The COVID-19 pandemic has had a global impact on society, affecting public health, economic and social aspects. Thus, it seems confirmed that the rate of suicidal ideation during the COVID pandemic is higher than that reported in studies on the general1 population before the pandemic and may result in higher suicide rates in the future. Beyond the deaths by suicide, we must also consider the existence of other victims who are not always treated but who are widely recognized in the literature as survivors.
It was Shneidman who referred to survivors as those individuals who feel emotionally, socially and financially affected by the suicide of a close relative. Initially, this author estimated that there was an average of six survivors for each suicide, but other studies indicate that the figure varies depending on the relationship and the age of the deceased. Likewise, survivors have a higher risk of mental illness, especially post-traumatic stress disorder and risk of suicide, as well as worse social adjustment.2 It should be noted that exposure to fatal and non-fatal suicidal behaviors is also a risk factor and that the impact of suicide is stronger when experienced during childhood and adolescence and compared to natural causes of death.2
That is why it is particularly important to pay attention to the preparation of the survivors' mourning to avoid complications. Grief is a universal, instinctive and adaptive response to loss. Fortunately, not all grief is complicated, but when it does happen, some authors pointed out that the greatest difficulties in dealing with grief were related to the first years after the loss, previous suicide attempts, and previous negative relationships with the deceased. Suicide survivors experience specific emotions highlighting grief, sadness, disbelief, guilt, confusion, rejection, shame, and anger. These painful experiences can be further complicated by the effects of stigma and trauma. Some studies postulate that although grief is a fluctuating and dynamic phenomenon, the tipping point generally occurs between the ages of 3 and 5 years, when the acute difficulties of grief that accompany a loss by suicide begin to diminish.3
Clearly, the number of suicide survivors is underestimated. It is usually considered that it is limited to the closest relatives without taking into account the health professionals who treated the patient and who, in another dimension, are also survivors of suicide.2 This aspect is particularly relevant because, being evidence that suicide survivors have a higher risk of suicide, it must be considered that physicians, regardless of their status as a survivor, also have a higher risk of suicide than the general population.4 There are few regulated interventions that are carried out at the institutional level to deal with it and that could be of interest for the best support to the health community.
The literature regarding the suitability of the use of different intervention strategies is ambiguous. Initial attention to traumatic anguish is usually recommended, support groups can be beneficial especially for the monitoring and management of specific situations and, as a last resort, pharmacotherapy and psychotherapy are reserved for those cases that already show adverse psychological effects or who are at high risk of suicide.5 However, some authors proposed that postvention intervention may be a useful strategy for suicide prevention in people affected by the suicide of relatives. Currently, these same authors advance their hypotheses suggesting that post-traumatic growth can occur, being conditioned by the time elapsed since the loss, adaptive coping strategies and help-seeking.5
Ethical considerationsThere are not considerations.
Data sharing not applicable to this article as no datasets were generated or analyzed during the study.
Data availabilityThe data that support the findings of this study are available on request from the corresponding authors.
FundingThis study has not received funding.
Author contributionAll authors contributed substantially to this study:
María Irigoyen-Otiñano and Margarita Puigdevall conceived the study, María Irigoyen-Otiñano wrote the manuscript. Carla Albert-Porcar, Cecilia Borrás-Murcia and Ana González-Pinto revised the work adding important intellectual content. All authors read and approved the final version of the manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
FundingThis study has not received funding.
Data sharing not applicable to this article as no datasets were generated or analyzed during the study.
The authors appreciate the contribution of all associations that contribute to mental health care for suicide survivors.