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Introduction

“Suicide is the act of deliberately taking one’s own life” [1]. Suicide accounts for about 1.5% of all deaths globally [2], or about 12 deaths per 100,000 people [3]. Men commit suicide at a higher rate than women do overall; in the developing world, the rate is 1.5 times higher than in the developed world, at 3.5 times higher [2]. Suicide is usually most common among those past the age of 70 [4] however, in some countries, those aged between 15 and 30 are at the highest risk [5]. In terms of region, Europe had the highest suicide rates in 2015 [6]. It is recorded that 10 to 20 million non-fatal suicides are attempted every year [7]. Suicide attempts have the potential to cause harm and permanent disabilities [1,7]. In the Western world, attempts are more common among the youth [8].

Although there is lack of reliable data from sub Saharan Africa [9], information gathered shows that many African countries are also experiencing a rise in suicide rates and these trends are not easy to explain [10]. In Africa one factor that runs through is the lack of professional assistance and research [11,12]. About four (4) people die in the Eastern African country of Kenya daily from suicide [13].

In Ghana, the scenario is similar to the general African situation; very little offcial records of data exist [14], on the other hand, a prior subjective and journalistic report indicates that approximately 1556 individuals (or five per day) die by suicide in Ghana on a yearly basis [15]. Victims of the suicides were mostly male (85.92%), with age ranging 10-86 years [16]. Commonly identified suicide methods included “self hanging (67.94%), firearms (18.32%), and self poisoning (8.93%)” [16]. Three superordinate themes were identified in a qualitative study by Spillane et al. regarding the experiences that follow a suicide bereavement and how it affects the mental and physical health of family members': co occurrence of grief and health reactions; disparity in supports after suicide and reconstructing life after suicidal death of relative [17]. They found that “initial feelings of guilt, blame, shame and anger often manifested in enduring physical, psychological and psychosomatic difficulties”. They further found that “support needs were diverse and were often related to the availability or absence of informal support by family or friends” [17].

In conclusion it was established that “healthcare professionals’ awareness of the adverse physical and psychosomatic health difficulties experienced by family members bereaved by suicide is essential; thus, proactively facilitating support for this group could help to reduce the negative health sequelae because the effects of suicide bereavement are wide ranging, including high levels of stress, depression, anxiety and physical health difficulties” [17].

Other research showed “suicide affects millions of individuals worldwide and leaves a devastating impact on family members left behind, herein referred to as survivors” [18].

Offspring who experience parental suicide prior to young adulthood are at increased risk for suicide and hospitalization for suicide attempt as compared with those who experience a parent's death by other means. Young off spring who survive parental suicide have received special research attention because they lost a caregiver during a critical developmental period and may be more vulnerable to suicide attempt and suicide. The risk in offspring who lost a parent to suicide or an unintentional injury during childhood surpassed the other age groups' risk approximately 5 years after the origin and, for the youngest group, continued to rise over decades, the study noted. These offspring had higher levels of anger and depressive symptoms than those who lost a parent through other means. The risk decreased with time for offspring who lost a parent during adolescence or early adulthood, peaking one to two years following the parent's passing. Compared to offspring who lost a parent to an unintentional injury, those who lost a parent to suicide in their childhood and early adulthood began hospitalizing for suicide attempts earlier. The study concluded that children who lose a parent early in life had a different hospitalization risk for attempting suicide than those who lose a parent later in life. The findings point to crucial periods for vigilant surveillance and intervention regarding the likelihood of suicide attempts, particularly in the first two years following the death of a parent for older age groups and throughout several decades for children surviving parental death [18].

Findings from the Avon Longitudinal Study of Parents and Children (ALSPAC) Birth Cohort indicated that while maternal suicide attempt was unrelated to self harm without intent, it did raise the risk of suicidal thoughts and self harm with intent in offspring. Paternal suicide attempt results were less clear cut and did not reach statistical significance. Maternal SA poses a significant risk for mental morbidity in their offspring, even if it may go unnoticed by medical specialists [19].

However, the study also looked at the potential relationship between parental suicide attempts and offspring internalizing, externalizing, and attention/hyperactivity problems in both childhood and adolescence. Parental suicide attempts and offspring mental health problems in childhood and adolescence confirmed that the relationship between parental suicide attempts and offspring suicide risk had been established [20]. The study looked at the relationship between parental suicide attempts and adolescent off spring mental health issues and how it was mediated by childhood mental health issues.

Throughout the study period, parental suicide attempts over a lifetime were linked to internalizing, externalizing, and attention/hyperactivity issues in their teenage children. Behavioral issues in their youth were linked to parental suicide attempts prior to the childhood assessment. According to the mediation models, parental suicide attempts prior to the childhood assessment had a noteworthy indirect impact on the externalizing and attention/hyperactivity issues that arise in adolescence, through the behavioral problems that the children experienced during their early years.

According to their findings, children with behavioral problems should ask their clinicians about their parents' history of attempted suicide, as these children may have externalizing and attention/hyperactivity problems in adolescence as a result of familial vulnerability to suicide. These findings also emphasize the significance of evaluating and tracking mental health issues in children whose parents have been hospitalized for attempting suicide [20].

Numerous negative behavioral and health effects have been connected to childhood exposure to suicidal behavior by parents. The prevalence of SUDs among individuals who were exposed to parental suicide attempts as children was compared using data from the National Epidemiologic Survey on Alcohol and Related Conditions. The results showed that there was no correlation between exposure to parental suicide attempts as a child and an increased risk of developing alcohol, cannabis, or cocaine use disorders. On the other hand, there was a substantial increase in the likelihood that people who witnessed a parent attempt suicide as a kid would later meet the criteria for stimulant, sedative, tranquilizer, and opiate use disorders. Regarding the strength of the association between exposure to parental suicide attempts and the risk of SUD in men and women, no discernible gender differences were found. Childhood exposure to parental suicide attempts is a vulnerability factor for low prevalence illicit drugs (such as stimulants, sedatives, tranquilizers, and opioids), but not for more widely used substances, even after adjusting for a variety of sociodemographic, parental, mental health, and childhood adversity confounds [20].

According to the multivariate models, the off spring of a parent who attempted suicide were more likely to attempt suicide themselves, but not to die by suicide. Off spring exposed after birth had a greater chance of trying suicide than offspring not exposed, particularly if the parent attempted during the children's youth, adolescence, or early adulthood [21]. An initial motherly SA elevated likelihood of suicide attempt among kids, independent of date.

Depending on the timing and gender of the parent who attempted suicide, the effect of a parental SA on the off spring's chance of attempting suicide varied, indicating that both genetic and environmental factors may contribute to the transmission of suicide risk [22].

“There exists an association of family factors, including high family conflict and low parental monitoring, with suicidality and self injury in children” [23].

A sizable section of the community experiences suicide loss, and although with its widespread occurrence, suicide death is still stigmatized. Health practitioners should be aware of how suicide stigma affects friends and family members who have survived so they can respond appropriately and offer helpful assistance. Survivors of suicide said they felt condemned, blamed, and ashamed. They felt that the suicide was often uncomfortable and embarrassing, which added to the secrecy and avoidance. Suicidality, self harm, depression, and overall psychological distress were all correlated with higher levels of perceived stigma [24].

Bereavement by suicide poses a risk for negative consequences pertaining to bereavement, social functioning, mental health, and suicidal thoughts and actions. As a result, postvention, or suicide bereavement care, has been recognized as a crucial suicide prevention tactic.

Numerous intervention modalities, study populations, control groups, and outcome measures relating to mourning, psychological issues, and suicide were used in these investigations. Overall, the research's quality was subpar. While there was some evidence supporting the efficacy of therapies for simple sorrow, there was not enough data to support the effectiveness of interventions for complex grieving. Based on the limited evidence available, therapies that appear to hold promise include those that engage the social surroundings of the bereaved, entail therapeutic, educational, and supportive methods, and consist of a series of sessions facilitated by qualified professionals.

More study across the lifespan is necessary to avoid mourning and its negative effects on mental health because individuals who have lost a loved one to suicide are more likely to experience unfavorable grief, mental illness, and suicidal behavior [25].

Materials and Method

Research Aim

The aim of the study was to describe the responses of suicide attempters’ families in relation to the general effects of the attempt on the family in selected communities in the Greater Accra Region of Ghana.

Research Design

Selection of participants was carried out using an exploratory descriptive qualitative approach. Purposive sampling technique alongside phenomenological approach was used for the data collection and analysis of the data to be able to describe the in depth effect of the suicide on the family. The design of the semi structured interview guide was used because it is flexible and allows the utilization of open ended questions which in turn helps in the attainment of in depth information from participants. The process of thematic analysis was done by initially uploading the data onto the MAXQDA 20 software and going through the data acquired in order to become familiar with it; then data relevant codes were generated. As the data was organized under the various codes, themes were developed from the coded data; these themes were reviewed, defined and then utilized for the write up.

Ethical Consideration

Consent: Information sheets describing the purpose, procedures and benefits of the qualitative studies were provided to participants. Written consent was also obtained for participation and audio recording of the studies.

Confidentiality procedures: To ensure anonymity, codes or pseudonyms were used instead of names of participants. All interviews were scheduled at a time and place of convenience to all participants. Interviews were carried out privately to ensure privacy. To ensure confidentiality, all audio recordings of interviews and transcribed data were kept safely under lock and key on a password protected computer. This will only be made accessible when the need arises.

Settings of the study

The study was conducted in the Ningo Prampram, Ledzokuku Krowor municipal, Ga East, Weija Gbawe municipal and Ga South municipal with the help of Community Psychiatric Nurses in charges all in the Greater Accra region of Ghana.

Demographic Characteristics of Participants

The demographic data of the participants included age, gender, marital status, level of education, religion, place of work, years or duration of work and place of residence. Seven (7) participants were successfully interviewed (2 males and 5 females). The age range of the participants was 18 years to 50 years. Out of the 7 participants, 6 were married and 1 of them was unmarried. Five (5) of the participants were Christians and two (2) were non religious. The relatives included two brothers, three sisters, a mother and a father.

Results

The objective was to describe the general response of the suicide attempter’s family to the suicide attempt. The general response of the family to the attempt was both negative and positive. The negative responses were anger and shock, while the positive responses were concern and solidarity. The anger and shock were short to medium term, while concern and solidarity were medium to long term responses.

Anger, as a response of family members to the suicide attempt

Anger was described by participants as the way they felt after a relative had attempted to take their life. This anger was seen as short to medium term. The study showed that many family members asked a lot of questions as to why their family member would attempt to do such a disgusting thing and the pain increased when they considered how much investment in terms of time, food, clothing, care, education, money among other things that was going to go down the drain if the victim had completed the suicide and the future potential the suicide attempter carried. Another thing that also angered the family members was the good name of the family that was going to be dragged in the mud because of this suicide attempt. Which shows that the anger was expressed by the immediate family who believe that people will ask questions like what the family members did to the victim to push him/her to this extreme, and all sorts of rumours will be circulated. Beyond that it casts a slur on the family name, in the African culture communities become like an extended family and many discussions are made concerning different families; when you ask about any particular family name in the community, you will quickly be given the family’s background information, without even asking for it, therefore in the future whenever someone wants to either marry or make some good investment into the suicide attempter’s family, the people in the community will tell the potential investor that it is a family of good for nothing suicide attempters and that will most definitely discourage many an investor. This stigma will not easily be taken away from the family.

The following illustrative quotes of some angry family members:

“It is humiliating and demoralizing. I really got annoyed. Sometimes I see him to be a useless boy. He should appreciate us hmmm.” (45-years old father, SAF 1)

The victim’s father feels angry because the actions of his son makes the father look irresponsible in the sight of the general community as people might think his child training skills were ineffective.

Sometimes even siblings feel ashamed to be associated with these attempters because it casts a slur on their personality and image, one victim’s sister recounted:

“It is infuriating. At times I feel very sad, other times I feel ashamed and ask myself why and how did this happen? At times it makes me very angry” (35-years old sister, SAF 4)

“I was so angry. How can David do such a thing? After all the love we have shown him, hmm. “This is very painful and annoying considering the fact that the image of the family was permanently tarnished in the eyes of outsiders” (38- Years old brother, SAF 2).

Shock as a response of family members to the suicide attempt

In addition to anger, other immediate family members were so shocked to hear that a trusted family member could attempt such a despicable thing. In the event where there existed prior signs and comments from the attempter, the family are usually not too shocked or surprised about the attempt but where the person in question had no obvious issues, the family gets really jolted in the wake of the event. This shock was seen as short to medium term.

One of the participants said:

“Everybody who knows David will be shocked that he tried such a thing. With his education, intelligence and smartness, we didn't expect that from him at all, so with the least notice and prompting everybody came around to verify what had happened; to take that tool and attempt suicide? No! That was not the David we knew. I think they were equally surprised the same way I was. Yeah” (38- years old brother, SAF 2).

The attempter did not show any signs here and even if there were, most of the close relations did not place any value on it because this victim was well educated and intelligent and naturally everybody expected him to know better; however when it comes to psychological disturbances, logical reasoning is usually set aside and this is what made the family receive the shock

Another participant responded:

“Oooooh she likes making friends and she is not very quiet, she is playful, she is at peace with everyone, so I am really shocked at what happened, not in my wildest thoughts could I imagine my sister doing this.”(32 years old sister,SAF 3)

The shock received by the family here stems from the fact that normally a person changes in behaviour before such an event, however in the case of this attempter she maintain her original behaviour and showed no signs of psychological stress, thus leaving the family in serious shock and asking themselves what will suddenly made their sister make such a decision.

Concern and solidarity as a response of the family members to suicide attempt

Despite the fact that many family members were angry and shocked, they could not help but show concern for their loved ones, and they imagined this victim might have really suffered because of both physical and emotional injuries the attempter has received. It also brought solidarity; unity, togetherness and mutual support within the nuclear family as well as the extended family; many family members that had not been together for a long time were brought together by this event and they brought in encouragement for the victim.

The following quotes elucidate the above point:

“That very moment everybody came around, you know here in our society, we are like an extended family, so when one person encounters a problem, you have people in the neighbourhood trooping to the house to see what had happened. It is sometimes even not about money o! They just want to show you that they are with you, the solidarity is there paa. I think they were equally concerned the same way I was, seriously I was amazed the way they were all worried about what had happened, you could see they felt the pain we were feeling as a nuclear family, those who were not able to come here physically would actually call and ask about how we were faring” (38-years old brother, SAF 2)

“They were actually worried about the situation when it happened, they would ask questions like, how are things now; is there anything we can do to help you and they would often tell me we are praying with you” (46-years old mother, SAF 6).

“Everyone was concerned because we have lost both parents. So, we only have each other. The pain of losing even one parent was not easy, talk of losing both. They kept saying, o why would he try such a thing when he knows that you don’t have any other family but yourselves” (28-years old sister, SAF 7).

Discussion

The study described the general response of the suicide attempter’s family to the suicide attempt which contributed to the individual’s wellbeing. It was discovered that the suicide attempt had three major effects on the family which included, anger, shock, concern and solidarity. The suicide attempter’s family expressed their vulnerabilities through their response to the suicide attempt of the family member.

Some attempter’s family received the news of the suicide attempt with anger. They could not believe that the attempters could really do what they did, considering how much the family had invested in them. Where the attempter had parents, these parents felt angry because they saw the suicide attempt as a very selfish act [26,27], that is to say, the attempter did not consider the fact that he/she was not an island, and that every act has an effect on everyone in the family; this really made some parents angry. This is in similitude with a phenomenological study of the experiences of bereaved families by suicide in South Korea which showed that families bereaved by suicide had a sense of anger, among other emotions (Lee, 2022).

Other families were also in total shock after discovering their family member had attempted suicide. This was because many of the family members never expected this particular family member to do what he or she did, this was consistent with the study by [26]. Some did not understand what could possibly drive their relative to attempt suicide. The questions and the emotional flood could drown one’s soul. Existing literature, consistent with this study found that families experienced a state of shock and paralysis during the initial days and weeks following a family member’s suicide attempt [28].

Study participants revealed that when their family member attempted suicide and they were at their lowest moments, it had an effect of bringing the extended family and friends around to express solidarity and concern. They came around to see what had occurred, how and why it happened and to comfort the family whilst counselling the attempter. Beyond physical concern and solidarity, studies elsewhere in the USA also show that for grieving black boys, online worlds offer unusual space for emotional freedom, social support, and solidarity. The advent of social media is a good example of such digital solidarity. Through modern phone applications like Whatsapp, Facebook, Twitter, Instagram, Tiktok and many others, the world truly becomes a global village. Various groupings on these apps become like virtual families that offer solidarity and support for each other in moments of grief [29].

Implications

The implications of the findings for mental health services and support systems in Ghana include massive education for the general public and families on how to handle such traumatic occurrences; in order to protect themselves from overreacting towards the suicide attempter and thus aggravating the already fragile psychological state of the suicide attempter. The establishment of specialized health units by mental health authorities dedicated to suicide issues might also go a long way to help. Family support systems that help identify vulnerable groups who are then offered tailor made solutions can be a preventive measure for families.

Conclusion

In conclusion most family members found themselves in a dilemma because even though one individual carried out the act of trying to end their life, the individual was not an isolated island, and that every individual is linked directly or indirectly to a long chain of other individuals; therefore, any action, taken by this individual will definitely have some effect on others linked to them. The study showed that when a person attempts suicide, it has major consequences on their family, both nuclear and extended; this therefore calls for prompt and targeted measures to help nip suicide attempts in the bud. The strategies may include easy access to mental health services in every health facility in communities. Properly trained and well equipped staff who posted to such facilities would help attend to psychologically vulnerable family members. Community health education and home visits by mental health professionals would also help to disseminate essential health information to families and communities.

Limitation

It only focussed on married, unmarried, Christians, non-religious, brothers, sisters, mother and a father; therefore the views of the divorced other religious organizations and other relatives opinions were not included.

Future Research

Suggested area of research should include infusing suicide education prevention in children; thus Suicide prevention education should be integrated in the school curriculum.

Declarations

Ethics Approval

Ethical clearance was attained from the Ghana Health Service Ethics Review Committee (GHS-ERC: 013/07/22).

Consent to Participate

Informed consent was obtained from all the participating suicide attempters’ who were selected for the study before participating in the study.

Availability of Data and Materials

The datasets generated and/or analyzed will be made available upon request from the corresponding author on request.

Competing Interests

The authors AAB, FG, EA, PDG declares that they have no competing interests. Thus the authors hereby declare to have no relationship or competing financial engagements that could influence the work reported in this paper.

Funding

Author received no external funding in the process of undertaking the study.

Authors’ Contributions

AAB collected data, analyzed and put the results together. Author FG, EA and PDG read and approved the manuscript.

Acknowledgements

I want to say a big thank you to the five districts hospitals that permitted me to conduct the research in their settings and the Community Psychiatric Nurses in charges who readily availed themselves to assist in the interview process.