REVIEW

Psychological autopsy studies – a review

E.T. Isometsä*Mood Disorders & Suicide Research Unit, Department of Mental Health and Alcohol Research, National Public HealthInstitute, Mannerheimintie 166 FIN-00300 Helsinki, Finland

(Received 12 April 2001; accepted 31 August 2001)

Summary – Psychological autopsy is one of the most valuable tools of research on completed suicide. The methodinvolves collecting all available information on the deceased via structured interviews of family members, relatives orfriends as well as attending health care personnel. In addition, information is collected from available health care andpsychiatric records, other documents, and forensic examination. Thus a psychological autopsy synthesizes theinformation from multiple informants and records. The early generation of psychological autopsies established thatmore than 90% of completed suicides have suffered from usually co-morbid mental disorders, most of them mooddisorders and/or substance use disorders. Furthermore, they revealed the remarkable undertreatment of these mentaldisorders, often despite contact with psychiatric or other health care services. More recent psychological autopsystudies have mostly used case-control designs, thus having been better able to estimate the role of various risk factorsfor suicide. The future psychological autopsy studies may be more focused on interactions between risk factors or riskfactor domains, focused on some specific suicide populations of major interest for suicide prevention, or combinedpsychological autopsy methodology with biological measurements. © 2001 Éditions scientifiques et médicalesElsevier SAS

alcoholism / co-morbidity / depression / psychological autopsy / suicide

INTRODUCTION

‘Psychological autopsy’ refers to a research method bywhich comprehensive retrospective information is col-lected concerning victims of completed suicide. Theaim of the procedure is to get as clear and accurate aview of the life situation, personality, mental health andpossible treatment provided by health care facilitiespreceding suicide as possible. This process faces someunavoidable methodological problems, but can usuallybe undertaken, and offers some unique insights into the

process of suicide [14, 19]. By now, more than 20major psychological autopsy projects have been carriedout in diverse countries and cultures – in NorthAmerica, Europe, Australia and New Zealand, Israel,Taiwan and India, with a number of further majorprojects ongoing in various settings. Thus we currentlyhave an accumulating global base of information aboutthe pathways to suicide, the characteristics of the vic-tims, and some common problems in preventing sui-cide that these life histories reveal. The present paperreviews the history, methodology, and some relevantfindings from these studies.

*Correspondence and reprints.E-mail address: erkki.isometsa@ktl.fi (E.T. Isometsä).

Eur Psychiatry 2001 ; 16 : 379-85© 2001 Éditions scientifiques et médicales Elsevier SAS. All rights reservedS0924933801005946/REV

HISTORY OF THE PSYCHOLOGICAL AUTOPSYMETHOD

Some researchers of self-destructive behaviour had actu-ally investigated suicides already in the 1920s in Parisand the 1930s in New York by collecting informationabout a victim from various available sources [14, 32].However, the first modern psychological autopsy studyof consecutive suicides was conducted by Eli Robinsand his colleagues in the Washington University in St.Louis, MO, USA, in 1956–57 [32]. They carefullyinvestigated 134 consecutive suicides during a period of1 year. Their findings were replicated by Dorpat andRipley in a second study in the Seattle area a few yearslater [16]. At about the same time, Robert Litman,Norman Farberow and Edwin Schneidman at the LosAngeles Suicide Prevention Center (LASPC) had devel-oped a method to help the medical examiner’s office todecide whether a deceased had completed suicide ordied accidentally; Edwin Schneidman has been cred-ited for coining the term ‘psychological autopsy’ [14].However, although the LASPC group was very influ-ential in many ways, their focus was largely in classify-ing causes of death. For the future psychologicalautopsies the work by Robins et al. [32] was a more

important model, as it deliberately investigated sui-cides, involved standardised interviews of the next ofkin, and examined all consecutive suicides in a definedcatchment area.

The first European psychological autopsy study wasconducted by Barraclough and coworkers in West Sus-sex and Portsmouth in England in 1966–69, carefullyexamining 100 consecutive suicides [5]. Since then,several psychological autopsy studies have been con-ducted in a number of countries in Europe, NorthAmerica, Australia and New Zealand, Israel, Taiwanand 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 keyreference is made for each project). Overall, the find-ings from these studies are highly convergent irrespec-tive of culture, and provide an accumulating base ofinformation concerning the factors related to suicide.However, there are still few studies that include ruralsuicides or elderly victims, and too few studies con-ducted outside Western or Northern Europe, the USA,or Canada.

The first generation of these studies were uncon-trolled, descriptive studies of consecutive suicide cases.As such, they provided valuable first insights into the

Table I. The psychological autopsy studies of unselected general population suicides.

Study [ref] N Sample Country

Robins et al., 1959 [32] 134 unselected USADorpat and Ripley, 1960 [16] 114 unselected USABarraclough et al., 1974 [5] 100 unselected UKBeskow, 1979 [6] 271 unselected SwedenChynoweth et al.,1980 [13] 135 unselected AustraliaMitterauer, 1981 [28] 145 unselected AustriaShafii et al., 1985 [35] 21 adolescent USARich et al., 1986 [31] 283 unselected USAArato et al., 1988 [3] 200 unselected HungaryBrent et al., 1988 [8] 67 adolescent USARuneson, 1989 [33] 58 adolescent SwedenÅsgård, 1990 [4] 104 female SwedenConwell et al., 1991 [15] 141 elderly USAApter et al., 1991 [2] 43 young male IsraelThe National Suicide Prevention Project in Finland [21] 1397 unselected FinlandLesage et al., 1994 [25] 75 young male CanadaCheng, 1995 [12] 116 unselected TaiwanShaffer et al, 1996 [34] 119 adolescent USAFoster, 1997 [18] 117 unselected UK (N. Ireland)Waern et al., 1999 [38] 85 elderly SwedenAppleby et al.,1999 [1] 84 young adult UKVijayakumamar and Rajkumar, 1999 [36] 100 unselected IndiaCavanagh et al., 1999 [9] 45 unselected UK (Scotland)

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nature of fatal suicidal behaviour, but also had somemethodological limitations. During the last decade asecond generation of psychological autopsies hasemerged. Such studies (e.g., [1, 12, 18, 25, 34, 36])have mostly applied a case-control design, had theirliving control subjects drawn from a representativegeneral population sample, and used standardised inter-views to ascertain mental disorders and theirco-morbidity, among both their cases and their con-trols.

THE PSYCHOLOGICAL AUTOPSY METHODOLOGY

General features

The psychological autopsy procedure has two mainelements, 1) extensive interviews of family membersand other close intimates; and 2) collecting all possiblemedical, psychiatric and other relevant documents ofthe deceased. A typical psychological autopsy has one ortwo main informants, e.g., a spouse, partner, parent oradult child, or other next of kin, and often anotherinformant representing the attending health care per-sonnel. In addition, other informants, including othernext of kin, friends, or attending personnel may also beinterviewed. An excellent practically oriented method-ological review of psychological autopsy, particularlyuseful for researchers within the United Kingdom, hasrecently been published by Hawton et al. [19]. In thefollowing, the methodology of the research phase of theNational Suicide Prevention Project in Finland in1987–88, the largest psychological autopsy projectundertaken, is described in more detail in order toillustrate a psychological autopsy procedure.

The psychological autopsy procedureof the research phase of the National Suicide Pre-vention Project in Finland

The National Suicide Prevention Project was set up bythe Finnish National Board of Health in 1986, and itsexplicated aim was to reduce suicide mortality in Fin-land. During the research phase of the project, allsuicides committed in Finland between April 1, 1987and March 31, 1988 (N = 1397) were carefully recordedand analysed using the psychological autopsy method.

The definition of suicide was based on the Finnishlaw for determining causes of death – in every case ofviolent, sudden or unexpected death the possibility ofsuicide is assessed by police and medicolegal investiga-

tions involving autopsy and forensic examinations. Forthe 12-month duration of the research phase of theproject this data gathering was more detailed thanusual. Data concerning victims classified as suicides inforensic examination were collected via comprehensiveinterviews with the relatives and attending health carepersonnel, from psychiatric, medical and social agencyrecords, and from suicide notes. The interviews wereconducted by all together 245 mental health profes-sionals, about half (47%) of whom were psychologists,the remaining being mostly psychiatric nurses (27%),social workers (15%), or physicians (8%). The inter-view forms were planned for the project, and the pro-fessionals were trained in their use. Four types ofinterview were conducted:– 1) Face-to-face interviews of family members wereusually conducted in their homes, with informed con-sent obtained beforehand. The interview was usuallyundertaken about 4 months after the suicide, and had amean duration of 2 hours and 45 minutes. The struc-tured interview forms contained 234 items concerningthe victim’s everyday life and behaviour, family factors,use of alcohol and other drugs, previous suicidality,help-seeking and recent life events. This interview couldbe undertaken in 1155 (83%) of the 1397 suicide cases;– 2) Health care professionals who had attended thevictim during the previous 12 months were interviewedface-to-face with a structured form containing 113items about the victim’s state of health, treatment in thehealth care system, psychosocial stressors and level offunctioning; this interview was conducted in 612(43.8%) of the cases. In the remaining cases, thereusually were so few health care contacts that no profes-sional who would have known the deceased well wasavailable;– 3) The last contact with health or social agencyprofessionals was separately evaluated by interviewingthe attending person either face-to-face or by telephonewith a semi-structured interview containing eight items.This was undertaken in 860 (61.6%) of the cases; and– 4) Additional unstructured interviews were made bytelephone if needed. These informants could includeother relatives, friends, or other intimates.

Information was also taken from death certificates(100%), psychiatric and medical records (1129 [80.8%]of the cases), police and forensic reports (99.9%), sui-cide notes (left by 389 [27.8%] of the cases), and otheravailable records on the cases. A multidisciplinary teamdiscussed all the cases, and comprehensive case reports

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were written on the basis of all information available[21, 24, 27].

Investigating mental disorders as a part of the psy-chological autopsy

Almost all psychological autopsy studies have investi-gated mental disorders of suicide victims as a part oftheir study design. This necessitates both collectinginformation from various attending treatment facilitiesas well as interviewing the attending personnel and thenext of kin by using structured interview methods. Atpresent most studies apply structured interviews avail-able for clinical research. It is essential that if personal-ity disorders are to be investigated, the focus is notexclusively in victims’ behaviour during the finalmonths. Integrating information from several sources isdesirable as, e.g., parents of adolescent are not alwaysaware of the substance use problems their offspring mayhave had.

In the National Suicide Prevention Project in Fin-land, the mental disorders of suicide victims were exam-ined in a diagnostic study of a non-stratified randomsample of 229 (16.4%) of the total 1397 suicides. Theretrospective diagnostic evaluation of the cases accord-ing to DSM-III-R criteria, weighing and integrating allavailable information, took place in two phases [21].First, two pairs of psychiatrists independently madeprovisional best estimate diagnoses, the reliability ofwhich was tested; second, all cases involving any diag-nostic disagreement were reanalysed with a third psy-chiatrist to achieve consensus for the final best estimatediagnoses. The reliability achieved ranged from moder-ate to excellent (kappa 0.52 to 0.94) [21]. However,some smaller psychological autopsy studies in whichthe information is collected and diagnoses assigned byonly a few interviewers and diagnosticians, havereported excellent reliability (kappa 0.80–1.00 ) in vir-tually all diagnostic categories (e.g., [10-12, 17, 25]).Having fewer interviewers and diagnosticians likelyreduces methodological error variance, and results inhigher reliability.

Overall, the more than 20 major psychologicalautopsy projects have documented that with rare excep-tions, the presence of a mental disorder is a necessary,although not a sufficient condition for a completedsuicide to occur. The findings of these studies aresummarised in table II. The two most prevalent catego-ries of mental disorders among completed suicides aremood disorders and substance use disorders. Further-

more, co-morbidity of mental disorders seems to be therule [1, 11, 17, 18, 21, 36]. The second-generationcontrolled psychological autopsies have confirmed theremarkable impact of concurrent mood and substanceuse [12] or mood and personality disorders [17] inmultiplying the risk for suicide.

Control cases

The choice of an appropriate control group has beendebated during the evolution of the method. Ulti-mately the type of control subject is determined by thehypotheses tested. As most researchers have been look-ing for risk factors for suicide as compared with thegeneral population using a case-control design, a natu-ral choice may be age- and gender-matched controlcases. However, it is difficult to exclude biases intro-duced by the fact that the cases are deceased whereas thecontrols are not. Ideally, information on the livingcontrols should be obtained from their next of kin inorder to avoid information bias. How high a propor-tion of the eligible controls consent to this is anothermatter. Living psychiatric control cases might be thechoice when investigating possible specific risk factorsthat operate in the selected high-risk populations, as therisk factors for completed suicide often are factors select-ing patients to be referred to psychiatrists, and do notnecessarily help in differentiating between high and lowrisk within a high-risk population.

Some authors have advocated use of controls matchedfor bereavement, such as victims of traffic accidents orother causes of death. While similarity in terms ofbereavement is an obvious advantage, a problem is thatvictims of traffic accidents are unlikely to represent arandom sample of the general population. Overall, thechoice of controls depends on the scientific questionthe researchers attempt to answer [19].

Table II. The prevalence of mental disorders preceding suicide in thepsychological autopsy studies.

Mental disorder Range of current prevalence

Depressive disorders 30–90%Bipolar disorder 0–23%Schizophrenia 2–12%Alcohol dependence/abuse 15–56%Personality disorders 0–57%Any mental disorder 81–100%

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Ethical considerations

Ethical questions are particularly important when inter-viewing subjects who have recently lost their familymember in often traumatic, anxiety- and guilt-provoking, sometimes chaotic conditions. The psycho-logical autopsy is usually conducted between 3 to 12months after the occurrence of suicide, in order topermit time for bereavement [14, 19].

It is common practice to approach the intervieweefirst by a letter and then via telephone. The intervieweesare to be fully informed about the study, and can onlybe interviewed if they give informed consent to partici-pate, and have full right to refuse at any point in time.The integrity of the deceased is to be respected. Thismay sometimes be difficult when, e.g., the deceasedsuffered from personality pathology or abused sub-stances; however, even then can research questions beformulated in a respectful and understanding manner,rather pointing out the ultimate suffering of both thevictim and the next of kin.

Psychological autopsy researchers usually find thatthe family members actually find the research interviewrelieving rather than stressful. If needed, any next of kinneeding further psychological support or psychiatrictreatment should be helped to get in contact with therespective facilities.

PSYCHOLOGICAL AUTOPSY AND SUICIDE PREVEN-TION

Communication of suicide intent

Communication of suicide intent is an obvious sign ofsuicide risk, although its absence is by no means aguarantee of no risk. Suicide communication has been afocus of investigation in almost all psychological autopsystudies. However, precisely what constitutes ‘commu-nication of suicide intent’ is far from equivocal, and therange of victims who reportedly communicated theirintent varies therefore widely. If only very explicit state-ments of intent are included, then it appears that aboutone-third to one-half of all victims have communicatedtheir intent to family members, and a roughly similarproportion (but not necessarily the same subjects) tohealth care professionals during the final few months[5, 24, 32].

One of the reasons why suicides seem so commonlyto occur as a surprise is that in completed suicides,communication of intent is not very common tempo-

rally close to the act. This may perhaps be because of adeliberate decision not to let anyone intervene, ambiva-lence concerning the subject, or hopelessness. Forexample, of those 100 suicides having met a health careprofessional the very day of suicide in Finland in 1987-88, only 21% had communicated their intent [23].Thus the pathway leading to a completed suicide doesnot usually include telling about the intent to someoneduring the final days. If the subject had been ambiva-lent of the decision and sought help by contacting aprofessional, then this help-seeking had failed.

Recency of health care contracts

A contact with health care facilities is a necessary pre-requisite for health care to intervene in preventingsuicide. Thus investigating whether subjects who com-plete suicide have been in any contact with health carepreceding suicide is important in order to estimate thepotentials of health care interventions. Overall it seemsthat about half of the eventual suicides have been incontact with various health care settings during theirfinal month. The data on health care contacts preced-ing suicide recently has been systematically reviewed[29].

Specific treatment received for mental disorders

Overall 30–90% of all suicides have suffered fromdepressive disorders preceding the fatal act [1-6, 8, 12,13, 15, 16, 18, 21, 25, 28, 31-36, 38]. Major depres-sion is the most important single mental disorder relatedto suicide risk, so it is pertinent to investigate howdepression was treated before suicide. The psychologi-cal autopsy literature concerning adult suicides hasbeen convergent in documenting that the vast majorityof these have received no specific treatment for depres-sion, and if they have, it seems usually to have beeninadequate. Only about one-third have received anti-depressant therapy, and very few regular psychotherapy,or ECT [5, 24]. If strict criteria are used to defineadequate treatment, almost all suicides in major depres-sion seem to have occurred in untreated or under-treated cases. For suicide prevention the need to improvethe quality of care and continuous follow-up in thetreatment of major depression has seemed evident.However, the high likelihood of various types of psy-chiatric and somatopsychiatric co-morbidity, a variableperiod (up to almost 30 years) between first psychiatriccontacts and completed suicide, and the common lack

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of communication of suicidal intent to health careprofessionals revealed by these studies unavoidably com-plicate this task.

This prevailing view of non- or undertreatment hasrecently been challenged by a study suggesting that aconsiderable proportion of elderly suicides in the Goth-enburg area in Sweden in 1994 to 1996 had actuallybeen more adequately treated before completed suicide[37]. This might reflect increasing awareness of depres-sion and suicide risk among physicians during the early90s, and improving treatment of depression amongelderly in the general population. It may also suggestlimitations in the potential to prevent suicides byimproving the treatment of depression. A major ques-tion – besides replication – is whether these findingsconcerning elderly suicides can be generalised to otherage groups. A psychological autopsy study of subjectscompleting suicide during lithium treatment suggestedthat poor compliance with the treatment may be amajor obstacle for suicide prevention [22]. Thus, mereprovision of treatment is unlikely to be successful.

The findings concerning the treatment received havebeen quite similar also regarding other mental disor-ders. Subjects with substance use disorders seem to haverarely received any specific treatment for their disorder,even if they had been in contact with health care [30].Also, in suicides among subjects with schizophreniaundertreatment may be a contributing factor [20].However, whether any psychiatric treatment actually iseffective in reducing suicide mortality remainsunknown. Study of completed suicides can only help ingenerating reasonable hypotheses, and raising aware-ness of quality of care problems.

THE FUTURE OF PSYCHOLOGICAL AUTOPSY

Given the number of psychological autopsies alreadypublished, future psychological autopsies should bemore carefully targeted into high-risk groups and ques-tions relevant for suicide prevention, such as the treat-ment they received as compared with other patients.Due to its multifactorial etiology, integrating differentdomains of risk factors is likely to further advanceunderstanding of suicide. The studies which combinepsychiatric and psychosocial domains of risk factors inpsychological autopsy (e.g., [10, 17]), or in which it hasbeen used in investigating family history of suicidalbehaviour [7] or in a postmortem autoradiographical5-HTT binding study [26], are excellent examples ofseminal applications of psychological autopsy.

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