When a close friend or relative dies by suicide: the impact on mental health and social functioning of young adults Dr Alexandra Pitman UCL PhD Thesis 2014 Declaration: I, Alexandra Pitman, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. SIGNED: 1 Table of contents Declaration: .................................................................................................................. 1 Abstract: ....................................................................................................................... 8 Preface .......................................................................................................................... 9 Acknowledgements .................................................................................................... 10 Chapter 1 Introduction .......................................................................................... 12 1.1 Definition of research topic ......................................................................... 12 1.2 Policy background ....................................................................................... 27 1.3 Choice of sampling frame for cross-sectional study ................................... 32 1.4 Use of internet-mediated research ............................................................... 35 1.5 Study purpose .............................................................................................. 42 Chapter 2 Systematic review of studies measuring the impact of suicide bereavement on mental health and suicide mortality ................................................. 46 2.1 Abstract ....................................................................................................... 46 2.2 Introduction ................................................................................................. 46 2.3 Methods ....................................................................................................... 48 2.4 Results ......................................................................................................... 49 2.5 Discussion ................................................................................................... 58 2.6 Conclusions ................................................................................................. 63 Chapter 3 Methods ................................................................................................ 64 3.1 Hypotheses .................................................................................................. 64 3.2 Study design ................................................................................................ 65 3.3 Funding and ethical approval: ..................................................................... 65 3.4 Recruitment ................................................................................................. 65 3.5 Inclusion criteria .......................................................................................... 72 2 3.6 Exclusion criteria ......................................................................................... 73 3.7 Questionnaire design ................................................................................... 73 3.8 Exposure definition ..................................................................................... 76 3.9 Outcome measures ...................................................................................... 76 3.10 Other covariates derived: ......................................................................... 79 3.11 Questionnaire structure ............................................................................ 84 3.12 Sample size calculation:........................................................................... 85 3.13 Pilot study ................................................................................................ 88 3.14 Administration of questionnaires ............................................................. 89 3.15 Data entry and data cleaning .................................................................... 90 3.16 Distribution of continuous variables ........................................................ 91 3.17 Missing data: ............................................................................................ 91 3.18 Analysis plan............................................................................................ 97 3.19 Sensitivity analyses ................................................................................ 102 3.20 Qualitative data analysis ........................................................................ 103 3.21 Follow-up study ..................................................................................... 105 Chapter 4 Results ................................................................................................ 107 4.1 Results of preliminary qualitative study of bereaved adults ..................... 107 4.2 Results of national survey of young adults at HEIs .................................. 115 Chapter 5 Discussion .......................................................................................... 168 5.1 Qualitative preliminary study findings ...................................................... 168 5.2 Cross-sectional study findings ................................................................... 169 5.3 Alternative explanations for findings: ....................................................... 175 5.4 Results in the context of other studies: ...................................................... 186 5.5 Strengths of the study ................................................................................ 196 5.6 Limitations of the study: ............................................................................ 198 5.7 Implications ............................................................................................... 206 3 5.8 Future research .......................................................................................... 213 Chapter 6 Conclusions ........................................................................................ 222 Chapter 7 Appendices ......................................................................................... 224 7.1 Appendix 1: Oral & poster presentations of progressive stages in the UCL Bereavement Study .............................................................................................. 224 7.2 Appendix 2: Publications arising from thesis ............................................ 227 7.3 Appendix 3: Systematic review of the effect of suicide bereavement on mental health and suicide risk .............................................................................. 228 7.4 Appendix 4: Systematic review of the epidemiology of suicide in young men 228 7.5 Appendix 5: Confirmation of ethics approval ........................................... 228 7.6 Appendix 6: Table of responses by UK HEI ............................................. 228 7.7 Appendix 7: Online questionnaire & sampling email used in UCL Bereavement Study .............................................................................................. 242 7.8 Appendix 8: UCL Bereavement Study website......................................... 242 7.9 Appendix 9: Information sheet and consent form for cross-sectional study 242 7.10 Appendix 10: Diagnostic distribution of continuous covariates & outcomes .............................................................................................................. 243 7.11 Appendix 11: Interview topic guide ...................................................... 253 4 Table of tables Table 4-1: Extent of missing data on key variables by exposure group .................. 123 Table 4-2: Table showing sample socio-demographic characteristics ..................... 125 Table 4-3: Table showing sample clinical characteristics ........................................ 129 Table 4-4: Table showing sample bereavement characteristics ............................... 133 Table 4-5: Comparison of main outcomes by bereavement exposure ..................... 137 Table 4-6: Table showing results of unadjusted analysis of all outcomes (sudden natural deaths as reference category) ....................................................................... 141 Table 4-7: Table showing results of unadjusted analysis of all outcomes (sudden unnatural deaths as reference category) ................................................................... 143 Table 4-8: Table showing results of adjusted analysis of primary outcomes (sudden natural deaths as reference category) ....................................................................... 148 Table 4-9: Table showing results of adjusted analysis of secondary binary outcomes (sudden natural deaths as reference category) ......................................................... 149 Table 4-10: Table showing results of analysis of secondary continuous outcomes (sudden natural deaths as reference category) ......................................................... 151 Table 4-11: Table showing results of analysis of secondary tertile outcomes (sudden natural deaths as reference category) ....................................................................... 152 Table 4-12: Summary table of adjusted analysis of primary outcomes (sudden natural deaths as reference category) ..................................................................................