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Psychiatric diagnoses in 3275 suicides: a meta-analysis

  • Geneviève Arsenault-Lapierre1,
  • Caroline Kim1 and
  • Gustavo Turecki1Email author
BMC Psychiatry20044:37

DOI: 10.1186/1471-244X-4-37

Received: 13 April 2004

Accepted: 04 November 2004

Published: 04 November 2004

Abstract

Background

It is well known that most suicide cases meet criteria for a psychiatric disorder. However, rates of specific disorders vary considerably between studies and little information is known about gender and geographic differences. This study provides overall rates of total and specific psychiatric disorders in suicide completers and presents evidence supporting gender and geographic differences in their relative proportion.

Methods

We carried out a review of studies in which psychological autopsy studies of suicide completers were performed. Studies were identified by means of MEDLINE database searches and by scanning the reference list of relevant publications. Twenty-three variables were defined, 16 of which evaluating psychiatric disorders. Mantel-Haenszel Weighted Odds Ratios were estimated for these 16 outcome variables.

Results

Twenty-seven studies comprising 3275 suicides were included, of which, 87.3% (SD 10.0%) had been diagnosed with a mental disorder prior to their death. There were major gender differences. Diagnoses of substance-related problems (OR = 3.58; 95% CI: 2.78–4.61), personality disorders (OR = 2.01; 95% CI: 1.38–2.95) and childhood disorders (OR = 4.95; 95% CI: 2.69–9.31) were more common among male suicides, whereas affective disorders (OR = 0.66; 95% CI: 0.53–0.83), including depressive disorders (OR = 0.53; 95% CI: 0.42–0.68) were less common among males. Geographical differences are also likely to be present in the relative proportion of psychiatric diagnoses among suicides.

Conclusions

Although psychopathology clearly mediates suicide risk, gender and geographical differences seem to exist in the relative proportion of the specific psychiatric disorders found among suicide completers.

Background

Suicide is an important public health problem that is among the leading causes of death in Western countries [1]. Over the last years, the relationship between suicide and mental disorders has been the focus of several studies and has generated important debate [2]. This relationship has been investigated by different strategies, but particularly by the psychological autopsy method [3], which is generally considered the method of choice to retrieve postmortem information on psychopathology. The psychological autopsy procedure entails the retrospective psychiatric assessment of the deceased by variable methodologies, but generally by means of proxy-based interviews. This procedure is also frequently completed by having access to medical and other relevant dossiers from the subject on whom the psychological autopsy is carried out [4, 5].

It is well established that psychopathology is an important predictor of suicide completion [6], but there is considerable variability between studies in rates of total and specific psychiatric disorders [7]. One of the most consistent findings in suicidology is the excess of male suicides observed in most countries [8], with a few notable and important exceptions, such as China [1, 9]. Geographic origin is another important source of variation [1]. However, the possibility that clinical and other behavioural factors could at least partly mediate gender and geographic differences in suicide rates has been little explored. The aim of this study was to carry out quantitative syntheses of overall and specific psychiatric diagnoses found in suicide studies and to explore possible gender and geographical differences in the distribution of psychiatric disorders among suicide completers.

Methods

Study identification

To identify studies for this review, the National Library of Medicine (NLM) PubMed database was searched up to December 2002 using English language and human study limits. The Medical Subject Heading (MeSH) terms "suicide AND psychological autopsy", "suicide AND psychopathology", "suicide AND (postmortem diagnoses OR postmortem diagnosis)", and "(mental disorders/*epidemiology) AND prevalence AND ((suicide/*statistics & numerical data) NOT suicide attempts)" were used. Finally, in order to find other articles not obtained through electronic searches, reference lists from original studies as well as from not independent studies were screened.

Study selection

The inclusion criteria for considering articles for this review were as follow. Studies had to: 1) be original, 2) be published in English, 3) contain information on diagnostic distribution, 4) include suicide completers unselected according to specific mental disorders, 5) use of a psychological autopsy method, which for the purpose of this review was considered as the process of reconstructing psychiatric diagnoses based either on interviews with informants (regardless of the specific diagnostic instrument methodology) or on review of multiple official records that contained interviews with informants such as general practitioners, other professionals and relatives or friends, 6) use of standard diagnostic criteria (any versions of the Diagnostic and Statistical Manual of Mental Disorders, the International Classification of Diseases or the Research Diagnostic Criteria).

Studies were excluded if: 1) their sample was not independent from that investigated in another study (see below for criteria on which one was included), 2) they were reports on suicide in one specific diagnostic category and 3) if diagnoses were simply extracted from medical records without review of multiple sources of information.

A single reviewer (G.A.L.) made a prior screening to identify and select articles. When titles and abstracts were deemed adequate or when they remained too obscure to reach a verdict, full texts were retrieved for further evaluation in conformity with the inclusion and exclusion criteria.

Study assessment

A total of 23 variables were defined, three of which relate to demographic information, four other concern the method of diagnosis, and 16 evaluate the presence of psychiatric diagnoses. To obtain the latter 16 variables (shown in table 1; see additional file), every diagnostic term used in the original studies was categorised into one of the 16 pre-defined groups. So diagnoses such as "intermittent depressive disorder" or "neurotic depression" reported in some studies were coded under "depressive disorders' variable and diagnoses such as "alcohol use", "alcohol misuse" and "alcohol abuse" were coded as "alcohol problems". All substances noted as other than alcohol were coded under "other substances problems". These two variables were then recoded as "any substance problems". The same was achieved with the "depressive disorders" and "bipolar disorders" which were recoded as "any affective disorders".

Disorders labelled as "other" or as a subset of various disorders without further specification were left aside. For all studies the most specific diagnosis was considered. That is, when the authors broke down general diagnosis such as "affective disorder" into "depressive disorders" and "bipolar disorders", only these more specific diagnoses were noted and accounted for in our study.

When two studies or more were carried on the same population, the study with the largest sample and the most informative report was consistently selected. When multiple diagnoses and principal diagnoses (those deemed by the investigators as more related to the suicide) were reported, preference was given to the former. In four cases, secondary diagnoses were added to principal diagnoses to obtain multiple diagnoses [1013]. Studies for which controls were selected among psychiatric in-patients or matched to suicides by mental diagnosis, only suicide cases were included in our analysis [12, 14]. In the study by Graham and Burvill [15], controls were older suicide completers, and so they were included in our suicide group. In the study by Hawton et al. [10], only diagnoses for suicides obtained by means of an interview were included. In three case-control studies [1618], not all suicide cases were matched to a control. In these cases, we considered the full suicide sample in the descriptive analyses, but only the control-matched suicides in the quantitative analyses.

Statistical analysis

Descriptive analyses and homogeneity tests were carried out before pooling the data. In order to determine the risks of having had a disorder, suicides and controls were recorded in 2 × 2 tables. These data were then stratified by the 16 outcome variables and Mantel-Haenszel Weighted Odds Ratios (OR) and 95% confidence intervals (95% CI) were estimated. Gender differences were also explored by means of Odds Ratios. Major disorders were then compared between the different demographic areas by means of χ2 to assess variations in the diagnostic distribution across these demographic areas. All statistical analyses were carried out using Epi Info 6, version 6.04d (C.D.C., U.S.A.; W.H.O., Geneva, Switzerland).

Results

A total of 152 studies were initially identified. After selection according to inclusion/exclusion criteria, 27 studies were included in this review. The most common reasons for exclusion were that a) no diagnostic distribution was provided (n = 46) [6, 1963], b) samples were pre-selected according to a psychiatric disorder (n = 30) [6493], c) there was another report on the same sample that either included more subjects or was more informative (n = 29) [3, 94121]. Four other studies were about non-completers [122125]. Another was not in English [126], and others reported only on one type of disorder [127, 128], and therefore, they were all excluded. Additional 14 studies [7, 129141] were excluded because the diagnostic criteria were either unspecified or not standard.

The studies by Rich et al. [99] and by Foster et al [142] were not independent from, respectively, Rich et al. [143] and Foster et al. [144]. Although non-independent, these studies provided information of different quality, and thus, were included in our review. Accordingly, Rich et al. [99] and Foster et al. [142] were considered, respectively in the gender difference analysis and the case-control comparisons, whereas the study by Rich et al. [143] and Foster et al. [144] were considered for the descriptive analysis.

Methodological assessment

Among the 27 studies that were retained, 52% (14/27) were case-control studies. Eighty-one percent (22/27) of the studies were published after 1990. Sixty-seven percent of the studies (18/27) used DSM diagnostic criteria, whereas only 22% (6/27) and 11% (3/27) used the ICD and RDC diagnostic criteria respectively. Multiple diagnoses were investigated in 63% (17/27) of the studies, whereas principal diagnoses only were given for the other 10 studies. A description of the demographic and methodological features of these 27 studies is shown in table 2.
Table 2

Description of the 27 studies included in this meta-analysis

Study

Year

Origin

Diagnostic criteria

Methods

Number of diagnoses

n Suicide

With a Dx (%)

n Control

with a Dx (%)

Matched

Appleby et al.[151]*

1999

England

ICD-10

Official records and interviews

Multiple

84

76 (90%)

64

17 (27%)

Living ± 5 year and sex

Apter et al.[145]*

1993

Israel

DSM-III

Official records and interviews

Principal

43

35 (81%)

   

Asgard U.[147]*

1990

Sweden

RDC

Official records and interviews

Principal

104

99 (95%)

   

Cavanagh et al.[14]

1999

Scotland

DSM-III

Official records and interviews

Principal

45

44 (98%)

   

Cheng et al.[16]*

1995

Taiwan

DSM-III-R

Official records and interviews

Multiple

116

114 (98%)

226

130 (58%)

Living ± 5 years, sex, area of residence

Conwell et al.[156]*

1996

USA

DSM-III-R

Official records and interviews

Multiple

141

127 (90%)

   

Foster et al.[142,144]

1997/1999

Ireland

DSM-III-R

Official records and interviews

Multiple

118

106 (90%)

117

30 (26%)

List of deceased's GP Age, gender, marital status

Harwood et al.[17]*

2001

England

ICD-10

Official records and interviews

Multiple

100

93 (93%)

54

N/A

Natural deaths Age and sex

Hawton et al.[10]

2002

England

ICD-10

Official records and interviews

Multiple

42

38 (90%)

84

6 (7%)

Living nurses ± 10 years, specialty and seniority

Henriksson et al.[11]

1993

Finland

DSM-III-R

Official records and interviews

Multiple

229

225 (98%)

   

Houston et al.[12]

2001

England

ICD-10

Official records and interviews

Multiple

47

40 (85%)

   

Lesage et al.[150]

1994

Canada

DSM-III-R

Official records and interviews

Multiple

75

69 (92%)

75

N/A

Living Neighbourhood, age, marital status and occupation

Phillips et al.[9]*

2002

China

DSM-IV

Interviews with informants

Principal

519

325 (63%)

536

93 (17%)

Accidental deaths Geographical areas

Rich et al.[143]

1986

USA

DSM-III

Official records and interviews

Multiple

283

258 (91%)

   

Runeson B.[153]

1989

Sweden

DSM-III-R

Official records and interviews

Principal

58

57 (98%)

   

Shaffer et al.[18]*

1996

USA

DSM-III

Official records and interviews

Multiple

119

108 (91%)

   

Shaffi et al.[13]*

1988

USA

DSM-III

Official records and interviews

Multiple

21

20 (95%)

21

11 (52%)

Living friends Sex, age, race, education, religion, income, and father's education

Vijayakumar et al.[159]*

1999

India

DSM-III-R

Official records and interviews

Principal

100

88 (88%)

100

14 (14%)

Living SES, sex and ± 2 years

Waern et al.[154]*

2002

Sweden

DSM-IV

Official records and interviews

Multiple

85

82 (96%)

153

28 (18%)

Living Sex, ± 2 years

Boardman et al.[152]

1999

England

ICD-10

Multiple official records

Multiple

212

151 (71%)

212

40 (19%)

Unnatural deaths ± 5 years and sex

Cantor et al.[157]

1989

Australia

DSM-III-R

Multiple official records

Principal

47

41 (87%)

   

Groholt et al.[149]*

1997

Norway

DSM-III-R

Multiple official records

Multiple

121

90 (74%)

   

Thacore et al.[158]

2000

Australia

ICD-9

Multiple official records

Principal

75

46 (65%)

   

Graham et al.[15]

1992

Australia

DSM-III

Multiple official records

Multiple

136

120 (88%)

   

Brent et al.[148]

1999

USA

DSM-III

Interviews with informants

Multiple

140

115 (82%)

131

32 (24%)

Living Age, race, gender, country and SES

Cerel et al.[155]

2000

USA

RDC

Interviews with informants

Multiple

15

13 (87%)

201

70 (35%)

Non-suicide bereaved family

Arato et al.[146]*

1987

Hungary

RDC

Interviews with informants

Principal

200

162 (81%)

   

* Based on axis I disorders only.

N/A – information not available or not clear

Demographic features

A total of 3275 suicides were included in our study with a mean number of 121 (standard deviation (SD) 103) suicides per study. There were 11 studies where diagnoses were given by gender for a subtotal of 933 males and 462 females [10, 11, 18, 99, 144150]

There were 14 studies [1012, 14, 17, 142, 145147, 149, 151154] carried out in Europe, including one in Israel [145]. These 14 European studies comprised a total of 1488 suicides. Seven studies were from North America [13, 18, 143, 148, 150, 155, 156] with 794 suicides, three others were from Australia [15, 157, 158] with 258 suicides and, finally, three were from Asia [9, 16, 159]. with 735 suicides.

Diagnostic distribution

The mean percentage of suicides with a psychiatric diagnosis was 87.3 % (SD 10.0 %). However, only 14 of the 27 studies reported both axes I and II disorders (see table 2). The remaining 13 studies only assessed axis I diagnoses. The mean percentage of controls with a diagnosis was, as expected, lower (34.9 % SD 25.1 %). As a comparison, among studies not included because the diagnostic criteria were not specified or not standard, the mean percentage of suicides with a diagnosis was not statistically different from that of the studies included in this review (78.7% SD 21.0%, χ2 : 2.27, p = 0.13).

On average, 43.2% (SD 18.5%) of suicide cases were diagnosed with any affective disorders (including depressive and bipolar disorders) and 25.7% (SD 14.8%) with other substance problems. In these groups, respectively, depressive disorders and alcohol problems were the most frequent. Finally, personality disorders represented 16.2% (SD 8.6%) of the suicide diagnoses and psychotic disorders, including schizophrenia accounted for 9.2% (SD 10.2%).

The samples from the 14 case-control studies were found homogeneous for the 16 outcome variables according to a homogeneity test (results not shown), allowing us to pool the individual studies and determine overall risks.

Table 1 (see additional file) shows that, with the exception of organic disorders and adjustment disorders, suicide cases had a higher risk of being diagnosed than controls with each of the diagnoses considered. Of these diagnoses, the risks for psychotic disorders were the highest (OR = 15.38; 95% CI: 3.53–97.82) followed by the variable "at least one psychiatric disorder" (OR = 10.50; 95% CI: 9.60–13.56). The risk for schizophrenia was also particularly high (OR = 5.56; 95% CI: 3.12–10.24). This is due to the fact that there were only 15 control subjects altogether diagnosed with schizophrenia and two with psychotic disorders.

Statistically significant differences were found when male and female suicide cases were compared (see table 3). However, gender-based comparisons should be considered cautiously as, when available, demographic information indicated that female suicides included in the studies reviewed tended to be older than males (table 5). Nevertheless, even considering this potential limitation, the results are interesting. The risks for alcohol (OR = 2.19; 95% CI: 1.63–2.95), other substance problems (OR = 2.02; 95% CI: 1.32–3.10), and any substance problems (OR = 3.58; 95% CI: 2.78–4.61), personality disorders (OR = 2.01; 95% CI: 1.38–2.95) or childhood disorders (OR = 4.95; 95% CI: 2.69–9.31) were greater in male as opposed to female suicides. On the other hand, the risks of having depressive disorders (OR = 0.53; 95% CI: 0.42–0.68) or any affective disorders (OR = 0.66; 95% CI: 0.53–0.83) were lower in males.
Table 3

Odds Ratios for major outcome variables across sexes

Disorders

n for females

n for males

OR (95% CI)

χ2

p-value

Any psychiatric disorders

398

801

0.98 (0.70–1.36)

0.02

0.881

Schizophrenia

17

44

1.30 (0.71–2.39)

0.79

0.373

Other psychotic disorders or psychosis NOS

15

40

1.33 (0.71–2.56)

0.88

0.347

Somatoform, anxiety and neurotic disorders

33

83

1.27 (0.85–1.97)

1.24

0.265

Bipolar disorders

26

43

0.81 (0.48–1.38)

0.68

0.409

Organic disorders

6

15

1.24 (0.45–3.60)

0.20

0.656

Adjustment disorders

31

64

1.02 (0.64–1.64)

0.01

0.917

Disorders more likely if male

     

Alcohol problems

73

272

2.19 (1.63–2.95)

29.57

0.000

Other substances problems

32

122

2.02 (1.32–3.10)

11.89

0.001

Any substances problems

110

436

3.58 (2.78–4.61)

110.18

0.000

Personality disorders

41

153

2.01 (1.38–2.95)

14.60

0.000

Childhood disorders

13

117

4.95 (2.69–9.31)

34.57

0.000

Disorders more likely if female

     

Depressive disorders

199

268

0.53 (0.42–0.68)

28.56

0.000

Any affective disorders

272

454

0.66 (0.53–0.83)

12.91

0.000

Other disorders

16

12

0.36 (0.16–0.82)

7.44

0.006

Table 5

Descriptive analysis of the age and sex of subjects

 

Age (mean ± SD)

n [Studies]

All regions

  

28.5 ± 12.8

880 [11,18,143,145,148-150,158]

34.5 ± 17.8

333 [11,18,143,147-149,158]

Both sexes*

41.6 ± 17.8

794 [11,14,17,149,151,154,157,158]

American Studies

  

26.0 ± 12.3

491 [18,143,148,150]

27.3 ± 18.9

127 [18,143,148]

Both sexes*

N/A

N/A

European Studies

  

27.2 ± 15.4

314 [11,145,149]

37.9 ± 18.9

191 [11,147,149]

Both sexes*

42.3 ± 20.8

672 [11,14,15,17,151,154]

Australian Studies

  

42.5

491 [158]

45.7

15 [158]

Both sexes*

39.5 ± 5.2

122 [157,158]

Asian Studies

  

N/A

N/A

N/A

N/A

Both sexes*

N/A

N/A

N/A – information not available

* Both sexes refers to studies in which information on age by sex was not provided, and thus, only mean age for the whole sample was available.

Analysing the data according to geographic areas, the diagnostic distribution of the key diagnoses found in suicides differed significantly between world regions (see table 4), but as mentioned above, potential age-related biases may apply (table 5). The American suicides were more often diagnosed with a psychiatric disorder than suicides in the other regions of the world; 89.7 % (SD 4.2 %) of the American suicides had at least one diagnosis, whereas 88.8 % (SD 8.9 %) of the European suicides, 83.0 % (SD 18.4 %) of the Asian suicides and 78.9 % (SD 15.3 %) of the Australian suicides had at least one psychiatric diagnosis.
Table 4

Diagnostic distribution across different regions of the world

 

European (%)

North American (%)

Australian (%)

Asian (%)

χ2

Affective disorders

753 (48.5)

390 (33.6)

71 (32.7)

335 (51.3)

11.3*

Substances-related disorders

390 (18.6)

573 (40.1)

106 (24.1)

135 (26.7)

12.1*

Schizophrenia and other psychotic disorders or psychosis NOS

125 (7.5)

42 (4.2)

29 (24.3)

53 (8.4)

24.1*

Personality disorders

197 (16.8)

75 (13.4)

75 (17.7)

20 (17.7)

1.2n.s.

At least one Diagnosis

1298 (88.8)

710 (89.7)

207 (78.9)

527 (83.0)

6.4n.s.

* Significant at p ≤ 0.01

n.s.Non significant

Discussion

Total psychopathology

Since the first psychological autopsy studies by Robins et al. [139] in North America and by Barraclough et al. [7] in Europe, a relatively small number of studies have been carried out. These original studies were descriptive in nature, and only more recently case-control studies have been performed. The data from these studies have consistently suggested a clear relationship between mental disorders and suicide. Here we systematically reviewed these studies and pooled their results whenever possible. Our results show that, on average, 87.3 % of the subjects who committed suicide had a mental disorder. On the other hand, an average of 14.0 % of these subjects was not diagnosed with a psychiatric disorder. A possible explanation is that a diagnosis failed to be detected due to various methodological shortcomings. This possibility is concrete, as psychological autopsy studies rely on informants and/or available medical information to generate diagnostic data. In some cases, the informant has little information on the last weeks or months of life of the subject. Therefore, it is possible that the overall rate of psychopathology observed is still underestimated. This is consistent with findings from recent studies by our group focusing on suicides without an axis I diagnosis [160].

Specific diagnoses

This review confirms the overall impression from individual studies that affective, substance-related, personality and psychotic disorders account for most of the diagnoses among suicides. The two single most common diagnostic categories among suicide completers were any affective disorders (diagnosed in 43.2 % of suicide cases), and any substance disorders (present in 25.7 % of suicide cases). Recent studies on comorbidity indicate that suicide completers are more likely to have more than one psychiatric diagnosis [142, 161]. In a comparison with matched community controls, Foster et al. [142] found a significant increase in suicide risk in the presence of Axis I-Axis II comorbidity (OR = 346.0, p < 0.0001). Our group [161], investigating male completers and controls from the general population, found that suicide cases had an average of 2.36 diagnoses and that comorbidity in completers tended to be of three different patterns, according to mean number of diagnoses (range 1.19 – 4.05) and presence of impulsive-aggressive behaviours. Thus, it would have been interesting to assess overall levels of comorbidity in this review, as well as to investigate what is the amount of overlap between the different diagnoses investigated. However, very little, if any, information about comorbidity was present in the original studies reviewed and this information was impossible to retrieve from the published data.

Gender differences

The investigation of gender differences in rates of psychopathology associated to suicide should be regarded in light of the methodological limitations of this review, which are primarily related to difficulties in comparing studies carried out using different methodological procedures, diagnostic instruments and criteria, in addition to potential differences in sample characteristics, including age distribution. However, given the important effect that gender seems to have as a suicide risk moderator and the relative lack of appropriate investigation focusing on gender differences in suicide completion, the observed differences in rates of psychopathology in male and female suicides are interesting and should be considered for validation in future studies. Our results indicate that the risk of substance-related disorders, personality disorders and childhood disorders are significantly higher in male suicides, whereas, the risk of affective disorders, specifically, depressive disorders, are greater in female suicides. On average, any substance problems represented 41.8 % (SD 21.1 %) of the male diagnoses and 24.0 % (SD 16.5 %) of the female diagnoses (χ2 7.29 p = 0.007), whereas affective disorders represented 59.4 % (SD 13.9 %) of the female diagnoses and 47.4 % (SD 12.7 %) of the male diagnoses (χ2 2.88 p = 0.089).

Although there has been much discussion on possible factors that could help explain gender differences in suicide rates, most of the studies have primarily focused on psychosocial and demographic risk factors. There is very little data on the possible role of psychiatric and/or behavioural characteristics, which may also mediate gender differences in suicide risk. This study suggests that the underlying psychiatric morbidity may be different in male and female suicide completers. An important question that follows is whether or not the differences found in this study between male and female suicides are the consequence of gender differences in the prevalence of psychiatric disorders in the general population. Although possible, it is unlikely that differences in population rates of psychiatric disorders could explain the different distribution of psychiatric disorders observed in this study, as the gender-specific risks found were not consistently reflecting gender-differences observed in prevalence rates (for instance, schizophrenia and psychotic disorders) and they were not always in the same direction (for instance, personality disorders).

An interesting finding of this study was precisely the absence of gender differences in schizophrenia. This is not necessarily inconsistent with suggestions that most of the suicide cases in schizophrenia are males [162164], as our findings basically indicate that there are no relative differences between genders in the proportion of suicide cases that are diagnosed with schizophrenia. However, our findings are inconsistent with the common generalization that schizophrenics tend to commit suicide early in the course of the disease because, given gender-differences in the age at onset in schizophrenia [165], with males more likely to have the onset at younger ages, one would expect a considerably higher proportion of schizophrenia among male completers, even if the age distribution in our sample suggests that women in general seemed older than men. In summary, despite the potential methodological limitations discussed above, our results in gender differences in clinical correlates of suicide are interesting and should be further investigated.

Geographic differences

We also found differences in rates of psychiatric disorders in studies from different geographic origins. This finding may indicate social and cultural factors influencing how one views and interprets suicide and cultural biases towards or against specific diagnoses. Alternatively, as discussed for gender-based comparisons, demographic (age, rural vs. urban samples, socioeconomic and educational level, etc.) differences between the samples could explain some of these results. In view of that, similar limitations, as those for the analysis of gender differences, apply to the analysis of geographical differences in rates of psychopathology associated to suicide (see table 5). American women seem younger than in any other region, Australian women and men appear older than those in the other regions, and no Asian studies provide age means for their sample. In spite of these limitations, our review suggests that, although psychopathology mediates suicide worldwide, there seem to be differences across different parts of the world in the relative proportion of the specific psychiatric disorders found among suicide completers. As mentioned above, these differences may be attributed to variance in psychological autopsy methodologies between countries, or yet, to important differences in the prevalence of psychiatric disorders. Although it is possible that methodological differences between studies play a certain role explaining some of the differences found, it is unlikely that they accounted for all differences found as the studies included in these regional comparisons used similar methods and diagnostic criteria, whereas the differences found were substantial. It is not likely either that diversity between countries in prevalence of psychiatric disorders account for all the observed regional differences, as for some of these disorders, such as schizophrenia, it is thought that there is little variation in prevalence rates between different populations [166]. Thus, the geographical differences observed in the relative proportion of psychiatric disorders among suicide completers is an interesting issue that should be further explored.

Most limitations of this study are common to all quantitative systematic reviews. In particular to this study, one should take into account that the quantitative review was carried out with studies that, although published in a relatively short period of time (from 1986 to 2002), have variation in diagnostic criteria used and have different methodological rigor. Moreover, it is possible that between-study variation in the distribution of a series of demographic variables could have had an impact on our findings. We chose not to control for these methodological differences as given the diverse sources of possible variation, doing so would have considerably limited the number of studies included in the review. Therefore, we opted to be more inclusive and consider the results of this review as preliminary and providing information to be further investigated.

Over the course of this study, a report on another meta-analysis of psychological autopsy studies was published. This study, by Cavanagh et al. [167], reviewed the literature on psychological autopsies and yielded similar overall results. However, there are differences between the study by Cavanagh et al [167] and ours, both in methodology and major aims. While they identified studies through a larger number of library databases, they included only studies up to June 2000. Moreover, they did not investigate risks attributed to specific diagnostic categories, but rather risks attributed to mental health disorders, presence of an affective disorder and comorbidity. They also investigated the role of a few social variables and did not carry out analyses exploring a possible gender and geographic difference in relative rates of psychopathology.

Conclusions

Our study carried out a systematic review of psychological autopsy studies of suicide and indicates that overall, 87.3% of suicide cases have a history of psychiatric disorders. We also found that male suicides have a different psychiatric profile than female suicide cases and that the relative proportion of psychiatric disorders in suicide completers tends to vary according to geographical region.

Declarations

Acknowledgment

This study was partly funded by CIHR grant MOP-38078 and a NARSAD grant. GT is a CIHR scholar.

Authors’ Affiliations

(1)
McGill Group for Suicide Studies, Douglas Hospital Research Centre, Department of psychiatry, McGill University

References

  1. WHO: World Health Report 2000. Health System: Improving Performance. 2000, Ref Type: ReportGoogle Scholar
  2. Tanney BL: Psychiatric diagnoses and suicidal acts. In Comprehensive textbook of suicidology. Edited by: Marris RW, Berman AL, Sylverman MM. 2000, New York: The Guilford Press, 311-341.Google Scholar
  3. Farberow NL, Shneidman ES, Neuringer C: Case history and hospitalization factors in suicides of neuropsychiatric hospital patients. J Nerv Ment Dis. 1966, 132: 32-44.Google Scholar
  4. Hawton K, Appleby L, Platt S, Foster T, Cooper J, Malmberg A, Simkin S: The psychological autopsy approach to studying suicide: a review of methodological issues. J Affect Disord. 1998, 50: 269-276. 10.1016/S0165-0327(98)00033-0.PubMedGoogle Scholar
  5. Isometsa ET: Psychological autopsy studies – a review. Eur Psychiatry. 2001, 16: 379-385. 10.1016/S0924-9338(01)00594-6.PubMedGoogle Scholar
  6. Lonnqvist JK, Henriksson MM, Isometsa ET, Marttunen MJ, Heikkinen ME, Aro HM, Kuoppasalmi KI: Mental disorders and suicide prevention. Psychiatry Clin Neurosci. 1995, 49 (Suppl 1): S111-S116.PubMedGoogle Scholar
  7. Barraclough B, Bunch J, Nelson B, Sainsbury P: A hundred cases of suicide: clinical aspects. Br J Psychiatry. 1974, 125: 355-373.PubMedGoogle Scholar
  8. Heuveline P, Slap GB: Adolescent and young adult mortality by cause: age, gender, and country, 1955 to 1994. J Adolesc Health. 2002, 30: 29-34. 10.1016/S1054-139X(01)00329-9.PubMedPubMed CentralGoogle Scholar
  9. Phillips MR, Yang G, Zhang Y, Wang L, Ji H, Zhou M: Risk factors for suicide in China: a national case-control psychological autopsy study. Lancet. 2002, 360: 1728-1736. 10.1016/S0140-6736(02)11681-3.PubMedGoogle Scholar
  10. Hawton K, Simkin S, Rue J, Haw C, Barbour F, Clements A, Sakarovitch C, Deeks J: Suicide in female nurses in England and Wales. Psychol Med. 2002, 32: 239-250.PubMedGoogle Scholar
  11. Henriksson MM, Aro HM, Marttunen MJ, Heikkinen ME, Isometsa ET, Kuoppasalmi KI, Lonnqvist JK: Mental disorders and comorbidity in suicide. Am J Psychiatry. 1993, 150: 935-940.PubMedGoogle Scholar
  12. Houston K, Hawton K, Shepperd R: Suicide in young people aged 15–24: a psychological autopsy study. J Affect Disord. 2001, 63: 159-170. 10.1016/S0165-0327(00)00175-0.PubMedGoogle Scholar
  13. 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: 227-233. 10.1016/0165-0327(88)90020-1.PubMedGoogle Scholar
  14. Cavanagh JT, Owens DG, Johnstone EC: Suicide and undetermined death in south east Scotland. A case-control study using the psychological autopsy method. Psychol Med. 1999, 29: 1141-1149. 10.1017/S0033291799001038.PubMedGoogle Scholar
  15. Graham C, Burvill PW: A study of coroner's records of suicide in young people, 1986–88 in Western Australia. Aust N Z J Psychiatry. 1992, 26: 30-39.PubMedGoogle Scholar
  16. Cheng AT: Mental illness and suicide. A case-control study in east Taiwan. Arch Gen Psychiatry. 1995, 52: 594-603.PubMedGoogle Scholar
  17. Harwood D, Hawton K, Hope T, Jacoby R: Psychiatric disorder and personality factors associated with suicide in older people: a descriptive and case-control study. Int J Geriatr Psychiatry. 2001, 16: 155-165. 10.1002/1099-1166(200102)16:2<155::AID-GPS289>3.0.CO;2-0.PubMedGoogle Scholar
  18. Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, Flory M: Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry. 1996, 53: 339-348.PubMedGoogle Scholar
  19. Sanborn DE, Sanborn CJ, Cimbolic P: Two Years of Suicide: A Study of Adolescent Suicide in New Hampshire. Child Psychiatry and Human Development. 1973, 4: 234-242.Google Scholar
  20. Cattell H, Jolley DJ: One hundred cases of suicide in elderly people. Br J Psychiatry. 1995, 166: 451-457.PubMedGoogle Scholar
  21. Litman RE, Curphey T, Shneidman E, Farberow NL, Tabachnick N: Investigations of Equivocal Suicides. JAMA. 1996, 184: 924-929.Google Scholar
  22. Sainsbury P: Suicide in later life. Gerontol Clin (Basel). 1962, 4: 161-170.Google Scholar
  23. McCarthy PD, Walsh D: Suicide in Dublin. Br Med J. 1966, 5500: 1393-1396.Google Scholar
  24. Hartelius H: A study of suicides in Sweden 1951–63, including a comparison with 1925–1950. Acta Psychiatr Scand. 1967, 43: 121-143.PubMedGoogle Scholar
  25. Jacobson S, Jacobson DM: Suicide in Brighton. Br J Psychiatry. 1972, 121: 369-377.PubMedGoogle Scholar
  26. Ottosson JO, Perris C: Multidimensional classification of mental disorders. Psychol Med. 1973, 3: 238-243.PubMedGoogle Scholar
  27. Amir M: Suicide among minors in Israel. Isr Ann Psychiatr Relat Discip. 1973, 11: 219-269.PubMedGoogle Scholar
  28. Dizmang LH, Watson J, May PA, Bopp J: Adolescent suicide at an Indian reservation. Am J Orthopsychiatry. 1974, 44: 43-49.PubMedGoogle Scholar
  29. Miller JP: Suicide and adolescence. Adolescence. 1975, 10: 11-24.PubMedGoogle Scholar
  30. Bagley C, Jacobson S, Rehin A: Completed suicide: a taxonomic analysis of clinical and social data. Psychol Med. 1976, 6: 429-438.PubMedGoogle Scholar
  31. Pitts FN, Schuller AB, Rich CL, Pitts AF: Suicide among U.S. women physicians, 1967–1972. Am J Psychiatry. 1979, 136: 694-696.PubMedGoogle Scholar
  32. Hagnell O, Rorsman B: Suicide in the Lundby study: a controlled prospective investigation of stressful life events. Neuropsychobiology. 1980, 6: 319-332.PubMedGoogle Scholar
  33. Hegde RS: Suicide in rural Communities. Ind J Psychiatry. 1980, 22: 368-370.Google Scholar
  34. Bourque LB, Kraus JF, Cosand BJ: Attributes of suicide in females. Suicide Life Threat Behav. 1983, 13: 123-138.PubMedGoogle Scholar
  35. Shafii M, Carrigan S, Whittinghill JR, Derrick A: Psychological autopsy of completed suicide in children and adolescents. Am J Psychiatry. 1985, 142: 1061-1064.PubMedGoogle Scholar
  36. Angst J, Clayton P: Premorbid personality of depressive, bipolar, and schizophrenic patients with special reference to suicidal issues. Compr Psychiatry. 1986, 27: 511-532. 10.1016/0010-440X(86)90055-6.PubMedGoogle Scholar
  37. Beratis S: Suicide in southwestern Greece 1979–1984. Acta Psychiatr Scand. 1986, 74: 433-439.PubMedGoogle Scholar
  38. Lindesay J: Trends in Self-Poisoning in the Elderly 1974–1983. Int J Geriatr Psychiatry. 1986, 1: 37-43.Google Scholar
  39. Thompson TR: Childhood and adolescent suicide in Manitoba: a demographic study. Can J Psychiatry. 1987, 32: 264-269.PubMedGoogle Scholar
  40. Poteet DJ: Adolescent suicide. A review of 87 cases of completed suicide in Shelby County, Tennessee. Am J Forensic Med Pathol. 1987, 8: 12-17.PubMedGoogle Scholar
  41. Diekstra RF: Suicidal behavior in adolescents and young adults: the international picture. Crisis. 1989, 10: 16-35.PubMedGoogle Scholar
  42. Banerjee G, Nandi PN, Nandi S, Sarkar S, Boral GC, Ghosh A: The vulnerability of Indian women to suicide. A field Study. Ind J Psychiatry. 1990, 32: 305-308.Google Scholar
  43. King E, Barraclough B: Violent death and mental illness. A study of a single catchment area over eight years. Br J Psychiatry. 1990, 156: 714-720.PubMedGoogle Scholar
  44. Thorslund J: Suicide among Inuit youth in Greenland 1977–86. Arctic Med Res. 1991, 299-302. Suppl
  45. Duberstein PR, Conwell Y, Caine ED: Age differences in the personality characteristics of suicide completers: preliminary findings from a psychological autopsy study. Psychiatry. 1994, 57: 213-224.PubMedGoogle Scholar
  46. Gaylord MS, Lester D: Suicide in the Hong Kong subway. Soc Sci Med. 1994, 38: 427-430. 10.1016/0277-9536(94)90442-1.PubMedGoogle Scholar
  47. McClure GMG: Suicide in children and adolescents in England and Wales 1960–1990. Br J Psychiatry. 1994, 165: 510-514.PubMedGoogle Scholar
  48. Rich CL, Runeson BS: Mental illness and youth suicide. Am J Psychiatry. 1995, 152: 1239-1240.PubMedGoogle Scholar
  49. Arieli A, Gilat I, Aycheh S: Suicide among Ethiopian Jews: a survey conducted by means of a psychological autopsy. J Nerv Ment Dis. 1996, 184: 317-319. 10.1097/00005053-199605000-00009.PubMedGoogle Scholar
  50. Grabbe L, Demi A, Camann MA, Potter L: The health status of elderly persons in the last year of life: a comparison of deaths by suicide, injury, and natural causes. Am J Public Health. 1997, 87: 434-437.PubMedPubMed CentralGoogle Scholar
  51. Malmberg A, Hawton K, Simkin S: A study of suicide in farmers in England and Wales. J Psychosom Res. 1997, 43: 107-111. 10.1016/S0022-3999(97)00114-1.PubMedGoogle Scholar
  52. Rothberg JM: The Army psychological autopsy: then and now. Mil Med. 1998, 163: 427-433.PubMedGoogle Scholar
  53. Marshall D, Soule S: Accidental deaths and suicides among Alaska Natives, 1979–1994. Int J Circumpolar Health. 1998, 57 (Suppl 1): 497-502.PubMedGoogle Scholar
  54. Pitkala K, Isometsa ET, Henriksson MM, Lonnqvist JK: Elderly suicide in Finland. Int Psychogeriatr. 2000, 12: 209-220. 10.1017/S1041610200006335.PubMedGoogle Scholar
  55. Di Nunno N, Costantinides F, Bernasconi P, Di Nunno C: Suicide by hara-kiri: a series of four cases. Am J Forensic Med Pathol. 2001, 22: 68-72. 10.1097/00000433-200103000-00014.PubMedGoogle Scholar
  56. Weller EB, Weller RA: Suicide in youth. Depress Anxiety. 2001, 14: 155-156. 10.1002/da.1060.PubMedGoogle Scholar
  57. Bateman C: Doctor burnout silent and fatal. S Afr Med J. 2001, 91: 98-100.PubMedGoogle Scholar
  58. Miller M: Geriatric suicide: the Arizona study. Gerontologist. 1978, 18: 488-495.PubMedGoogle Scholar
  59. Guze SB, Robins E: Suicide and primary affective disorders. Br J Psychiatry. 1970, 117: 437-438.PubMedGoogle Scholar
  60. Sainsbury P: Clinical aspects of suicide and its prevention. Br J Hosp Med. 1978, 19: 156-162.PubMedGoogle Scholar
  61. Shaffer D, Fisher P: The epidemiology of suicide in children and young adolescents. J Am Acad Child Psychiatry. 1981, 20: 545-565.PubMedGoogle Scholar
  62. Carlson GA, Miller DC: Suicide, affective disorder, and women physicians. Am J Psychiatry. 1981, 138: 1330-1335.PubMedGoogle Scholar
  63. Spellman A, Heyne B: Suicide? Accident? Predictable? Avoidable? The psychological autopsy in jail suicides. Psychiatr Q. 1989, 60: 173-183.PubMedGoogle Scholar
  64. Seager CP, Flood RA: Suicide in Bristol. Br J Psychiatry. 1965, 111: 919-932.PubMedGoogle Scholar
  65. Hoberman HM, Garfinkel BD: Completed suicide in children and adolescents. J Am Acad Child Adolesc Psychiatry. 1988, 27: 689-695.PubMedGoogle Scholar
  66. Krupinski J, Polke P, Stoller A: Psychiatric Disturbances in Attenpted and Completed Suicides in Victoria During 1963. Med J Aust. 1965, 2: 773-778.PubMedGoogle Scholar
  67. Edwards JE, Whitlock FA: Suicide and attempted suicide in Brisbane. 1. Med J Aust. 1968, 1: 932-938.PubMedGoogle Scholar
  68. Flood RA, Seager CP: A Retrospective Examination of Psychiatric Case Records of Patients who subsequently Committed Suicide. Br J Psychiatry. 1968, 114: 443-450.PubMedGoogle Scholar
  69. Rorsman B, Hagnell O, Lanke J: Mortality psychiatric specialist care in the Lundby study. Age-standardized death rates in different forms of psychiatric services in a total population investigated during a 25-year period. Neuropsychobiology. 1983, 9: 2-8.PubMedGoogle Scholar
  70. Lindekilde K, Wang AG: Train suicide in the county of Fyn 1979–82. Acta Psychiatr Scand. 1985, 72: 150-154.PubMedGoogle Scholar
  71. Babigian HM, Lehman A, Reed S: Suicide in psychiatric and non-psychiatric populations. Acta Psychiatr Belg. 1986, 86: 528-532.PubMedGoogle Scholar
  72. Conwell Y, Rotenberg M, Caine ED: Completed suicide at age 50 and over. J Am Geriatr Soc. 1990, 38: 640-644.PubMedGoogle Scholar
  73. Kettl P, Bixler EO: Alcohol and suicide in Alaska Natives. Am Indian Alsk Native Ment Health Res. 1993, 5: 34-45.PubMedGoogle Scholar
  74. Milne S, Matthews K, Ashcroft GW: Suicide in Scotland 1988–1989. Psychiatric and physical morbidity according to primary care case notes. Br J Psychiatry. 1994, 165: 541-544.PubMedGoogle Scholar
  75. Harris MR, Holman J, Bates AA, DeLima Z, Howard ES, Ivanenko A, Lunsford RJ, James WA, el Mallakh RS: Completed suicides and emergency psychiatric evaluations: the Louisville experience. J Ky Med Assoc. 2000, 98: 210-212.PubMedGoogle Scholar
  76. Mortensen PB, Agerbo E, Erikson T, Qin P, Westergaard-Nielsen N: Psychiatric illness and risk factors for suicide in Denmark. Lancet. 2000, 355: 9-12. 10.1016/S0140-6736(99)06376-X.PubMedGoogle Scholar
  77. He XY, Felthous AR, Holzer CE, Nathan P, Veasey S: Factors in prison suicide: one year study in Texas. J Forensic Sci. 2001, 46: 896-901.PubMedGoogle Scholar
  78. Boothroyd LJ, Kirmayer LJ, Spreng S, Malus M, Hodgins S: Completed suicides among the Inuit of northern Quebec, 1982–1996: a case-control study. CMAJ. 2001, 165: 749-755.PubMedPubMed CentralGoogle Scholar
  79. Schmidt P, Müller R, Dettmeyer D, Madea B: Suicide in children, adolescents and young adults. Forensic Science International. 2002, 127: 161-167. 10.1016/S0379-0738(02)00095-6.PubMedGoogle Scholar
  80. Beskow J: Suicide in mental disorder in Swedish men. Acta Psychiatr Scand Suppl. 1979, 1-138.Google Scholar
  81. Nuttall EA, Evenson RC, Cho DW: A comparison of suicide and undetermined deaths in psychiatric patients. Suicide Life Threat Behav. 1980, 10: 167-174.PubMedGoogle Scholar
  82. Rorsman B, Hagnell O, Lanke J: Mortality and hidden mental disorder in the Lundby Study. Age-standardized death rates among mentally ill 'non-patients' in a total population observed during a 25-year period. Neuropsychobiology. 1983, 10: 83-89.PubMedGoogle Scholar
  83. Winokur G, Black DW: Psychiatric and medical diagnoses as risk factors for mortality in psychiatric patients: a case-control study. Am J Psychiatry. 1987, 144: 208-211.PubMedGoogle Scholar
  84. Cullberg J, Wasserman D, Stefansson CG: Who commits suicide after a suicide attempt? An 8 to 10 year follow up in a suburban catchment area. Acta Psychiatr Scand. 1988, 77: 598-603.PubMedGoogle Scholar
  85. Vogel R, Wolfersdorf M: Suicide and mental illness in the elderly. Psychopathology. 1989, 22: 202-207.PubMedGoogle Scholar
  86. Allebeck P, Allgulander C: Psychiatric diagnoses as predictors of suicide. A comparison of diagnoses at conscription and in psychiatric care in a cohort of 50,465 young men. Br J Psychiatry. 1990, 157: 339-344.PubMedGoogle Scholar
  87. Allebeck P, Allgulander C: Suicide among young men: psychiatric illness, deviant behaviour and substance abuse. Acta Psychiatr Scand. 1990, 81: 565-570.PubMedGoogle Scholar
  88. Chandrasena R, Beddage V, Fernando ML: Suicide among immigrant psychiatric patients in Canada. Br J Psychiatry. 1991, 159: 707-709.PubMedGoogle Scholar
  89. Marcus P, Alcabes P: Characteristics of suicides by inmates in an urban jail. Hosp Community Psychiatry. 1993, 44: 256-261.PubMedGoogle Scholar
  90. Ramsay L, Gray C, White T: A review of suicide within the State Hospital, Carstairs 1972–1996. Med Sci Law. 2001, 41: 97-101.PubMedGoogle Scholar
  91. Powell J, Geddes J, Deeks J, Goldacre M, Hawton K: Suicide in psychiatric hospital in-patients. Risk factors and their predictive power. Br J Psychiatry. 2000, 176: 266-272. 10.1192/bjp.176.3.266.PubMedGoogle Scholar
  92. Proulx F, Lesage AD, Grunberg F: One hundred in-patient suicides. Br J Psychiatry. 1997, 171: 247-250.PubMedGoogle Scholar
  93. Dennehy JA, Appleby L, Thomas CS, Faragher EB: Case-control study of suicide by discharged psychiatric patients. BMJ. 1996, 312: 1580-PubMedPubMed CentralGoogle Scholar
  94. Shaffer D: Suicide in childhood and early adolescence. J Child Psychol Psychiatry. 1974, 15: 275-291.PubMedGoogle Scholar
  95. Kraft DP, Babigian HM: Suicide by persons with and without psychiatric contacts. Arch Gen Psychiatry. 1976, 33: 209-215.PubMedGoogle Scholar
  96. Miller M: A psychological autopsy of a geriatric suicide. J Geriatr Psychiatry. 1977, 10: 229-242.PubMedGoogle Scholar
  97. Hagnell O, Rorsman B: Suicide in the Lundby study: a comparative investigation of clinical aspects. Neuropsychobiology. 1979, 5: 61-73.PubMedGoogle Scholar
  98. Rich CL, Fowler RC, Young D, Blenkush M: San Diego suicide study: comparison of gay to straight males. Suicide Life Threat Behav. 1986, 16: 448-457.PubMedGoogle Scholar
  99. Rich CL, Ricketts JE, Fowler RC, Young D: Some differences between men and women who commit suicide. Am J Psychiatry. 1988, 145: 718-722.PubMedGoogle Scholar
  100. Brent DA, Perper JA, Goldstein CE, Kolko DJ, Allan MJ, Allman CJ, Zelenak JP: Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry. 1988, 45: 581-588.PubMedGoogle Scholar
  101. Rothberg JM, Fagan J, Shaw J: Suicides in United States Army Personnel, 1985–1986. Mil Med. 1990, 155: 452-456.PubMedGoogle Scholar
  102. Thorslund J: Inuit suicides in Greenland. Arctic Med Res. 1990, 49: 25-33.PubMedGoogle Scholar
  103. Conwell Y, Caine ED, Olsen K: Suicide and cancer in late life. Hosp Community Psychiatry. 1990, 41: 1334-1339.PubMedGoogle Scholar
  104. Rich CL, Sherman M, Fowler RC: San Diego Suicide Study: the adolescents. Adolescence. 1990, 25: 855-865.PubMedGoogle Scholar
  105. Conwell Y, Olsen K, Caine ED, Flannery C: Suicide in later life: psychological autopsy findings. Int Psychogeriatr. 1991, 3: 59-66. 10.1017/S1041610291000522.PubMedGoogle Scholar
  106. Carlson GA, Rich CL, Grayson P, Fowler RC: Secular trends in psychiatric diagnoses of suicide victims. J Affect Disord. 1991, 21: 127-132. 10.1016/0165-0327(91)90059-2.PubMedGoogle Scholar
  107. Marttunen MJ, Aro HM, Henriksson MM, Lonnqvist JK: Mental disorders in adolescent suicide. DSM-III-R axes I and II diagnoses in suicides among 13- to 19-year-olds in Finland. Arch Gen Psychiatry. 1991, 48: 834-839.PubMedGoogle Scholar
  108. Runeson B, Beskow J: Borderline personality disorder in young Swedish suicides. J Nerv Ment Dis. 1991, 179: 153-156.PubMedGoogle Scholar
  109. Brent DA, Perper JA, Moritz G, Allman C, Friend A, Roth C, Schweers J, Balach L, Baugher M: Psychiatric risk factors for adolescent suicide: a case-control study. J Am Acad Child Adolesc Psychiatry. 1993, 32: 521-529.PubMedGoogle Scholar
  110. King EA, Barraclough BM: Suicide. Lancet. 1993, 342: 744-745. 10.1016/0140-6736(93)91737-7.PubMedGoogle Scholar
  111. Marttunen MJ, Henriksson MM, Aro HM, Heikkinen ME, Isometsa ET, Lonnqvist JK: Suicide among female adolescents: characteristics and comparison with males in the age group 13 to 22 years. J Am Acad Child Adolesc Psychiatry. 1995, 34: 1297-1307. 10.1097/00004583-199510000-00014.PubMedGoogle Scholar
  112. Henriksson MM, Marttunen MJ, Isometsa ET, Heikkinen ME, Aro HM, Kuoppasalmi KI, Lonnqvist JK: Mental disorders in elderly suicide. Int Psychogeriatr. 1995, 7: 275-286. 10.1017/S1041610295002031.PubMedGoogle Scholar
  113. Henriksson MM, Isometsa ET, Hietanen PS, Aro HM, Lonnqvist JK: Mental disorders in cancer suicides. J Affect Disord. 1995, 36: 11-20. 10.1016/0165-0327(95)00047-X.PubMedGoogle Scholar
  114. Gould MS, Fisher P, Parides M, Flory M, Shaffer D: Psychosocial risk factors of child and adolescent completed suicide. Arch Gen Psychiatry. 1996, 53: 1155-1162.PubMedGoogle Scholar
  115. Isometsa E, Heikkinen M, Henriksson M, Marttunen M, Aro H, Lonnqvist J: Differences between urban and rural suicides. Acta Psychiatr Scand. 1997, 95: 297-305.PubMedGoogle Scholar
  116. Marttunen M, Henriksson M, Pelkonen S, Schroderus M, Lonnqvist J: Suicide among military conscripts in Finland: a psychological autopsy study. Mil Med. 1997, 162: 14-18.PubMedGoogle Scholar
  117. Cheng AT, Mann AH, Chan KA: Personality disorder and suicide. A case-control study. Br J Psychiatry. 1997, 170: 441-446.PubMedGoogle Scholar
  118. Duberstein PR, Conwell Y, Cox C: Suicide in widowed persons. A psychological autopsy comparison of recently and remotely bereaved older subjects. Am J Geriatr Psychiatry. 1998, 6: 328-334.PubMedGoogle Scholar
  119. Groholt B, Ekeberg O, Wichstrom L, Haldorsen T: Suicide among children and younger and older adolescents in Norway: a comparative study. J Am Acad Child Adolesc Psychiatry. 1998, 37: 473-481. 10.1097/00004583-199805000-00008.PubMedGoogle Scholar
  120. Conwell Y, Lyness JM, Duberstein P, Cox C, Seidlitz L, DiGiorgio A, Caine ED: Completed suicide among older patients in primary care practices: a controlled study. J Am Geriatr Soc. 2000, 48: 23-29.PubMedGoogle Scholar
  121. 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: 360-365. 10.1192/bjp.177.4.360.PubMedGoogle Scholar
  122. Gardner E, Bahn A, Mack M: Suicide and psychiatric care in the aging. Arch Gen Psychiatry. 1964, 10: 547-PubMedGoogle Scholar
  123. Venkoba Rao A, Mahendran N: One hundred female burn cases – a study in suicidology. Ind J Psychiatry. 1989, 31: 43-50.Google Scholar
  124. Cole DA: Psychopathology of adolescent suicide: hopelessness, coping beliefs, and depression. J Abnorm Psychol. 1989, 98: 248-255. 10.1037//0021-843X.98.3.248.PubMedGoogle Scholar
  125. Iliev YT, Mitrev IN, Andonova SG: Psychopathology and psychosocial causes in adult deliberate self-poisoning in Plovdiv region, Bulgaria. Folia Med (Plovdiv). 2000, 42: 30-33.Google Scholar
  126. Tamakoshi A, Ohno Y, Yamada T, Aoki K, Hamajima N, Wada M, Kawamura T, Wakai K, Lin SY: Depressive mood and suicide among middle-aged workers: findings from a prospective cohort study in Nagoya, Japan. J Epidemiol. 2000, 10: 173-178.PubMedGoogle Scholar
  127. Diekstra RF, van Egmond M: Suicide and attempted suicide in general practice, 1979–1986. Acta Psychiatr Scand. 1989, 79: 268-275.PubMedGoogle Scholar
  128. Egeland JA, Sussex JN: Suicide and family loading for affective disorders. JAMA. 1985, 254: 915-918. 10.1001/jama.254.7.915.PubMedGoogle Scholar
  129. Burvill PW: Suicide in Western Australia, 1967. An analysis of coroners' records. Aust N Z J Psychiatry. 1971, 5: 37-44.PubMedGoogle Scholar
  130. Cattell H: Elderly suicide in London: an analysis of coroner's inquests. Int J Geriatr Psychiatry. 1988, 3: 251-261.Google Scholar
  131. Chynoweth R, Tonge JI, Armstrong J: Suicide in Brisbane – a retrospective psychosocial study. Aust N Z J Psychiatry. 1980, 14: 37-45.PubMedGoogle Scholar
  132. Dorpat T, Ripley H: A study of suicide in the Seattle area. Comprehensive Psychiatry. 1960, 1: 349-359.PubMedGoogle Scholar
  133. Eisele JW, Frisino J, Haglund W, Reay DT: Teenage suicide in King County, Washington. II. Comparison with adult suicides. Am J Forensic Med Pathol. 1987, 8: 210-216.PubMedGoogle Scholar
  134. Farberow NL, Simon MD: Suicides in Los Angeles and Vienna. An intercultural study of two cities. Public Health Rep. 1969, 84: 389-403.PubMedPubMed CentralGoogle Scholar
  135. Holding TA, Barraclough BM: Psychiatric morbidity in a sample of a London coroner's open verdicts. Br J Psychiatry. 1975, 127: 133-143.PubMedGoogle Scholar
  136. Kelleher MJ, Keohane B, Corcoran P, Keeley HS: Elderly suicides in Ireland. Ir Med J. 1997, 90: 72-74.PubMedGoogle Scholar
  137. Kosky RJ, Dundas P: Death by hanging: implications for prevention of an important method of youth suicide. Aust N Z J Psychiatry. 2000, 34: 836-841. 10.1046/j.1440-1614.2000.00807.x.PubMedGoogle Scholar
  138. Mishara BL: Suicide in the Montreal subway system: characteristics of the victims, antecedents, and implications for prevention. Can J Psychiatry. 1999, 44: 690-696.PubMedGoogle Scholar
  139. Robins E, Murphy GE, Wilkinson RH, Gassner S, Kayes J: Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. Am J Public Health. 1959, 49: 888-898.Google Scholar
  140. Rorsman B, Hagnell O, Lanke J: Violent death and mental disorders in the Lundby Study. Accidents and suicides in a total population during a 25-year period. Neuropsychobiology. 1982, 8: 233-240.PubMedGoogle Scholar
  141. Snowdon J, Baume P: A study of suicides of older people in Sydney. Int J Geriatr Psychiatry. 2002, 17: 261-269. 10.1002/gps.586.PubMedGoogle Scholar
  142. Foster T, Gillespie K, McClelland R, Patterson C: Risk factors for suicide independent of DSM-III-R Axis I disorder. Case-control psychological autopsy study in Northern Ireland. Br J Psychiatry. 1999, 175: 175-179.PubMedGoogle Scholar
  143. Rich CL, Young D, Fowler RC: San Diego suicide study. I. Young vs old subjects. Arch Gen Psychiatry. 1986, 43: 577-582.PubMedGoogle Scholar
  144. Foster T, Gillespie K, McClelland R: Mental disorders and suicide in Northern Ireland. Br J Psychiatry. 1997, 170: 447-452.PubMedGoogle Scholar
  145. Apter A, Bleich A, King RA, Kron S, Fluch A, Kotler M, Cohen DJ: Death without warning? A clinical postmortem study of suicide in 43 Israeli adolescent males. Arch Gen Psychiatry. 1993, 50: 138-142.PubMedGoogle Scholar
  146. Arato M, Demeter E, Rihmer Z, Somogyi E: Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatr Scand. 1988, 77: 454-456.PubMedGoogle Scholar
  147. Asgard U: A psychiatric study of suicide among urban Swedish women. Acta Psychiatr Scand. 1990, 82: 115-124.PubMedGoogle Scholar
  148. Brent DA, Baugher M, Bridge J, Chen T, Chiappetta L: Age- and sex-related risk factors for adolescent suicide. J Am Acad Child Adolesc Psychiatry. 1999, 38: 1497-1505. 10.1097/00004583-199912000-00010.PubMedGoogle Scholar
  149. Groholt B, Ekeberg O, Wichstrom L, Haldorsen T: Youth suicide in Norway, 1990–1992: a comparison between children and adolescents completing suicide and age- and gender-matched controls. Suicide Life Threat Behav. 1997, 27: 250-263.PubMedGoogle Scholar
  150. Lesage AD, Boyer R, Grunberg F, Vanier C, Morissette R, Menard-Buteau C, Loyer M: Suicide and mental disorders: a case-control study of young men. Am J Psychiatry. 1994, 151: 1063-1068.PubMedGoogle Scholar
  151. Appleby L, Cooper J, Amos T, Faragher B: Psychological autopsy study of suicides by people aged under 35. Br J Psychiatry. 1999, 175: 168-174.PubMedGoogle Scholar
  152. Boardman AP, Grimbaldeston AH, Handley C, Jones PW, Willmott S: The North Staffordshire Suicide Study: a case-control study of suicide in one health district. Psychol Med. 1999, 29: 27-33. 10.1017/S0033291798007430.PubMedGoogle Scholar
  153. Runeson B: Mental disorder in youth suicide. DSM-III-R Axes I and II. Acta Psychiatr Scand. 1989, 79: 490-497.PubMedGoogle Scholar
  154. Waern M, Runeson BS, Allebeck P, Beskow J, Rubenowitz E, Skoog I, Wilhelmsson K: Mental disorder in elderly suicides: a case-control study. Am J Psychiatry. 2002, 159: 450-455. 10.1176/appi.ajp.159.3.450.PubMedGoogle Scholar
  155. Cerel J, Fristad MA, Weller EB, Weller RA: Suicide-bereaved children and adolescents: II. Parental and family functioning. J Am Acad Child Adolesc Psychiatry. 2000, 39: 437-444. 10.1097/00004583-200004000-00012.PubMedGoogle Scholar
  156. Conwell Y, Duberstein PR, 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: 1001-1008.PubMedGoogle Scholar
  157. Cantor CH, Hill MA, McLachlan EK: Suicide and related behaviour from river bridges. A clinical perspective. Br J Psychiatry. 1989, 155: 829-835.PubMedGoogle Scholar
  158. Thacore VR, Varma SL: A study of suicides in Ballarat, Victoria, Australia. Crisis. 2000, 21: 26-30. 10.1027//0227-5910.21.1.26.PubMedGoogle Scholar
  159. Vijayakumar L, Rajkumar S: Are risk factors for suicide universal? A case-control study in India. Acta Psychiatr Scand. 1999, 99: 407-411.PubMedGoogle Scholar
  160. Ernst C, Lalovic A, Lesage AD, Seguin M, Trautman P, Turecki G: Suicide and no axis I psychopathology. BMC psychiatry. 2004, 4:Google Scholar
  161. Kim C, Lesage AD, Seguin M, Chawky N, Vanier C, Lipp O, Turecki G: Patterns of comorbidity in male suicide completers. 2002.Google Scholar
  162. Breier A, Astrachan BM: Characterization of schizophrenic patients who commit suicide. Am J Psychiatry. 1984, 141: 206-209.PubMedGoogle Scholar
  163. Nyman AK, Jonsson H: Patterns of self-destructive behaviour in schizophrenia. Acta Psychiatr Scand. 1986, 73: 252-262.PubMedGoogle Scholar
  164. Rossau CD, Mortensen PB: Risk factors for suicide in patients with schizophrenia: nested case-control study. Br J Psychiatry. 1997, 171: 355-359.PubMedGoogle Scholar
  165. Konnecke R, Hafner H, Maurer K, Loffler W, an der HW: Main risk factors for schizophrenia: increased familial loading and pre- and peri-natal complications antagonize the protective effect of oestrogen in women. Schizophr Res. 2000, 44: 81-93. 10.1016/S0920-9964(99)00139-5.PubMedGoogle Scholar
  166. Jablensky A: Epidemiology of schizophrenia: the global burden of disease and disability. Eur Arch Psychiatry Clin Neurosci. 2000, 250: 274-285. 10.1007/s004060070002.PubMedGoogle Scholar
  167. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM: Psychological autopsy studies of suicide: a systematic review. Psychol Med. 2003, 33: 395-405. 10.1017/S0033291702006943.PubMedGoogle Scholar
  168. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/4/37/prepub

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© Arsenault-Lapierre et al; licensee BioMed Central Ltd. 2004

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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