REVIEW
Summary 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. 2001 ditions scientifiques et mdicales
Elsevier SAS
alcoholism / co-morbidity / depression / psychological autopsy / suicide
INTRODUCTION
Psychological autopsy refers to a research method by
which comprehensive retrospective information is collected concerning victims of completed suicide. The
aim of the procedure is to get as clear and accurate a
view of the life situation, personality, mental health and
possible treatment provided by health care facilities
preceding suicide as possible. This process faces some
unavoidable methodological problems, but can usually
be undertaken, and offers some unique insights into the
380
E.T. Isomets
Sample
Country
134
114
100
271
135
145
21
283
200
67
58
104
141
43
1397
75
116
119
117
85
84
100
45
unselected
unselected
unselected
unselected
unselected
unselected
adolescent
unselected
unselected
adolescent
adolescent
female
elderly
young male
unselected
young male
unselected
adolescent
unselected
elderly
young adult
unselected
unselected
USA
USA
UK
Sweden
Australia
Austria
USA
USA
Hungary
USA
Sweden
Sweden
USA
Israel
Finland
Canada
Taiwan
USA
UK (N. Ireland)
Sweden
UK
India
UK (Scotland)
important model, as it deliberately investigated suicides, involved standardised interviews of the next of
kin, and examined all consecutive suicides in a defined
catchment area.
The first European psychological autopsy study was
conducted by Barraclough and coworkers in West Sussex and Portsmouth in England in 196669, carefully
examining 100 consecutive suicides [5]. Since then,
several psychological autopsy studies have been conducted in a number of countries in Europe, North
America, Australia and New Zealand, Israel, Taiwan
and India. Studies published by the end of year 2000
[1-6, 8, 9, 12, 13, 15, 16, 18, 21, 25, 28, 31-36, 38]
have been listed in table I (for brevity, only one key
reference is made for each project). Overall, the findings from these studies are highly convergent irrespective of culture, and provide an accumulating base of
information concerning the factors related to suicide.
However, there are still few studies that include rural
suicides or elderly victims, and too few studies conducted outside Western or Northern Europe, the USA,
or Canada.
The first generation of these studies were uncontrolled, descriptive studies of consecutive suicide cases.
As such, they provided valuable first insights into the
Eur Psychiatry 2001 ; 16 : 37985
381
382
E.T. Isomets
Depressive disorders
Bipolar disorder
Schizophrenia
Alcohol dependence/abuse
Personality disorders
Any mental disorder
Ethical considerations
Ethical questions are particularly important when interviewing subjects who have recently lost their family
member in often traumatic, anxiety- and guiltprovoking, sometimes chaotic conditions. The psychological autopsy is usually conducted between 3 to 12
months after the occurrence of suicide, in order to
permit time for bereavement [14, 19].
It is common practice to approach the interviewee
first by a letter and then via telephone. The interviewees
are to be fully informed about the study, and can only
be interviewed if they give informed consent to participate, and have full right to refuse at any point in time.
The integrity of the deceased is to be respected. This
may sometimes be difficult when, e.g., the deceased
suffered from personality pathology or abused substances; however, even then can research questions be
formulated in a respectful and understanding manner,
rather pointing out the ultimate suffering of both the
victim and the next of kin.
Psychological autopsy researchers usually find that
the family members actually find the research interview
relieving rather than stressful. If needed, any next of kin
needing further psychological support or psychiatric
treatment should be helped to get in contact with the
respective facilities.
PSYCHOLOGICAL AUTOPSY AND SUICIDE PREVENTION
Communication of suicide intent
Communication of suicide intent is an obvious sign of
suicide risk, although its absence is by no means a
guarantee of no risk. Suicide communication has been a
focus of investigation in almost all psychological autopsy
studies. However, precisely what constitutes communication of suicide intent is far from equivocal, and the
range of victims who reportedly communicated their
intent varies therefore widely. If only very explicit statements of intent are included, then it appears that about
one-third to one-half of all victims have communicated
their intent to family members, and a roughly similar
proportion (but not necessarily the same subjects) to
health care professionals during the final few months
[5, 24, 32].
One of the reasons why suicides seem so commonly
to occur as a surprise is that in completed suicides,
communication of intent is not very common tempoEur Psychiatry 2001 ; 16 : 37985
383
384
E.T. Isomets
REFERENCES
1 Appleby L, Cooper J, Amos T, Faragher B. Psychological autopsy
of suicides by people under 35. Br J Psychiatry 1999 ; 175 :
168-74.
2 Apter A, Bleich A, King RA, Kron S, Fluch A, Kotler M, et al.
Death without warning? A clinical postmortem study of suicide
in 43 Israeli adolescent males. Arch Gen Psychiatry 1993 ; 50 :
138-42.
3 Arato M, Demeter E, Rihmer Z, Somogyi E. Retrospective
psychiatric assessment of 200 suicides in Budapest. Acta Psychiatr Scand 1988 ; 77 : 454-6.
4 sgrd U. A psychiatric study of suicide among urban Swedish
women. Acta Psychiatr Scand 1990 ; 82 : 115-24.
5 Barraclough BM, Bunch J, Nelson B, Sainsbury P. A hundred
cases of suicide: clinical aspects. Br J Psychiatry 1974 ; 125 :
355-73.
6 Beskow J. Suicide and mental disorder in Swedish men. Acta
Psychiatr Scand 1979 ; 277 (Suppl) : 1-138.
7 Brent DA, Bridge J, Johnsson B, Conolly J. Suicidal behavior
runs in families. A controlled family study of adolescent suicide
victims. Arch Gen Psychiatry 1996 ; 53 : 1145-57.
8 Brent DA, Perper JA, Goldstein CE, Kolko DJ, Allan MJ,
Allman CJ, et al. Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Arch
Gen Psychiatry 1988 ; 45 : 581-8.
9 Cavanagh JTO, Owens DGC, Johnstone EC. Suicide and
undetermined death in south east Scotland. A case-control
study using the psychological autopsy method. Psychol Med
1999 ; 29 : 1141-9.
10 Cheng AT, Chen TH, Chen CC, Jenkins R. Psychosocial and
psychiatric risk factors for suicide. Case-control psychological
autopsy study. Br J Psychiatry 2000 ; 177 : 360-5.
11 Cheng ATA, Mann AH, Chan KA. Personality disorder and
suicide. Br J Psychiatry 1997 ; 170 : 441-6.
12 Cheng ATA. Mental illness and suicide. A case-control study in
East Taiwan. Arch Gen Psychiatry 1995 ; 52 : 594-603.
13 Chynoweth R, Tonge JI, Armstrong J. Suicide in Brisbane: a
retrospective psychosocial study. Aust NZ J Psychiatry 1980 ;
14 : 37-45.
14 Clark DC, Horton-Deutsch SL. Assessment in absentia: the
value of the psychological autopsy method for studying antecedents of suicide and predicting future suicides. In: Maris RW,
Berman AL, Maltsberger JT, Yufit RI, Eds. Assessment and
prediction of suicide. New York: Guilford Press; 1992. p. 14482.
15 Conwell Y, Duberstein P, Cox C, Herrmann JH, Forbes NT,
Caine ED. Relationships of age- and axis I diagnoses in victims
of completed suicide: a psychological autopsy study. Am J
Psychiatry 1996 ; 153 : 1001-8.
16 Dorpat TL, Ripley HS. A study of suicide in the Seattle area.
Compr Psychiatry 1960 ; 1 : 349-59.
17 Foster T, Gillespie K, McClelland R, Patterson C. Risk factors
for suicide independent of DSM-III-R Axis I disorder. Br J
Psychiatry 1999 ; 175 : 175-9.
18 Foster T, Gillespie K, McClelland R. Mental disorders and
suicide in Northern Irelend. Br J Psychiatry 1997 ; 170 :
447-52.
19 Hawton K, Appleby L, Platt S, Foster T, Cooper J, Malmberg A, et al. The psychological autopsy method: a review of
methodological issues. J Affect Disord 1998 ; 50 : 269-76.
20 Heil H, Isomets ET, Henriksson MM, Heikkinen ME, Marttunen MJ, Lnnqvist JK. Suicide victims with schizophrenia in
different treatment phases and the adequacy of antipsychotic
medication. J Clin Psychiatry 1999 ; 60 : 200-8.
Eur Psychiatry 2001 ; 16 : 37985
385
30 Pirkola S, Isomets E, Henriksson M, Heikkinen M, Marttunen M, Lnnqvist J. The treatment received by substance
dependent male and female suicide victims. Acta Psychiatrica
Scandinavica 1999 ; 99 : 207-13.
31 Rich CL, Young D, Fowler RC. San Diego Suicide Study. I:
young vs. old subjects. Arch Gen Psychiatry 1986 ; 43 : 577-82.
32 Robins E, Gassner S, Kayes J, Wilkinson RH, Murphy GE. The
communication of suicidal intent: a study of 134 consecutive
cases of successful (completed) suicide. Am J Psychiatry 1959 ;
115 : 724-33.
33 Runeson B. Mental disorders in youth suicide: DSM-III-R axes
I and II. Acta Psychiatr Scand 1989 ; 79 : 490-7.
34 Shaffer D, Gould M, Fisher P, Trautman P, Moreau D, Kleinman M, et al. Psychiatric diagnosis in child and adolescent
suicide. Arch Gen Psychiatry 1996 ; 53 : 339-48.
35 Shafii M, Steltz-Lenarsky J, Derrick AM, Beckner C, Whittinghill JR. Comorbidity of mental disorders in the post-mortem
diagnosis of completed suicide in children and adolescents. J
Affect Disord 1988 ; 15 : 227-33.
36 Vijayakumar L, Rajkumar S. Are risk factors for suicide universal? A case-control study in India. Acta Psychiatr Scand 1999 ;
99 : 407-11.
37 Waern M, Beskow J, Runeson B, Skoog I. High rate of antidepressant treatment in elderly people who commit suicide. BMJ
1996 ; 313 : 1118.
38 Waern M, Beskow J, Runeson B, Skoog I. Suicidal feelings in
the last year of life in elderly people who commit suicide. Lancet
1999 ; 354 : 917-8.