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Do 90% of Suicide Victims Really have Serious Mental Illness? Psychological Autopsy Studies, Psychopathology, and Suicide
Abstract
For more than fifty years the psychological autopsy has been used in suicide research. The most common application is to determine the incidence of diagnosable psychiatric disorders in suicide victims. These studies have consistently found that about ninety percent of the decedents who were the subjects of such inquiries had signs of mental illness based on interviews of those who knew them in life. This finding is cited to such an extent that it almost seems to be axiomatic. As a result, mental illness appears to overshadow other suicide risk factors. Individuals with mental illness have a high risk of suicide but this may be because of exposure to many other risk factors, some of which are precipitated by mental illness or which interact with it. Psychological autopsy-based studies of suicide victims have received little critical attention. Here they are examined in terms of the reliability of informants, the methodology, feasibility of diagnosis by proxy, other data, and new theories of suicide.
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Rogers and Lester review the major fields and issues for understanding suicide, find what is lacking, and make many recommendations for future theory and research in each area.
This report is the first WHO publication of its kind and brings
together what is known in a convenient form so that
immediate actions can be taken. The report aims to increase
the awareness of the public health significance of suicide
and suicide attempts and to make suicide prevention a
higher priority on the global public health agenda. It aims to
encourage and support countries to develop or strengthen
comprehensive suicide prevention strategies in a
multisectoral public health approach. This report proposes
practical guidance on strategic actions that governments
can take on the basis of their resources and existing suicide
prevention activities. In particular, there are evidence-based
and low-cost interventions that are effective, even in
resource-poor settings.
The causes of suicidal behaviour are not fully understood; however, this behaviour clearly results from the complex interaction of many factors. Although many risk factors have been identified, they mostly do not account for why people try to end their lives. In this Review, we describe key recent developments in theoretical, clinical, and empirical psychological science about the emergence of suicidal thoughts and behaviours, and emphasise the central importance of psychological factors. Personality and individual differences, cognitive factors, social aspects, and negative life events are key contributors to suicidal behaviour. Most people struggling with suicidal thoughts and behaviours do not receive treatment. Some evidence suggests that different forms of cognitive and behavioural therapies can reduce the risk of suicide reattempt, but hardly any evidence about factors that protect against suicide is available. The development of innovative psychological and psychosocial treatments needs urgent attention.
A meta-review, or review of systematic reviews, was conducted to explore the risks of all-cause and suicide mortality in major mental disorders. A systematic search generated 407 relevant reviews, of which 20 reported mortality risks in 20 different mental disorders and included over 1.7 million patients and over a quarter of a million deaths. All disorders had an increased risk of all-cause mortality compared with the general population, and many had mortality risks larger than or comparable to heavy smoking. Those with the highest all-cause mortality ratios were substance use disorders and anorexia nervosa. These higher mortality risks translate into substantial (10-20 years) reductions in life expectancy. Borderline personality disorder, anorexia nervosa, depression and bipolar disorder had the highest suicide risks. Notable gaps were identified in the review literature, and the quality of the included reviews was typically low. The excess risks of mortality and suicide in all mental disorders justify a higher priority for the research, prevention, and treatment of the determinants of premature death in psychiatric patients.
One of the most established "truths" in suicidology is that almost all (90% or more) of those who kill themselves suffer from one or more mental disorders, and a causal link between the two is implied. Psychological autopsy (PA) studies constitute one main evidence base for this conclusion. However, there has been little reflection on the reliability and validity of this method. For example, psychiatric diagnoses are assigned to people who have died by suicide by interviewing a few of the relatives and/or friends, often many years after the suicide. In this article, we scrutinize PA studies with particular focus on the diagnostic process and demonstrate that they cannot constitute a valid evidence base for a strong relationship between mental disorders and suicide. We show that most questions asked to assign a diagnosis are impossible to answer reliably by proxies, and thus, one cannot validly make conclusions. Thus, as a diagnostic tool psychological autopsies should now be abandoned. Instead, we recommend qualitative approaches focusing on the understanding of suicide beyond mental disorders, where narratives from a relatively high number of informants around each suicide are systematically analyzed in terms of the informants' relationships with the deceased.
The question of whether suicide bereavement is different from mourning after other types of deaths has important theoretical and clinical implications. Some recent literature reviews have argued that the differences may be minimal. In contrast, this article suggests that suicide bereavement is distinct in three significant ways: the thematic content of the grief, the social processes surrounding the survivor, and the impact suicide has on family systems. In addition, problems in the methodology used to compare different bereavement experiences are addressed. Some clinical implications of these conclusions, including the need for homogeneous support groups, psychoeducational services, and family and social network interventions are also discussed.
Suicide is a complex outcome of multiple, inter-related factors. This article presents the epidemiology of completed and attempted suicide and discusses the known risk factors for suicide within a framework designed to encourage a systematic approach to theory testing and prevention. Mental and addictive disorders, frequently in co-occurrence, are the most powerful risk factors for suicide in all age groups, accounting for over 90 percent of all completed suicides. In combination with proximal risk factors such as access to firearms or other lethal means, recent and severe stressful life events, and intoxication, they can form the necessary and sufficient conditions for suicide.
Ethical issues have been raised about using the psychological autopsy approach in the study of suicide. The impact on informants of control cases who participated in case-control psychological autopsy studies has not been investigated.
(1) To investigate whether informants of suicide cases recruited by two approaches (coroners' court and public mortuaries) respond differently to the initial contact by the research team. (2) To explore the reactions, reasons for participation, and comments of both the informants of suicide and control cases to psychological autopsy interviews. (3) To investigate the impact of the interviews on informants of suicide cases about a month after the interviews.
A self-report questionnaire was used for the informants of both suicide and control cases. Telephone follow-up interviews were conducted with the informants of suicide cases.
The majority of the informants of suicide cases, regardless of the initial route of contact, as well as the control cases were positive about being approached to take part in the study. A minority of informants of suicide and control cases found the experience of talking about their family member to be more upsetting than expected. The telephone follow-up interviews showed that none of the informants of suicide cases reported being distressed by the psychological autopsy interviews.
The acceptance rate for our original psychological autopsy study was modest.
The findings of this study are useful for future participants and researchers in measuring the potential benefits and risks of participating in similar sensitive research. Psychological autopsy interviews may be utilized as an active engagement approach to reach out to the people bereaved by suicide, especially in places where the postvention work is underdeveloped.
This paper's main aim is to argue the methodological case for a particular approach to researching the sociology of suicide. By way of illustrating the use of this approach it also offers some brief examples of substantive findings about the gendered character of men's suicides. The first half of the article explains and justifies the research approach. This is a qualitatively-driven mixed method and dual paradigm study of individual suicides. It is a sociological study which draws on the tradition of psychological autopsies of suicide; hence the term 'sociological autopsy'. The second half of the article offers brief illustrative findings from a specific research project which employed the sociological autopsy approach. This was a study of 100 suicide case files from a coroner's office in the UK. There is discussion of common sense assumptions about suicide in men; the construction of evidence in case files; a typology of gendered suicides where relationship breakdown seems to be the principal trigger; and the value of case-based analysis, with a single case discussed in some detail.
Risk factors for suicide attempts have rarely been studied comprehensively in more than one psychiatric disorder, preventing estimation of the relative importance and the generalizability of different putative risk factors across psychiatric diagnoses. The authors conducted a study of suicide attempts in patients with mood disorders, psychoses, and other diagnoses. Their goal was to determine the generalizability and relative importance of risk factors for suicidal acts across diagnostic boundaries and to develop a hypothetical, explanatory, and predictive model of suicidal behavior that can subsequently be tested in a prospective study.
Following admission to a university psychiatric hospital, 347 consecutive patients who were 14-72 years old (51% were male and 68% were Caucasian) were recruited for study. Structured clinical interviews generated axis I and axis II diagnoses. Lifetime suicidal acts, traits of aggression and impulsivity, objective and subjective severity of acute psychopathology, developmental and family history, and past substance abuse or alcoholism were assessed.
Objective severity of current depression or psychosis did not distinguish the 184 patients who had attempted suicide from those who had never attempted suicide. However, higher scores on subjective depression, higher scores on suicidal ideation, and fewer reasons for living were reported by suicide attempters. Rates of lifetime aggression and impulsivity were also greater in attempters. Comorbid borderline personality disorder, smoking, past substance use disorder or alcoholism, family history of suicidal acts, head injury, and childhood abuse history were more frequent in suicide attempters.
The authors propose a stress-diathesis model in which the risk for suicidal acts is determined not merely by a psychiatric illness (the stressor) but also by a diathesis. This diathesis may be reflected in tendencies to experience more suicidal ideation and to be more impulsive and, therefore, more likely to act on suicidal feelings. Prospective studies are proposed to test this model.
The psychological autopsy method offers the most direct technique currently available for examining the relationship between particular antecedents and suicide. This systematic review aimed to examine the results of studies of suicide that used a psychological autopsy method.
A computer aided search of MEDLINE, BIDS ISI and PSYCHLIT, supplemented by reports known to the reviewers and reports identified from the reference lists of other retrieved reports. Two investigators systematically and independently examined all reports. Median proportions were determined and population attributable fractions were calculated, where possible, in cases of suicide and controls.
One hundred and fifty-four reports were identified, of which 76 met the criteria for inclusion; 54 were case series and 22 were case-control studies. The median proportion of cases with mental disorder was 91% (95 % CI 81-98%) in the case series. In the case-control studies the figure was 90% (88-95%) in the cases and 27% (14-48%) in the controls. Co-morbid mental disorder and substance abuse also preceded suicide in more cases (38%, 19-57%) than controls (6%, 0-13%). The population attributable fraction for mental disorder ranged from 47-74% in the seven studies in which it could be calculated. The effects of particular disorders and sociological variables have been insufficiently studied to draw clear conclusions.
The results indicated that mental disorder was the most strongly associated variable of those that have been studied. Further studies should focus on specific disorders and psychosocial factors. Suicide prevention strategies may be most effective if focused on the treatment of mental disorders.
It is unclear why approximately 10% of suicide completers seem to be psychiatrically normal. To better understand this issue, we studied suicide completers without an axis I diagnosis and compared them, on measures of psychopathology other than axis I, to normal controls and suicide cases with axis I psychopathology.
168 suicide cases were examined by way of a psychological autopsy with the best possible informant. Sixteen cases did not meet criteria for an axis I diagnosis; each of these cases was then age and gender matched to 52 suicide completers with an axis I disorder and 110 normal controls.
Fourteen of sixteen suicide cases without an axis I diagnosis had detectable abnormalities that were more similar to the axis I diagnosed suicide group than to a living group. Both suicide groups were similar in the total number of past suicide attempts, the total number of individuals with an axis II disorder, and similar scores on measures of impulsive-aggressive behaviors.
These findings suggest that most of the individuals who committed suicide and appeared psychiatrically normal after a psychological autopsy may probably have an underlying psychiatric process that the psychological autopsy method, as commonly carried out, failed to detect.
Previous research on sociocultural factors for Chinese suicide have been basically limited to single case studies or qualitative research with ethnographic methodology. The current study examines the major risk factors and some cultural uniqueness related to Chinese rural suicide using a quantitative design.
This is a case control study with 66 completed suicides and 66 living controls obtained from psychological autopsy interviews in rural China.
Both bivariate analyses and the multiple regression model have found that the Chinese rural suicide patterns are basically similar to those in most other cultures in the world: strong predictors of rural Chinese suicide are the psychopathological, psychological, and physical health variables, followed by social support and negative and stressful life events. Other significant correlates include lower education, poverty, religion, and family disputes.
Culture has an important impact on suicide patterns in a society.
The key role of prevention and treatment of mental disorders in the prevention of suicide is widely acknowledged. Which specific disorders need to be targeted remains to be conclusively demonstrated.
To re-examine the presence of psychiatric diagnosis in cases of completed suicide from a global perspective.
A review of studies reporting diagnoses of mental disorders in cases of completed suicide with or without history of admission to mental hospitals.
Most cases were from Europe and North America (82.2%). The majority (98%) of these had a diagnosis of at least one mental disorder. Among all diagnoses, mood disorders accounted for 30.2%, followed by substance-use related disorders (17.6%), schizophrenia (14.1%), and personality disorders (13.0%).
The mental health paradigm in suicide prevention covers just a part of the problem. Antisuicide strategies focusing exclusively on the identification and treatment of depression need to be reconsidered. In addition to this, other mental disorders should be targeted, in particular alcohol-use disorders and schizophrenia. More emphasis should also be placed on psychosocial and environmental interventions diminishing and counteracting stress.
The psychological autopsy is a procedure that assists in the classification of equivocal deaths, where the manner of death is not immediately clear. The procedure involves a thorough and systematic retrospective analysis of the decedent's life, with a particular focus on suicide risk factors, motives, and intentions. It has been used for almost 50 years to assist medical examiners, collect research data, inform suicide prevention efforts, and as a forensic tool in courts. The psychological autopsy is a time-consuming process that requires the investigator to analyze all relevant data from a wide array of sources so that a rich psychological biography emerges. A properly conducted psychological autopsy provides a level of important detail far beyond that obtained from a simple review of demographic data or a police narrative. The psychological autopsy methodology has met admissibility standards in a few criminal and civil cases. However, the problem of a lack of standardization has been cited as a main limitation. Until a standardized protocol is developed and accepted, admissibility will likely be determined on a case-by-case basis.
Kelly, Thomas M., Ph.D., Ph.D., University of Pittsburgh School of Social Work 1996, Post Doctoral Fellow, Pittsburgh Adolescent Research Center - "A Comparison of Suicide Completers with Psychiatrically Disordered and Non-Disordered Subjects Via the Psychological Autopsy Method"
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Suicidal behavior takes over a million lives worldwide every year. Non-fatal suicidal behavior is estimated to be 25 to 50 times more common 1. Finding ways to identify those at risk is a key public health goal, but researchers and clinicians alike have been stumped in the quest to decrease suicide rates using primary, secondary and tertiary prevention strategies. Our predictors simply do not work well, especially in identifying short-term risk.
One potential contributor to the poor performance of predictors may relate to how well they are identified and tracked in medical records. We have proposed a remedy for an essential risk factor for both suicide attempt and suicide: a prior history of suicidal behavior. Defining suicidal behavior disorder as a separate diagnosis 2 and providing clearly delineated criteria would bring suicidal behavior in line with parameters established by the WPA, promoting common, cross-national nomenclature and language for psychiatric disorders. Importantly, it would lead to methods to identify suicidal behavior in individual patients, with prominent documentation in medical records, key to secondary and tertiary prevention strategies.
Psychological autopsy studies in which in-depth interviews are conducted with relatives or other informants are a key method of investigation in suicide research. These interviews are likely to be emotive and potentially stressful for informants. We followed up 68 informants approximately one month after they were interviewed in three recent studies of suicide in high risk groups (young people, farmers and doctors) to determine their reactions to the interviews. Nearly all the informants (96.9%) said they preferred being approached through a letter from a member of the research team rather than by someone else. While some relatives (22.1%) understandably reported being upset during the interview and/or immediately afterwards, a month later only one informant reported feeling worse than usual. A beneficial effect was suggested in at least a third. Although only 30 informants accepted the offer of a bereavement information pack, probably because in many cases the interviews were conducted rather a long time after the deaths, 90% of these found the pack helpful. It is suggested that such a pack be included in future psychological autopsy studies and that follow-up evaluations of the kind reported here be conducted in order to ensure that potential negative effects of such studies be identified and avoided in further studies.
This article discusses findings of an exploratory study of the psychological and social experience of suicide survivors. Detailed interviews were conducted with twenty-four people who had lost loved ones to suicide within the last five years. The study focuses on neglected dimensions of the adjustment problems of survivors by investigating the perceptions, thoughts, and feelings of survivors themselves over a broad range of questions. Major areas of concern are: 1) survivors' responses to the suicide, specifically patterns of explanation and blaming; 2) the impasse in interpersonal relations; 3) the dynamics of stigma, normlessness, and fear in survivors' contacts with others; and 4) negative and positive personal changes occurring in survivors as a result of their loss. Our findings suggest that survivors face complex problems of emotional, personal, and social adjustment requiring further attention by researchers and helping professionals.
the phrase "psychological autopsy" refers to a procedure for reconstructing an individual's psychological life after the fact, particularly the person's lifestyle and those thoughts, feelings, and behaviors manifested during the weeks preceding death, in order to achieve a better understanding of the psychological circumstances contributing to a death / highlight some of the findings generated by psychological autopsy research, relying on studies published in English and based for the most part on work done in the United States, Canada, the United Kingdom, Australia, and Sweden / pay particular attention to significant findings, methodological innovations, alternate definitions of the psychological autopsy method, and implications for predicting or averting suicides / conclude . . . with a brief discussion of five clinical case vignettes from the perspective of psychological autopsy research
application of the psychological autopsy method to youth suicides / application of the psychological autopsy method to suicides by elderly persons / equivocal death consultations to the Los Angeles medical examiner / the accuracy of reported suicide statistics / Shneidman's broader view of the psychological autopsy / retrospective studies of psychiatric inpatient and jail suicides / the suicide postmortem conference and the clinical audit / psychological autopsy studies for forensic purposes / methodological considerations / research assessment instruments / the experience of being interviewed for a psychological autopsy study / standards for future psychological autopsy studies (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Empirical studies of suicide survivors with designs that include control groups are reviewed. Investigations are discussed individually with respect to those in which participating survivors are friends or a combination of many different relationships to the deceased, parents of the deceased child, and spouses. Following the review is a brief discussion of the commonalities of the findings and the most frequent methodological difficulties. Concluding comments suggest methodological improvements as well as issues and groups for which additional investigations are needed.
Background
While numerous past reviews of psychological autopsy (PA) studies have examined the relationship between mental disorder and suicide, there has been little systematic investigation of suicide occurring in the absence of any identifiable psychiatric condition.
Aim
This article reviews available literature on the topic by considering Axis I, sub-threshold, mild disorders and personality disorders.
Method
We conducted a systematic review of PA studies from 2000 onwards. Studies included in the review had to clearly describe the proportion of suicide cases without a classifiable mental disorder or sub-threshold condition.
Results
Up to 66.7% of suicide cases remained without diagnosis in those studies that only examined Axis I disorders ( n = 14). Approximately 37.1% of suicide cases had no psychiatric condition in research papers that assessed personality and Axis I disorders ( n = 9), and 37% of suicides had no Axis I, sub-threshold/mild conditions ( n = 6). In general, areas in China and India had a higher proportion of suicides without a diagnosis than studies based in Europe, North America or Canada.
Conclusion
Variation in the proportion of suicide cases without a psychiatric condition may reflect cultural specificities in the conceptualization and diagnosis of mental disorder, as well as methodological and design-related differences between studies.
The study's purpose was to describe and compare depression, anxiety, and quality of life, by degree of relationship, between closely related and distantly related survivors (persons close to the suicide victim, or "suicide survivors"; N = 60) during the acute phase of bereavement (within 1 month of the death). The close relationship category included spouses, parents, children, and siblings, whereas the distant relationship category included in-laws, aunts/uncles, and nieces/nephews. Analysis of covariance examined differences between the two groups on the symptom measures. Results indicate that, after controlling for age and gender effects, closely related survivors had significantly higher mean levels of depression and anxiety and had lower levels of mental health quality of life. There were no statistically significant differences on the physical health quality of life subscale.
Essential knowledge on suicide is derived from studies that include interviews with survivors. In this paper, we discuss methodological and ethical issues pertaining to the interview method known as "psychological autopsy"; the discussion is based on our application of the method to three studies of suicides in Sweden and on a review of other investigations. Interviewing a survivor is a delicate matter, and the integrity of the deceased, the integrity and health of the informant, and the psychological strain on the interviewer must all be taken into consideration. The interviewer should have clinical experience in order to be prepared to deal with interviewees in grief. Contact by telephone, followed by an introductory letter, provides an opportunity to meet survivors in an empathic manner and has a low rejection rate. A 2- to 6-month interval between suicide and interview is recommended. The survivor's reactions to the interview should be evaluated in order to expand the empirical base for ethical considerations. Studies on the validity and reliability of the method are necessary.
Five hundred psychological autopsies on equivocal (suicide versus accident) deaths were reviewed to ascertain which factors are significant in making the determination between suicidal and accidental deaths. Factors varied in relative importance according to the method used to cause death. Significant factors included life-style, recent stress, suicidal communications, previous self-destructive behaviors, history of depression, and obvious factors from the physical evidence such as large amounts of drugs in the blood. Although the court-provided decision guideline is "a preponderance of the evidence", in practice, the assembled evidence is often used to construct a "most credible" scenario to explain the death.
The information presented here is on the incidence of suicide in the United States and in other countries where reporting procedures are reliable. The problem of underreporting is discussed and put into perspective. Secular trends in suicide incidence are presented, and it is shown how these have varied a great deal for different age groups. Age, ethnic, and cultural differences in incidence are demonstrated, and explanatory theories for these differences are put forward. The phenomenon of cluster suicide is described, and possible explanations for this are discussed. The limitations of death certificate data and the advantages (and limitations) of the psychological autopsy method are presented. Results from previous psychological autopsy studies on epidemiologically sound samples are summarized. Results (preliminary) from a current psychological autopsy study on consecutive adolescent suicides in the New York Metropolitan area are presented. Family history data and diagnostic profiles of completed suicides are emphasized.
A test of validity of the psychiatric diagnoses obtained by the psychological autopsy procedure is described in a consecutive series of 67 adolescent suicide victims. Family history of mental illness in first-degree relatives of subjects was obtained blind to subject diagnosis using the family history method. It was hypothesized that subjects with a given diagnosis, compared with subjects without this diagnosis, would show an increased rate of this disorder among first-degree relatives. This hypothesis was supported insofar as specific associations between subject diagnosis and familial rates of illness were demonstrated for major depression, bipolar illness, conduct and antisocial disorder and substance abuse. These results provide further support for the validity of diagnoses obtained through the psychological autopsy procedure.
This overview article examines the applications of the psychological autopsy method in determining proximate causation in suicide cases. The article reviews the history of the psychological autopsy and describes its procedure and how it has proved helpful in explicating proximate causation. The five standards currently used by the courts to determine proximate causation in suicide cases are described, as are a variety of applications of the psychological autopsy method, including its application to workers' compensation cases, product liability cases, and medical malpractice cases. In particular, issues of prediction and protection are addressed. Finally, there is a discussion of an application of the psychological autopsy to criminal cases. The article concludes with a discussion of the issues raised in the use of the psychological autopsy during expert testimony and the considerations that should be addressed by an expert witness contemplating the use of the psychological autopsy method.
Mental disorders have a strong association with suicide. This meta-analysis, or statistical overview, of the literature gives an estimate of the suicide risk of the common mental disorders.
We searched the medical literature to find reports on the mortality of mental disorders. English language reports were located on MEDLINE (1966-1993) with the search terms mental disorders', 'brain injury', 'eating disorders', 'epilepsy', 'suicide attempt', 'psychosurgery', with 'mortality' and 'follow-up studies', and from the reference lists of these reports. We abstracted 249 reports with two years or more follow-up and less than 10% loss of subjects, and compared observed numbers of suicides with those expected. A standardised mortality ratio (SMR) was calculated for each disorder.
Of 44 disorders considered, 36 have a significantly raised SMR for suicide, five have a raised SMR which fails to reach significance, one SMR is not raised and for two entries the SMR could not be calculated.
If these results can be generalised then virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders with substance misuse disorders lying between. However, within these broad groupings the suicide risk varies widely.
To investigate the validity of best-estimate methodology for making psychiatric diagnoses among individuals who attempted suicide.
Subjects were 80 patients admitted for treatment following a suicide attempt. Psychiatric diagnoses based on structured interviews with subjects were compared with diagnoses made based on interviews with proxy respondents. In both cases, interview information was supplemented with pre-admission psychiatric and medical records to inform diagnoses.
Diagnostic agreement, based on kappa coefficients, was substantial for major depression and bipolar disorders, and moderate for non-affective psychoses, organic mood and anxiety disorders. Agreement was substantial for substance dependence but poor for substance abuse disorders.
Results support best-estimate methodology for making mood and substance dependence diagnoses in research of suicidal behavior in this age group, with potential implications for interpreting postmortem research of completed suicide.
Psychological autopsy is one of the most valuable tools of research on completed suicide. The method involves collecting all available information on the deceased via structured interviews of family members, relatives or friends as well as attending health care personnel. In addition, information is collected from available health care and psychiatric records, other documents, and forensic examination. Thus a psychological autopsy synthesizes the information from multiple informants and records. The early generation of psychological autopsies established that more than 90% of completed suicides have suffered from usually co-morbid mental disorders, most of them mood disorders and/or substance use disorders. Furthermore, they revealed the remarkable undertreatment of these mental disorders, often despite contact with psychiatric or other health care services. More recent psychological autopsy studies have mostly used case-control designs, thus having been better able to estimate the role of various risk factors for suicide. The future psychological autopsy studies may be more focused on interactions between risk factors or risk factor domains, focused on some specific suicide populations of major interest for suicide prevention, or combined psychological autopsy methodology with biological measurements.
Familial clustering of suicidal behaviour has been well documented. We aimed to assess whether family history of completed suicide and mental illness that results in admission to hospital are risk factors for suicide, and whether these factors interact.
We did a nested case-control study using data from Danish longitudinal registers. We included 4262 people who had committed suicide aged 9-45 years during 1981-97 (cases), and 80238 population-based controls matched for age, sex, and date of suicide. Suicide and psychiatric history of parents and siblings and socioeconomic, demographic, and psychiatric data for every case were retrieved and merged. Data were analysed with conditional logistic regression.
A family history of completed suicide and psychiatric illness significantly and independently increased suicide risk (odds ratio 2.58 [95% CI 1.84-3.61] and 1.31 [1.19-1.45], respectively). These effects were not accounted for by the socioeconomic status and psychiatric history of cases. A history of family psychiatric illness significantly raised suicide risk only in people without a history of psychiatric illness (1.55 [1.38-1.75]), whereas a family history of suicide increased suicide risk irrespective of psychiatric illness (2.37 [1.11-5.09] and 2.66 [1.82-3.88]) for people with and without a psychiatric history, respectively.
Completed suicide and psychiatric illness in relatives are risk factors for suicide, and the effect of family suicide history is independent of the familial cluster of mental disorders. Family history of suicide should be established in the assessment of suicide risk.
The extant adoption, twin, and family studies of suicide and suicidal behavior are reviewed. Suicidal behavior is highly familial, and on the basis of twin and adoption studies, heritable as well. Both completed and attempted suicide form part of the clinical phenotype that is familially transmitted, as rates of suicide attempt are elevated in the family members of suicide completers, and completion rates are elevated in the family members of attempters. A family history of suicidal behavior is associated with suicidal behavior in the proband, even after adjusting for presence of psychiatric disorders in the proband and family, indicating transmission of attempt that is distinct from family transmission of psychiatric disorder. Impulsive aggression in probands and family members is associated with family loading for suicidal behavior, and may contribute to familial transmission of suicidal behavior. Shared environment effects such as abuse, imitation, or transmission of psychopathology are other possible explanations.
One of the delineating elements found in suicide bereavement versus normal bereavement is the stigma experienced by survivors. This review of the literature will provide insight into stigma as an underlying element in suicide bereavement and point to the role of health professionals in dealing with this complex issue. Historical review and empirical studies are analyzed to provide a framework for how suicide relates to natural bereavement. The conclusion is that suicide bereavement is different from natural loss. The challenge to health care providers is to sort through the complex issues surrounding the individual and their social network to find mechanisms that lead to resolution.
Suicide has a profound effect on the family, friends, and associates of the victim that transcends the immediate loss. As those close to the victim suffer through bereavement, a variety of reactions and coping mechanisms are engaged as each individual sorts through individual reactions to the difficult loss. Bereavement refers to “all the physiological, psychological, behavioral, and social response patterns displayed by an individual following the loss (usually through death) of a significant person or thing” (Dunne, Dunne-Maxim & McIntosh, 1987). Bereavement following suicide is complicated by the complex psychological impact of the act on those close to the victim. It is further complicated by the societal perception that the act of suicide is a failure by the victim and the family to deal with some emotional issue and ultimately society affixes blame for the loss on the survivors. This individual or societal stigma introduces a unique stress on the bereavement process that in some cases requires clinical intervention.
This paper reviews research based on the psychological autopsy (PA) method applied to the study of suicide. It evidences the presence of a number of methodological problems. Shortcomings concern sampling biases in the selection of control subjects, confounding influences of extraneous variables, and reliability of the assessment instruments. The absence of homogeneity among studies in the procedure employed, as well as the lack of defined guidelines for performing this type of inquiry are emphasized. Questions needing empirical investigation in the future are pointed out. It is concluded that the validity and reliability of findings emerging from the use of this method of investigation would benefit from a standardization of its application.
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