Perceived Effectiveness of Components of Interventions to Support People Bereaved By Suicide

Abstract

Abstract: Background: Suicide bereavement increases the probability of adverse outcomes related to grief, social functioning, mental health, and suicidal behavior. While more support for individuals bereaved by suicide has become available, the evidence regarding its effectiveness is not straightforward. The literature suggests that identifying best-practice components is key in designing effective postvention interventions. Aims: This metareview aims to identify components of suicide bereavement interventions perceived to be effective by suicide-bereaved people. Method: The review adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Systematic searches in Medline, PsycINFO, Embase, Emcare, EBM Reviews, Scopus, and Web of Science identified 11 eligible systematic reviews published between 2008 and 2023. The methodological quality was assessed using the Measurement Tool to Assess Systematic Reviews (AMSTAR-2) (PROSPERO registration CRD42023458300). Results: Our narrative synthesis reported the components perceived to be effective in relation to structure and content of interventions, facilitators, and modality (peer, group, community, online). Limitations: The quality of the included reviews varied considerably, and not all reviews reported on perceived effectiveness of interventions’ components. Meta-analysis of findings was not possible due to study heterogeneity. Conclusion: The findings provide crucial information for researchers, service providers, and policymakers to enhance the provision of evidence-based support for people bereaved by suicide.

People bereaved by suicide contend with profound grief reactions and diverse psychosocial consequences. There is a pronounced variation in the number of people affected by suicide, depending on the relationship, age, and intensity of contact. The literature indicates that between six family members and 135 community members can be exposed to one suicide (Cerel et al., 2019), and in total, about one in five people are affected by suicide (Andriessen et al., 2017). Given that an estimated 700,000 people die by suicide globally each year (WHO, 2023), this high annual incidence suggests substantial clinical and public health consequences. Suicide-bereaved individuals face an increased mortality rate and an elevated risk of suicidal ideation and behavior (Del Carpio et al., 2021; Molina et al., 2019; Pitman et al., 2022). Suicide bereavement also heightens the risk for depression, posttraumatic stress disorder (PTSD), and prolonged grief disorder (Levi-Belz & Ben-Yaish, 2022; Mitchell & Terhorst, 2017).

While sharing similarities with grief following other types of bereavement, those bereaved by suicide can experience more pronounced grief reactions (Andriessen et al., 2016; Kõlves et al., 2019), such as stigmatization, shame, guilt, and feelings of responsibility (Bottomley et al., 2023; Oexle et al., 2018; Pitman et al., 2018). Stigma in suicide bereavement refers to negative social attitudes, discrimination, and judgment following the loss (Pitman et al., 2016). Studies describing the stigma associated with suicide bereavement report that the bereaved often feel ashamed, blamed, and judged, prompting them to conceal the cause of death, with heightened self-stigma associated with psychological distress, depression, suicidality, and self-harm (Evans & Abrahamson, 2020). Stigmatization and the associated consequences can be reinforced by cultural aspects, depending on how suicides are viewed in the respective cultural circles (Hanschmidt et al., 2016). These grief responses, as well as the increased likelihood of social isolation for those who have been bereaved by suicide, and their reluctance to seek help may contribute to the development and persistence of mental health problems (Andriessen et al., 2016; Pitman et al., 2014).

The complexity of suicide bereavement demands trauma-informed, culturally informed, acceptable, and clinically effective interventions, provided equitably to support the bereaved. Suicide-bereaved individuals value both peer and professional support (Kaspersen et al., 2022; V. Ross et al., 2019). Peer support is a system of providing emotional, social, and practical assistance by individuals who share similar experiences or challenges, creating a mutual understanding (Kiemen et al., 2023). Professional support includes support from mental health professionals, doctors, or specially trained bereavement counselors (McGill et al., 2023; V. Ross et al., 2019). However, there are concerns that both professional and peer suicide bereavement support services may be under-utilized due to restrictions on their accessibility, including geographical inequities. While published systematic reviews have examined the effectiveness of interventions in this field, their inclusion criteria have varied, and they have not considered the perspective of end users. While some reviews have only included controlled trials, other reviews have had no restrictions on study design. In addition, the reviews differ greatly in terms of the information extracted. There is therefore a need for a synthesis of service users’ views on the characteristics and components that may contribute to the effectiveness of the included interventions. As no previous metareview has been conducted on this topic, the aim of this metareview was to extract and synthesize findings on the components of suicide bereavement interventions perceived to be effective and the perspective of the bereaved, as derived from existing systematic reviews on interventions for people bereaved by suicide.

Methods

The metareview was conducted following the PRISMA guidelines (Page et al., 2021), using a preregistered protocol (PROSPERO CRD42023458300). We defined perceived effectiveness as the extent to which components were perceived as helpful by participants or facilitators in contributing to a subjective reduction in distress and/or improved coping and grief processing.

Search Strategy

Our strategy was designed to answer the research question: What are effective components and best practices of interventions for people bereaved by suicide? Systematic searches were conducted in Medline, PsycINFO, Embase, Emcare, EBM Reviews, Scopus, and Web of Science. Searches were limited to literature reviews published in peer-reviewed journals, with no restrictions on language, location, or publication date. We hand-searched references of eligible articles to identify additional systematic reviews or meta-analyses and conducted a forward citation search of eligible articles. All coauthors were asked to share relevant articles from their own records.

Search terms were agreed among coauthors and checked by a research librarian. The Medline search string combined medical subject headings (MeSH) and search terms: (grief/OR grief.mp OR bereavement/OR bereavement.mp OR mourning.mp) AND (suicide/OR suicide.mp OR suicide loss.mp OR suicide loss survivor.mp OR suicide cluster.mp) AND (intervention.mp OR therapy.mp OR treatment.mp OR support.mp OR psychotherapy/OR psychotherapy.mp OR counselling/ OR counselling.mp OR postvention.mp OR psychoeducation.mp OR psycho-education.mp OR support group.mp OR self-help.mp OR self-help groups/OR self-help group*.mp OR social media/OR social media.mp OR internet/OR internet.mp OR online.mp) AND (“systematic review”/OR systematic review.mp OR Meta-Analysis/OR meta-analysis.mp). This was adapted for the other databases.

One researcher (L.H.) conducted the search on October 13, 2023, and screened titles and abstracts for eligibility. Two researchers (K.A., L.H.) independently reviewed the full texts of potentially eligible papers. Any disagreements were resolved through discussion. An updated search on June 20, 2024, did not yield any new eligible papers.

Inclusion and Exclusion Criteria

Inclusion criteria were (1) study population: people of any age bereaved by suicide, (2) intervention: interventions aiming to support the mental health and well-being of people bereaved by suicide, (3) outcomes: indicators of the perceived effectiveness of the intervention in addressing grief, mental health, social functioning, and/or suicidality, (4) study design: systematic review or meta-analysis.

Exclusion criteria were (1) systematic reviews or meta-analyses not reporting findings specific to suicide-bereaved people and (2) scoping reviews (i.e., reviews mapping the literature).

Data Extraction

Two researchers (A.K.P., L.H.) independently extracted and tabulated the following data: author; year; number, type, country, and year of included studies; participants’ characteristics; intervention characteristics; outcomes and measures; and views on components. Any disagreement was resolved through discussion. Missing information was obtained from the original authors where possible. The data extraction tables were shared with all coauthors to elicit feedback on clarity of the presentation and key messages.

Quality Assessment

Risk of bias and methodological quality were assessed using the Measurement Tool to Assess Systematic Reviews (AMSTAR-2) checklist (Shea et al., 2017), which rates reviews as higher quality based on the number of criteria met. Three researchers (A.K.P., K.A., L.H.) independently performed the quality assessment, determining whether each criterion applied, partially applied, or did not apply, generating scores denoting high, moderate, low, and critically low quality. Any disagreements were resolved by discussion.

Data Synthesis

We synthesized findings as a narrative synthesis, categorizing aspects of interventions perceived to be effective components in terms of their structure and type. A meta-analysis was not possible due to study heterogeneity.

Results

Study Selection

The search yielded 233 publications, of which 11 systematic reviews met the inclusion criteria (Abbate et al., 2022; Adshead et al., 2023; Andriessen, Krysinska, Hill, et al., 2019; Andriessen, Krysinska, Kõlves, & Reavley, 2019; Inostroza et al., 2023; Journot-Reverbel et al., 2017; Lestienne et al., 2021; Linde et al., 2017; McDaid et al., 2008; Szumilas & Kutcher, 2011; Wagner et al., 2021). Figure 1 presents the search and selection process. A list of excluded reviews after full-text screening is provided in Table E1 in the Electronic Supplementary Material 1 (ESM 1) ^{(278.1KB, pdf)} .

Figure 1. PRISMA flow diagram.

Review Characteristics

The 11 eligible reviews were published between 2008 and 2023 and included 79 individual studies conducted between 1982 and 2021 (see Table E2 in ESM1 ^{(278.1KB, pdf)} ), of which 27 studies were included in more than one review (see Table E3 in ESM 1 ^{(278.1KB, pdf)} ). All reviews reported their results as a narrative synthesis. No review conducted a meta-analysis, and none focused specifically on perceptions of effective intervention components. All reviews were published in English, except for one in German (Wagner et al., 2021). Six reviews included only quantitative studies (Andriessen, Krysinska, Hill, et al., 2019; Andriessen, Krysinska, Kõlves, & Reavley, 2019; Journot-Reverbel et al., 2017; McDaid et al., 2008; Szumilas & Kutcher, 2011; Wagner et al., 2021), one review included only qualitative studies (Adshead et al., 2023), and four included both qualitative and quantitative (Abbate et al., 2022; Inostroza et al., 2023; Lestienne et al., 2021; Linde et al., 2017). Five reviews included studies describing interventions targeting suicide-bereaved adults (Adshead et al., 2023; Andriessen, Krysinska, Kõlves, & Reavley, 2019; Inostroza et al., 2023; Lestienne et al., 2021; Wagner et al., 2021), one focused solely on suicide-bereaved children and adolescents (Journot-Reverbel et al., 2017), while the remaining reviews reported on interventions for mixed groups.

Two reviews focused exclusively on studies of peer support (Adshead et al., 2023; Inostroza et al., 2023), one review focused only on group interventions (Journot-Reverbel et al., 2017), and one focused on evaluations of online interventions (Lestienne et al., 2021). The remaining reviews had no limitations regarding the delivery format, describing formats such as community-based interventions (Abbate et al., 2022; Szumilas & Kutcher, 2011), school-based interventions (Abbate et al., 2022; Szumilas & Kutcher, 2011), family-oriented interventions (Andriessen, Krysinska, Hill, et al., 2019; McDaid et al., 2008), individual support (Andriessen, Krysinska, Hill, et al., 2019; Wagner et al., 2021), and a combination of group and individual support (Linde et al., 2017).

The reviews varied widely in assessed outcomes and measures. The main outcomes assessed were perceptions of interventions having an impact on grief, depression, suicidality, and general health.

The interventions were delivered by varied facilitators. In most cases, these included peers (Abbate et al., 2022; Adshead et al., 2023; Andriessen, Krysinska, Hill, et al., 2019; Inostroza et al., 2023; Linde et al., 2017; McDaid et al., 2008; Szumilas & Kutcher, 2011), but also clinicians/therapists (Abbate et al., 2022; Andriessen, Krysinska, Hill, et al., 2019; Andriessen, Krysinska, Kõlves, & Reavley, 2019; Journot-Reverbel et al., 2017; Linde et al., 2017; McDaid et al., 2008; Szumilas & Kutcher, 2011; Wagner et al., 2021), nurses (Abbate et al., 2022; Szumilas & Kutcher, 2011; Wagner et al., 2021), researchers (Andriessen, Krysinska, Kõlves, & Reavley, 2019; Linde et al., 2017; Wagner et al., 2021), and school staff (Andriessen, Krysinska, Hill, et al., 2019) were involved.

Quality Assessment

The overall methodological quality of the reviews was rated as low to moderate (see Table E4 in ESM 1 ^{(278.1KB, pdf)} ). Four reviews were rated as low quality, and one was rated as critically low. The remaining five reviews were rated moderate quality. None were judged to be high quality. The quality aspects most frequently rated as inadequate were the comprehensiveness of the literature search strategy, independent data extraction, provision of a list of excluded studies, and identifying sources of funding.

Effective Components

For this metareview, components perceived to be effective were first identified and then summarized thematically. This resulted in a total of three main categories of components: (1) structure and content of the intervention, (2) facilitator, and (3) modality (peer, group, community, online).

It was not possible to report the age range of participants, the range of number of sessions, the length of the intervention, and the time since loss as the information was not consistently reported in the reviews or the original studies.

The components are presented and discussed below. All results can be seen in Table A1 in the Appendix. Two reviews (Journot-Reverbel et al., 2017; Wagner et al., 2021) did not report on any components perceived to be effective and are therefore not included in Table A1.

Structure and Content of Interventions

Psychoeducation in terms of information on grief and suicide bereavement was perceived as an effective component in three reviews independent of the delivery format (Andriessen, Krysinska, Hill, et al., 2019; Andriessen, Krysinska, Kõlves, & Reavley, 2019; Szumilas & Kutcher, 2011). Psychoeducation was seen to enable the bereaved to better assess and understand their grief, thereby helping process the loss (Andriessen, Krysinska, Hill, et al., 2019). Two reviews mentioned the consistency of interventions as an important component (Abbate et al., 2022; Adshead et al., 2023). Participants therefore felt that regular support is essential and necessary. Regularly timed support programs were seen to provide routine and consistency, which the bereaved experienced as helpful (Abbate et al., 2022). Two reviews also mentioned a fixed structure and predetermined topics as particularly helpful as these allowed the bereaved to prepare for the sessions (Abbate et al., 2022; Andriessen, Krysinska, Hill, et al., 2019). From the perspective of the bereaved, structured sessions could provide a certain amount of stability in the grieving process. The value of manuals and guidelines for conducting an intervention was also highlighted in this context. These support the implementation of the intervention for the facilitators, and participants seemed to benefit from the predefined and standardized structure of the intervention (Andriessen, Krysinska, Hill, et al., 2019).

Closed and homogenous groups appeared to be an important feature of interventions (Abbate et al., 2022; Adshead et al., 2023), with an optimal group size of 5–8 participants suggested (Adshead et al., 2023). Closed groups were seen to provide a familiar atmosphere, building trust among participants (Adshead et al., 2023). Three reviews reported that participants found it helpful when an intervention was adapted to the participants’ grief level and culture-specific grief reactions and involved a degree of flexibility regarding the content of the sessions within a fixed structure (Adshead et al., 2023; Andriessen, Krysinska, Kõlves, & Reavley, 2019; McDaid et al., 2008).

Facilitators of Interventions

Included studies described interventions delivered by a variety of facilitators, identifying beneficial features of facilitators regardless of their profession. Six reviews mentioned the importance of being well-trained as an important characteristic (Abbate et al., 2022; Adshead et al., 2023; Andriessen, Krysinska, Hill, et al., 2019; Andriessen, Krysinska, Kõlves, & Reavley, 2019; McDaid et al., 2008; Szumilas & Kutcher, 2011). Bereaved individuals could benefit from their expertise and are encouraged to address their grief during the interventions (Adshead et al, 2023).

One review reported that the interventions were perceived to be helpful where the facilitator had appropriate training in leading the group, acted professionally, and appeared competent (Adshead et al., 2023). Two reviews reported the combination of professional and peer facilitators as beneficial (Andriessen, Krysinska, Kõlves, & Reavley, 2019; McDaid et al., 2008). One review highlighted facilitator empathy as a key factor (Adshead et al., 2023) and the value of group leaders modeling how they had dealt with suicide loss (Andriessen, Krysinska, Kõlves, & Reavley, 2019).

Modality of Interventions

Peer Support

Two reviews identified a feeling of belonging as a key benefit of peer support (in group or individual settings; Abbate et al., 2022; Inostroza et al., 2023). Acceptance from peers in a safe space was seen to help address feelings of stigmatization and provide social support in the grieving process (Inostroza et al., 2023). The feeling of sharing experiences (Adshead et al., 2023), having experienced a similar type of bereavement (Abbate et al., 2022), and being able to express feelings and thoughts without judgment (Inostroza et al., 2023) were reported as particularly helpful by the participants, as well as contact with peers engendering a sense of normalcy (Adshead et al., 2023; Inostroza et al., 2023). Bereaved individuals reported feeling less alone with what they had experienced (Inostroza et al., 2023). One review also mentioned the value of peer support providing opportunities to learn strategies for dealing with grief (Inostroza et al., 2023).

Group Support

Three reviews reported specific components of group interventions for suicide-bereaved individuals (Abbate et al., 2022; Adshead et al., 2023; Linde et al., 2017). Sharing one's own story within a group was seen to lead to a greater understanding of one’s own experience and the construction of a narrative (Abbate et al., 2022), putting one's loss into perspective and gaining sense-making (Abbate et al., 2022; Adshead et al., 2023). The group itself was often seen as a protected space by the bereaved individuals in which suicide-bereaved people were able to express their feelings without feeling stigmatized (Abbate et al., 2022). By sharing and talking about their own experience, group members felt they could enhance their coping strategies and insights, such as acceptance of the view that the suicide could not have been prevented (Abbate et al., 2022; Adshead et al., 2023). Group settings also provided suicide-bereaved individuals with an opportunity to talk about the deceased and to remember them through their stories (Abbate et al., 2022). One review identified cognitive restructuring and the learning of solution strategies as particularly helpful components (Linde et al., (2017). All three reviews identified the perceived helpfulness of communication with others and the associated sense of belonging.

Community Support

Three reviews reported components of community interventions (Abbate et al., 2022; Andriessen, Krysinska, Hill, et al., 2019; Andriessen, Krysinska, Kõlves, & Reavley, 2019). Community interventions refer to various organized efforts and support services provided within a wider community. Suicide-bereaved individuals found it particularly helpful to spread awareness of suicide and suicide bereavement in the wider community to galvanize suicide prevention and postvention activity (Abbate et al., 2022; Andriessen, Krysinska, Hill, et al., 2019). By engaging with a larger community, suicide-bereaved individuals felt that they had the opportunity to share their experiences, gain acknowledgment of their grief, and offer support to others (Andriessen, Krysinska, Kõlves, & Reavley, 2019). This created opportunities for dialogue and stimulated the meaning-making process (Abbate et al., 2022). One review highlighted the opportunities to reach other people through community interventions and to connect with support services that would otherwise not be achieved (Abbate et al., 2022).

Online Support

One review focused exclusively on online interventions (Lestienne et al., 2021), while another review included one study of online-based support alongside in-person interventions (Abbate et al., 2022). Online support could include forums, memorials, chats, or Facebook groups. Importantly, the internet provided quickly accessible information for suicide-bereaved individuals (Abbate et al., 2022; Lestienne et al., 2021). The fact that support could be sought anonymously was seen as particularly valuable (Lestienne et al., 2021), making it easier for the bereaved to talk and write openly about the bereavement with less fear of stigmatization. Participants also stated that they mainly use the internet to search for information but also to get support or to give support to others (Lestienne et al., 2021). It was also perceived by many as a safe space to express uncomfortable feelings, such as shame, guilt, or anger (Lestienne et al., 2021). Online memorials provided an opportunity to remember the deceased person, which facilitated the continuing bond (Lestienne et al., 2021). In addition, the 24-h availability of online resources (e.g., forums, memorials) and their easy access were highly valued.

Discussion

This was the first metareview aimed at identifying the components of suicide bereavement support interventions perceived to be effective in addressing grief and mental health. The interventions evaluated varied widely in terms of target group, intervention type, facilitator, and outcomes described.

One consistent finding was the importance placed on aspects of the structure and content of interventions. A fixed structure and manualized interventions seem to be perceived as particularly effective by suicide-bereaved individuals while providing support to facilitators guiding the intervention. This finding resonates with those in a review of bereavement interventions more broadly (Kent et al., 2020), which emphasized the importance of a structured approach in facilitating the grieving process from the perspective of bereaved individuals and preventing adverse outcomes. Future studies can focus on the development of practice guidelines and recommendations to improve support services and enhance outcomes (Kent et al., 2020; Ross et al., 2021). As highlighted in a systematic review of studies describing clinicians’ views on manualized psychotherapy interventions (Forbat et al., 2015), manuals facilitate a systematic approach and the replicability of interventions. As manuals can be seen as inflexible and negative by some facilitators, some flexibility in the implementation of interventions is necessary, tailored to the individual nature of grief (Forbat et al., 2015). Such modularized interventions have been suggested as particularly suited to people bereaved by violent causes (Rheingold & Williams, 2018), offering a compromise between manual-based yet flexible support, and are acceptable both to participants and to facilitators (Williams et al., 2018).

The finding from our review that trained facilitators represent a valued component of suicide bereavement support complements the finding from a scoping review of grief support training that appropriate training provides facilitators with confidence, self-efficacy, and additional knowledge, which was seen to lead to better support (Sikstrom et al., 2019).

Our finding regarding the value placed on support from others, whether peers, group members, or the community, is corroborated by the broader literature on social support (particularly peer support, often that most readily available) in grief interventions (Dyregrov, 2004; Griffin et al., 2022; McMenamy et al., 2008). However, peer groups are often not evaluated for their effectiveness, which indicates the need for evaluation studies and more rigorous designs to counteract poor mental health outcomes. Although peer support can provide a safe space and a sense of belonging and hope for many (Griffin et al., 2022; Hybholt et al., 2022), group support can also be re-traumatizing and distressing for others through hearing details about the bereavement (Higgins et al., 2022), reinforcing the need to identify the perceived effective components.

Online bereavement support has increased significantly in recent years, gaining popularity due to its low-threshold accessibility, anonymity, and flexibility (Beaunoyer et al., 2020; Robinson & Pond, 2019; Wagner et al., 2020). It is therefore not surprising that these features of online-based support were identified as particularly important in our review. Online grief interventions have been shown to be effective and can significantly reduce grief and PTSD symptoms (Wagner et al., 2020), while online support can counteract fear of stigmatization, difficulties in finding support locally, and facilitate connecting with others (Azorina et al., 2019; V. Ross et al., 2019). Online support can also help to reach individuals bereaved by suicide. A study by Pitman et al. (2017) showed that only one in four suicide-bereaved individuals sought help due to a lack of support services or fear of stigmatization. Despite the many advantages and the increasing acceptance of web-based support, there is a clear need for improvement (Leaune et al., 2022). While most participants used the internet as part of their grieving process (Leaune et al., 2022), they rated these resources as insufficient, and many suggested the development of a specific platform where suicide bereavement information and resources are easily accessible, including the opportunity to create online memorials (Krysinska & Andriessen, 2015). Memorials can help people process their grief and facilitate a continuing bond by posting photos or writing and sharing about the deceased person.

Strengths and Limitations

Our preregistered, systematic approach was a strength. However, the 11 included systematic reviews were all assessed to be of weak to moderate methodological quality, highlighting the need for high-quality reviews (and individual studies). It was not possible to report specific population or intervention characteristics (e.g., the number of sessions; time from loss to receiving the interventions) due to missing information in either the reviews or the original studies. Some reviews included the same evaluations, which could lead to bias in the reporting of the results, but we took them into account in our synthesis. Furthermore, meta-analysis was impossible as study outcomes were heterogeneous. None of the reviews or interventions targeted older suicide-bereaved people (aged 70+), a population that is generally underrepresented in suicide bereavement research (Hybholt et al., 2020) despite their need for adequate support (Hafford-Letchfield et al., 2022). Almost all studies were conducted in high-income countries, limiting generalizability of findings to low- and middle-income settings. It is also important to note that the reviews included and the interventions they contain all originate from Western countries and no particular focus was placed on culture or religion. When developing support for people bereaved by suicide, the cultural aspects of grief management and how suicide is dealt with in these cultures should be considered. It was also not possible to examine gender differences in terms of perceived effectiveness, as the gender distribution in the individual studies was not always reported. Suicide bereavement interventions may be less helpful for men due to gender differences in emotional expression and coping mechanisms, which often do not align with traditional therapeutic approaches focused on verbalization and emotional sharing. Additionally, men are underrepresented in (suicide) grief research, leading to a lack of tailored support (Logan et al., 2024). This gap in research and intervention strategies underscores the necessity for more inclusive and diverse studies to better support all individuals affected by suicide loss. In addition, the included reviews do not report on the recruitment process, rendering it impossible to determine whether the results are representative. As this review does not focus on the social support of bereaved people, further studies should continue to consider this aspect of support. The distinctions between modalities are not always clearly defined. Specifically, in group formats and peer support settings, the included reviews do not consistently clarify whether the perceived benefits were attributed to peer support or the group format itself.

Conclusions

This metareview identified components of suicide bereavement support that are perceived to be helpful to the bereaved, highlighting the need for intervention design to be led by these findings, better meeting the needs of people bereaved by suicide. Such new iterations of suicide bereavement support should be evaluated using methodologically high-quality trial designs, incorporating both qualitative and mechanistic designs. It is hoped that such work will improve adverse health and well-being outcomes among the suicide bereaved as well as enhance insights into the mechanisms of effective interventions.

Electronic Supplementary Material

The electronic supplementary material is available with the online version of the article at https://doi.org/10.1027/0227-5910/a000978

• ESM 1. The ESM contains the list of excluded studies after full text screening, the characteristics of the included systematic reviews and the primary study overlap. ^{(278.1KB, pdf)}

Biographies

Author Biographies

Laura Hofmann, PhD, is a clinical psychologist and a licensed psychotherapist (CBT). She works as a postdoctoral researcher at the Medical School Berlin, Germany. Her research focuses on suicide bereavement, grief, suicide prevention and voluntary assisted dying.

Adelia Khrisna Putri, MSc Clinical Mental Health, is a PhD candidate at the Centre for Mental Health and Community Wellbeing, University of Melbourne, and an assistant professor at the Faculty of Psychology, Universitas Gadjah Mada. Her research focuses on suicide bereavement and postvention.

Alexandra Pitman, PhD, is a professor of psychiatry in the UCL Division of Psychiatry (University College London) and an honorary consultant psychiatrist in the veterans’ mental health team at North London NHS Foundation Trust. Her clinical and research interests relate to the care of people who feel suicidal.

Jason Bantjes, PhD, is a registered psychologist and Chief Specialist Scientist at the South African Medical Research Council. He holds an honorary appointment as a professor in the Department of Psychiatry and Mental Health at the University of Cape Town, South Africa.

Dolores Angela Castelli Dransart, PhD, is full professor at the HES-SO University of Applied Sciences and Arts Western Switzerland, School of Social Work Fribourg. Her interests focus on the impact of suicide on relatives and care providers, and on ethical and professional issues related to assisted suicide and EOL decisions.

Hilary Causer, PhD, is a research fellow at the School of Health Sciences, University of Surrey, UK. Her research interests include workplace suicide, postvention and postvention guidance, and the cultural, social and political contexts within which suicide occurs. Hilary has previously worked in child protection and mental health settings in the third and public sectors.

Julie Cerel, PhD, is a licensed clinical psychologist and professor in the College of Social Work at the University of Kentucky, USA. She is the director of the Suicide Prevention & Exposure Lab at the University of Kentucky and the Wilson Profession of Mental Health. Her research has focused on suicide exposure and bereavement, suicide attempt survivors and suicide prevention.

Amy Chow, PhD, RSW, is an endowed professor in health and social work at the University of Hong Kong, SAR China. Her research interests include bereavement, end-of-life care and suicide prevention.

Diego De Leo, DSc, MD, is an emeritus professor of psychiatry and former president of both the International Association for Suicide Prevention and the International Academy for Suicide Research. Current president of the Italian psychogeriatric Association and director of the Slovene Centre for Suicide Research.

William Feigelman, PhD, is emeritus professor in sociology at Nassau Community College, Garden City, NY, USA. He is author or coauthor of seven books and 100 journal articles on a wide variety of social science subjects. Most recently, his work has focused on youth suicide and suicide bereavement.

Christine Genest, RN, PhD, is an associate professor in nursing at the Université de Montréal, Canada. She is a regular researcher at the Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices (CRISE). Her research is on public safety personnel suicide but also postvention as a form of suicide prevention.

Eve Griffin (PhD) is the Chief Executive Officer at the National Suicide Research Foundation, Cork, Ireland. Eve’s research interests include the epidemiology of self-harm, program evaluation, and suicide bereavement. She collaborates regularly with those working in policy and clinical practice.

Lisbeth Hybholt, PhD, MScN, RN, is a senior researcher at the Research Unit, Mental Health Services East, Psychiatry Region Zealand, Denmark, and the Psychiatric Research Unit, Psychiatry Region Zealand, Denmark. She is also an assistant professor at the Department of Regional Health Research, University of Southern Denmark. Her research focuses on psychosocial rehabilitation within mental health.

Daisuke Kawashima, PhD, is a professor at the School of Psychology, Chukyo University, Japan. His research focuses on suicide prevention, grief after bereavement, and end-of-life care.

Kairi Kõlves, PhD, GCert Epi, MA, BA, is a professor at the Australian Institute for Suicide Research and Prevention, School of Applied Psychology and Director of the World Health Organization Collaborating Centre for Research and Training in Suicide Prevention at Griffith University, Australia. She has expertise in suicide research and prevention.

Karolina Krysinska, PhD, MA Psychology, is a senior research fellow at the Centre for Mental Health and Community Wellbeing, Melbourne School of Population and Global Health, The University of Melbourne, Australia. She is an experienced suicidologist with over 25 years of experience in the field, and has published and presented extensively on suicide, suicide prevention, lived experience, and postvention.

Edouard Leaune, MD, PhD, is an associate professor at the University Claude Bernard Lyon 1, the Hospices Civils de Lyon, and the Centre Hospitalier le Vinatier. He also is an affiliate academic in the Division of Psychiatry at the University College London, UK. He has a broad interest in suicide research with a major focus on suicide bereavement and postvention.

Antoon A. Leenaars, PhD, CPsych, is a clinical and forensic researcher/clinician with associations and affiliations with individuals/institutions/universities around the world. He was the founding/first editor-in-chief of the journal Archives of Suicide Research. He has a broad interest in suicide research with a major focus on the psychological autopsy. He is a recipient of IASP’s Stengel Award.

Yossi Levi-Belz, PhD, is a professor, clinical psychologist, and the Chair of the Lior Tsfaty Center for Suicide and Mental Pain Studies at Ruppin Academic Center in Israel. His research interests include the psychological mechanisms of suicidal behavior as well as trauma, moral injury, and posttraumatic growth.

Sandra McNally, MA, LISAC, is the Prevention Manager for EMPACT-Suicide Prevention Center in Arizona. She is a member of the Arizona Suicide Prevention Coalition and the Special Interest Group for Suicide Bereavement/Postvention for the International Association for Suicide Prevention. She is an adjunct professor at Grand Canyon and Ottawa Universities.

Pernilla Omerov, PhD, RN, MSN, is an associate professor of caring science specializing in psychiatric care at Marie Cederschiöld University, Sweden. She also works with suicide prevention and postvention at the Family Care Competence Centre (Nka) and at the Centre for Psychiatry Research (CPF), Karolinska Institute and Stockholm Health Care Services, all located in Sweden.

Silvia Pelaez, MD, psychiatrist, is Director of Ultimo Recurso, the first suicidology institution in Uruguay, coauthor of Law 18097 in Suicide Prevention, and former Co-Chair of IASP. She is author of the only suicide prevention plans of Uruguay and Director of permanent training courses in Uruguay and other countries in Latin America.

Jennifer Peprah, PhD, MPhil Clinical Psychology, Bsc, is a casual academic at the School of Psychological Sciences, University of Newcastle, and a family practitioner at Ozchild. Her research focuses on suicide bereavement and postvention as well as adolescent sexual health.

Vita Poštuvan, PhD, is a professor of psychology at the University of Primorska, Slovenia. She works as a deputy head at the Slovene Center for Suicide Research and leads clinical research in suicidology, bereavement, crisis intervention, ethics in psychology, and mindfulness-based approaches. She also works as a counseling and crisis psychologist.

Inês Rothes, PhD, is clinical psychologist, assistant professor at Faculty of Psychology and Education Sciences, and researcher at CPUP – Center for Psychology at University of Porto, Portugal. Her research activities have been focused on suicidology and public mental health. She is the current president of the Portuguese Society of Suicidology.

Karen Scavacini, Psychologist, PhD in psychology, MA in public health, is the founder of the Vita Alere Institute in Brazil and Director of the Center for Research and Innovation in Mental Health, Technology and Suicidology. Her major focus of study is suicide prevention and postvention. She is the national representative of Brazil for IASP for the second time.

Paolo Scocco is a psychiatrist, psychotherapist, and Mindful SelfCompassion Teacher. He is the current president of SOPROXI Onlus.

Regina Seibl, PhD, is a mental health professional working for a mental health care provider in Innsbruck, Austria. She is a member of SUPRA (SUicide PRevention Austria, the national suicide prevention program), head of SUPRA’s working group on postvention, and also trainer for suicide prevention and postvention (for clinician survivors and family loss survivors).

Anneli Silvén Hagström, PhD, is an associate professor and senior lecturer in the Department of Social Work, Stockholm University, Sweden. Her research primarily focuses on children and young people affected by parental suicide, with a particular emphasis on targeted postvention measures.

Paulius Skruibis, PhD, is Head of the Suicide Research Centre at Vilnius University, Lithuania. He also works as a psychotherapist and provides support for people bereaved by suicide.

Prakarn Thomyangkoon, psychiatrist, assistant professor, is an executive committee member of the Psychiatric Association of Thailand. He is the founder and innovator of the PRAKARN Model Group Psychotherapy for Survivors of Suicide Loss, and serves as the national representative of Thailand for IASP.

Jemaima Tiatia-Siau is a professor of Pacific Studies, School of Māori Studies and Pacific Studies, and Pro-Vice Chancellor Pacific at the University of Auckland, New Zealand. She is of Samoan descent specializing in suicide prevention and postvention, mental health and well-being, Pacific Studies, health inequities and climate change, and mental well-being.

Ruth Van der Hallen, PhD, psychodynamic psychologist, is an associate professor in clinical psychology at Erasmus University Rotterdam, The Netherlands. Her research focuses on understanding individual differences in trauma and suicide prevention, with a commitment to developing innovative interventions to enhance well-being and address mental health challenges.

Birgit Wagner, PhD, is professor of clinical psychology and behavioral therapy at the Medical School Berlin, Germany. She is a clinical psychologist with extensive expertise in the implementation of new technologies in the field of traumatic stress disorder and prolonged grief disorder, including suicide prevention.

Karl Andriessen, PhD, is a senior research fellow at the Centre for Mental Health and Community Wellbeing, Melbourne School of Population and Global Health, The University of Melbourne, Australia. He has a broad interest in suicide research with a major focus on postvention. He is Co-Chair of the IASP SIG on Suicide Bereavement and Postvention.

Appendix

Table A1. Perceived effective components of interventions.

Author (year)	Main components
	Structure and content of intervention	Facilitator	Peer support	Group support	Community	Online support
Abbate et al. (2022)	- Consistency of intervention - Fixed structure and fixed topics - Sense of routine - Closed groups	- Expertise from facilitators - External supervision for facilitators - Sharing with facilitators	- Similar loss encourages belongingness - Sensemaking through meeting likeminded people	- Sharing and hearing other's stories - Putting experience into perspective - Finding resolution - Meaning making - Remembering the deceased - Constructing a narrative - Safe space - Sense of community - Enabling active coping	- Opportunities for dialogue - Raising public awareness - Engaging with public - Connecting with therapy, grief support services and other survivors - Safe and supportive environment - Social sharing of meaning making	- Information on bereavement and practical matters relating to the death
Adshead et al. (2023)	- Homogeneity of groups - Closed groups - Consistency of intervention - Group size (5–8 participants) - Adjusting the intervention to different grief levels of participants	- Competency and empathy - Training of facilitators	- Shared experiences - Sense of normalcy - Similarity in age, kinship, time since loss	- Sense of permission from the group to feel and express emotions - Seeking and attributing meaning, causation and sense-making - Open discussion without being stigmatized - Safe and accepting space - Reconstructing the story of the suicide	n/a	n/a
Andriessen, Krysinska, Hill, et al. (2019)	- Manuals and guidelines - Psychoeducational aspects - Interventions need sufficient number of sessions over a sufficient length in time	- Trained facilitators	n/a	n/a	- Involving the wider community	n/a
Andriessen, Krysinska, Kõlves, and Reavley (2019)	- Adjusting the level of intervention to the level of grief - Intervention specifically focused on suicide grief - Psychoeducation	- Trained facilitators - Facilitators as role models - Combination of professional and trained peer supporter	n/a	n/a	- Finding recognition in one’s grief - Sharing experiences - Providing support to others - Involvement of wider community	n/a
Inostroza et al. (2023)	n/a	n/a	- Social support - Not being judged - Acceptance - Developing a collective identity as “survivors” - Developing a sense of belonging - Feelings of hope and normalcy - Learning strategies from others - Validation by peers - Allowing oneself to express emotions, talk about loss, reveal fears and guilt	n/a	n/a	n/a
Lestienne et al. (2021)	n/a	n/a	n/a	n/a	n/a	- Offering help and support - Discussing taboo and stigmatized topics - Easy accessible information - Deceased can be memorialized - Meaning making through discussions - Expression of feelings like guilt, shame & anger - Easy access - Available 24/7 - Anonymity
Linde et al. (2017)	n/a	n/a	n/a	- Cognitive restructuring - Consolidation of support - Communication with others - Learning problem solving	n/a	n/a
McDaid et al. (2008)	- Adapting the intervention to culture-specific grief reactions	- Professional facilitators - Facilitators are a combination of professional and trained suicide loss survivor	n/a	n/a	n/a	n/a
Szumilas and Kutcher (2011)	- Psychoeducation	- Trained facilitators	- Reaching other people with similar loss	n/a	n/a	n/a

Conflict of Interest: The authors have no competing interests to declare.

Authorship: KA conceptualized and led the study. KA and LH wrote and registered the protocol. LH searched the literature and assessed titles and abstracts. KA and LH screened the full texts. AKP and LH extracted the data. AKP, KA, and LH conducted the quality assessment. KA and LH drafted the manuscript. All coauthors were involved in the process and their feedback was incorporated into the manuscript and tables. All authors contributed to the manuscript and approved its final version.

Open Data: The metareview was conducted following the PRISMA guidelines (Page et al., 2021), using a preregistered protocol (PROSPERO CRD42023458300).

Funding Statement

Funding: Open access publication enabled by MSB Medical School Berlin, Germany.