Suicide risk is highly prevalent among substance users, a population vulnerable to complications in bereavement. This study used network analysis to examine relationships between Prolonged Grief Disorder (PGD) symptoms and suicide risk among bereaved individuals in addiction treatment. Participants were 196 bereaved substance users. The Risk of Suicide Scale and the Spanish version of the Inventory of Complicated Grief were applied. Gaussian Graphical Models with LASSO regularization explored associations between symptoms, assessing centrality, expected influence, and bridge centrality. Network robustness was tested via bootstrapping using R and SPSS. In that sense, the network of PGD symptoms and suicide risk showed good stability. “Disbelief over what happened,” “feeling life is empty without the deceased,” “bitterness over the death,” and “thoughts of suicide” had the highest strength indicators. In conclusion, PGD symptoms play a crucial role in suicide risk among substance users, underscoring the need for targeted, personalized interventions.
AhnS. Y.YuS.KimJ. E.SongI. H. (2023). The relationship between suicide bereavement and suicide ideation: Analysis of the mediating effect of complicated grief. Journal of Affective Disorders, 331(15), 43–49. https://doi.org/10.1016/j.jad.2023.03.008
2.
AnderssonH.MostiM.NordfjærnT. (2022). Suicidal ideation among inpatients with substance use disorders: Prevalence, correlates and gender differences. Psychiatry Research, 317(114848). https://doi.org/10.1016/j.psychres.2022.114848
3.
BeardC.MillnerA. J.ForfeardM.FriedE. I.HsuK. J.TreadwayM. T.LeonardC. V.KertzS. J.BjörgvinssonT. (2016). Network analysis of depression and anxiety symptom relationships in a psychiatric sample. Psychological Medicine, 46(16), 3359–3369. https://doi.org/10.1017/S0033291716002300
4.
BernalM.HaroJ. M.BernertS.BrughaT.de GraafR.BruffaertsR.LépineJ. P.de GirolamoG.VilagutG.GasquetI.TorresJ. V.KovessV.HeiderD.NeelemanJ.KesslerR.AlonsoJ.ESEMED/MHEDEA Investigators. (2007). Risk factors for suicidality in Europe: Results from the ESEMED study. Journal of Affective Disorders, 101(1-3), 27–34. https://doi.org/10.1016/j.jad.2006.09.018
5.
BoelenP.LenferinkL. (2020). Symptoms of prolonged grief, posttraumatic stress, and depression in recently bereaved people: Symptom profiles, predictive value, and cognitive behavioural correlates. Social Psychiatry and Psychiatric Epidemiology, 55(6), 765–777. https://doi.org/10.1007/s00127-019-01776-w
6.
BonannoG. A.MalgaroliM. (2020). Trajectories of grief: Comparing symptoms from the DSM-5 and ICD-11 diagnoses. Depression and Anxiety, 37(1), 17–25. https://doi.org/10.1002/da.22902
7.
BorgesG.WaltersE. E.KesslerR. C. (2000). Associations of substance use, abuse, and dependence with subsequent suicidal behavior. American Journal of Epidemiology, 151(8), 781–789. https://doi.org/10.1093/oxfordjournals.aje.a010278
BorsboomD.DesernoM. K.RhemtullaM.EpskampS.FriedE. I.McNallyR. J.RobinaughD. J.PeruginiM.DalegeJ.CostantiniG.IsvoranuA. M.WysockiA. C.van BorkuloC. D.van BorkR.WaldorpL. J. (2021). Network analysis of multivariate data in psychological science. Nature Reviews Methods Primers, 1(58), 1–18. https://doi.org/10.1038/s43586-021-00055-w
10.
BrigantiG.ScutariM.EpskampS.BorsboomD.HoekstraR. H. A.GolinoH. F.ChristensenA. P.MorvanY.EbrahimiO. V.CostantiniG.HeerenA.RonJ. d.BringmannL. F.HuthK.HaslbeckJ. M. B.IsvoranuA. M.MarsmanM.BlankenT.GilbertA.McNallyR. J. (2024). Network analysis: An overview for mental health research. International Journal of Methods in Psychiatric Research, 33(4), 1–24. https://doi.org/10.1002/mpr.2034
11.
ChenJ.ChenZ. (2008). Extended bayesion information criteria for model selection with large model spaces. Biometrika, 95(3), 759–771. https://doi.org/10.1093/biomet/asn034
12.
ConstantiniG.RichetinJ.PrietiE.CasiniE.EpskampS.PeruginiM. (2019). Stability and variability of personality networks. A tutorial on recent developments in network psychometrics. Personality and Individual Differences, 136, 68–78. https://doi.org/10.1016/j.paid.2017.06.011
13.
CrumpC.SundquistJ.KendlerK.EdwardsA.SundquistK. (2021). Comparative risk of suicide by specific substance use disorders: A national cohort study. Journal of Psychiatric Research, 144, 247–254. https://doi.org/10.1016/j.jpsychires.2021.10.017
14.
Dell’OssoK.CarmassiC.RucciP.CiapparelliA.ConversanoC.MarazzitiD. (2011). Complicated grief and suicidality: The impact of subthreshold mood symptoms. CNS Spectrums, 16(1), 1–6. https://doi.org/10.1017/S1092852912000090
15.
DoreG.MillsK.MurrayR.TeessonM.FarrugiaP. (2012). Post-traumatic stress disorder, depression and suicidality in inpatients with substance use disorders. Drug and Alcohol Review, 31(3), 294–302. https://doi.org/10.1111/j.1465-3362.2011.00314.x
16.
EpskampS.BorsboomD.FriedE. (2018). Estimating psychological networks and their accuracy: A tutorial paper. Behavior Research Methods, 50(1), 195–212. https://doi.org/10.3758/s13428-017-0862-1
17.
EpskampS.CramerA.WaldorpL.SchmittmannV.BorsboomD. (2012). Graph: Network visualizations of relationships in psychometric data. Journal of Statistical Software, 48(4), 1–18. https://doi.org/10.18637/jss.v048.i04
18.
FarleyM.GoldingJ.YoungG.MulliganM.MinkoffJ. (2004). Trauma history and relapse probability among patients seeking substance abuse treatment. Journal of Substance Abuse Treatment, 27(2), 161–167. https://doi.org/10.1016/j.jsat.2004.06.006
19.
FolkmanS. (2001). Revised coping theory and the process of bereavement. In StroebeM.HanssonR. O.SchutH.StroebeW. (Eds.), Handbook of bereavement research and practice: Advances in theory and intervention (pp. 113–132). American Psychological Association Press.
20.
Fonseca-PedreroE. (2017). Network analysis: A new way of understanding psychopathology?Revista de Psiquiatía y Salud Mental, 10(4), 206–215. https://doi.org/10.1016/j.rpsmen.2017.10.005
21.
Fonseca-PedreroE.Díez-GómezA.de la BarreraU.Sebastian-EnescoC.Ortuño-SierraJ.Montoya-CastillaI.Lucas-MolinaB.InchaustiF.Pérez-AlbénizA. (2020). Suicidal behaviour in adolescents: A network analysis. Revista de Psiquiatía y Salud Mental, 17(1), 3–10. https://doi.org/10.1016/j.rpsm.2020.04.007
22.
FordH.LynchF.PetersonE.LuC.HuY.RossomR.WaitzfelderB.Owen‐SmithA.HubleyS.PrabhakarD.WilliamsK.BeckA.SimonG.AhmedaniB.Owen‐SmithA.WilliamsL. (2020). Substance use disorders and risk of suicide in a general US population: A case control study. Addiction Science & Clinical Practice, 15(1), Article 14. https://doi.org/10.1186/s13722-020-0181-1
23.
FriedE.van BorkuloC.CramerA.BoschlooL.SchoeversR. A.BorsboomD. (2017). Mental disorders as networks of problems: A review of recent insights. Social Psychiatry and Psychiatric Epidemiology, 5(52), 1–10. https://doi.org/10.1007/s00127-016-1319-z
24.
FurrS.JohnsonW.GoodallC. (2015). Grief and recovery: The prevalence of grief and loss in substance abuse treatment. Journal of Addictions & Offender Counseling, 36(1), 43–56. https://doi.org/10.1002/j.2161-1874.2015.00034.x
25.
GidzgierP.BariM.López-AtanesM.LotzinA.GrundmannJ.HillerP.SchneiderB.SchäferI. (2023). Improving care for SUD patients with complex trauma–relationships between childhood trauma, dissociation, and suicidal behavior in female patients with PTSD and SUD. Frontiers in Psychiatry, 12(13). https://doi.org/10.3389/fpsyt.2022.1047274
26.
GrohJ. C.CunmulajJ. (2020). Women, addiction, and grief: A quality improvement initiative. Archives of Psychiatric Nursing, 34(4), 224–229. https://doi.org/10.1016/j.apnu.2020.04.008
27.
GuldinM. B.Ina Siegismund KjaersgaardM.Fenger-GronM.Thorlund PartnerE.LiJ.PriorA.VestergardM. (2017). Risk of suicide, deliberate self-harm and psychiatric illness after the loss of a close relative: A nationwide cohort study. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 16(2), 193–199. https://doi.org/10.1002/wps.20422
28.
HolmstrandC.BogrenM.MattissonC.BrådvikL. (2015). Long-term suicide risk in people with no, one or more mental disorders: The Lundby study 1947–1997. Acta Psychiatrica Scandinavica, 132(6), 459–469. https://doi.org/10.1111/acps.12506
29.
IsvoranuA. M.AbdinE.ChongS. A.VaingankarJ.BorsboomD.SubramaniamM. (2021). Extended network analysis: From psychopathology to chronic illness. BMC Psychiatry, 21(1), Article 119. https://doi.org/10.1186/s12888-021-03128-y
30.
JergaA. M.ShaverP. R.WilkinsonR. B. (2011). Attachment insecurities and identification of at-risk individuals following the death of a loved one. Journal of Social and Personal Relationships, 28(7), 891–914. https://doi.org/10.1177/0265407510397987
31.
JonesP.MaR.McNallyR. (2021). Bridge centrality: A network approach to understanding comorbidity. Multivariate Behavioral Research, 56(2), 353–367. https://doi.org/10.1080/00273171.2019.1614898
32.
KaplanH.SadockB. (1998). Sinopsis de psiquiatría. Williams & Wilkins.
33.
LathamA.PrigersonH. (2004). Suicidality and bereavement: Complicated grief as psychiatric disorder presenting greater risk for suicidality. Suicide and Life-Threatening Behavior, 34(4), 350–362. https://doi.org/10.1521/suli.34.4.350.53737
34.
LenferinkL.NickersonA.de KeijserJ.SmidG. E.BoelenP. A. (2020). Trajectories of grief, depression, and posttraumatic stress in disaster-bereaved people. Depression and Anxiety, 37(1), 35–44. https://doi.org/10.1002/da.22850
35.
LimoneroJ.LacastaM.GarcíaJ.MatéJ.PrigersonH. (2009). Adaptación al castellano del inventario de duelo complicado. Medicina Paliativa, 16(5), 291–297.
36.
LundorffM.HolmgrenH.ZachariaeR.Farver-VestergaardI.O’ConnorM. (2017). Prevalence of prolonged grief disorder in adult bereavement: A systematic review and metaanalysis. Journal of Affective Disorders, 1(212), 138–149. https://doi.org/10.1016/j.jad.2017.01.030
37.
MaccallumF.BryantR. (2013). A cognitive attachment model of prolonged grief: Integrating attachments, memory, and identity. Clinical Psychology Review, 33(6), 713–727. https://doi.org/10.1016/j.cpr.2013.05.001
38.
MaccallumF.BryantR. A. (2019). A network approach to understanding quality of life impairments in prolonged grief disorder. Journal of Traumatic Stress, 33(1), 106–115. https://doi.org/10.1002/jts.22383
39.
ManciniA. D.PratiG.BonannoG. A. (2011). Do shattered worldviews lead to complicated grief? Prospective and longitudinal analyses. Journal of Social and Clinical Psychology, 30(2), 184–215. https://doi.org/10.1521/jscp.2011.30.2.184
40.
MartinS.PrivetteG. (1989). Process model of grief therapy in an alcohol treatment program. Journal for Specialists in Group Work, 14(1), 46–52. https://doi.org/10.1080/01933928908411886
41.
MasferrerL.CaparrósB. (2017). Risk of suicide and personality disorders among substance users. International Journal of Environmental Research and Public Health, 14(3), Article 316. https://doi.org/10.3390/ijerph14030316
42.
MasferrerL.Garre-OlmoJ.CaparrósB. (2017). Factor structure and concurrent construct validity of ICG among bereaved substance users. Actas Espanolas de Psiquiatria, 45(2), 47–55.
43.
MitchellA. M.KimY.PrigersonH. G.Kay MortimerM. (2005). Complicated grief and suicidal ideation in adult survivors of suciide. Suicide and Life-Threatening Behavior, 35(5), 498–506. https://doi.org/10.1521/suli.2005.35.5.498
44.
PlutchikR.Van PraagH.ConteH. R.PicardS. (1989). Correlates of suicide and violence risk, I: The suicide risk measure. Comprehensive Psychiatry, 30(4), 296–302. https://doi.org/10.1016/0010-440x(89)90053-9
45.
PrigersonH. G.FrankE.KaslS. V.ReynoldsC. F.AndersonB.ZubenkoG. S.418 HouckP. R.GeorgeC. J.KupferD. J. (1995). Complicated grief and bereavement related depression as distinct disorders: Preliminary empirical validation in elderly 420 bereaved spouses. American Journal of Psychiatry, 152(1), 22–30. https://doi.org/10.1176/ajp.152.1.22
46.
R Core Team. (2018). R: A language and environment for statistical computing. R Foundation for Statistical Computing. https://www.R-project.org
RizkM. M.HerzogS.DugadS.StanleyB. (2021). Suicide risk and addiction: The impact of alcohol and opioid use disorders. Current Addiction Reports, 8(2), 194–207. https://doi.org/10.1007/s40429-021-00361-z
49.
RuttenR.BroekmanT.SchippersG.SchellekensA. (2021). Symptom networks in patients with substance use disorders. Drug and Alcohol Dependence, 229 Pt B, Article 109080. https://doi.org/10.1016/j.drugalcdep.2021.109080
50.
SantamariaS.IglesiasC.AlonsoM. (2004). Comportamientos suicidas y consume de sustancias psicotropas. In BobesJ.SáizP.García-PortillaM.BascaránM.BousoñoB. (Eds.), Comportamientos suicidas, prevención y tratamiento (pp. 91–95). Ars Medica.
51.
SekowskiM.PrigersonH. (2022). Associations between symptoms of prolonged grief disorder and depression and suicidal ideation. British Journal of Clinical Psychology, 61(4), 1211–1218. https://doi.org/10.1111/bjc.12381
ShearM. K.SimonN.WallM.ZisookS.NeimeyerR.DuanN.ReynoldsC.LebowitzB.SungS.GhesquiereA.GorscakB.ClaytonP.ItoM.NakajimaS.KonishiT.MelhemN.MeertK.SchiffM.O’ConnorM. F.KeshaviahA. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28(2), 103–117. https://doi.org/10.1002/da.20780
StroebeM.SchutH.Van den Bout (2013). Complicated grief: Scientific foundations for health care professionals. Routledge.
56.
StroebeM.StroebeW.AbakoumkinG. (2005). The broken heart: Suicidal ideation in bereavement. American Journal of Psychiatry, 162(11), 2178–2180. https://doi.org/10.1176/appi.ajp.162.11.2178
57.
TibshiraniR. (1996). Regression shrinkage and selection via the lasso. Journal of the Royal Statistical Society - Series B: Statistical Methodology, 58(1), 267–288. https://doi.org/10.1111/j.2517-6161.1996.tb02080.x
58.
Van OrdenK.WitteT.CukrowiczK.BraithwaiteS.SelbyE.JoinerT. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600. https://doi.org/10.1037/a0018697
59.
World Health Organization. (2023). Suicide worldwide in 2021: Global age-standardized suicide rates. World Health Organization.
60.
ZuckoffA.ShearK.FrankE.DaleyD.SeligmanK.SilowashR. (2006). Treating complicated grief and substance use disorders: A pilot study. Journal of Substance Abuse Treatment, 30(3), 205–211. https://doi.org/10.1016/j.jsat.2005.12.001
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
