- Research article
- Open Access
- Open Peer Review
Psychiatric diagnoses in 3275 suicides: a meta-analysis
BMC Psychiatryvolume 4, Article number: 37 (2004)
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.
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.
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.
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.
Suicide is an important public health problem that is among the leading causes of death in Western countries . Over the last years, the relationship between suicide and mental disorders has been the focus of several studies and has generated important debate . This relationship has been investigated by different strategies, but particularly by the psychological autopsy method , 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 , but there is considerable variability between studies in rates of total and specific psychiatric disorders . One of the most consistent findings in suicidology is the excess of male suicides observed in most countries , with a few notable and important exceptions, such as China [1, 9]. Geographic origin is another important source of variation . 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.
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.
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.
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 [10–13]. 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 , controls were older suicide completers, and so they were included in our suicide group. In the study by Hawton et al. , only diagnoses for suicides obtained by means of an interview were included. In three case-control studies [16–18], 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.
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).
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, 19–63], b) samples were pre-selected according to a psychiatric disorder (n = 30) [64–93], c) there was another report on the same sample that either included more subjects or was more informative (n = 29) [3, 94–121]. Four other studies were about non-completers [122–125]. Another was not in English , and others reported only on one type of disorder [127, 128], and therefore, they were all excluded. Additional 14 studies [7, 129–141] were excluded because the diagnostic criteria were either unspecified or not standard.
The studies by Rich et al.  and by Foster et al  were not independent from, respectively, Rich et al.  and Foster et al. . Although non-independent, these studies provided information of different quality, and thus, were included in our review. Accordingly, Rich et al.  and Foster et al.  were considered, respectively in the gender difference analysis and the case-control comparisons, whereas the study by Rich et al.  and Foster et al.  were considered for the descriptive analysis.
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.
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, 144–150]
There were 14 studies [10–12, 14, 17, 142, 145–147, 149, 151–154] carried out in Europe, including one in Israel . 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.
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.
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.
Since the first psychological autopsy studies by Robins et al.  in North America and by Barraclough et al.  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 .
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.  found a significant increase in suicide risk in the presence of Axis I-Axis II comorbidity (OR = 346.0, p < 0.0001). Our group , 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.
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 [162–164], 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 , 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.
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 . 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. , reviewed the literature on psychological autopsies and yielded similar overall results. However, there are differences between the study by Cavanagh et al  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.
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.
WHO: World Health Report 2000. Health System: Improving Performance. 2000, Ref Type: Report
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.
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.
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.
Isometsa ET: Psychological autopsy studies – a review. Eur Psychiatry. 2001, 16: 379-385. 10.1016/S0924-9338(01)00594-6.
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.
Barraclough B, Bunch J, Nelson B, Sainsbury P: A hundred cases of suicide: clinical aspects. Br J Psychiatry. 1974, 125: 355-373.
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.
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.
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.
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.
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.
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.
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.
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.
Cheng AT: Mental illness and suicide. A case-control study in east Taiwan. Arch Gen Psychiatry. 1995, 52: 594-603.
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.
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.
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.
Cattell H, Jolley DJ: One hundred cases of suicide in elderly people. Br J Psychiatry. 1995, 166: 451-457.
Litman RE, Curphey T, Shneidman E, Farberow NL, Tabachnick N: Investigations of Equivocal Suicides. JAMA. 1996, 184: 924-929.
Sainsbury P: Suicide in later life. Gerontol Clin (Basel). 1962, 4: 161-170.
McCarthy PD, Walsh D: Suicide in Dublin. Br Med J. 1966, 5500: 1393-1396.
Hartelius H: A study of suicides in Sweden 1951–63, including a comparison with 1925–1950. Acta Psychiatr Scand. 1967, 43: 121-143.
Jacobson S, Jacobson DM: Suicide in Brighton. Br J Psychiatry. 1972, 121: 369-377.
Ottosson JO, Perris C: Multidimensional classification of mental disorders. Psychol Med. 1973, 3: 238-243.
Amir M: Suicide among minors in Israel. Isr Ann Psychiatr Relat Discip. 1973, 11: 219-269.
Dizmang LH, Watson J, May PA, Bopp J: Adolescent suicide at an Indian reservation. Am J Orthopsychiatry. 1974, 44: 43-49.
Miller JP: Suicide and adolescence. Adolescence. 1975, 10: 11-24.
Bagley C, Jacobson S, Rehin A: Completed suicide: a taxonomic analysis of clinical and social data. Psychol Med. 1976, 6: 429-438.
Pitts FN, Schuller AB, Rich CL, Pitts AF: Suicide among U.S. women physicians, 1967–1972. Am J Psychiatry. 1979, 136: 694-696.
Hagnell O, Rorsman B: Suicide in the Lundby study: a controlled prospective investigation of stressful life events. Neuropsychobiology. 1980, 6: 319-332.
Hegde RS: Suicide in rural Communities. Ind J Psychiatry. 1980, 22: 368-370.
Bourque LB, Kraus JF, Cosand BJ: Attributes of suicide in females. Suicide Life Threat Behav. 1983, 13: 123-138.
Shafii M, Carrigan S, Whittinghill JR, Derrick A: Psychological autopsy of completed suicide in children and adolescents. Am J Psychiatry. 1985, 142: 1061-1064.
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.
Beratis S: Suicide in southwestern Greece 1979–1984. Acta Psychiatr Scand. 1986, 74: 433-439.
Lindesay J: Trends in Self-Poisoning in the Elderly 1974–1983. Int J Geriatr Psychiatry. 1986, 1: 37-43.
Thompson TR: Childhood and adolescent suicide in Manitoba: a demographic study. Can J Psychiatry. 1987, 32: 264-269.
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.
Diekstra RF: Suicidal behavior in adolescents and young adults: the international picture. Crisis. 1989, 10: 16-35.
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.
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.
Thorslund J: Suicide among Inuit youth in Greenland 1977–86. Arctic Med Res. 1991, 299-302. Suppl
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.
Gaylord MS, Lester D: Suicide in the Hong Kong subway. Soc Sci Med. 1994, 38: 427-430. 10.1016/0277-9536(94)90442-1.
McClure GMG: Suicide in children and adolescents in England and Wales 1960–1990. Br J Psychiatry. 1994, 165: 510-514.
Rich CL, Runeson BS: Mental illness and youth suicide. Am J Psychiatry. 1995, 152: 1239-1240.
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.
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.
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.
Rothberg JM: The Army psychological autopsy: then and now. Mil Med. 1998, 163: 427-433.
Marshall D, Soule S: Accidental deaths and suicides among Alaska Natives, 1979–1994. Int J Circumpolar Health. 1998, 57 (Suppl 1): 497-502.
Pitkala K, Isometsa ET, Henriksson MM, Lonnqvist JK: Elderly suicide in Finland. Int Psychogeriatr. 2000, 12: 209-220. 10.1017/S1041610200006335.
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.
Weller EB, Weller RA: Suicide in youth. Depress Anxiety. 2001, 14: 155-156. 10.1002/da.1060.
Bateman C: Doctor burnout silent and fatal. S Afr Med J. 2001, 91: 98-100.
Miller M: Geriatric suicide: the Arizona study. Gerontologist. 1978, 18: 488-495.
Guze SB, Robins E: Suicide and primary affective disorders. Br J Psychiatry. 1970, 117: 437-438.
Sainsbury P: Clinical aspects of suicide and its prevention. Br J Hosp Med. 1978, 19: 156-162.
Shaffer D, Fisher P: The epidemiology of suicide in children and young adolescents. J Am Acad Child Psychiatry. 1981, 20: 545-565.
Carlson GA, Miller DC: Suicide, affective disorder, and women physicians. Am J Psychiatry. 1981, 138: 1330-1335.
Spellman A, Heyne B: Suicide? Accident? Predictable? Avoidable? The psychological autopsy in jail suicides. Psychiatr Q. 1989, 60: 173-183.
Seager CP, Flood RA: Suicide in Bristol. Br J Psychiatry. 1965, 111: 919-932.
Hoberman HM, Garfinkel BD: Completed suicide in children and adolescents. J Am Acad Child Adolesc Psychiatry. 1988, 27: 689-695.
Krupinski J, Polke P, Stoller A: Psychiatric Disturbances in Attenpted and Completed Suicides in Victoria During 1963. Med J Aust. 1965, 2: 773-778.
Edwards JE, Whitlock FA: Suicide and attempted suicide in Brisbane. 1. Med J Aust. 1968, 1: 932-938.
Flood RA, Seager CP: A Retrospective Examination of Psychiatric Case Records of Patients who subsequently Committed Suicide. Br J Psychiatry. 1968, 114: 443-450.
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.
Lindekilde K, Wang AG: Train suicide in the county of Fyn 1979–82. Acta Psychiatr Scand. 1985, 72: 150-154.
Babigian HM, Lehman A, Reed S: Suicide in psychiatric and non-psychiatric populations. Acta Psychiatr Belg. 1986, 86: 528-532.
Conwell Y, Rotenberg M, Caine ED: Completed suicide at age 50 and over. J Am Geriatr Soc. 1990, 38: 640-644.
Kettl P, Bixler EO: Alcohol and suicide in Alaska Natives. Am Indian Alsk Native Ment Health Res. 1993, 5: 34-45.
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.
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.
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.
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.
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.
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.
Beskow J: Suicide in mental disorder in Swedish men. Acta Psychiatr Scand Suppl. 1979, 1-138.
Nuttall EA, Evenson RC, Cho DW: A comparison of suicide and undetermined deaths in psychiatric patients. Suicide Life Threat Behav. 1980, 10: 167-174.
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.
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.
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.
Vogel R, Wolfersdorf M: Suicide and mental illness in the elderly. Psychopathology. 1989, 22: 202-207.
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.
Allebeck P, Allgulander C: Suicide among young men: psychiatric illness, deviant behaviour and substance abuse. Acta Psychiatr Scand. 1990, 81: 565-570.
Chandrasena R, Beddage V, Fernando ML: Suicide among immigrant psychiatric patients in Canada. Br J Psychiatry. 1991, 159: 707-709.
Marcus P, Alcabes P: Characteristics of suicides by inmates in an urban jail. Hosp Community Psychiatry. 1993, 44: 256-261.
Ramsay L, Gray C, White T: A review of suicide within the State Hospital, Carstairs 1972–1996. Med Sci Law. 2001, 41: 97-101.
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.
Proulx F, Lesage AD, Grunberg F: One hundred in-patient suicides. Br J Psychiatry. 1997, 171: 247-250.
Dennehy JA, Appleby L, Thomas CS, Faragher EB: Case-control study of suicide by discharged psychiatric patients. BMJ. 1996, 312: 1580-
Shaffer D: Suicide in childhood and early adolescence. J Child Psychol Psychiatry. 1974, 15: 275-291.
Kraft DP, Babigian HM: Suicide by persons with and without psychiatric contacts. Arch Gen Psychiatry. 1976, 33: 209-215.
Miller M: A psychological autopsy of a geriatric suicide. J Geriatr Psychiatry. 1977, 10: 229-242.
Hagnell O, Rorsman B: Suicide in the Lundby study: a comparative investigation of clinical aspects. Neuropsychobiology. 1979, 5: 61-73.
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.
Rich CL, Ricketts JE, Fowler RC, Young D: Some differences between men and women who commit suicide. Am J Psychiatry. 1988, 145: 718-722.
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.
Rothberg JM, Fagan J, Shaw J: Suicides in United States Army Personnel, 1985–1986. Mil Med. 1990, 155: 452-456.
Thorslund J: Inuit suicides in Greenland. Arctic Med Res. 1990, 49: 25-33.
Conwell Y, Caine ED, Olsen K: Suicide and cancer in late life. Hosp Community Psychiatry. 1990, 41: 1334-1339.
Rich CL, Sherman M, Fowler RC: San Diego Suicide Study: the adolescents. Adolescence. 1990, 25: 855-865.
Conwell Y, Olsen K, Caine ED, Flannery C: Suicide in later life: psychological autopsy findings. Int Psychogeriatr. 1991, 3: 59-66. 10.1017/S1041610291000522.
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.
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.
Runeson B, Beskow J: Borderline personality disorder in young Swedish suicides. J Nerv Ment Dis. 1991, 179: 153-156.
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.
King EA, Barraclough BM: Suicide. Lancet. 1993, 342: 744-745. 10.1016/0140-6736(93)91737-7.
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.
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.
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.
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.
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.
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.
Cheng AT, Mann AH, Chan KA: Personality disorder and suicide. A case-control study. Br J Psychiatry. 1997, 170: 441-446.
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.
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.
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.
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.
Gardner E, Bahn A, Mack M: Suicide and psychiatric care in the aging. Arch Gen Psychiatry. 1964, 10: 547-
Venkoba Rao A, Mahendran N: One hundred female burn cases – a study in suicidology. Ind J Psychiatry. 1989, 31: 43-50.
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.
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.
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.
Diekstra RF, van Egmond M: Suicide and attempted suicide in general practice, 1979–1986. Acta Psychiatr Scand. 1989, 79: 268-275.
Egeland JA, Sussex JN: Suicide and family loading for affective disorders. JAMA. 1985, 254: 915-918. 10.1001/jama.254.7.915.
Burvill PW: Suicide in Western Australia, 1967. An analysis of coroners' records. Aust N Z J Psychiatry. 1971, 5: 37-44.
Cattell H: Elderly suicide in London: an analysis of coroner's inquests. Int J Geriatr Psychiatry. 1988, 3: 251-261.
Chynoweth R, Tonge JI, Armstrong J: Suicide in Brisbane – a retrospective psychosocial study. Aust N Z J Psychiatry. 1980, 14: 37-45.
Dorpat T, Ripley H: A study of suicide in the Seattle area. Comprehensive Psychiatry. 1960, 1: 349-359.
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.
Farberow NL, Simon MD: Suicides in Los Angeles and Vienna. An intercultural study of two cities. Public Health Rep. 1969, 84: 389-403.
Holding TA, Barraclough BM: Psychiatric morbidity in a sample of a London coroner's open verdicts. Br J Psychiatry. 1975, 127: 133-143.
Kelleher MJ, Keohane B, Corcoran P, Keeley HS: Elderly suicides in Ireland. Ir Med J. 1997, 90: 72-74.
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.
Mishara BL: Suicide in the Montreal subway system: characteristics of the victims, antecedents, and implications for prevention. Can J Psychiatry. 1999, 44: 690-696.
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.
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.
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.
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.
Rich CL, Young D, Fowler RC: San Diego suicide study. I. Young vs old subjects. Arch Gen Psychiatry. 1986, 43: 577-582.
Foster T, Gillespie K, McClelland R: Mental disorders and suicide in Northern Ireland. Br J Psychiatry. 1997, 170: 447-452.
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.
Arato M, Demeter E, Rihmer Z, Somogyi E: Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatr Scand. 1988, 77: 454-456.
Asgard U: A psychiatric study of suicide among urban Swedish women. Acta Psychiatr Scand. 1990, 82: 115-124.
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.
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.
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.
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.
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.
Runeson B: Mental disorder in youth suicide. DSM-III-R Axes I and II. Acta Psychiatr Scand. 1989, 79: 490-497.
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.
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.
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.
Cantor CH, Hill MA, McLachlan EK: Suicide and related behaviour from river bridges. A clinical perspective. Br J Psychiatry. 1989, 155: 829-835.
Thacore VR, Varma SL: A study of suicides in Ballarat, Victoria, Australia. Crisis. 2000, 21: 26-30. 10.1027//0227-5910.21.1.26.
Vijayakumar L, Rajkumar S: Are risk factors for suicide universal? A case-control study in India. Acta Psychiatr Scand. 1999, 99: 407-411.
Ernst C, Lalovic A, Lesage AD, Seguin M, Trautman P, Turecki G: Suicide and no axis I psychopathology. BMC psychiatry. 2004, 4:
Kim C, Lesage AD, Seguin M, Chawky N, Vanier C, Lipp O, Turecki G: Patterns of comorbidity in male suicide completers. 2002.
Breier A, Astrachan BM: Characterization of schizophrenic patients who commit suicide. Am J Psychiatry. 1984, 141: 206-209.
Nyman AK, Jonsson H: Patterns of self-destructive behaviour in schizophrenia. Acta Psychiatr Scand. 1986, 73: 252-262.
Rossau CD, Mortensen PB: Risk factors for suicide in patients with schizophrenia: nested case-control study. Br J Psychiatry. 1997, 171: 355-359.
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.
Jablensky A: Epidemiology of schizophrenia: the global burden of disease and disability. Eur Arch Psychiatry Clin Neurosci. 2000, 250: 274-285. 10.1007/s004060070002.
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.
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/4/37/prepub
This study was partly funded by CIHR grant MOP-38078 and a NARSAD grant. GT is a CIHR scholar.
The author(s) declare that they have no competing interests.
GAL carried out the search, extraction of data, analysis and drafted the manuscript. CK helped with the design of the review, and the statistical analysis. GT conceived the study and participated in the design and coordination. All authors read and approved the final manuscript.