According to the World Health Organization (2022), approximately 800,000 people die by suicide every year, a number that equates to one person taking their life every 40 seconds. These figures put suicide and suicide attempts among the leading causes of mortality worldwide (World Health Organization, 2014). During the last half century, suicide rates have risen globally by 60%, something that is particularly true for young adults (Nock et al., 2008). As a result, it is evident that suicide and suicide attempts present a worrying public health concern that needs to be addressed (World Health Organization, 2014).
Research shows that the offspring of parents that have died from suicide are more prone to suicidal behaviour. However, even though exposure to parental suicide has been associated with an increased risk for suicide and suicide attempts, it is unclear whether parental suicide is a specific risk factor or whether, in general, the death of a parent during a vulnerable phase increases the risk of suicide.
Through their paper, the authors aimed to quantify this risk using a meta-analysis and to identify potential effect modifiers and determinants of this association (Calderaro et al, 2021).
Exposure to parental suicide has been linked with an increased risk for suicide/suicide attempts in offspring, but we still don’t know much about it.
Methods
The authors searched the PubMed, PsycInfo and Embase databases for works published up to 2020. Inclusion criteria revolved around the observation of the history of parental death by suicide, the comparison with non-exposed people and how suicide and/or suicide attempt were operationally defined.
The primary outcome was the relative risk of the occurrence of a suicide attempt and suicide in children of parents who had died by suicide compared with children of two living parents. Furthermore, the authors were interested in the risk for attempted and completed suicide after parental suicide versus the relative risk for attempted and completed suicide after parental death by other causes.
Two authors independently screened the potential papers for inclusion. Conflicts in unclear cases were resolved via discussion with a third author until a consensus was reached. The risk of bias of the included studies was assessed using the Newcastle–Ottawa Scale for assessing the quality of non-randomised studies in meta-analyses.
Results
Out of the 3,614 articles, the search yielded 20 studies that met the inclusion criteria and were included in the meta-analyses.
Offspring exposed to parental suicide were three times more likely to die by suicide (RR = 2.97, 95% CI 2.50 to 3.53) and two times more prone to attempt suicide (RR = 1.76, 95% CI 1.58 to 1.96) than offspring of two living parents. Furthermore, their risk of dying by or attempting suicide was significantly higher compared with offspring bereaved by other causes of death. An observation the authors characterise, rightfully so, as “noteworthy” was that the risk of dying by suicide is increased substantially more than the risk of attempting suicide.
Standardised measures were showed that the included studies were of high methodological rigour. The data was mainly retrieved from national population registries, in order to gain large statistical power and reliability.
Children of parents that have died of suicide are 3 times more likely to die by suicide compared to children with two living parents.
Conclusions
The authors concluded that the experience of losing a parent to suicide is a strong and independent risk factor for suicidal behaviour in offspring. Furthermore, they argue that their findings highlight the need for prevention strategies, outreach programmes and support interventions that target suicide-related outcomes in the exposed population.
The experience of losing a parent to suicide is a strong and independent risk factor for suicidal behaviour in offspring.
Strengths and limitations
As far as regarding the limitations of the study, besides the main general known limitations of meta-analyses, two in my opinion stood out. Firstly, as the authors utilised registry-based data, which happen to be readily available in Scandinavian countries, resulted in 16 out of the 20 papers included using data from that geographical area. Even though these databases are data-rich and elaborate, their use does limit the representativeness and validity of the findings.
Secondly, even though the paper is one of the first meta-analyses of its nature it would be interesting to see what a subgroup analysis with regards to other potential risk factors such as coming from LMIC (low- and middle-income countries), belonging to a minority group, considering the brutality of the parental suicide or suicide attempt and/or the existence of mental health comorbidities in the offspring.
On the other hand with regards to the strengths of it, by reading through the paper, it is evident that the authors paid great attention to controlling for bias. By utilising a variety of methodological approaches such as funnel plots and Egger’s test for reporting bias and all the recommendations of the Cochrane Collaboration, we can conclude that the data was analysed in a very rigorous manner. To add on, the idea and execution of it come to add an important piece of literature to our understanding of the risk factors of this phenomenon.
Future research can explore the risk of people who identify as an ethnic minority and/or the existence of mental health comorbidities in the offspring.
Implications for practice
All in all, this paper highlights the significant risks the experience of losing a parent to suicide may have in their offspring. By identifying these risk factors for those affected firsthand, the use of targeted and be preventative interventions for suicide are backed up quantitatively. Understanding the risks of having been through such a life defining event may also allow mental health professionals to gain more insight into their clients. This insight may be influential in providing the assistance that offspring bereaved by parental suicide need, by protecting them systematically in various aspects of their everyday life.
Identifying risk factors for suicide in bereaved people can help with developing preventive interventions, better and more compassionate care.
Statement of interests
None.
Links
Primary paper
Calderaro, M., Baethge, C., Bermpohl, F., Gutwinski, S., Schouler-Ocak, M., & Henssler, J. (2021). Offspring’s risk for suicidal behaviour in relation to parental death by suicide: systematic review and meta-analysis and a model for familial transmission of suicide. The British Journal of Psychiatry, 1-9.
Other references
World Health Organization. (2022) WHO Suicide Data. (accessed February 3, 2022).
World Health Organization. (2014). Preventing suicide: A global imperative. World Health Organization.
Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., . . . Williams, D. (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. The British Journal of Psychiatry, 192(2), 98-105.
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