Eur Psychiatry 2001 ; 16 : 379-85

2001 ditions scientifiques et mdicales Elsevier SAS. All rights reserved

S0924933801005946/REV

REVIEW

Psychological autopsy studies a review

E.T. Isomets*
Mood Disorders & Suicide Research Unit, Department of Mental Health and Alcohol Research, National Public Health
Institute, 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 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

*Correspondence and reprints.

E-mail address: erkki.isometsa@ktl.fi (E.T. Isomets).

process of suicide [14, 19]. By now, more than 20

major psychological autopsy projects have been carried
out in diverse countries and cultures in North
America, Europe, Australia and New Zealand, Israel,
Taiwan and India, with a number of further major
projects ongoing in various settings. Thus we currently
have an accumulating global base of information about
the pathways to suicide, the characteristics of the victims, and some common problems in preventing suicide that these life histories reveal. The present paper
reviews the history, methodology, and some relevant
findings from these studies.

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E.T. Isomets

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

Study [ref]
Robins et al., 1959 [32]
Dorpat and Ripley, 1960 [16]
Barraclough et al., 1974 [5]
Beskow, 1979 [6]
Chynoweth et al.,1980 [13]
Mitterauer, 1981 [28]
Shafii et al., 1985 [35]
Rich et al., 1986 [31]
Arato et al., 1988 [3]
Brent et al., 1988 [8]
Runeson, 1989 [33]
sgrd, 1990 [4]
Conwell et al., 1991 [15]
Apter et al., 1991 [2]
The National Suicide Prevention Project in Finland [21]
Lesage et al., 1994 [25]
Cheng, 1995 [12]
Shaffer et al, 1996 [34]
Foster, 1997 [18]
Waern et al., 1999 [38]
Appleby et al.,1999 [1]
Vijayakumamar and Rajkumar, 1999 [36]
Cavanagh et al., 1999 [9]

HISTORY OF THE PSYCHOLOGICAL AUTOPSY

METHOD
Some researchers of self-destructive behaviour had actually investigated suicides already in the 1920s in Paris
and the 1930s in New York by collecting information
about a victim from various available sources [14, 32].
However, the first modern psychological autopsy study
of consecutive suicides was conducted by Eli Robins
and his colleagues in the Washington University in St.
Louis, MO, USA, in 195657 [32]. They carefully
investigated 134 consecutive suicides during a period of
1 year. Their findings were replicated by Dorpat and
Ripley in a second study in the Seattle area a few years
later [16]. At about the same time, Robert Litman,
Norman Farberow and Edwin Schneidman at the Los
Angeles Suicide Prevention Center (LASPC) had developed a method to help the medical examiners office to
decide whether a deceased had completed suicide or
died accidentally; Edwin Schneidman has been credited for coining the term psychological autopsy [14].
However, although the LASPC group was very influential in many ways, their focus was largely in classifying causes of death. For the future psychological
autopsies the work by Robins et al. [32] was a more

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

Psychological autopsy studies

nature of fatal suicidal behaviour, but also had some

methodological limitations. During the last decade a
second generation of psychological autopsies has
emerged. Such studies (e.g., [1, 12, 18, 25, 34, 36])
have mostly applied a case-control design, had their
living control subjects drawn from a representative
general population sample, and used standardised interviews to ascertain mental disorders and their
co-morbidity, among both their cases and their controls.
THE PSYCHOLOGICAL AUTOPSY METHODOLOGY
General features
The psychological autopsy procedure has two main
elements, 1) extensive interviews of family members
and other close intimates; and 2) collecting all possible
medical, psychiatric and other relevant documents of
the deceased. A typical psychological autopsy has one or
two main informants, e.g., a spouse, partner, parent or
adult child, or other next of kin, and often another
informant representing the attending health care personnel. In addition, other informants, including other
next of kin, friends, or attending personnel may also be
interviewed. An excellent practically oriented methodological review of psychological autopsy, particularly
useful for researchers within the United Kingdom, has
recently been published by Hawton et al. [19]. In the
following, the methodology of the research phase of the
National Suicide Prevention Project in Finland in
198788, the largest psychological autopsy project
undertaken, is described in more detail in order to
illustrate a psychological autopsy procedure.
The psychological autopsy procedure
of the research phase of the National Suicide Prevention Project in Finland
The National Suicide Prevention Project was set up by
the Finnish National Board of Health in 1986, and its
explicated aim was to reduce suicide mortality in Finland. During the research phase of the project, all
suicides committed in Finland between April 1, 1987
and March 31, 1988 (N = 1397) were carefully recorded
and analysed using the psychological autopsy method.
The definition of suicide was based on the Finnish
law for determining causes of death in every case of
violent, sudden or unexpected death the possibility of
suicide is assessed by police and medicolegal investigaEur Psychiatry 2001 ; 16 : 37985

381

tions involving autopsy and forensic examinations. For

the 12-month duration of the research phase of the
project this data gathering was more detailed than
usual. Data concerning victims classified as suicides in
forensic examination were collected via comprehensive
interviews with the relatives and attending health care
personnel, from psychiatric, medical and social agency
records, and from suicide notes. The interviews were
conducted by all together 245 mental health professionals, about half (47%) of whom were psychologists,
the remaining being mostly psychiatric nurses (27%),
social workers (15%), or physicians (8%). The interview forms were planned for the project, and the professionals were trained in their use. Four types of
interview were conducted:
1) Face-to-face interviews of family members were
usually conducted in their homes, with informed consent obtained beforehand. The interview was usually
undertaken about 4 months after the suicide, and had a
mean duration of 2 hours and 45 minutes. The structured interview forms contained 234 items concerning
the victims everyday life and behaviour, family factors,
use of alcohol and other drugs, previous suicidality,
help-seeking and recent life events. This interview could
be undertaken in 1155 (83%) of the 1397 suicide cases;
2) Health care professionals who had attended the
victim during the previous 12 months were interviewed
face-to-face with a structured form containing 113
items about the victims state of health, treatment in the
health care system, psychosocial stressors and level of
functioning; this interview was conducted in 612
(43.8%) of the cases. In the remaining cases, there
usually were so few health care contacts that no professional who would have known the deceased well was
available;
3) The last contact with health or social agency
professionals was separately evaluated by interviewing
the attending person either face-to-face or by telephone
with a semi-structured interview containing eight items.
This was undertaken in 860 (61.6%) of the cases; and
4) Additional unstructured interviews were made by
telephone if needed. These informants could include
other 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%), suicide notes (left by 389 [27.8%] of the cases), and other
available records on the cases. A multidisciplinary team
discussed all the cases, and comprehensive case reports

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E.T. Isomets

were written on the basis of all information available

[21, 24, 27].

Table II. The prevalence of mental disorders preceding suicide in the

psychological autopsy studies.
Mental disorder

Investigating mental disorders as a part of the psychological autopsy

Almost all psychological autopsy studies have investigated mental disorders of suicide victims as a part of
their study design. This necessitates both collecting
information from various attending treatment facilities
as well as interviewing the attending personnel and the
next of kin by using structured interview methods. At
present most studies apply structured interviews available for clinical research. It is essential that if personality disorders are to be investigated, the focus is not
exclusively in victims behaviour during the final
months. Integrating information from several sources is
desirable as, e.g., parents of adolescent are not always
aware of the substance use problems their offspring may
have had.
In the National Suicide Prevention Project in Finland, the mental disorders of suicide victims were examined in a diagnostic study of a non-stratified random
sample of 229 (16.4%) of the total 1397 suicides. The
retrospective diagnostic evaluation of the cases according to DSM-III-R criteria, weighing and integrating all
available information, took place in two phases [21].
First, two pairs of psychiatrists independently made
provisional best estimate diagnoses, the reliability of
which was tested; second, all cases involving any diagnostic disagreement were reanalysed with a third psychiatrist to achieve consensus for the final best estimate
diagnoses. The reliability achieved ranged from moderate to excellent (kappa 0.52 to 0.94) [21]. However,
some smaller psychological autopsy studies in which
the information is collected and diagnoses assigned by
only a few interviewers and diagnosticians, have
reported excellent reliability (kappa 0.801.00 ) in virtually all diagnostic categories (e.g., [10-12, 17, 25]).
Having fewer interviewers and diagnosticians likely
reduces methodological error variance, and results in
higher reliability.
Overall, the more than 20 major psychological
autopsy projects have documented that with rare exceptions, the presence of a mental disorder is a necessary,
although not a sufficient condition for a completed
suicide to occur. The findings of these studies are
summarised in table II. The two most prevalent categories of mental disorders among completed suicides are
mood disorders and substance use disorders. Further-

Depressive disorders
Bipolar disorder
Schizophrenia
Alcohol dependence/abuse
Personality disorders
Any mental disorder

Range of current prevalence

3090%
023%
212%
1556%
057%
81100%

more, co-morbidity of mental disorders seems to be the

rule [1, 11, 17, 18, 21, 36]. The second-generation
controlled psychological autopsies have confirmed the
remarkable impact of concurrent mood and substance
use [12] or mood and personality disorders [17] in
multiplying the risk for suicide.
Control cases
The choice of an appropriate control group has been
debated during the evolution of the method. Ultimately the type of control subject is determined by the
hypotheses tested. As most researchers have been looking for risk factors for suicide as compared with the
general population using a case-control design, a natural choice may be age- and gender-matched control
cases. However, it is difficult to exclude biases introduced by the fact that the cases are deceased whereas the
controls are not. Ideally, information on the living
controls should be obtained from their next of kin in
order to avoid information bias. How high a proportion of the eligible controls consent to this is another
matter. Living psychiatric control cases might be the
choice when investigating possible specific risk factors
that operate in the selected high-risk populations, as the
risk factors for completed suicide often are factors selecting patients to be referred to psychiatrists, and do not
necessarily help in differentiating between high and low
risk within a high-risk population.
Some authors have advocated use of controls matched
for bereavement, such as victims of traffic accidents or
other causes of death. While similarity in terms of
bereavement is an obvious advantage, a problem is that
victims of traffic accidents are unlikely to represent a
random sample of the general population. Overall, the
choice of controls depends on the scientific question
the researchers attempt to answer [19].
Eur Psychiatry 2001 ; 16 : 37985

Psychological autopsy studies

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

rally close to the act. This may perhaps be because of a

deliberate decision not to let anyone intervene, ambivalence concerning the subject, or hopelessness. For
example, of those 100 suicides having met a health care
professional the very day of suicide in Finland in 198788, only 21% had communicated their intent [23].
Thus the pathway leading to a completed suicide does
not usually include telling about the intent to someone
during the final days. If the subject had been ambivalent of the decision and sought help by contacting a
professional, then this help-seeking had failed.
Recency of health care contracts
A contact with health care facilities is a necessary prerequisite for health care to intervene in preventing
suicide. Thus investigating whether subjects who complete suicide have been in any contact with health care
preceding suicide is important in order to estimate the
potentials of health care interventions. Overall it seems
that about half of the eventual suicides have been in
contact with various health care settings during their
final month. The data on health care contacts preceding suicide recently has been systematically reviewed
[29].
Specific treatment received for mental disorders
Overall 3090% of all suicides have suffered from
depressive disorders preceding the fatal act [1-6, 8, 12,
13, 15, 16, 18, 21, 25, 28, 31-36, 38]. Major depression is the most important single mental disorder related
to suicide risk, so it is pertinent to investigate how
depression was treated before suicide. The psychological autopsy literature concerning adult suicides has
been convergent in documenting that the vast majority
of these have received no specific treatment for depression, and if they have, it seems usually to have been
inadequate. Only about one-third have received antidepressant therapy, and very few regular psychotherapy,
or ECT [5, 24]. If strict criteria are used to define
adequate treatment, almost all suicides in major depression seem to have occurred in untreated or undertreated cases. For suicide prevention the need to improve
the quality of care and continuous follow-up in the
treatment of major depression has seemed evident.
However, the high likelihood of various types of psychiatric and somatopsychiatric co-morbidity, a variable
period (up to almost 30 years) between first psychiatric
contacts and completed suicide, and the common lack

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E.T. Isomets

of communication of suicidal intent to health care

professionals revealed by these studies unavoidably complicate this task.
This prevailing view of non- or undertreatment has
recently been challenged by a study suggesting that a
considerable proportion of elderly suicides in the Gothenburg area in Sweden in 1994 to 1996 had actually
been more adequately treated before completed suicide
[37]. This might reflect increasing awareness of depression and suicide risk among physicians during the early
90s, and improving treatment of depression among
elderly in the general population. It may also suggest
limitations in the potential to prevent suicides by
improving the treatment of depression. A major question besides replication is whether these findings
concerning elderly suicides can be generalised to other
age groups. A psychological autopsy study of subjects
completing suicide during lithium treatment suggested
that poor compliance with the treatment may be a
major obstacle for suicide prevention [22]. Thus, mere
provision of treatment is unlikely to be successful.
The findings concerning the treatment received have
been quite similar also regarding other mental disorders. Subjects with substance use disorders seem to have
rarely received any specific treatment for their disorder,
even if they had been in contact with health care [30].
Also, in suicides among subjects with schizophrenia
undertreatment may be a contributing factor [20].
However, whether any psychiatric treatment actually is
effective in reducing suicide mortality remains
unknown. Study of completed suicides can only help in
generating reasonable hypotheses, and raising awareness of quality of care problems.
THE FUTURE OF PSYCHOLOGICAL AUTOPSY
Given the number of psychological autopsies already
published, future psychological autopsies should be
more carefully targeted into high-risk groups and questions relevant for suicide prevention, such as the treatment they received as compared with other patients.
Due to its multifactorial etiology, integrating different
domains of risk factors is likely to further advance
understanding of suicide. The studies which combine
psychiatric and psychosocial domains of risk factors in
psychological autopsy (e.g., [10, 17]), or in which it has
been used in investigating family history of suicidal
behaviour [7] or in a postmortem autoradiographical
5-HTT binding study [26], are excellent examples of
seminal applications of psychological autopsy.

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