The role of premeditation in suicide: Identifying factors associated with increased planning among suicide decedents.

INTRODUCTION: Suicide premeditation is a critical factor to consider when assessing suicide risk. Understanding which individuals are more or less likely to plan their suicidal behavior can shed light on how suicidal thoughts turn into actions. METHOD: The present study used psychological autopsy data to identify factors associated with level of premeditation among 131 adults who died by suicide. RESULTS: Logistic regression analyses indicated that suicide decedents with higher premeditation scores had higher odds of being diagnosed with a depressive disorder and choosing a violent suicide method, specifically a firearm. Individuals with lower premeditation scores had higher odds of being diagnosed with a polysubstance use disorder. CONCLUSION: Suicide decedents exhibiting greater premeditation before their deaths were different in several ways from suicide decedents exhibiting less premeditation. A better understanding of suicide premeditation can ultimately aid in the development of improved risk assessments and targeted safety interventions for those struggling with suicidal thoughts.

Suicide among young-old and old-old adults in rural China: A case-control psychological autopsy study.

OBJECTIVE: Late-life suicide is a vital public health concern. Though gerontological research suggested the young-old and old-old phases were heterogeneous, age differences in the elderly suicide have not been well studied due to the lack of comparable control groups and small samples. The study aimed to examine the age-specific suicidal characteristics and risk factors among the young-old (60-79) and old-old (over 80) elderly. METHODS: Two hundred and forty two suicide decedents and 242 living comparisons were enrolled in a 1:1 matched case-control psychological autopsy study in rural China: 173 young-old and 69 old-old in each group. Suicidal characteristics, demographic characteristics, living arrangements, physical health, mental disorder, and psychosocial factors were collected. We used logistic regression models to assess risk factors of suicide and test for interactions between age and each risk factor. RESULTS: Pesticide suicide was more prevalent among young-old suicides than old-old suicides (56.07% vs. 40.58%, p = 0.029). Non-currently married, unemployment, mental disorder, higher disability in physical activities of daily living, higher hopelessness and higher depressive symptom were significantly associated with suicide among older adults. The effect of poor function in physical activities of daily living on suicide was significantly greater during younger ages (p for interaction = 0.038). CONCLUSIONS: Findings indicated that most suicidal characteristics and risk factors for completed suicide were generally similar among young-old and old-old adults. But poor function in physical activities of daily living predicted increase suicide risk only at younger ages. In addition to common risk factors, age-specific factors should also be noted in suicide prevention. CLINICAL TRIAL REGISTRATION: According to the ICMJE, purely observational studies (those in which the assignment of the medical intervention is not at the discretion of the investigator) will not require registration. Our study was not registered because this is a case-control study. But all procedures of the study were carried out in accordance with the latest version of the Declaration of Helsinki. The study were approved by the Institutional Review Boards of the Central South University, Shandong University, and Guangxi Medical University.

Physical diseases and elderly suicide in rural China: A case-control psychological autopsy study.

OBJECTIVES: Physical diseases are well-established risk factor for suicide, particularly among older adults. However, little is known about the underlying mechanism of the association. This study aimed to describe the prevalence of physical diseases and their influences on the elderly in rural China and to examine the underlying mechanisms of the relationship between physical diseases and suicide. METHODS: This matched case-control psychological autopsy study was conducted from June 2014 to September 2015. Consecutive suicide cases (242) among people aged 60 years or above were identified in three Chinese provinces. The suicide cases were 1:1 matched with living comparisons based on age, gender and residential area. Two informants for each participant were interviewed to collect data on their demographic characteristics, the severity index of physical diseases, depressive symptoms, feelings of hopelessness, mental disorders and social support. RESULTS: A significant difference was found between suicide cases and living comparisons regarding the prevalence of physical diseases (83.5% vs 66.5%, p < 0.001) and their severity (11.3 ± 6.2 vs 6.7 ± 5.3, p < 0.001). Independent risks of suicide included the following: not currently married (OR = 2.81, 95% CI = [1.04, 7.62]), mental disorders (OR = 7.18, 95% CI = [1.83, 28.13]), depressive symptoms (OR = 1.15, 95% CI = [1.05, 1.26]) and feelings of hopelessness (OR = 1.51, 95% CI = [1.20, 1.90]). The structural equation model indicated that the relationship between the severity index of physical diseases and suicide was mediated by depressive symptoms, feelings of hopelessness and mental disorders. CONCLUSION: The severity and number of physical diseases were found to be correlated with suicide among the elderly in rural China, after controlling for demographic characteristics. Physical diseases elevate one's suicide risk by increasing depressive symptoms, feelings of hopelessness and mental disorders. Efforts for suicide prevention should be integrated with strategies to treat physical diseases along with psychological interventions.

The path not taken: Distinguishing individuals who die by suicide from those who die by natural causes despite a shared history of suicide attempt.

OBJECTIVES: This study aimed to identify variables that distinguish suicide risk among individuals with previous suicide attempts. METHOD: Using psychological autopsy procedures, we evaluated 86 decedents who had at least one lifetime suicide attempt before eventual death by suicide (n = 65) or natural causes (n = 21). RESULTS: The Suicide Death group was more likely to be male, to have alcohol in the toxicology report at time of death, and to have a depression diagnosis, while the Natural Cause Death group was more likely to have personality disorder traits, a polysubstance use disorder, higher reported health stress, and an antidepressant in the toxicology report at time of death. Hopelessness and ambivalence were found to distinguish between groups during the 6 months before death. CONCLUSIONS: These findings suggest important differences between individuals with a shared history of a suicide attempt who die by suicide versus natural causes.

Suicide among older adults: Interactions among key risk factors.

OBJECTIVE: The present study aimed to understand how key risk factors of older adult suicide interact to ultimately lead to death by suicide using data collected post-mortem. METHOD: A psychological autopsy was used to gather detailed information about psychiatric diagnosis, medical problems, social isolation, and negative attitudes expressed by the individual during the six months prior to their death. Interviews with next-of-kin, medical and psychiatric records, and the Cumulative Illness Rating Scale for Geriatrics were used. Subjects included 32 older adults who died by suicide and 45 older adults who died by natural causes. RESULTS: Hopelessness, depression, and negative health attitudes were strongly correlated with suicide. Older age was associated with social isolation, suggesting an indirect relationship with suicide via hopelessness, depression, and negative health attitudes. Physical illness did not increase risk. Multivariate analyses suggested that hopelessness fully mediated the effects of social isolation, negative health attitudes, and depression on suicide. CONCLUSIONS: Psychological factors played the largest role in suicide deaths compared to social isolation and physical illness. Suicide interventions aimed at older adults should ensure hopelessness, depression, and negative health attitudes are primary targets.

Additional Value of Peer Informants in Psychological Autopsy Studies of Youth Suicides.

In this study, we examined the feasibility and added value of including peer informants in a psychological autopsy study of youth suicides. Peer semi-structured interview data from 16 cases were analyzed qualitatively and compared to parent data. Results show that peers added information to parents' narratives in general and particularly on social relationships, bullying, school experiences, social media, and family relations. Peers also provided additional information on the presence of certain issues (such as social media contagion) as well as on the emotional impact from certain adverse events that seemed to have functioned as precipitating factors. We conclude that including peers in psychological autopsy studies of youth suicides is feasible and of added value but that more research is desirable. The results initially can be used in the design of psychological autopsies so that the maximum amount of information about each suicide will be learned.

Proxy measures of premortem cognitive aptitude in postmortem subjects with schizophrenia.

BACKGROUND: Postmortem human brain studies provide the molecular, cellular, and circuitry levels of resolution essential for the development of mechanistically-novel interventions for cognitive deficits in schizophrenia. However, the absence of measures of premortem cognitive aptitude in postmortem subjects has presented a major challenge to interpreting the relationship between the severity of neural alterations and cognitive deficits within the same subjects. METHODS: To begin addressing this challenge, proxy measures of cognitive aptitude were evaluated in postmortem subjects (N = 507) meeting criteria for schizophrenia, major depressive or bipolar disorder, and unaffected comparison subjects. Specifically, highest levels of educational and occupational attainment of the decedent and their parents were obtained during postmortem psychological autopsies. RESULTS: Consistent with prior findings in living subjects, subjects with schizophrenia had the lowest educational and occupational attainment relative to all other subject groups, and they also failed to show the generational improvement in attainment observed in all other subject groups. CONCLUSIONS: Educational and occupational attainment data obtained during postmortem psychological autopsies can be used as proxy measures of premortem cognitive function to interrogate the neural substrate of cognitive dysfunction in schizophrenia.

Gender-specific risk for late-life suicide in rural China: a case-control psychological autopsy study.

BACKGROUND: despite unique gender patterns of suicide among older people in rural China, research addressing this issue is scarce. This study aims to clarify the gender-specific risk factors of late-life suicide in rural China. METHODS: the study included 242 persons (51% male) aged 60 and above who had committed suicide between June 2014 and September 2015 in the rural areas of three provinces of China. Using 1:1 matched case-control design, 242 living controls matched in age, gender and neighbourhood were randomly selected. Psychological autopsy interviews and psychological assessments were conducted with two informants for each suicide and living control, respectively. RESULTS: men used alcohol before suicide more than women (12.6 versus 4.7%, P < 0.05). There was no gender difference in suicide method, suicide intent and previous attempts. Univariate analysis showed that married status, mental disorder, depressive symptoms, hopelessness, impulsivity, loneliness, social support, family function and quality of life were associated with suicide in both genders. For men, other risk factors were chronic physical illness and functions of daily living. Variables remaining in the multivariable model for both men and women were depressive symptoms and hopelessness. DISCUSSION: depression and hopelessness are the two major risk factors for suicide among both older men and woman in rural China. Suicide prevention programmes focusing on depression and hopelessness in this population are indicated. Also needed are continued efforts to develop and refined gender-specialised strategies to identify high-risk individuals or groups and to enhance targeted support in the rural community.

Reliability and validity of short Beck Hopelessness Scale in psychological autopsy study among Chinese rural elderly.

BACKGROUND: Older adults represent the segment of population most exposed to the risk of suicide nearly everywhere in the world. Previous studies showed that hopelessness was an important risk factor for suicide. AIMS: This study aimed to evaluate the reliability and validity of the four-item Beck Hopelessness Scale (BHS-4) in psychological autopsy study among Chinese rural elderly. METHOD: Two-stage stratified cluster sampling method was used to select research sites. Using case-control psychological autopsy study, face-to-face interviews were conducted to collected information. RESULTS: A total of 242 elderly suicide deaths and 242 matched living comparisons were investigated, including 135 males and 107 females for each group. Intraclass Correlation Coefficients (ICC) of the controls were 0.682-0.713. The median score of BHS-4 among suicides was significantly higher than that among controls. The corrected correlation coefficient between items and total score were 0.184-0.723. Cronbach's Alphas coefficient was 0.834. Only one common factor was precipitated by exploratory factor analysis and the cumulative variance contribution rates were 59.558% for suicides and 52.722% for living controls. The correlation coefficient between hopelessness and depression were 0.481 among suicide death and 0.617 among living controls. CONCLUSION: The information provided by the informants through psychological autopsy method had high reliability to reflect the actual situation of suicides and controls. BHS-4 has good reliability and validity among Chinese rural elderly suicides. It is suitable for psychological autopsy study among Chinese rural elderly.

The pattern of stressful life events prior to suicide among the older adults in rural China: a national case-control psychological autopsy study.

BACKGROUND: There is a lack of evidence concerning the stressful life events experienced prior to suicide which may be associated with an increased suicide risk among Chinese rural older adults. The aim of this study was to identify the pattern of stressful life events prior to suicide among the older adults in China. METHODS: Twelve counties were randomly selected using two-stage stratified cluster sampling method. Suicide cases aged 60 years and older (n = 242) were collected from those counties from June 2014 to September 2015. Matched living controls were selected 1:1 with suicide cases by age, gender, and location. Data were collected using face-to-face interviews by a psychological autopsy method. The Life Event Scale for the Elderly was used to measure the stressful life events prior to suicide/interviews. RESULTS: Approximately 99.6% of suicide cases and 88.4% of controls experienced at least one stressful life event. The suicide group experienced more long-term stressful life events than recent stressful life events. The top three most frequent stressful life events for the suicide group were being diagnosed with chronic disease, hospitalization, and being diagnosed with terminal illness. More female suicide cases experienced the death of a spouse, while more males experienced hospitalization, diagnosis with terminal illness and family poverty. Experiencing at least one stressful life event, an unstable marital status, physical diseases and mental disorders were shown to increase the risk of suicide. CONCLUSIONS: Stressful life events were common for the rural older adults, especially long-term stressful life events. The experience of at least one stressful life event can increase suicide risk among this population. More attention should be paid to the rural older adults who experienced more long-term stressful life events and health related life events.

The mental and physical health profile of people who died by suicide: findings from the Suicide Support and Information System.

PURPOSE: There is limited research on the associations between factors relating to mental and physical health in people who died by suicide. METHODS: Consecutive suicide cases were included in a psychological autopsy study as part of the Suicide Support and Information System in southern Ireland. Chi-square tests and logistic regression analysis were used to examine factors associated with recorded presence or absence of mental and physical health problems. RESULTS: The total sample comprised 307 suicide cases, the majority being male (80.1%). Sixty-five percent had a history of self-harm and 34.6% of these cases had not been seen or treated following previous self-harm, although most (80.3%) had a history of recent GP attendance. Mental health diagnoses were present in 84.8% of cases where this variable was documented, and among these, 60.7% had a history of substance misuse and 30.6% had physical health problems. Variables associated with mental illness included gender, older age, previous self-harm episode(s), and presence of drugs in toxicology at time of death. Variables associated with physical illness included older age, death by means other than hanging, and previous self-harm episode(s). CONCLUSIONS: Different factors associated with suicide were identified among people with mental and physical illness and those with and without a diagnosis, and need to be taken into account in suicide prevention. The identified factors highlight the importance of integrated care for dual-diagnosis presentations, restricting access to means, and early recognition and intervention for people with high-risk self-harm.

Psychosocial, psychiatric and work-related risk factors associated with suicide in Ireland: optimised methodological approach of a case-control psychological autopsy study.

BACKGROUND: Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls. METHODS: The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners' registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners' records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources. CONCLUSIONS: The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

The validity of proxy-based data on loneliness in suicide research: a case-control psychological autopsy study in rural China.

BACKGROUND: There is a lack of evidence for the role of loneliness on suicide using psychological autopsy method, and the validity of proxy informants' reports on loneliness is not well established. This study aimed to investigate the validity of proxy respondent reports on loneliness, and the reliability and validity of the University of California Los Angeles Loneliness Scale-6 (ULS-6) as used in psychological autopsy method with rural elderly people in China. METHODS: Two hundred forty-two suicide cases and 242 normal community controls were selected, and the psychological autopsy method was utilized to collect information. Data from proxy respondents of the living controls were compared with data reported by the targets (gold standards). RESULTS: Subject-proxy concordance for ULS-6 was fair (ICC = 0.447) in the living controls. The suicide cases were more likely to have a higher score of ULS-6 than the living controls. Additionally, our data supported that ULS-6 had adequate psychometric properties in both suicide and control groups: factor analyses yielded one-factor component solution; Cronbach's alpha (both > 0.90) demonstrated excellent internal consistency; the Spearman correlation analysis indicated that the ULS-6 score was positively correlated with depression; and negatively correlated with QOL and social support. CONCLUSIONS: Results support proxy-based data on loneliness in research of suicide in older adults in rural China, and the ULS-6 is a psychometrically sound instrument for measuring loneliness in psychological autopsy studies.

How to integrate proxy data from two informants in life event assessment in psychological autopsy.

BACKGROUND: Life event assessment is an important part in psychological autopsy, and how to integrate its proxy data from two informants is a major methodological issue which needs solving. METHODS: Totally 416 living subjects and their two informants were interviewed by psychological autopsy, and life events were assessed with Paykel's Interview for Recent Life Events. Validities of integrated proxy data using six psychological autopsy information reconstruction methods were evaluated, with living subjects' self-reports used as gold-standard criteria. RESULTS: For all the life events, average value of Youden Indexes for proxy data by type C information reconstruction method (choosing positive value from two informants) was larger than other five methods'. For family life related events, proxy data by type 1st information reconstruction method were not significantly different from living subjects' self-reports (P = 0.828). For all other life events, proxy data by type C information reconstruction method were not significantly different from the gold-standard. CONCLUSIONS: Choosing positive value is a relatively better method for integrating dichotomous (positive vs. negative) proxy data from two informants in life event assessment in psychological autopsy, except for family life related events. In that case, using information provided by 1st informants (mainly family member) is recommended.

Suicide in Nepal: Qualitative Findings from a Modified Case-Series Psychological Autopsy Investigation of Suicide Deaths.

South Asia accounts for the majority of the world's suicide deaths, but typical psychiatric or surveillance-based research approaches are limited due to incomplete vital surveillance. Despite rich anthropological scholarship in the region, such work has not been used to address public health gaps in surveillance and nor inform prevention programs designed based on surveillance data. Our goal was to leverage useful strategies from both public health and anthropological approaches to provide rich narrative reconstructions of suicide events, told by family members or loved ones of the deceased, to further contextualize the circumstances of suicide. Specifically, we sought to untangle socio-cultural and structural patterns in suicide cases to better inform systems-level surveillance strategies and salient community-level suicide prevention opportunities. Using a mixed-methods psychological autopsy approach for cross-cultural research (MPAC) in both urban and rural Nepal, 39 suicide deaths were examined. MPAC was used to document antecedent events, characteristics of persons completing suicide, and perceived drivers of each suicide. Patterns across suicide cases include (1) lack of education (72% of cases); (2) life stressors such as poverty (54%), violence (61.1%), migrant labor (33% of men), and family disputes often resulting in isolation or shame (56.4%); (3) family histories of suicidal behavior (62%), with the majority involving an immediate family member; (4) gender differences: female suicides were attributed to hopeless situations, such as spousal abuse, with high degrees of social stigma. In contrast, male suicides were most commonly associated with drinking and resulted from internalized stigma, such as financial failure or an inability to provide for their family; (5) justifications for suicide were attributions to 'fate' and personality characteristics such as 'stubbornness' and 'egoism'; (5) power dynamics and available agency precluded some families from disputing the death as a suicide and also had implications for the condemnation or justification of particular suicides. Importantly, only 1 out of 3 men and 1 out of 6 women had any communication to family members about suicidal ideation prior to completion. Findings illustrate the importance of MPAC methods for capturing cultural narratives evoked after completed suicides, recognizing culturally salient warning signs, and identifying potential barriers to disclosure and justice seeking by families. These findings elucidate how suicide narratives are structured by family members and reveal public health opportunities for creating or supplementing mortality surveillance, intervening in higher risk populations such as survivors of suicide, and encouraging disclosure.

The Role of Self-Esteem in Suicides Among Young Men.

This study explores self-esteem in suicide among young males with no earlier history of suicide attempt(s) or treatment in mental health services. The data come from an ongoing psychological autopsy study; 10 cases of young men aged 18 to 30, were selected to generate a phenomenologically based understanding of the psychological mechanisms and processes involved in the suicidal process. The analyses are based on in-depth interviews with 61 closely connected individuals, as well as suicide notes. We used Interpretative Phenomenological Analysis. For these young men, the transition to young adulthood, a period of major life challenges, seemed to be associated with personal defeats. According to their significant others, the deceased seemed to have experienced intolerable discrepancies between their actual performances and their ideal self standards. Four themes emerged from the analysis: (a) striving to find a viable path to life as an adult man; (b) experiencing a sense of failure according to own standards; (c) emotional self-restriction in relationships; and (d) strong feelings of loneliness and rejection of self. Improved understanding of suicides outside the mental illness paradigm may have important implications for preventive strategies.

Psychological autopsy study comparing suicide decedents, suicide ideators, and propensity score matched controls: results from the study to assess risk and resilience in service members (Army STARRS).

BACKGROUND: The suicide rate has increased significantly among US Army soldiers over the past decade. Here we report the first results from a large psychological autopsy study using two control groups designed to reveal risk factors for suicide death among soldiers beyond known sociodemographic factors and the presence of suicide ideation. METHODS: Informants were next-of-kin and Army supervisors for: 135 suicide cases, 137 control soldiers propensity-score-matched on known sociodemographic risk factors for suicide and Army history variables, and 118 control soldiers who reported suicide ideation in the past year. RESULTS: Results revealed that most (79.3%) soldiers who died by suicide have a prior mental disorder; mental disorders in the prior 30-days were especially strong risk factors for suicide death. Approximately half of suicide decedents tell someone that they are considering suicide. Virtually all of the risk factors identified in this study differed between suicide cases and propensity-score-matched controls, but did not significantly differ between suicide cases and suicide ideators. The most striking difference between suicides and ideators was the presence in the former of an internalizing disorder (especially depression) and multi-morbidity (i.e. 3+ disorders) in the past 30 days. CONCLUSIONS: Most soldiers who die by suicide have identifiable mental disorders shortly before their death and tell others about their suicidal thinking, suggesting that there are opportunities for prevention and intervention. However, few risk factors distinguish between suicide ideators and decedents, pointing to an important direction for future research.

Pathways to Suicide in Lesbian and Gay Populations in Australia: A Life Chart Analysis.

Given the continued paucity of research into suicide in lesbian and gay (LG) people, there is a need to investigate the characteristics of those LG suicides that are able to be identified. The aim of this article was to analyze pathways to suicide in lesbian and gay individuals by way of life charts. Data were gathered through of 24 psychological autopsy interviews with next-of-kin of an LG person who had died by suicide. The female (n = 5) and male (n = 19) cases in this study clustered into younger and older suicides. The defining feature of the younger suicides was lack of acceptance by family and, to a lesser extent, self, and that of the older suicides was romantic relationship conflict, although this was also common in younger suicides. There appears to have been, furthermore, an accumulation of risk factors, particularly in the period prior to death where these specific risk factors combined with other life stressors, such as work problems. Initiatives to reduce stigma around diversity in sexuality and to support families and young people through the "coming out" process as well as services designed to assist those experiencing problems in same-sex relationships, in particular, would appear to be the most relevant within the trajectories presented.

Suicide in Nepal: a modified psychological autopsy investigation from randomly selected police cases between 2013 and 2015.

PURPOSE: Yearly, 600,000 people complete suicide in low- and middle-income countries, accounting for 75% of the world's burden of suicide mortality. The highest regional rates are in South and East Asia. Nepal has one of the highest suicide rates in the world; however, few investigations exploring patterns surrounding both male and female suicides exist. This study used psychological autopsies to identify common factors, precipitating events, and warning signs in a diverse sample. METHODS: Randomly sampled from 302 police case reports over 24 months, psychological autopsies were conducted for 39 completed suicide cases in one urban and one rural region of Nepal. RESULTS: In the total police sample (n = 302), 57.0% of deaths were male. Over 40% of deaths were 25 years or younger, including 65% of rural and 50.8% of female suicide deaths. We estimate the crude urban and rural suicide rates to be 16.1 and 22.8 per 100,000, respectively. Within our psychological autopsy sample, 38.5% met criteria for depression and only 23.1% informants believed that the deceased had thoughts of self-harm or suicide before death. Important warning signs include recent geographic migration, alcohol abuse, and family history of suicide. CONCLUSIONS: Suicide prevention strategies in Nepal should account for the lack of awareness about suicide risk among family members and early age of suicide completion, especially in rural and female populations. Given the low rates of ideation disclosure to friends and family, educating the general public about other signs of suicide may help prevention efforts in Nepal.

Do Undiagnosed Suicide Decedents Have Symptoms of a Mental Disorder?

BACKGROUND: Psychological autopsy studies consistently report that the rate of detected mental disorders among suicide decedents is below 100%. This implies three possibilities: (a) a subset of suicide decedents did not have a mental disorder at the time of death; (b) all suicide decedents suffered from a mental disorder, but some were undetected due to methodological limitations; and/or (c) suicide decedents with an undetected mental disorder displayed significant and perhaps subclinical features of a mental disorder. OBJECTIVE: In this article, we examined these possibilities by evaluating the differences in symptoms and stressors between suicide decedents who were undiagnosed and those diagnosed with a mental disorder at the time of death. METHOD: We reviewed 130 case studies of community-based suicide decedents originally described in Robins' (1981) psychological autopsy study. RESULTS: Without exception, suicide decedents in Robins' sample suffered either from a clearly diagnosable mental disorder or displayed features indicative of a significant, even if subclinical, presentation of a mental disorder. Undiagnosed and diagnosed suicide decedents did not significantly differ with regards to demographics, violence of suicide method, suicide attempt history, the number and intensity of stressful life events preceding death, and whether their death was a murder-suicide. CONCLUSION: Although clearly not all who suffer from mental disorders will die by suicide, these findings imply that all who die by suicide appear to exhibit, at minimum, subclinical psychiatric symptoms with the great majority showing prominent clinical symptoms. We conclude with clinical implications and recommendations for future study.