Research coauthored by Ms Abbott and published in Suicide and Life-Threatening Behavior compared 85 young adults who had been exposed to the loss of 3 high-school friends to suicide in adolescence with 67 unexposed young adults.3 The degree of closeness to the deceased peers was positively correlated with survivors’ level of grief and the belief that suicide is not preventable. Among participants who had been close to the peers, the results further show prolonged grief in those who received a high level of social support. “It is possible that peer groups who went through this rare and painful experience together sought more social support from within the affected peer group,” says Ms Abbott. “This might have been adaptive, but it also might have created risk of corumination, which is an increased focus on negative emotions within a peer group that increases friendship quality but can predict negative outcomes,” although she noted that this area warrants further investigation.

Research reported in the Journal of Affective Disorders in 2015 explored the role of “assortative relating,” a potential explanation proposing that high-risk adolescents associate with each other and share risk factors for suicidal behaviors.4 “This situation is exacerbated by the fact that these groups would tend to share exposure to other acute risk factors or stressors,” Dr Randall said. If a group of patients suddenly loses a therapist, for example, they will each be negatively affected by the experience. “This second explanation is almost certainly partially correct and I don’t think it is very controversial as a partial explanation,” he said.

 

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An analysis of self-report data from 4834 school-attending adolescents revealed that those exposed to suicide attempts by peers had a higher rate of suicide attempts at baseline and at one-year follow-up, even after the researchers adjusted for a large number of factors. “This suggests that assortative relating is not a complete explanation, though it does not provide definitive evidence as to what the true explanation is,” Dr Randall said.

In a longitudinal study published in 2014 in American Sociological Review, researchers at the University of Memphis found that suicide attempts of friends and family members “do in fact trigger new suicidal thoughts and in some cases attempts, even after significant controls are introduced,” the authors wrote.5 “Our findings suggest that exposure to suicidal behaviors in significant others may teach individuals new ways to deal with emotional distress, namely by becoming suicidal,” they said.

Clinicians treating individuals who have been exposed to suicide may need to strike a delicate balance, considering the finding by Ms Abbott and colleagues that participants exposed to suicides were less likely to believe in preventability. This could be a way of avoiding feelings of guilt for not having been able to do anything to prevent the suicide, or it could signal hopelessness. “A potential hurdle for clinicians and communities following adolescent suicides is to promote preventability while simultaneously reducing feelings of guilt,” noted Abbott. “It might be helpful to target belief in preventability through prevention training and psychoeducation,” she said.

Additionally, clinicians should appreciate the importance of peer influence in adolescents. Those who are a part of friend groups affected by suicide clusters may have an elevated risk for prolonged grief, and group therapy might help reduce corumination for these adolescents. For most clinicians, addressing the issue “means being aware of whether a patient has been exposed to a death or an attempt among their peers and family and to assess whether this has had a negative effect on their patient and treat accordingly,” said Dr Randall.

References

1. Sullivan EM, Annest JL, Simon TR, Luo F, Dahlberg, LL. Suicide trends among persons aged 10-24 years — United States, 1994–2012. Morbid Mortal Wkly Rep. 2015; 64(08);201-205. 

2. Santa Clara County Public Health Department. Epi-aid on youth suicide in Santa Clara county. Available at: http://www.psnpaloalto.com/wp/wp-content/uploads/2016/02/SCC-Epi-Aid-overview.pdf. Accessed April 19, 2016.

3. Abbott CH, Zakriski AL. Grief and attitudes toward suicide in peers affected by a cluster of suicides as adolescents. Suicide Life Threat Behav. 2014;44:668-681.

4. Randall JR, Nickel NC, Colman I. Contagion from peer suicidal behavior in a representative sample of American adolescents. J Affect Disord. 2015;186:219-225.

5. Mueller AS, Abrutyn S. Are suicidal behaviors contagious in adolescence? Using longitudinal data to examine suicide suggestion. Am Sociol Rev. 2014;79(2):211-227.