a universal healthcare system that has permitted corresponding government-supported nationwide electronic health and social registries. These registry data capture all medical care received by the entire Danish population from birth to death — the registries are thus an incredible data source for health research in general, but also offer unique advantages in the study of suicide loss.
It is possible to study suicide loss by (a) identifying individuals who have died by suicide using a Cause of Death registry, (b) linking these suicide cases to suicide loss survivors (e.g., family members and partners) using social registries, and (c) examining their mental and physical health outcomes using healthcare registries. US population-based data sources typically do not have the ability to link suicide decedents to relatives because they only contain persons who use specific types of medical care or insurance (i.e., children, parents, spouses, and siblings of suicide decedents may receive care elsewhere). This form of selection bias is not present in the Danish registries because data are available for the entire population.
Suicide loss survivors are often understood to face heightened mental health challenges. What specific patterns or trends are you most interested in exploring regarding their mental and physical health outcomes?
There are three types of patterns and trends we are especially curious about. First, most epidemiological studies of suicide loss to date have defined outcomes using broad disorder categories (e.g., mood disorders, cardiovascular disease) and among specific types of family relationships, such as spouses exposed to suicide loss. Our team is excited to evaluate more specific and precise health outcomes across a range of relationships, such as distinguishing different types of anxiety disorder outcomes (e.g., panic disorder and generalized anxiety) across child loss survivors and parent loss survivors.
We are also interested in evaluating the association of suicide loss with gastrointestinal and inflammatory conditions, which have received increased attention in the stress and mental health literatures over recent years. Finally, we’re very interested in looking at patterns of co-occurring (comorbid) mental and physical health conditions such as generalized anxiety and gastrointestinal disorders. In general, comorbidity is an under-explored area among suicide loss survivors.
Your research also aims to analyze comorbidities among suicide loss survivors. Can you delve deeper into the importance of acknowledging that different medical conditions can present simultaneously? Also, how do you expect these patterns of disease to inform potential transdiagnostic treatments or interventions?
There is an expression among mental health researchers and clinicians that “comorbidity is the rule rather than the exception.” Epidemiologic research indicates that most people experience multiple mental health and physical health disorders at once and over their lifetime. Rates of comorbidity are even higher among individuals seeking treatment. Acknowledgement of comorbidity is important because conditions may share common “transdiagnostic” mechanisms that could serve as more efficient or effective targets of prevention and intervention.
For instance, discovering that a large group of suicide loss survivors experience co-occurring depression, phobic anxiety (social anxiety; agoraphobia), cardiovascular disease, and obesity could implicate behavioral underactivity or social withdrawal as plausible transdiagnostic mechanisms of comorbidity. These suspected mechanisms could be explicitly examined in future studies of suicide loss survivors and eventually targeted in a suicide postvention program by combining relevant cognitive-behavioral (behavioral activation), physical health (physical therapy), and medication interventions (SSRIs, statins).
The study will develop cohorts of individuals exposed to suicide loss, accidental death, and the general population. Could you explain the importance of comparing these groups in identifying suicide-specific health outcomes?
Although there is evidence that suicide loss is associated with adverse mental and physical health outcomes, most studies have drawn these conclusions by comparing the health of suicide loss survivors to the health of individuals in the general population, or to individuals exposed to any type of death (general bereavement). What is less clear is whether the impact of suicide loss is similar or different to the impact of other forms of traumatic or unexpected loss.
Despite the uncertainty around this issue, some prevention and treatment approaches are designed for any sudden or accidental death loss, viewing suicide loss as a similar type of event. Experts have called for studies that isolate the effects of suicide loss specifically by comparing exposure to suicide loss with exposure to other forms of unexpected or traumatic death, to disentangle their potential differential outcomes.
How do you think this project will contribute to postvention strategies that better support survivors in the wake of a loss?
We expect both to replicate prior findings surrounding key health outcomes (e.g., depression, PTSD, CVD), and to identify new mental and physical health outcomes associated with suicide loss. Our findings could contribute to postvention strategies in two primary ways. First, by informing assessment priorities, including what conditions clinicians should screen for (and when) in the aftermath of suicide loss. Second, by informing postvention targets, including specific types of mental and physical health symptoms and common comorbidities.
How do you plan to differentiate the health outcomes based on factors like the survivor’s relationship to the deceased or the amount of time passed since the loss? What insights do you hope to gain from these distinctions?
We plan to examine how the link between suicide loss and health outcomes may vary depending on personal factors and characteristics such as the type of relationship with the suicide decedent (e.g., parent, child, sibling, roommate), age of the loss survivor and suicide decedent, and time since the suicide loss. Identifying how outcomes vary (or not) across time and relationships could inform novel and more precise targets for prevention and intervention within the field of suicide postvention.
In addition, determining the time-periods during which certain outcomes are common can inform mechanism-focused studies, ultimately leading to more efficient and effective intervention. For instance, individuals may be at highest risk for specific internalizing disorders in the first year that follows suicide loss (e.g., generalized anxiety, OCD), but highest risk for adverse cardiovascular health outcomes 20 years later, thereby implicating internalizing psychopathology (e.g., worry, obsessional thinking) as a mechanism of subsequent cardiovascular problems.
You’ve mentioned that this project bridges two critical fields — suicide and trauma. How do you see this study expanding our understanding of trauma caused by suicide, and what implications might it have for future public health interventions?
I hope the study expands our understanding of the impact of suicide loss by identifying the gamut of health outcomes which may follow this highly stressful and often unexpected event. I am especially interested in whether suicide loss is associated with different outcomes compared to accidental death loss, to better understand if screening and postvention strategies should differ depending on the nature of the loss, or if the focus should be more broadly on unexpected loss.
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