Brief Report
The Broken Heart: Suicidal Ideation in Bereavement
Margaret Stroebe, Ph.D.
Wolfgang Stroebe, Ph.D.
Georgios Abakoumkin, Ph.D.
Objective: This report examined suicidal behavior during be-
reavement.
Method: Suicidal ideation was examined in a group of 60 re-
cently bereaved widows and widowers compared to 60 individ-
ually matched married comparison subjects.
S uicide rates in many Western countries have increased
considerably in recent decades, causing much concern.
Bereavement places people at a high risk of psychological
and mental debilities, including mortality (1). Suicide rates
are higher among bereaved people (particularly early in
bereavement) than for nonbereaved persons, and suicide
is one of the most excessive causes of death among the be-
reaved (2–4). Thus, it is important to identify the mediators
and moderators of suicidal behavior in bereavement. The
suicidal ideation domain provides potentially useful infor-
mation for understanding why bereaved persons attempt
or actually commit suicide. Although few of those with sui-
cidal ideation will act on their thoughts, ideation would
seem a precursor to suicidal acts. Furthermore, suicidal
ideation reflects thoughts of desperation in grieving that
need to be comprehended. However, investigations of sui-
cidal ideation in bereavement are rare.
Prigerson and colleagues examined relationships among
“complicated grief,” depression, and suicidal ideation in
bereaved persons, including young adults (5) and elderly
persons (6). Complicated grief emerged as an independent
predictor of suicidal ideation. Rosengard and Folkman (7)
investigated suicidal ideation among partners of men with
AIDS. Over 50% experienced suicidal ideation; the rates
were even higher in bereaved than in nonbereaved men.
These studies suggest high suicidal ideation among the be-
reaved and associated complications in grieving. However,
information is limited. The studies by Prigerson et al. (5)
and Szanto et al. (6) did not focus on comparing suicidal
ideation between bereaved and nonbereaved persons. Al-
though the study by Rosengard and Folkman (7) did so,
many nonbereaved partners may have already been antic-
ipating bereavement and even their own mortality. Overall,
information is still lacking. Are the rates for ideation, as for
suicide, really higher among the bereaved? Are there gen-
der differences? Does social support reduce suicidal ide-
ation, as Durkheim (2) suggested?
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Results: Suicidal ideation was higher among widowed people
than married people and was most excessive for widows. The
effect disappeared when there was control for emotional lone-
liness. Social support did not buffer bereaved individuals
against suicidal ideation but reduced suicidal ideation among
the married and bereaved alike.
Conclusions: Bereaved persons are at excess risk of suicidal
ideation compared to nonbereaved people. Heightened sui-
cidal ideation in bereavement is associated with extreme emo-
tional loneliness and severe depressive symptoms.
(Am J Psychiatry 2005; 162:2178–2180)
Studies of social support in bereavement have not con-
firmed the stress-theory assumption that social support
buffers persons against the deleterious effects of bereave-
ment (8). This finding is consistent with the attachment-
theory assumption that loss of an attachment figure re-
sults in emotional loneliness (a sense of utter aloneness,
whether or not the companionship of others is accessible),
which cannot be reduced by the social support of family or
friends (9). We used data from an earlier study of ours (8)
to assess the impact of marital bereavement and social
support on suicidal ideation and the mediating role of
emotional loneliness.
Method
The participants were 30 widows and 30 widowers (mean age=
53.05 years, SD=6.81) and 60 individually matched (by age, gen-
der, socioeconomic status, and number of children), married in-
dividuals (mean age=53.75, SD=6.83) who were under retirement
age. The prospective participants were sent a letter asking for
their participation. Those who did not decline by mail or tele-
phone were contacted a few days later to ask for an interview. To
achieve a study group of 60 widowed individuals, 217 persons
were approached. This rather low acceptance rate is typical for
bereavement research.
The data for the present analysis, collected 4–7 months post-
bereavement, were obtained from questionnaires given person-
ally to participants and returned by mail. We did not consider it
ethically appropriate to ask recently bereaved spouses a battery
of questions about suicidal ideation. Rosengard and Folkman (7)
asked a single question on a 3-point scale. We followed a similar
procedure, deriving our measure from the Beck Depression In-
ventory (10). Four statements (e.g., “I don’t have any thoughts of
killing myself,” “I would like to kill myself”) were presented in an
alternative-choice format.
Perceived social support was assessed with the Perceived Social
Support Inventory, a 20-item questionnaire (8) measuring four typ-
ical functions of social support (e.g., instrumental: “If I couldn’t go
shopping, I’d have somebody to shop for me”; appraisal: “If I need
advice on financial matters, I’d have someone to rely on”; emo-
tional: “I have nobody to talk to about my feelings and problems”;
contact: “I have hardly any friends who share my interests”). It has
high internal consistency (alpha=0.90). Emotional loneliness was
Am J Psychiatry 162:11, November 2005

assessed by using two items: “I feel lonely even when I am with
other people,” and “I often feel lonely” (alpha=0.78).
Results
Figure 1 presents mean suicidal ideation scores of mar-
ried and widowed individuals who rated above and below
the median scores on the Perceived Social Support Inven-
tory. A two-by-two-by-two (marital status-by-social sup-
port-by-gender) analysis of variance on suicidal ideation
yielded a marginally significant main effect of marital sta-
tus (F=3.16, df=1, 111, p<0.10), a main effect of social sup-
port (F=12.71, df=1, 111, p<0.01), a main effect of gender
(F=11.58, df=1, 111, p<0.01), and an interaction of gender
and social support (F=4.12, df=1, 111, p<0.05). The be-
reaved had higher levels of suicidal ideation than the mar-
ried people; women had higher scores than men. High lev-
els of social support were associated with lower levels of
suicidal ideation. This effect was stronger for women than
for men. The introduction of emotional loneliness as a co-
variate into this analysis eliminated the effect of bereave-
ment on suicidal ideation (F=0.10, df=1, 107, n.s.), leaving
all the other effects practically unchanged.
To examine the relationship of suicidal ideation to crite-
ria for potential psychiatric diagnosis, suicidal ideation
scores (for widows only) were analyzed by using the cutoff
point on the Beck Depression Inventory for severe depres-
sion (score of ≥19). The mean suicidal ideation value with
a severe depression score (mean=1.13, SD=0.99) was sig-
nificantly higher than for those with a low depression
score (mean=0.14, SD=0.35) (t=–5.46, df=57, p<0.001).
Correlations between suicidal ideation and scores on the
Beck Depression Inventory were much lower for those
with a Beck Depression Inventory score <19 (Pearson cor-
relation: r=0.28, p=0.05) than for those with a Beck Depres-
sion Inventory score ≥19 (Pearson correlation: r=0.92,
p<0.01). Thus, suicidal ideation seems closely related to
severe depressive symptoms among the bereaved.
Discussion
Loss of a partner, perception of low levels of social sup-
port, and being a woman were associated with increased
suicidal ideation. Women are frequently found to have
higher suicidal ideation and rates of suicide attempts than
men, but our results indicated more excessive risk of sui-
cidal ideation among widows than either widowers or
nonbereaved women/men. This suggests that bereave-
ment puts women at a worrisome high risk of suicidal ide-
ation (particularly given the results showing a close rela-
tionship with severe depressive symptoms), although we
must remember that—paradoxically—the prevalence of
completed suicides is typically higher in (bereaved) men
than in (bereaved) women (11). Although lack of social
support appears to have a more deleterious effect (its as-
sociation with higher suicidal ideation for women than for
men), again, there is no evidence of a buffering effect. So-
Am J Psychiatry 162:11, November 2005
BRIEF REPORTS
FIGURE 1. Suicidal Ideation in 60 Recently Bereaved Sub-
jects Versus 60 Matched, Married Comparison Subjects by
Bereavement, Gender, and Social Support
0.8
Low social support
Based on Beck Depression Inventory
0.7
High social support
0.6
Suicidal Ideation Score,
0.5
0.4
0.3
0.2
0.1
0.0
Widowed Married Widowed Married
Women Men
cial support reduces suicidal ideation equally for both
marital status categories.
The reason for the failure of social support to buffer the
bereaved against the deleterious impact of loss of a part-
ner became apparent from our analysis of covariance.
Statistical control for differences in emotional loneliness
eliminated the association between suicidal ideation and
marital status, although it did not affect either the effects
of social support or gender. This pattern is consistent
with the attachment-theory assumption that the effects
of loss of a partner and lack of social support are medi-
ated by different mechanisms. Thus, uniquely, the im-
pact of bereavement on suicidal ideation seems to be due
to intense emotional loneliness, fitting the notion of “the
broken heart.”
Received Oct. 4, 2004; revision received Dec. 17, 2004; accepted
Jan. 10, 2005. From the Department of Clinical Psychology and the
Department of Social and Organizational Psychology, Utrecht Univer-
sity; and the Department of Preschool Education, University of Thes-
saly, Volos, Greece. Address correspondence and reprint requests to
Dr. Margaret Stroebe, Department of Social and Organizational Psy-
chology, Utrecht University, Heidelberglaan 8, 3584CS Utrecht, the
Netherlands; m.s.stroebe-harrold@fss.uu.nl (e-mail).
References
1. Stroebe W, Stroebe M: Bereavement and Health. New York,
Cambridge University Press, 1987
2. Durkheim E: Suicide: A Study in Sociology (1897). Glencoe, Ill,
Free Press, 1951
3. Luoma J, Pearson J: Suicide and marital status in the United
States 1991–1996: is widowhood a risk factor? Am J Public
Health 2002; 92:1518–1522
4. Li J, Precht D, Mortensen P, Olsen J: Mortality of parents after
death of a child in Denmark: a nationwide follow-up study.
Lancet 2003; 361:363–367
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BRIEF REPORTS
5. Prigerson HG, Bridge J, Maciejewski PK, Beery LC, Rosenheck
RA, Jacobs SC, Bierhals AJ, Kupfer DJ, Brent DA: Influence of
traumatic grief on suicidal ideation among young adults. Am J
Psychiatry 1999; 156:1994–1995
6. Szanto K, Prigerson H, Houck P, Ehrenpreis L, Reynolds CF III:
Suicidal ideation in elderly bereaved: the role of complicated
grief. Suicide Life Threat Behav 1997; 27:194–207
7. Rosengard C, Folkman S: Suicidal ideation, bereavement, HIV
serostatus and psychosocial variables in partners of men with
AIDS. AIDS Care 1997; 9:373–384
Brief Report
Suicide Attempters’ Reaction to Survival
as a Risk Factor for Eventual Suicide
Gregg Henriques, Ph.D.
Amy Wenzel, Ph.D.
Gregory K. Brown, Ph.D.
Aaron T. Beck, M.D.
Objective: The authors’ goal was to evaluate whether suicide
attempters’ reaction to surviving their attempt predicted even-
tual suicide.
Method: Three hundred ninety-three suicide attempters were
categorized on the basis of their reaction to having survived
T he identification of patients who are most likely to kill
themselves following a suicide attempt presents a serious
challenge to clinicians (1). To examine risk factors for
eventual suicide, a prospective study that involved 499
suicide attempters who were recruited from a large public
hospital was conducted between 1970 and 1975 (2). Beck
and Steer (3) examined 413 of these attempters, 20 (4.8%)
of whom committed suicide during the follow-up period.
Of several clinical and demographic variables considered
(i.e., age, gender, race, marital status, employment status,
presence of a depressive diagnosis, presence of a schizo-
phrenia diagnosis, history of drug abuse, presence of an
alcoholism diagnosis, previous suicide attempt, Beck De-
pression Inventory [4] score, Beck Hopelessness Scale [5]
score, and Suicide Intent Scale [6] score), only a diagnosis
of alcoholism, unemployment, and score on the precau-
tions subscale of the Suicide Intent Scale accounted for
significant variance in predicting eventual suicide.
It was surprising that hopelessness did not predict even-
tual suicide because Beck et al. (7) found that hopeless-
2180 http://ajp.psychiatryonline.org
8. Stroebe W, Stroebe M, Abakoumkin G, Schut H: The role of
loneliness and social support in adjustment to loss: a test of at-
tachment versus stress theory. J Pers Soc Psychol 1996; 70:
1241–1249
9. Weiss R: Loneliness: The Experience of Emotional and Social
Isolation. Cambridge, Mass, MIT Press, 1975
10. Beck T, Rush A, Shaw B, Emery G: Cognitive Therapy of Depres-
sion. Chichester, UK, John Wiley & Sons, 1979
11. Velting D: Suicidal ideation and the five-factor model of per-
sonality. Pers Individ Dif 1999; 27:943–952
their attempt (i.e., glad to be alive, ambivalent, wished they
were dead) and were followed for 5 to 10 years to determine
whether they completed suicide.
Results: A survival analysis found that subjects who said that
they wished they had died after a suicide attempt were 2.5 times
more likely to commit suicide eventually than those who were
glad they survived and those who were ambivalent about the
attempt.
Conclusions: Suicide attempters’ reaction to surviving is an
important clinical variable that is easily assessed in evaluations
that occur following a suicide attempt.
(Am J Psychiatry 2005; 162:2180–2182)
ness was one of the most robust predictors of suicide in
hospitalized patients with suicidal ideation. Beck and
Steer (3) noted that hopelessness was assessed after the at-
tempt rather than before and that “its predictive validity
may be obscured by the psychological aftermath of the at-
tempt” (p. 208). This interpretation suggests that charac-
teristics of the aftermath of a suicide attempt might have
relevance in predicting ultimate suicide. Beautrais (1)
found that reactions to the attempt (e.g., hoping to die be-
fore making the attempt, failing to be relieved by survival)
contributed modestly in predicting eventual suicide in 302
suicide attempters.
The purpose of the current study was to reanalyze the
suicide attempters studied by Beck and Steer (3) to deter-
mine if their reaction to surviving the suicide attempt pre-
dicted eventual suicide. We hypothesized that individuals
who wished they were dead following the suicide attempt
would be at greater risk for killing themselves than those
who were glad to be alive or ambivalent.
Am J Psychiatry 162:11, November 2005