History of suicide attempt(s)

Five studies ^{Reference Fulginiti and Frey33–Reference Ruzhenkov, Ruzhenkova, Boeva and Moskvitina37} exploring suicide-related stigma as the exposure variable reported high levels of public suicide-related stigma and self-stigma among suicide attempt survivors. Of a sample of US suicide attempt survivors, 46% believed that their family members held stigmatising attitudes towards suicide attempt survivors. ^{Reference Fulginiti and Frey33} Twenty-nine per cent of participants in this sample had never told any of their family members about their suicide attempt, and, unsurprisingly, more perceived stigma about a suicide attempt was associated with greater concealment of a suicide attempt. ^{Reference Fulginiti and Frey33} Similar results were found in Russia, ^{Reference Ruzhenkov, Ruzhenkova, Boeva and Moskvitina37} where participants reported feelings of rejection and dislike from family members owing to their suicide attempt. This study also found that many felt guilty and isolated as a result of their suicide attempt. Among a sample of suicide attempt survivors in Australia, individuals personally stigmatised their own suicidality. ^{Reference Rimkeviciene, Mok, Shand, Hawgood and O’Gorman36} Although Hom et al ^{Reference Hom, Stanley, Duffy, Davis and Joiner34} did not find a significant relationship between suicide attempt history and suicide-related stigma, they did find public suicide-related stigma to be associated with an increased likelihood of future suicide attempts among US firefighters. Furthermore, anticipated stigma among suicide attempt survivors in the USA was associated with elevated risk of suicidal thoughts and behaviours even after controlling for time since last attempt and number of previous suicide attempts. ^{Reference Mayer, Ruesch, Frey, Nadorff, Drapeau and Sheehan35}

Those bereaved by suicide

There was only one study which investigated suicide-related stigma as the exposure variable among those who had been bereaved by suicide. Among a mostly female sample of 195 individuals bereaved by suicide in the US (n = 180 females), higher levels of perceived stigma towards those bereaved by suicide were associated with increased suicidality and decreased personal growth. ^{Reference Oexle, Feigelman and Sheehan38}

General population

In a sample of 104 Chinese and American women, viewing suicide as morally bad was associated with a greater risk of suicide. ^{Reference Domino, Su and Lee Johnson39} Moreover, in another sample of 944 Chinese students, public suicide-related stigma was found to inhibit suicide attempts but not suicidal ideation. ^{Reference Lyu and Li40} Conversely, among a sample of Chinese Indonesians, ^{Reference Prawira, Liem, Yulianto and Han41} public suicide-related stigma, in the form of viewing suicide as sinful, was associated with a decrease in an individual’s chances of experiencing self-harm or suicidal ideation.

Experience of suicide in professional and/or personal life

Two studies conducted among students ^{Reference Kearns, Muldoon, Msetfi and Surgenor42,Reference Yakunina, Rogers, Waehler and Werth43} and one among parents with children who experienced suicidal thoughts ^{Reference Burke, Calear, Cruwys and Batterham44} found suicide-related stigma to be a significant predictor of factors related to help-seeking. The direction of the relationship varied as a function of the source of help. In one study conducted with suicidologists, ^{Reference Roskar, Kralj, Andriessen, Krysinska, Vinko and Podlesek45} no association was found. A study ^{Reference Kearns, Muldoon, Msetfi and Surgenor42} conducted with students in Ireland found that stigma towards suicide attempts was the strongest predictor of help-seeking stigma, whereby an increase in stigma towards suicide attempts was associated with an increase in help-seeking stigma. Another study ^{Reference Yakunina, Rogers, Waehler and Werth43} of university students, conducted in the USA found that more public stigma towards suicide significantly increased help-seeking intentions from professional sources. However, the opposite relationship was found with regard to non-professional sources, in that more public suicide-related stigma was associated with a decrease in intentions to seek help from these sources. ^{Reference Yakunina, Rogers, Waehler and Werth43} The results of these studies ^{Reference Kearns, Muldoon, Msetfi and Surgenor42,Reference Yakunina, Rogers, Waehler and Werth43} suggest that suicide-related stigma decreases the intention of seeking help from friends and family but not necessarily from professional sources. Research conducted in Australia ^{Reference Burke, Calear, Cruwys and Batterham44} found that parents who reported higher levels of public stigma towards suicide had more negative attitudes towards help-seeking for their child and lowered intentions to seek help for their child. All three studies which found suicide-related stigma to be associated with a decrease in help-seeking considered help-seeking among young adults ^{Reference Kearns, Muldoon, Msetfi and Surgenor42,Reference Yakunina, Rogers, Waehler and Werth43} or parents’ help-seeking behaviours on behalf of their children aged between 12 and 18 years old. ^{Reference Burke, Calear, Cruwys and Batterham44}  By contrast, Roskar et al, ^{Reference Roskar, Kralj, Andriessen, Krysinska, Vinko and Podlesek45} who found no association between suicide-related stigma and help-seeking, conducted their research in Slovenia among suicidologists with an average age of 52 years. The studies also varied with respect to the type of suicide-related stigma measured; three studies ^{Reference Yakunina, Rogers, Waehler and Werth43–Reference Roskar, Kralj, Andriessen, Krysinska, Vinko and Podlesek45} measured public and perceived stigma towards those who die by suicide, whereas Kearns et al ^{Reference Kearns, Muldoon, Msetfi and Surgenor42} measured stigma towards suicide attempts.

Those with experience of suicidal ideation and/or behaviours

A study conducted with those who had past experiences of suicidal ideation in Australia found that increased public stigma towards people who die by suicide significantly predicted negative attitudes toward help-seeking and reduced intentions of seeking help from a mental health professional. ^{Reference Calear, Batterham and Christensen46} Further research in Australia ^{Reference Maclean, Forrester, Hawgood, O’Gorman and Rimkeviciene47} conducted among a sample of 140 individuals found that self-stigmatisation of suicidal behaviour was associated with decreased help-seeking intentions.

Those bereaved by suicide

In a single study of 81 individuals bereaved by suicide in Lithuania, ^{Reference Geležėlytė, Gailienė, Latakienė, Mažulytė-Rašytinė, Skruibis and Dadašev48} those who sought help tended to have higher levels of perceived stigmatisation and guilt about the death of a loved one as a result of suicide. These individuals also had more positive attitudes toward seeking help.

General population

Three studies ^{Reference Fong and Yip49–Reference Prawira and Sukmaningrum51} conducted among those with no history of suicide or exposure to suicide reported conflicting results. Al Shannaq and Aldalaykeh ^{Reference Al-Shannaq and Aldalaykeh50} focused on 707 Arab youths and found a negative association between attitudes towards psychological help-seeking and public stigma towards suicide; however, when multivariable regression analyses were conducted, public stigma towards suicide was not a significant predictor of help-seeking. Among 2022 students from Hong Kong, higher levels of public stigma towards suicide were associated with lowered help-seeking behaviours. ^{Reference Fong and Yip49} By contrast, research with 284 university students in Jakarta ^{Reference Prawira and Sukmaningrum51} found that higher levels of public stigma towards those who die by suicide were associated with increased intentions to seek help, suggesting that suicide-related stigma was a protective factor within this sample. ^{Reference Prawira and Sukmaningrum51}

Those bereaved by suicide

Two studies from the USA found that perceived suicide-related stigma was associated with significantly greater grief-related difficulties ^{Reference Oexle, Feigelman and Sheehan38,Reference Feigelman, Cerel, Sheehan and Oexle52} and an increased likelihood of the suicide being kept a secret. ^{Reference Oexle, Feigelman and Sheehan38}

History of suicidal ideation and/or attempt(s)

Two studies ^{Reference Rimkeviciene, Mok, Shand, Hawgood and O’Gorman36,Reference Ruzhenkov, Ruzhenkova, Boeva and Moskvitina37} with a combined total of 4072 participants reported that higher levels of personal stigmatisation of one’s own suicidality were associated with higher levels of psychological distress and/or psychotic symptoms.

Those bereaved by suicide

Among 240 people bereaved by suicide in Italy, levels of depression were positively associated with levels of perceived stigma towards those bereaved by suicide. ^{Reference Scocco, Preti, Totaro, Corrigan and Castriotta53} Perceived stigma towards those bereaved by suicide was also found to be positively associated with feelings of shame and guilt and negatively associated with well-being among those bereaved by suicide in Lithuania. ^{Reference Geležėlytė, Gailienė, Latakienė, Mažulytė-Rašytinė, Skruibis and Dadašev48}

General population

One study, conducted with a large sample of 2022 young adults in Hong Kong, found that viewing suicide as selfish was significantly associated with higher levels of psychological distress. ^{Reference Fong and Yip49}

Experience of suicide in professional and/or personal life

Across a range of populations (students, pharmacists, the general population and religious leaders), eight studies ^{Reference Williams, Cero, Gauthier and Witte54–Reference Calear, Morse, Christensen, McCallum, Werner-Seidler and Alexander61} found suicide-related stigma to be lower in those with experience of suicide in their professional and/or personal lives. Conversely, among a sample of 466 Spanish individuals, those who had been exposed to a loss or a suicide attempt reported greater public stigma towards those who die by suicide compared with those who had no experiences of suicide. ^{Reference Collado, Martinez, Cangas and Trigueros62} Further, the study by Murphy et al ^{Reference Murphy, O’Reilly, Ataya, Doucette, Martin-Misener and Rosen59} highlighted cultural differences, as more Australian than Canadian pharmacists endorsed the measure that those who die by suicide are cowardly, irresponsible and disconnected. A final study ^{Reference Wu, Chen, Batterham and Han63} conducted among Chinese students found no association between stigma towards suicide attempts or those bereaved by suicide and levels of exposure to suicide.

History of suicidal ideation

Six studies found suicidal ideation to be associated with lower levels of public stigma towards those who die by suicide, ^{Reference Batterham, Calear and Christensen32,Reference Williams, Cero, Gauthier and Witte54,Reference Kheibari, Cerel and Victor57,Reference Eskin, Voracek, Stieger and Altinyazar64–Reference Jahan, Sharif and Hasan66} whereas two studies conducted in Australia found the opposite. ^{Reference Batterham, Han, Calear, Anderson and Christensen67,Reference Sharwood, Calear, Batterham, Torok, McGillivray and Rheinberger68} These studies found that the presence of a suicide plan was associated with greater stigma towards those who die by suicide, ^{Reference Batterham, Han, Calear, Anderson and Christensen67} and those who had attended the emergency department for a suicidal crisis had higher levels of public stigma towards suicide compared with the community sample. ^{Reference Sharwood, Calear, Batterham, Torok, McGillivray and Rheinberger68} Furthermore, individuals who had attended the emergency department for a suicide attempt had higher levels of perceived stigma than their family members. ^{Reference Cerel, Currier and Conwell69} Moreover, two studies ^{Reference Wu, Chen, Batterham and Han63,Reference Han, Batterham, Calear, Wu, Shou and van Spijker70} in two separate Chinese samples found no significant correlations of suicidal ideation with public stigma towards suicide or with stigma towards suicide attempts and those bereaved by suicide. Further, Vatan et al ^{Reference Vatan, Gencoz, Walker and Lester71} reported conflicting findings across samples: in Turkish students, higher suicidal ideation scores were associated with higher levels of stigma towards attempted suicide, whereas the opposite was found within the American sample of students.

History of suicide attempt(s)

Using the Self-Stigma of Suicide Attempt Scale ^{Reference Sheehan, Oexle, Dubke, Wan and Corrigan72} in a US sample of 292 individuals, researchers found that those with a suicide attempt within the past year were more likely to apply stereotypes to themselves and experience harm as a result compared with those with more historical suicide attempts. ^{Reference Sheehan, Oexle, Dubke, Wan and Corrigan72} The same results were found when comparing those with multiple suicide attempts and those with only one attempt. ^{Reference Sheehan, Oexle, Dubke, Wan and Corrigan72} Three studies ^{Reference An and Lee73–Reference Scocco, Toffol and Preti75} found that those with a suicide attempt history had greater stigma towards suicide attempts and suicide more generally compared to those without. Among a sample of 679 individuals in the USA, which compared suicide attempt survivors’ and their families’ experiences of attending the emergency department after an attempt, researchers found that suicide attempt survivors were more likely to feel that staff made them feel punished or stigmatised owing to their suicide attempt compared with their family members (54.5 v. 28.8%). ^{Reference Cerel, Currier and Conwell69} This is consistent with a study from Slovenia, ^{Reference Roskar, Kralj, Andriessen, Krysinska, Vinko and Podlesek45} which found that a suicidal history was associated with anticipated suicide stigma. In a Korean sample, a history of suicide attempts significantly predicted the stigma an individual held towards others who had made a suicide attempt. ^{Reference Park, Kim, Cho and Lee76} Conversely, five studies found the opposite or no association at all. ^{Reference Batterham, Calear and Christensen32,Reference Williams, Cero, Gauthier and Witte54,Reference Kheibari, Cerel and Victor57,Reference Jahan, Sharif and Hasan66,Reference Arafat, Hussain, Hossain, Islam and Menon77} Two studies ^{Reference Williams, Cero, Gauthier and Witte54,Reference Kheibari, Cerel and Victor57} found lifetime suicide attempts to be negatively associated with public stigma regarding suicide. Among students and young adults from Bangladesh, a country where suicide is still illegal, public stigma towards those who die by suicide was found to be significantly lower in those with past suicide attempts compared with those without. ^{Reference Jahan, Sharif and Hasan66,Reference Arafat, Hussain, Hossain, Islam and Menon77} Furthermore, among 1286 Australian adults, no association was found between suicide attempt history and public suicide-related stigma. ^{Reference Batterham, Calear and Christensen32}

Those bereaved by suicide

Four studies ^{Reference Kolves, Zhao, Ross, Hawgood, Spence and de Leo78–Reference Pitman, Osborn, Rantell and King81} investigated the differences between suicide bereavement and other sudden bereavements using the Grief Experience Questionnaire ^{Reference Barrett and Scott82} in the UK ^{Reference Harwood, Hawton, Hope and Jacoby79,Reference Pitman, Osborn, Rantell and King81} and Australia. ^{Reference Kolves, Zhao, Ross, Hawgood, Spence and de Leo78,Reference Kolves, Zhao, Ross, Hawgood, Spence and de Leo80} These studies found that individuals bereaved by suicide had higher levels of suicide-related stigma, shame, guilt, rejection and responsibility than those bereaved by other sudden natural or unnatural deaths, ^{Reference Kolves, Zhao, Ross, Hawgood, Spence and de Leo78–Reference Pitman, Osborn, Rantell and King81} and that the differences between these groups persisted over time. ^{Reference Kolves, Zhao, Ross, Hawgood, Spence and de Leo78} Two studies ^{Reference Scocco, Preti, Totaro, Corrigan and Castriotta53,Reference Scocco, Preti, Totaro, Ferrari and Toffol83} conducted in Italy investigated different aspects of the relationship between perceived suicide-related stigma and suicide among those bereaved by suicide. Among 240 people bereaved by suicide in Italy, ^{Reference Scocco, Preti, Totaro, Corrigan and Castriotta53} levels of perceived stigma towards those bereaved by suicide increased as the number of days since their loved one’s suicide increased. The other study conducted in Italy ^{Reference Scocco, Preti, Totaro, Ferrari and Toffol83} found no significant differences between individuals bereaved by suicide with and without past suicide attempts in terms of their perceived suicide-related stigma scores.

One study ^{Reference Kheibari, Szechy, Cerel and Fruhbauerova84} explored differences in public suicide-related stigma between individuals bereaved by suicide and suicide attempt survivors in the USA. This study found no significant differences among those bereaved by suicide, suicide attempt survivors and those who were members of both groups in terms of the stigmatisation of suicide. Further, among those bereaved by suicide, no difference was found with regard to stigmatisation of suicide when comparing whether the loss involved an immediate family member or not. A multiple regression analysis found that those who experienced both a loss and an attempt had lower suicide-related stigma scores than those who were solely bereaved by suicide, and that feeling very close to the deceased was also associated with less suicide-related stigma.

Those bereaved by suicide

Among a sample of help-seeking individuals bereaved by suicide in Italy, ^{Reference Scocco, Preti, Totaro, Corrigan and Castriotta53} levels of complicated grief were not related to levels of perceived stigma towards those bereaved by suicide.

Experience of suicide in professional and/or personal life

Among a sample of 83 suicidologists in Slovenia, personal experiences with mental illness were associated with anticipated public suicide-related stigma. ^{Reference Roskar, Kralj, Andriessen, Krysinska, Vinko and Podlesek45} This was, however, a small sample of professionals, and so the results are not necessarily generalisable. Among a larger sample of Canadian and Australian pharmacists, ^{Reference Murphy, O’Reilly, Ataya, Doucette, Martin-Misener and Rosen59} individuals were more likely to agree with words describing those who die by suicide as pathetic, stupid, irresponsible and cowardly if they had not suffered from or had a close relation or friend with a mental illness.

History of suicidal ideation and/or attempt(s)

Among a mixed sample including people from the general population, people with a mental health condition, a suicide attempt history and those bereaved by suicide, those with a mental health condition stigmatised suicide attempts and those bereaved by suicide more than the general population. ^{Reference Scocco, Castriotta, Toffol and Preti74} Further, among 67 individuals in Italy, ^{Reference Scocco, Toffol and Preti75} higher levels of psychological distress were associated with higher levels of perceived stigma towards suicide attempts among those with a history of past suicide attempts. The study found no link between psychological distress and perceived stigma towards suicide attempts among individuals without a history of past suicide attempt. Two studies ^{Reference Sheehan, Oexle, Dubke, Wan and Corrigan72,Reference Frey, Hans and Cerel85} found that higher levels of self-stigma or perceived stigma towards suicide and suicide attempts were associated with higher levels of depression. Furthermore, self-stigma towards suicide attempts was associated with decreased recovery, self-esteem and empowerment among a US sample of 292 individuals. ^{Reference Sheehan, Oexle, Dubke, Wan and Corrigan72} Only two studies ^{Reference Batterham, Han, Calear, Anderson and Christensen67,Reference Sharwood, Calear, Batterham, Torok, McGillivray and Rheinberger68} found psychological distress to be associated with lower stigmatisation scores among those with experiences of suicidal behaviours. They were also the only studies to measure public stigma towards those who die by suicide, rather than suicide attempts and/or self-stigma of personal suicidal thoughts or attempts.

Those bereaved by suicide

A study comprising 155 individuals bereaved by suicide in Italy ^{Reference Scocco, Preti, Totaro, Ferrari and Toffol83} found levels of psychological distress and suffering to be positively associated with levels of perceived stigma towards those bereaved by suicide. This link persisted even after accounting for factors such as time since suicide, relationship to the decedent and demographic factors in both studies.

General population

Three studies conducted in Korea, China, and a mixed sample from Turkey and America ^{Reference Wu, Chen, Batterham and Han63,Reference Vatan, Gencoz, Walker and Lester71,Reference An and Lee73} found that higher levels of psychological distress and/or depression were associated with higher levels of public stigma towards suicide and perceived stigma towards suicide attempts. On the contrary, three studies conducted with the general population ^{Reference Batterham, Calear and Christensen32} and among university students ^{Reference Williams, Cero, Gauthier and Witte54,Reference Wahab, Shah, Sivachandran, Shahruddin, Ismail and Mohan86} found public suicide-related stigma to be lower in those with personal experiences of mental illness. ^{Reference Batterham, Calear and Christensen32,Reference Williams, Cero, Gauthier and Witte54,Reference Wahab, Shah, Sivachandran, Shahruddin, Ismail and Mohan86} Research conducted with a sample of 290 individuals in Malaysia ^{Reference Wahab, Shah, Sivachandran, Shahruddin, Ismail and Mohan86} used the Attitude Towards Suicide ^{Reference Renberg and Jacobson87} scale to measure a range of different attitudes towards suicide and found that those with a family history of psychiatric illness were less likely to agree with the stigmatising statement ‘suicide should not be committed, and it is a taboo’ compared with those without such a family history. ^{Reference Wahab, Shah, Sivachandran, Shahruddin, Ismail and Mohan86} However, in a study of 224 Chinese students ^{Reference Han, Batterham, Calear, Wu, Shou and van Spijker70} and another of 319 medical students from Nepal, ^{Reference Gupta, Sharma, Sah, Sharma, Jha and Chapagai88} there were no associations between depression or anxiety and public stigma towards suicide.

Experience of suicide in professional and/or personal life

Four studies ^{Reference Doria, Momper and Burrage89–Reference Osafo, Akotia, Quarshie, Andoh-Arthur and Boakye92} investigated the relationship between suicide and suicide-related stigma among those with experiences of suicide. Mugisha et al ^{Reference Mugisha, Hjelmeland, Kinyanda and Knizek90} investigated the relationship between public suicide-related stigma and suicide among the Baganda, a religious group based in Uganda. This study reported that the house where a person who died by suicide previously lived is often destroyed with all of its contents, as the property is seen as ‘socially infectious’. This study also found that the burial site is viewed as dangerous, with one participant stating: ‘Suicide is a danger including the burial site’. This quote also highlights the idea that suicide is a danger to those around the individual who has died by suicide. This idea of social transmission was also expressed in three other studies, ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Sheehan, Oexle, Armas, Wan, Bushman and Glover93,Reference Goulah-Pabst94} which investigated the relationship among those bereaved by suicide ^{Reference Sheehan, Oexle, Armas, Wan, Bushman and Glover93,Reference Goulah-Pabst94} and suicide attempt survivors. ^{Reference Sheehan, Corrigan and Al-Khouja6} In addition, a sample of 73 American Indian/Native youth, adults and elders in the USA were asked about suicide and reported mixed findings, with many saying that suicide was both normalised and stigmatised. ^{Reference Doria, Momper and Burrage89} Indeed, they argued that this dual understanding meant youth felt accustomed to suicide but also ashamed to talk about it. ^{Reference Doria, Momper and Burrage89} A study conducted in Ghana, ^{Reference Osafo, Knizek and Hjelmeland91} among a sample of nine clinical psychologists and eight emergency ward nurses, found that nurses viewed suicide as a sinful criminal act. They also viewed those who were suicidal as ‘wicked’ and ‘crazy’, and they blamed the suicidal person: ‘I make them feel guilty that what they are doing is a criminal offence’. By contrast, the psychologists were more likely to be empathetic and supportive, disagreeing with the view of suicide as a criminal act. Similar results were found among a sample of ten community leaders in Ghana, ^{Reference Osafo, Akotia, Quarshie, Andoh-Arthur and Boakye92} who reported viewing suicide as a criminal and immoral act that leads to anger among the community towards the family of those who have lost a loved one to suicide as well as the person who has attempted or died by suicide.

History of suicidal ideation and/or attempt

In total, 16 studies described the experiences of shame ^{Reference Binnix, Rambo, Abrutyn and Mueller95,Reference Blanchard and Farber96} and labelling ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Cerel, Currier and Conwell69,Reference Sheehan, Oexle, Armas, Wan, Bushman and Glover93,Reference Binnix, Rambo, Abrutyn and Mueller95,Reference Azizpour, Taghizadeh, Mohammadi and Vedadhir97–Reference Williams, Frey, Stage and Cerel107} felt by individuals with a history of suicidal ideation or suicide attempt(s). For example, one suicide attempt survivor stated, ‘It was sort of like I brought shame upon my family and stuff like that’, ^{Reference Binnix, Rambo, Abrutyn and Mueller95} and this shame may have led to the rejection of suicide attempt survivors by their family members, as was found in a sample of 20 individuals. ^{Reference Binnix, Rambo, Abrutyn and Mueller95} The fear of being stigmatised was also commonly reported across four studies; ^{Reference Sheehan, Oexle, Armas, Wan, Bushman and Glover93,Reference Azizpour, Taghizadeh, Mohammadi and Vedadhir97,Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100,Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101} for example, ‘…they assume that I’m not normal, mad or crazy’. ^{Reference Azizpour, Taghizadeh, Mohammadi and Vedadhir97} Seven studies ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Cerel, Currier and Conwell69,Reference Binnix, Rambo, Abrutyn and Mueller95,Reference Maple, Frey, McKay, Coker and Grey99–Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101,Reference Freeman, Strauss, Hamilton, Pugh, Browne and Caren105} also reported that many who had attempted suicide were labelled as ‘attention seeking’, ‘stupid’ or ‘weak’ by those around them; for example, ‘they told me I just did it for attention’. ^{Reference Cerel, Currier and Conwell69} Another common stereotype was that those who attempt suicide are selfish or doing it to hurt others: ‘only selfish people die by suicide’ ^{Reference Frey, Hans and Cerel98} and ‘How dare you do something… we are trying so hard to help you?’. ^{Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101} These stereotypes often appeared to be internalised, as studies ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Binnix, Rambo, Abrutyn and Mueller95,Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100,Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101,Reference Gaffney and Bergmans103,Reference Williams, Frey, Stage and Cerel107} found that participants viewed their attempt as something that signified that they were ‘selfish’, ‘crazy’, ‘silly’, ‘weak’, ‘useless’, ‘damaged’, ‘soft in the head’ or a ‘loser’.

Related to the findings above, eight studies ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Sheehan, Oexle, Armas, Wan, Bushman and Glover93,Reference Binnix, Rambo, Abrutyn and Mueller95–Reference Azizpour, Taghizadeh, Mohammadi and Vedadhir97,Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100,Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101,Reference Williams, Frey, Stage and Cerel107} found that among those with a suicidal history, stigmatising reactions from those around them often led to the internalisation of these suicide-related stigmas. To avoid these stigmatising attitudes, those with a suicidal history often chose to conceal their suicidal thoughts or behaviours. These studies were conducted in a range of countries with different cultural backgrounds (USA, Germany, Iran and Australia), but they all reported similar results. The following quotes highlight these findings: ‘I keep it in… I think there’s something about it that might make me feel like its expressing vulnerability or weakness’, ^{Reference Binnix, Rambo, Abrutyn and Mueller95} ‘It’s embarrassing’. ^{Reference Blanchard and Farber96} This secrecy and desire to conceal a suicide attempt was also described by family members of those who attempted suicide. ^{Reference Maple, Frey, McKay, Coker and Grey99}

Nine studies ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Sheehan, Oexle, Armas, Wan, Bushman and Glover93,Reference Frey, Hans and Cerel98,Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100,Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101,Reference Anderson, Rayner and Duckworth106–Reference Ünsal and İnan109} found that those who were suicidal experienced distancing from others or had distanced themselves from others to avoid suicide-related stigma, thereby perpetuating secrecy. One participant in a study conducted in the USA ^{Reference Frey, Hans and Cerel98} stated that her mother said: ‘If you’re going to be this way, I don’t want to know about it’. Others experienced ostracism and rejection from friends and family following an attempt ^{Reference Azizpour, Taghizadeh, Mohammadi and Vedadhir97,Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101,Reference Williams, Frey, Stage and Cerel107–Reference Ünsal and İnan109} : ‘I was told I was not part of the family… even my friends did not welcome me into their fold… I felt abandoned because it was like no one wanted to associate himself with a person who wanted to kill himself’ ^{Reference Osafo, Akotia, Andoh-Arthur and Quarshie108} and ‘A community can be so stigmatizing… they can actually further isolate that person who has a suicidal past’. ^{Reference Williams, Frey, Stage and Cerel107} Three studies, ^{Reference Frey, Hans and Cerel98,Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101,Reference Ünsal and İnan109} conducted in Turkey, Australia and the USA, found that after an attempt, individuals often felt blamed and misunderstood, which may have led to further feelings of rejection and ostracism: ‘I felt even more misunderstood… they put the blame on me’. ^{Reference Frey, Hans and Cerel98}

In a sample of 679 US citizens, the experiences of suicide attempt survivors and their family members when attending the emergency department after an attempt were investigated. ^{Reference Cerel, Currier and Conwell69} Suicide attempt survivors reported that nurses held views that suicide was sinful and a crime: ‘Didn’t I know I was committing a sin?’. Another participant reported that hospital staff ‘…treated me like a criminal’. Family members reported hearing similar stigmatising views: ‘nurses scolded [my mother] …telling her she will end up in hell and asking how she could do that to her family’. ^{Reference Cerel, Currier and Conwell69} A further five ^{Reference Blanchard and Farber96–Reference Frey, Hans and Cerel98,Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100,Reference Asare-Doku, Osafo and Akotia110} studies reported stigmatising beliefs that suicide was a sin or morally wrong. Two studies ^{Reference Sheehan, Oexle, Armas, Wan, Bushman and Glover93,Reference Maple, Frey, McKay, Coker and Grey99} found that doctors were also judgemental of suicide attempt survivors; for example, one participant stated: ‘One doctor said, “Get him out of here. He doesn’t deserve to be here”…’. ^{Reference Maple, Frey, McKay, Coker and Grey99} This stigmatisation of suicide was also highlighted by numerous quotes from a study conducted in Australia, ^{Reference Freeman, Strauss, Hamilton, Pugh, Browne and Caren105} which investigated the experiences of 35 individuals attending the emergency department with suicidal thoughts or behaviours; these quotes included: ‘…we can’t find a bed for you. I’m sorry you’re gonna have to go home because this isn’t a hotel’. On the contrary, a participant from another study conducted in Australia ^{Reference Maple, Frey, McKay, Coker and Grey99} stated that a doctor tried to destigmatise an attempt to her family members: ‘She had been blaming me and the doctor said, “No stop this is her illness”’. Three studies ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101,Reference Freeman, Strauss, Hamilton, Pugh, Browne and Caren105} reported the stigmatising view that those who attempt suicide are unable to recover; a family member of a suicide attempt survivor stated that a clinician told them ‘Once suicidal, always suicidal’, ^{Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101} and, when attending the emergency department for suicidal thoughts, one participant said in relation to doctors ‘they just say “oh, you again”’. ^{Reference Freeman, Strauss, Hamilton, Pugh, Browne and Caren105}

Four studies ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Sheehan, Oexle, Armas, Wan, Bushman and Glover93,Reference Binnix, Rambo, Abrutyn and Mueller95,Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101} found that discrimination in the workplace as a result of suicide-related stigma was commonly reported among those with experiences of suicidal thoughts and/or attempts. For example, a study conducted among those with a history of ideation and/or attempts ^{Reference Binnix, Rambo, Abrutyn and Mueller95} included quotes such as ‘And if you’re an employee there, clearly you don’t say that [you are suicidal] because if you do, you’re going to get fired or something like that’. Among Iranian women, suicide is viewed as unacceptable; however, stigmatising attitudes towards suicide in this group manifested slightly differently compared with other samples included in this review. For example, women who had attempted suicide were believed to have been having extra-marital affairs: ‘people will say that you have had extra marital sexual relationships!’. ^{Reference Azizpour, Taghizadeh, Mohammadi and Vedadhir97} In Ghana, suicide is condemned, and those who attempted suicide reported being physically attacked as a result: ‘They beat me up mercilessly, hitting me with all kinds of objects…’. ^{Reference Osafo, Akotia, Andoh-Arthur and Quarshie108} Similar findings were reported in a study of suicide attempt survivors in Australia; one participant stated ‘after the suicide attempt he actually treated me really badly. I was in a domestic violence situation… he was nastier than ever to me’. ^{Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101}

Those bereaved by suicide

Individuals bereaved by suicide also experience public suicide-related stigma, as is made explicit by quotes extracted from three studies ^{Reference Chapple, Ziebland and Hawton111,Reference Richardson, McDonnell, Carroll and O’Donnell113} : ‘I certainly have felt the stigma of suicide’, ^{Reference Chapple, Ziebland and Hawton111} ‘Somehow it is still a taboo topic’, ^{Reference Oexle, Puschner, Votruba, Rüsch and Mayer112} and ‘suicide is still taboo’. ^{Reference Richardson, McDonnell, Carroll and O’Donnell113} Twenty-one studies ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Goulah-Pabst94,Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102,Reference Mayer, Puschner, Votruba, Rüsch and Oexle104,Reference Chapple, Ziebland and Hawton111,Reference Oexle, Puschner, Votruba, Rüsch and Mayer112,Reference An Fhaili, Flynn and Dowling114,Reference Groh, Anthony and Gash128} explored the experience of those bereaved by suicide with respect to suicide-related stigma. Fourteen studies ^{Reference Goulah-Pabst94,Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102,Reference Mayer, Puschner, Votruba, Rüsch and Oexle104,Reference Oexle, Puschner, Votruba, Rüsch and Mayer112,Reference An Fhaili, Flynn and Dowling114,Reference Fielden116,Reference Ohayi118,Reference Ross, Kairi and De121,Reference Ali and Rehna123,Reference Chen, Zhang and McCormack127,Reference Groh, Anthony and Gash128} found that those bereaved by suicide reported experiencing suicide-related stigma in the form of feeling blamed, shamed, judged and isolated after their suicide loss. As a result, individuals bereaved by suicide chose to keep the suicide a secret to avoid these stigmatising attitudes. ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Goulah-Pabst94,Reference Azorina, Morant, Nesse, Stevenson, Osborn and King115,Reference Fielden116,Reference Peters, Cunningham, Murphy and Jackson119,Reference Pitman, Stevenson, Osborn and King120,Reference Heard, McGill, Skehan and Rose125,Reference Zou, Tang and Bie126} In a sample of ten people bereaved by suicide, ^{Reference Peters, Cunningham, Murphy and Jackson119} this was demonstrated by quotes such as ‘suicide is like just a stigma thing, people look down on you when you tell them how he died’. Similarly, in Taiwan, suicide is seen as shameful, and a person who dies by suicide is expelled from family ancestry as punishment. ^{Reference Tzeng, Su, Tzeng, Yeh, Chen and Chen122} Suicide-related stigma often led to social awkwardness ^{Reference Chapple, Ziebland and Hawton111,Reference Azorina, Morant, Nesse, Stevenson, Osborn and King115} and those bereaved by suicide isolating themselves and feeling alone and unsupported by those around them. ^{Reference Goulah-Pabst94,Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102,Reference Mayer, Puschner, Votruba, Rüsch and Oexle104,Reference Chapple, Ziebland and Hawton111,Reference An Fhaili, Flynn and Dowling114,Reference Peters, Cunningham, Murphy and Jackson119,Reference Ross, Kairi and De121,Reference Ali and Rehna123,Reference Heard, McGill, Skehan and Rose125,Reference Chen, Zhang and McCormack127} For example, a participant in a study conducted in Australia ^{Reference Ross, Kairi and De121} stated: ‘I felt a little bit rejected and a bit isolated’, and in another study in the UK, ^{Reference Chapple, Ziebland and Hawton111} participants reported being avoided by others: ‘people will walk across the other side of the street sometimes to avoid talking to you…’. Seven studies ^{Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102,Reference Mayer, Puschner, Votruba, Rüsch and Oexle104,Reference Oexle, Puschner, Votruba, Rüsch and Mayer112,Reference Peters, Cunningham, Murphy and Jackson119,Reference Ali and Rehna123,Reference Chen, Zhang and McCormack127,Reference Groh, Anthony and Gash128} found that individuals bereaved by suicide felt blamed for the death, as in the following quote ‘…they blame me’. ^{Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102} Contrary to this was a quote from a study conducted in Germany ^{Reference Mayer, Puschner, Votruba, Rüsch and Oexle104} : ‘they encouraged us and told us we are not to blame’, again indicating individual differences both between and within studies.

Similar to studies conducted with suicide attempt survivors and those experiencing suicidal ideation, five studies ^{Reference Sheehan, Corrigan and Al-Khouja6,Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102,Reference Mayer, Puschner, Votruba, Rüsch and Oexle104,Reference Oexle, Puschner, Votruba, Rüsch and Mayer112,Reference Ohayi118} reported that those bereaved by suicide also experienced being labelled as ‘loony’, ‘unstable’, ‘weak’, ‘cursed’, ‘dysfunctional’ or ‘abnormal’ because of their association with suicide. Again, these labels led to secrecy – ‘You can’t talk about it – lest they will label you unstable’ ^{Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102} – or a wish that a diagnosis of suicide was not given for the death of their relation, as in a prospective study conducted in Nigeria. ^{Reference Ohayi118} Parents whose children had died by suicide found it difficult to talk about because of suicide-related stigma; one participant in a study conducted in Australia ^{Reference Maple, Edwards, Plummer and Minichiello117} stated: ‘It is one of those… an embarrassing situation, and stigma still exists… it is very hard as a parent to accept’. Five studies ^{Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102,Reference Ohayi118,Reference Ali and Rehna123,Reference Sever and Ozdemir124,Reference Chen, Zhang and McCormack127} reported suicide as being viewed as sinful, immoral and wrong. In one study conducted in the USA, ^{Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102} a suicide survivor discussed the stigmatising language used around suicide and how this could lead to beliefs that it is morally wrong, illegal or a sin: ‘I couldn’t stand to hear committed suicide. It felt like [my loved one] committed a crime – robbery, rape, or murder’. Further, in two other studies, ^{Reference Ali and Rehna123,Reference Sever and Ozdemir124} Islamic individuals bereaved by suicide voiced the influence their religion had on their beliefs around suicide: ‘In our religion suicide is prohibited’. ^{Reference Ali and Rehna123} Like suicide attempt survivors, those bereaved by suicide reported experiencing discrimination in the workplace, ^{Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102,Reference Chapple, Ziebland and Hawton111,Reference Oexle, Puschner, Votruba, Rüsch and Mayer112,Reference Ross, Kairi and De121} for example: ‘I certainly have felt the stigma of suicide… I’ve felt it within my work colleagues’. ^{Reference Chapple, Ziebland and Hawton111}

People bereaved by suicide also expressed fears with regard to those who they had lost to suicide being labelled negatively. ^{Reference Sheehan, Corrigan, Al-Khouja, Lewy, Majo and Mead102,Reference Mayer, Puschner, Votruba, Rüsch and Oexle104,Reference Oexle, Puschner, Votruba, Rüsch and Mayer112} Those who had lost a loved one to suicide reported being told that the deceased was selfish; one participant stated, ‘others said that he was totally selfish’, and another stated ‘…people said that if they were me, they would hate him because what he did to me was not fair’. ^{Reference Mayer, Puschner, Votruba, Rüsch and Oexle104} Further, research conducted with a sample of 30 individuals in China ^{Reference Zou, Tang and Bie126} found that those who knew someone who died by suicide could often hold negative opinions of the individual. For example, some individuals bereaved by suicide distanced themselves from those they knew who died by suicide – as one participant stated, ‘I know that she is psychotic, and I am a normal person, so my world is definitely different from hers’ – and often, after a suicide, those around the individual who died changed their opinion of them: ‘My impression of him plummeted’. ^{Reference Zou, Tang and Bie126}

It may be worth highlighting that one of the studies conducted in Germany, ^{Reference Oexle, Puschner, Votruba, Rüsch and Mayer112} with an all-female sample, found that although all participants talked about fearing negative judgement, only around a quarter had experienced judgemental reactions. This highlights the negative influence that anticipated suicide-related stigma can have on individuals affected by suicide. In three studies, ^{Reference Sheehan, Oexle, Armas, Wan, Bushman and Glover93,Reference Gaffney and Bergmans103,Reference Oexle, Puschner, Votruba, Rüsch and Mayer112} some participants from a range of backgrounds (suicide attempt survivors, those bereaved by suicide) stated that talking about suicide was important to expel the stigma surrounding it, despite the negative social consequences. Participants in a study conducted in the USA ^{Reference Vatan, Gencoz, Walker and Lester71} stated that by disclosing their suicide attempt they were trying to challenge suicide-related stigma, which they hoped would help survivors of an attempt to manage their internalised suicide-related stigma. One participant explained: ‘The more we talk about it and the more people hear it, the less taboo it becomes, the less silent people are about it, and the less stigma’. ^{Reference Sheehan, Oexle, Armas, Wan, Bushman and Glover93} Further, a study conducted in Canada ^{Reference Gaffney and Bergmans103} highlighted the importance of talking about suicide within a peer support group, to overcome internalised suicide-related stigma: ‘I do have some value to bring from my experiences’. Similar results were found among those bereaved by suicide; one participant stated regarding their reason for sharing their loss: ‘I want people to realize that suicide is quite common, so that it is no longer taboo to talk about it’. ^{Reference Oexle, Puschner, Votruba, Rüsch and Mayer112}

Experience of suicide in professional and/or personal life

Research conducted with 73 individuals from the American Indian and Alaskan Native populations ^{Reference Doria, Momper and Burrage89} investigated the association between help-seeking and suicide-related stigma. One of the key findings from this study was that youth do not report feelings of suicidality because they are ‘scared to talk about it’ owing to stigmatising feelings of disgust and stupidity.

History of suicidal ideation and/or attempt(s)

Thirteen studies ^{Reference Maple, Frey, McKay, Coker and Grey99,Reference Rimkeviciene, Hawgood, O’Gorman and De Leo101,Reference Gaffney and Bergmans103,Reference Freeman, Strauss, Hamilton, Pugh, Browne and Caren105,Reference Anderson, Rayner and Duckworth106,Reference Ünsal and İnan109,Reference Richardson, McDonnell, Carroll and O’Donnell113,Reference An Fhaili, Flynn and Dowling114,Reference Heard, McGill, Skehan and Rose125,Reference Denmark, Hess and Becker129,Reference Richards, Whiteside, Ludman, Pabiniak, Kirlin and Hidalgo131} focused on those with personal experiences of suicidal thoughts and/or behaviours. These studies reported that the reasons these individuals had for not disclosing their suicidal thoughts or behaviours to both formal and informal sources of help centred around avoiding suicide-related stigma and staying silent. This silence was due to their experiences with feelings of shame, embarrassment, judgement and rejection, as well as a general fear surrounding talking about suicide. These findings are highlighted by quotes such as: ‘I was ashamed… So I decided not to tell anyone’, ^{Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100} and, when one participant was asked why they did not seek help, they simply stated: ‘shame’. ^{Reference Freedenthal and Stiffman130} Further, two studies ^{Reference Freedenthal and Stiffman130,Reference Richards, Whiteside, Ludman, Pabiniak, Kirlin and Hidalgo131} found that participants did not disclose suicidal ideation or intent because they were worried about being labelled as ‘crazy’; participants stated: ‘they might think I was crazy or something’. ^{Reference Freedenthal and Stiffman130} The prospect of being labelled crazy was linked to a fear of hospital admission and severe treatment, as described by participants in three studies ^{Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100,Reference Heard, McGill, Skehan and Rose125,Reference Skogstad, Deane and Spicer132} : ‘I was scared they will put me into a locked ward’. ^{Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100} There was also a shame associated with attempting suicide, as highlighted by the following quote: ‘I don’t tell anybody because you feel stupid, because you didn’t see through what you intended’. ^{Reference Maple, Frey, McKay, Coker and Grey99} These results indicate that those in need of help use silencing and avoidant behaviours to avoid feeling stigmatised.

Help-seeking experiences are not always positive, owing to the stigmatisation of suicide by healthcare professionals. These attitudes can often be internalised, as was found by three studies ^{Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100,Reference Gaffney and Bergmans103,Reference Freeman, Strauss, Hamilton, Pugh, Browne and Caren105} involving suicide attempt survivors in three different countries (Germany, Canada and Australia). This internalisation could lead to the individual wanting to cope with suicidality on their own; indeed, one participant in a study in Germany ^{Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100} stated: ‘I realized I have to deal with it myself. I decided not to seek professional help or talk to others about it anymore’. Similarly, in studies conducted in Canada ^{Reference Gaffney and Bergmans103} and the UK, ^{Reference Anderson, Rayner and Duckworth106} negative reactions were experienced within a hospital setting; one participant shared that her ‘negative experiences with the system were confirmation that I’m worthless’, and, upon hearing similar experiences within the focus groups, she thought ‘maybe I deserve better too’. ^{Reference Gaffney and Bergmans103} A study conducted in Australia ^{Reference Freeman, Strauss, Hamilton, Pugh, Browne and Caren105} further emphasised the dangers of negative help-seeking experiences, as young people experiencing suicidal thoughts or behaviours reported that if they had negative experiences at the emergency department they would be deterred from attending again in the future, increasing their suicide risk. Among the German sample, ^{Reference Oexle, Herrmann, Staiger, Sheehan, Rusch and Krumm100} two participants did not discuss avoidant behaviour in response to suicide-related stigma and reported less distress; these participants may not have internalised the stigma associated with suicide like the others quoted above.

Those bereaved by suicide

Among people bereaved by suicide, two studies ^{Reference An Fhaili, Flynn and Dowling114,Reference Ohayi118} found that shame related to the loss of a loved one to suicide prohibited participants from seeking help for their own health concerns. For example, in a study conducted in Ireland, ^{Reference An Fhaili, Flynn and Dowling114} participants bereaved by suicide did not want to sit in a general practitioner’s waiting room as a result of feeling ashamed about their loss to suicide, and in one instance backdoor entry was arranged ‘so that no one could see her’. ^{Reference An Fhaili, Flynn and Dowling114} This pattern was also found among a Nigerian sample, ^{Reference Ohayi118} as is highlighted by the following quote: ‘If any of us now will even go to the hospital for anything, people will say that another of their brothers wanted to kill himself’. ^{Reference Ohayi118} As a result of the stigmatisation of suicide, participants found it hard to accept the death and believed accepting help would be accepting the death: ‘Help… for what?… It means that I agree that my relation hanged himself’. ^{Reference Ohayi118}

General population

Among male prisoners in New Zealand, negative labelling of those reporting suicidal thoughts, such as ‘attention-seeking’ and ‘mentally weak’, contributed to the men not seeking help for their suicidal thoughts. ^{Reference Skogstad, Deane and Spicer132}

Those bereaved by suicide

Four studies ^{Reference Mugisha, Hjelmeland, Kinyanda and Knizek90,Reference Mayer, Puschner, Votruba, Rüsch and Oexle104,Reference Tzeng, Su, Tzeng, Yeh, Chen and Chen122,Reference Sever and Ozdemir124} found that those who had lost a loved one to suicide often chose to keep the death a secret and struggled to grieve openly owing to the stigmatisation of suicide. In a study conducted among the Taiwanese community, ^{Reference Tzeng, Su, Tzeng, Yeh, Chen and Chen122} one participant stated: ‘We kept a low profile to hold that funeral… my mother did not die naturally, my father wanted to keep it low profile…’, highlighting the secrecy surrounding suicide. Further, research conducted among the Baganda population (a religious group in Uganda) uncovered an unwritten law within the community that meant they were expected to grieve inwardly if they lost a loved one to suicide, as described in the following quote: ‘When one commits suicide, within our tradition, you are not allowed to shed tears as a sign that you are not in approval of the act’. ^{Reference Mugisha, Hjelmeland, Kinyanda and Knizek90} Moreover, after a death, the Baganda use songs and sayings which usually devalue the person who died by suicide, and the usual grieving period is not allowed; instead, the deceased must be buried immediately. ^{Reference Mugisha, Hjelmeland, Kinyanda and Knizek90} Similarly, in two other studies, ^{Reference Mayer, Puschner, Votruba, Rüsch and Oexle104,Reference Sever and Ozdemir124} the same point was made; one individual bereaved by suicide recalled being told: ‘This is a suicide, don’t be sad’.

Mental health

No qualitative studies that investigated people’s experiences of suicide-related stigma and mental health were included in this review.