Psychological autopsy studies: Past,present,and future

To the Editor,

Psychological autopsy is one of the most important tools of investigations of completed suicide (Cavanagh et al., 2003; Isometsä, 2001). The purpose of psychological autopsy studies is to collect sufficient information about the circumstances of a person’s death to understand the reasons for the suicide. Investigators attempt to get clear and correct information on the life situation, personality, psychological and physical health, and treatments preceding suicide. This method is based on a combination of interviews of those closest to the deceased and an examination of corroborating evidence from sources such as medical records or social work reports.

Some researchers of self-violence investigated suicides already in the 1920s in Paris and the 1930s in New York by gathering information about suicide victims from various sources (Isometsä, 2001). The first modern psychological autopsy studies were conducted in 1950s–1960s. The first generation of psychological autopsy investigations consisted of uncontrolled, descriptive investigations of suicide cases. They provided helpful insights into the nature of suicides. More recently, the second generation of psychological autopsy investigations has been developed. These studies usually apply a case-control design and use standardized interviews to diagnose psychiatric disorders and their comorbidity, among both the cases and the controls. Selection of the most appropriate control group is usually determined by the hypotheses of the study.

Psychological autopsy studies of suicide victims have found a high prevalence of mental disorders in people who have committed suicide: psychiatric disorders were identified in almost all suicides (93–100%), depression being the most frequent (30–70%), then alcoholism (15–27%), and schizophrenia (2–12%) (Hawton et al., 1998). Psychological autopsy investigations have shown that marital disruption, unemployment, lower socio-economic status, living alone, a recent migration, early parental deprivation, family history of suicidal behavior and psychopathology, poor physical health, and stressful life events are associated with suicide (Cheng et al., 2000).

Psychological autopsy has some unavoidable limitations. For example, there may be a recall bias on the part of informants of suicides (Cavanagh et al., 2003; Heikkinen et al., 1993). Informants may underreport major personal events of suicide victims because informants did not know about them. In some cases, the informants’ personal psychological reaction to suicide may lead to overreporting events. Also, medical examiners, coroners, and their equivalents may be more likely to return suicide verdicts in those with known psychiatric disorders (Cavanagh et al., 2003).

Despite certain limitations, psychological autopsy is probably the best technique currently available for determining the association between particular risk factors and suicide. It is necessary to study suicide victims because the clinical features of suicide ideators, attempters, and completers may be very different. Future psychological autopsy studies should focus on high-risk groups, such as military veterans or physicians. New general studies will also be needed because the pattern of suicide changes over time. More psychological autopsy studies are truly required because we will not be able to predict or prevent suicide until we have a good knowledge of what makes people suicidal.