Introduction

Among Canadians, there has been a steady decline in mental health status since 2007 [1]. According to Statistics Canada, 77% of youth and young adults ages 15–30, 75% of adults ages 31–46, and 72% of middle aged to older adults ages 47 and older, reported having excellent to good mental health in 2007 [1]. This percentage has steadily declined to 60% among youth and young adults, 66% among adults, and 69% among middle aged to older adults in 2019 [1]. On average more than 12 Canadians die by suicide everyday [2]. Suicide remains the second leading cause of death for those between the ages of 15–34, only surpassed by accidental deaths [3]. Each suicide leaves behind family members, friends, peers, and entire communities to manage the traumatic aftermath of this sudden loss. Those left behind are often referred to as survivors of suicide loss, suicide survivors or individuals bereaved by suicide [4]. These individuals will be referred to as survivors of suicide loss throughout this scoping review protocol.

Each suicide death leaves behind approximately six individuals [5]. This estimate was not based on empirical evidence, however, has been echoed widely [6]. This estimate closely aligns with what has been reported through Statistics Canada with estimates of 7 to 10 individuals impacted by each suicide loss [2]. However, more recently a random-digit dial survey found that approximately 135 individuals are exposed to each suicide within the United States [6]. This large discrepancy questions this widely accepted estimate and further speaks to the importance of understanding the impact of loss on the lives of those exposed to suicide.

Although consensus among researchers has yet to be reached regarding the definition of survivors of suicide loss, recent studies are moving towards providing a common language to identify and categorize the relationship and self-reported degree of closeness to the deceased [7–10]. Bereavement experiences can vary drastically for all types of survivors of suicide loss [10]. Cerel and colleagues suggest a continuum of survivorship with the following four categories (from low to high degree of closeness): 1) suicide exposed (e.g., those who know of someone who died by suicide; however, did not personally experience psychological distress / consequences related to the loss or any long term impacts); 2) suicide affected (e.g., those who lost someone to suicide and experienced psychological distress); 3) suicide bereaved, short term (e.g., those who were close to / had an attachment relationship to the individual who died by suicide and experienced a short term response to bereavement); and 4) suicide bereaved, long term (e.g., those who were close to / had an attachment relationship to the individual who died by suicide and experienced a long term response to bereavement) [8]. The latter three describe situations in which the death has significantly impacted the lives of survivors leading to negative functional or health-related consequences whether temporary/short term (e.g., suicide affected and suicide bereaved short term) or long term and chronic (e.g., suicide bereaved long term). The planned scoping review will include individuals that fall into any of the categories described by Cerel and colleagues [8].

Research has yet to be completed on specific physical and mental health consequences as they relate to the categories outlined in the proposed continuum of survivorship [8]. However, research conducted with survivors of suicide loss across the continuum suggests that they are at a higher risk of experiencing negative physical and mental health outcomes as compared to the general population [2, 4, 11, 12]. Pitman and colleagues compared survivors of suicide loss to those bereaving other types of loss [4]. They observed an increased risk of suicide, psychiatric admissions, and mental illness [4]. An exposure to suicide has also shown to increase the risk of post-traumatic stress disorder [13], depression [14], complicated grief [15], and suicidal ideations [16]. Further, Linde and colleagues studied the grief process following the experience of suicide loss, concluding that it is highly complex due to factors impacting those left behind [17]. In addition to the bereavement of an individual, survivors of suicide loss experience stigma, shame, guilt, need to conceal events surrounding death, blame, rejection, exposure to prior suicide attempts by deceased, familial history of mental health challenges, and strained relationships prior to and following the death [17]. These additional factors contribute to a complicated grief reaction or process, where individuals face further challenges adjusting to life post-loss [17, 18]. Complicated grief reactions are also associated with disruptions in daily functioning which can include a decrease in participation in meaningful activities [19, 20].

As described within occupational therapy literature, this scoping review will define meaningful activities as any task related to self-care, productivity, and leisure “that is performed with some consistency and regularity, that brings structure, and is given value and meaning by individuals and a culture” (i.e., occupation) [21, 22 p. 19]. The occupational therapy and occupational science literature suggests that engagement in meaningful activities can help individuals find meaning in life, ultimately, supporting recovery, meeting basic psychological needs and in turn, improving physical and mental health [23, 24].

There have been several previous reviews of the suicide bereavement and loss literature. A systematic mapping review of this literature completed by Maple and colleague [25], highlights that most studies since 1970 have focused on attitudes towards suicide, stigma, impact on health professionals, comparing types of loss, ethical papers on studying survivors, effectiveness of interventions, estimating exposure, and the experience of survivors, including cultural minorities/indigenous groups. More recent scoping reviews completed by Higgins and colleagues [26] and Kaspersen and colleagues [27], focused on peer-led interventions, and supports / services for those bereaved by suicide. Shields, Kavanagh and Russo completed a systematic review of the qualitative literature focusing on the bereavement process following suicide loss [28]. Their review highlighted three aspects of the bereavement process discussed often in qualitative literature: “the feelings following bereavement by suicide, the process of making meaning of the event, and the social context in which the feelings and meaning-making process occur” [28 p. 447]. This review also emphasized the important role that the meaning making process plays in adjusting to life post loss [28]. A search of the Open Science Framework database for registered scoping review protocols did not identify any literature reviews or protocols with the primary aim of exploring meaningful activities among individuals who have experienced a suicide loss. This protocol has been registered on Open Science Framework Registries (10.17605/OSF.IO/M2NES) and any amendments to this protocol will be reported in the completed scoping review.

Due to complexities related to the experience of suicide loss, the negative mental and physical health outcomes, and the increased risk of experiencing complicated grief, it is imperative that further research be undertaken. This research must focus on exploring concepts such as engagement in meaningful activities, that have shown potential in other contexts to act as protective factors to assist in bettering supports and services for those experiencing a loss. To date, a review synthesizing the literature as it relates to engagement in meaningful activities post suicide loss has yet to be completed. The objectives of this proposed scoping review are to: 1) explore the nature and extent to which the peer-reviewed, suicide loss and bereavement literature addresses engagement in meaningful activities of everyday living; and 2) identify key facilitators and/or barriers that may impact engagement in meaningful activities post-loss.

Methods

Stage 2: Identifying relevant studies

The Population-Concept-Context (PCC) framework provided by the JBI for scoping reviews will be used to inform the search strategy and identify relevant studies [Table 1; 31].

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Table 1. PCC framework: Inclusion and exclusion criteria.

https://doi.org/10.1371/journal.pone.0296522.t001

Inclusion criteria.

To be included studies must: 1) be in a published peer-reviewed journal article; 2) be considered an original literature review or a qualitative/quantitative/mixed methods study, written in English; 3) include participants impacted by suicide loss and bereavement (mixed sample studies are only to be included if they indicate independent results for suicide loss survivors); 4) discuss living/meaningful activity/activities of everyday living in any way and any capacity (e.g., as interventions, postventions, personal stories, quotes, etc.) within the study; and 5) published after 1969. Research on suicide postvention and post-loss intervention gained momentum in the late 1960’s [33, 34]. During this time, terminology concerning the concept of suicide loss began to develop into what it is today [8, 33, 34]. Therefore, this scoping review will be limited to suicide loss literature after 1969. Additional studies will be identified by reviewing the reference lists of included articles and previous review articles following the full text review.

Exclusion criteria.

This review will not include grey literature, books, book chapters, unpublished studies, dissertations, abstracts, and reports. In addition to barriers such as time and resource constraints, these criteria will enable the exclusion of non-peer reviewed work which will assist in ensuring studies included within the review will be of better methodological quality.

Search strategy.

Following multiple consultations with two rehabilitation sciences librarians working at the University of Toronto, two major concepts were identified to assist in the creation of the search strategy: 1) suicide; and 2) bereavement/loss. Meaningful activities of daily living or activities of daily living were not included as, during an exploratory search (completed December 2022), these concepts drastically narrowed the search results and omitted many studies that addressed specific activities within their title/abstract or study aim(s)/question(s)/objective(s) that may fall within the definition of meaningful activities of everyday living listed in the introduction.

The JBI guiding framework outlines three steps to creating a comprehensive search strategy [31]. These steps will allow the research team to ensure that the concepts of suicide and bereavement/loss are being explored to their full capacity to identify articles discussing meaningful activities. First, an initial limited search will be completed using MEDLINE and PsychInfo. The following search strategy will be used:

1. exp suicide (Medical Subject Heading (MeSH))
2. suicid*
3. 1 or 2
4. exp bereavement (MeSH)
5. (bereav* OR loss OR grie* OR mourn*)
6. 4 or 5
7. 3 and 6

During this step, an analysis of the first 10 retrieved articles from each database will be done examining the text within the title, abstract, and identified index terms to ensure all appropriate search terms are included within the search strategy. Next, a second search with all previously and newly identified keywords and index terms, as well as any newly identified keywords and index terms, will be done across all included databases. Again, the first 10 retrieved articles will be examined, and the search strategy will be updated.

To increase comprehensiveness, a novelle cascaded search method will be used to identify any missing or relevant terms to further improve this search strategy. The cascaded search method employs a year-by-year search of the literature to determine if additional relevant text words or index terms should be added. Articles published within a single year will be examined to determine if any alterations can be made to assist in increasing the number of relevant results. All relevant text words within the title and abstract, as well as index terms, used to describe the first 10 articles will be added to the search strategy. The cascaded search method is an iterative process, examining the search strategy across several calendar years. This is completed until new text words or index terms no longer emerge. Finally, JBI methodology outlines the completion of a reference list search following the full text review as the final step in the creation of a comprehensive search strategy.

An in-depth example of a search strategy for MEDLINE can be found in S1 Appendix. Relevant databases chosen in collaboration with librarians at the University of Toronto include MEDLINE, EMBASE, PsychInfo and CINAHL. The methods described above will allow for an extensive search of these four databases.

Limitations

This review does present with some limitations. To begin, as there has been a limited focus directly on meaningful activities within the suicide bereavement and loss literature, inclusion and exclusion criteria may not be easily applied to all studies leading to a potentially time-consuming review or the exclusion of relevant articles. This may be caused by articles not reporting the full scope of their results within their abstracts (e.g., not mentioning results related to adjustment to life, activities of daily living or meaningful activities within their abstracts) or abstracts within bereavement and loss literature not reporting suicide loss survivors as participants. This will be addressed through frequent consultation with the research team to allow for continuous clarification and refining of inclusion and exclusion criteria as reviewers become more familiar with language used within this field through the abstract and title review. In addition, this scoping review will only include articles in English and will not include grey literature, books, book chapters, unpublished studies, dissertations, and reports. This may also exclude relevant articles published in other languages and may miss relevant information found within other types of evidence.

Finally, the quality of included studies will be appraised; however, studies will not be excluded based on the results of their appraisal. This allows for the potential inclusion of lower quality articles. This decision was made as the scope of this review is large, including a wide range of methodologies and study designs. The intention of this review is to identify the nature and extent of the discussion on engagement in meaningful activities of everyday living post lost. This review is not aiming to evaluate the effectiveness of such engagement.

Supporting information

Acknowledgments

We would like to thank and acknowledge the contributions of Erica Nekolaichuk and Julia Martyniuk, Liaison & Education Librarians at the Gerstein Science Information Centre–University of Toronto, for providing guidance on search strategy development, and the completion of a comprehensive literature search.