The Mask of Suicide.

Although it has been stated that the majority of suicidal people give definite warnings of their suicidal intention, a percentage of suicidal people may dissemble (or mask), possibly 20%. The aim of this psychological autopsy (PA) study was to explore the mask of suicide, examining age and sex of the decedent, and survivors' relationship to the deceased. A PA study in Norway, with 120 survivors/informants, was undertaken. Overall, 80% of informants reported manifest and/or latent content of deception (dissembling); well above the 20% suggested. Three main themes emerged from the interviews of the 95 survivors that were related to the mask. In the opinion of the bereaved, reasons for the mask were due to: 1) Inability to adjust/impairment; 2) Relational problems; and 3) Weakened resilience. Differences in masking or (self) deception were found in the age of the decedent, but not in sex, nor in the survivors' closeness of the relationship. Older deceased people were perceived to exhibit more dissembling, associated to the suicide. Limitations are noted in this beginning study into the mask of suicide, and it is concluded that much greater research is needed to unmask the dangerous dissembling, maybe in some, self-deception.

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.

A Multidimensional Theory of Suicide.

BACKGROUND: Theory is the foundation of science; this is true in suicidology. Over decades of studies of suicide notes, Leenaars developed a multidimensional model of suicide, with international (crosscultural) studies and independent verification. AIM: To corroborate Leenaars's theory with a psychological autopsy (PA) study, examining age and sex of the decedent, and survivor's relationship to deceased. METHOD: A PA study in Norway, with 120 survivors/informants was undertaken. Leenaars' theoretical-conceptual (protocol) analysis was undertaken of the survivors' narratives and in-depth interviews combined. RESULTS: Substantial interjudge reliability was noted (κ = .632). Overall, there was considerable confirmatory evidence of Leenaars's intrapsychic and interpersonal factors in suicide survivors' narratives. Differences were found in the age of the decedent, but not in sex, nor in the survivor's closeness of the relationship. Older deceased people were perceived to exhibit more heightened unbearable intrapsychic pain, associated with the suicide. CONCLUSION: Leenaars's theory has corroborative verification, through the decedents' suicide notes and the survivors' narratives. However, the multidimensional model needs further testing to develop a better evidence-based way of understanding suicide.

Experiences of the bereaved in connection with the suicide of young men. / Etterlattes erfaringer ved selvmord hos unge menn.

BACKGROUND: On average 110 men under 35 years of age take their own lives in Norway each year. Few receive health assistance in the period prior to the suicide, and little research exists on contact with assistance agencies for persons who take their own lives, beyond studies of the number of doctor visits before the death. This study aimed to obtain knowledge of relatives' need for assistance from the health services, both to identify suicide risk and motivate them to seek help in life crises. MATERIAL AND METHOD: Sixty-one in-depth interviews with the bereaved next of kin of young men (18-30 years) were analysed using interpretative phenomenological analysis. RESULTS: The bereaved perceived the generally accepted assumption that suicide is attributable to mental illness as an obstacle to identifying suicide risk. Most of the bereaved saw no signs of mental illness before the suicide. The suicide crisis was associated with relational factors. The bereaved who had harboured the thought that a suicide risk existed found that it was not enough to urge the suicidal person to seek health assistance. Improved knowledge of suicide and seeking health assistance were measures that were proposed. INTERPRETATION: The findings challenge the current prevention model. Healthcare personnel as well as the general population should be better informed that mental illness is neither a sufficient nor a necessary factor to explain suicide, even though a higher risk of suicide is associated with some mental disorders.

Young Men, Masculinities, and Suicide.

Young men constitute one of the highest risk groups for suicide in most countries. This gives reason to explore how meanings attached to masculinity can be evoked and handled when a young man takes his life. In-depth interviews with 5 to 8 informants for each of 10 suicides, as well as suicide notes, were analyzed using Interpretative Phenomenological Analysis. The suicides appeared as signature acts of compensatory masculinity with the following themes: When hope is gone, no one must know; weakness was never allowed; and suicide conducted in a way to present oneself as heroic. The handling of masculinity in triggering suicidal plans and in carrying out suicide is intrinsically connected to avoidance of help-seeking behavior.

Barriers toward help-seeking among young men prior to suicide.

This study explores barriers to help-seeking among young men prior to suicide. We analyzed 61 in-depth interviews with parents, siblings, friends, and ex-partners of 10 young men (aged 18-30) with no record of mental illness, as well as 6 suicide notes, using interpretative phenomenological analysis. Three barriers emerged: (a) a total defeat; (b) no room for weakness; and (c) fear of mental disorder. The shame from falling short of standards (own/significant male others') could be a considerable barrier to help-seeking in a suicidal crisis.

Maladaptive Perfectionism: Understanding the Psychological Vulnerability to Suicide in Terms of Developmental History.

This study aimed to explore how the life history of suicide victims with no history of treatment in mental health care or of attempted suicide seemed to presdispose them to maladaptive perfectionism. The study is part of an ongoing psychological autopsy study. It aimed to produce a phenomenological understanding of the vulnerability to suicide related to perfectionism, based on the life history of six male suicide victims aged 22 to 58. Interpretative Phenomenological Analysis was used to analyze the interview data of 41 key informants. Three main themes emerged: (a) exposure to high expectations combined with little recognition and warmth; (b) reduced ability to cope with failures and weaknesses; and (c) fear of emotional rejection. Together these themes illustrate that feelings of shame, mainly resulting from an unfulfilled need for attachment, a desire for love and recognition may relate to maladaptive perfectionism, which influences the suicidal process. The results may have important implications for suicide prevention programs.

From a cracking façade to a total escape: maladaptive perfectionism and suicide.

This study explored the final stages of the suicide process among six men characterized as maladaptive perfectionists. These men, aged 22 to 58, had no history of suicide attempts or mental health treatment. In-depth interviews with 5 to 9 informants for each person were analyzed by using interpretative phenomenological analysis. Three themes emerged from the analysis: (a) a cracking façade; (b) a total loss of coping ability; and (c) a total escape. Suicide was related to a shameful defeat that was not reversible, and a loss of the ability to handle such feelings of defeat and shame.

Suicide and perfectionism: a psychological autopsy study of non-clinical suicides.

This study explores suicide in relation to perfectionism among individuals who died by suicide with no history of treatment in mental health care or of suicide attempts. The study is part of an ongoing psychological autopsy study (PA-study). It aimed to produce a phenomenological understanding of the dynamics/processes from perfectionism to suicide among 6 men aged 22 to 58. Interpretative Phenomenological Analysis (IPA) was used to analyze the interview data of 41 key informants. Based on the informants' narratives, it seemed that perfectionism left these men less able to cope with their (self-perceived) inability to meet their high expectations. Four themes emerged from analysis: 1) striving for success; 2) fear of failure; 3) keeping up the façade; and 4) rigidity. The results may be important in the prevention of nonclinical suicides, a group that is particularly difficult to identify, especially if the deceased have been regarded as very successful in many areas.

Exploring vulnerability to suicide in the developmental history of young men: a psychological autopsy study.

This study explores the developmental history of ten young men who completed suicide in the transition to adulthood. The young men, aged 18-30, had no previous history of suicide attempts or treatment in mental health. In-depth interviews with four to eight informants for each suicide were analyzed using Interpretative Phenomenological Analysis. Three developmental issues from early age onwards emerged: (a) unsuccessful in becoming independent; (b) weakened competence to deal with shame; and (c) trapped in anger. The capacity to regulate emotions like shame and anger could make certain men vulnerable to suicide when facing adult challenges and defeats.

Pushing the boundaries: understanding self-harm in a non-clinical population.

This study investigates 122 people's descriptions of their self-harm experiences using thematic analysis. Analysis revealed four themes: What counts as self-harm, What leads to self-harm, Intentions and Managing stigma. Our participants challenged commonly accepted understandings in terms of method, outcome and intentions. Several difficulties associated with discriminating between suicidal and non-suicidal self-harm were highlighted, which may be important in clinical practice. Few participants mentioned diagnosed psychiatric disorders; they best understood self-harm through their social experiences. Focusing on social understandings of self-harm may help reduce associated stigma and barriers to help-seeking.

Self-harm and conventional gender roles in women.

A total of thirty-two women admitted to a general hospital for medical treatment after self-harming completed measures of conventional positive and negative masculinity and femininity. Comparisons were made with two control groups with no self-harm history; 33 women receiving psychiatric outpatient treatment and a nonclinical sample of 206 women. Multinomial logistic regression analyses showed that those with lower scores on Instrumentality and Unmitigated Agency (positive and negative masculinity) and higher scores on Insecurity (negative femininity) had greater odds of self-harming. Relationships were weaker after accounting for generalized self-efficacy. Results are discussed in relation to previous findings and suggestions for prevention are made.

Treatment received, satisfaction with health care services, and psychiatric symptoms 3 months after hospitalization for self-poisoning.

BACKGROUND: Patients who self-poison have high repetition and high mortality rates. Therefore, appropriate follow-up is important. The aims of the present work were to study treatment received, satisfaction with health care services, and psychiatric symptoms after hospitalization for self-poisoning. METHODS: A cohort of patients who self-poisoned (n = 867) over a period of 1 year received a questionnaire 3 months after discharge. The Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS), and Generalized Self-Efficacy Scale (GSE) were used. The participation rate was 28% (n = 242); mean age, 41 years; 66% females. RESULTS: Although only 14% of patients were registered without follow-up referrals at discharge, 41% reported no such measures. Overall, satisfaction with treatment was fairly good, although 29% of patients waited more than 3 weeks for their first appointment. A total of 22% reported repeated self-poisoning and 17% cutting. The mean BDI and BHS scores were 23.3 and 10.1, respectively (both moderate to severe). The GSE score was 25.2. BDI score was 25.6 among patients with suicide attempts, 24.9 for appeals, and 20.1 for substance-use-related poisonings. CONCLUSIONS: Despite plans for follow-up, many patients reported that they did not receive any. The reported frequency of psychiatric symptoms and self-harm behavior indicate that a more active follow-up is needed.

Psychological autopsy studies as diagnostic tools: are they methodologically flawed?

One of the most established "truths" in suicidology is that almost all (90% or more) of those who kill themselves suffer from one or more mental disorders, and a causal link between the two is implied. Psychological autopsy (PA) studies constitute one main evidence base for this conclusion. However, there has been little reflection on the reliability and validity of this method. For example, psychiatric diagnoses are assigned to people who have died by suicide by interviewing a few of the relatives and/or friends, often many years after the suicide. In this article, we scrutinize PA studies with particular focus on the diagnostic process and demonstrate that they cannot constitute a valid evidence base for a strong relationship between mental disorders and suicide. We show that most questions asked to assign a diagnosis are impossible to answer reliably by proxies, and thus, one cannot validly make conclusions. Thus, as a diagnostic tool psychological autopsies should now be abandoned. Instead, we recommend qualitative approaches focusing on the understanding of suicide beyond mental disorders, where narratives from a relatively high number of informants around each suicide are systematically analyzed in terms of the informants' relationships with the deceased.

Changes in mental health services and suicide mortality in Norway: an ecological study.

BACKGROUND: Mental disorders are strongly associated with excess suicide risk, and successful treatment might prevent suicide. Since 1990, and particularly after 1998, there has been a substantial increase in mental health service resources in Norway. This study aimed to investigate whether these changes have had an impact on suicide mortality. METHODS: We used Poisson regression analyses to assess the effect of changes in five mental health services variables on suicide mortality in five Norwegian health regions during the period 1990-2006. These variables included: number of man-labour years by all personnel, number of discharges, number of outpatient consultations, number of inpatient days, and number of hospital beds. Adjustments were made for sales of alcohol, sales of antidepressants, education, and unemployment. RESULTS: In the period 1990-2006, we observed a total of 9480 suicides and the total suicide rate declined by 26%. None of the mental health services variables were significantly associated with female or male suicide mortality in the adjusted analyses (p > 0.05). Sales of antidepressants (adjusted Incidence Rate Ratio = 0.98; 95% CI = 0.97-1.00) and sales of alcohol (adjusted IRR = 1.41; 95% CI = 1.18-1.72) were significantly associated with female suicide mortality; education (adjusted IRR = 0.86; 95% CI = 0.79-0.94) and unemployment (adjusted IRR = 0.91; 95% CI = 0.85-0.97) were significantly associated with male suicide mortality. CONCLUSIONS: The adjusted analyses in the present study indicate that increased resources in Norwegian mental health services in the period 1990-2006 were statistically unrelated to suicide mortality.

Chain of care for patients who have attempted suicide: a follow-up study from Bærum, Norway.

BACKGROUND: Individuals who have attempted suicide are at increased risk of subsequent suicidal behavior. Since 1983, a community-based suicide prevention team has been operating in the municipality of Bærum, Norway. This study aimed to test the effectiveness of the team's interventions in preventing repeated suicide attempts and suicide deaths, as part of a chain of care model for all general hospital treated suicide attempters. METHODS: Data has been collected consecutively since 1984 and a follow-up was conducted on all individuals admitted to the general hospital after a suicide attempt. The risk of repeated suicide attempt and suicide were comparatively examined in subjects who received assistance from the suicide prevention team in addition to treatment as usual versus those who received treatment as usual only. Logistic regression and Cox regression were used to analyze the data. RESULTS: Between January 1984 and December 2007, 1,616 subjects were registered as having attempted suicide; 197 of them (12%) made another attempt within 12 months. Compared to subjects who did not receive assistance from the suicide prevention team, individuals involved in the prevention program did not have a significantly different risk of repeated attempt within 6 months (adjusted OR = 1.08; 95% CI = 0.66-1.74), 12 months (adjusted OR = 0.86; 95% CI = 0.57-1.30), or 5 years (adjusted RR = 0.90; 95% CI = 0.67-1.22) after their first recorded attempt. There was also no difference in risk of suicide (adjusted RR = 0.85; 95% CI = 0.46-1.57). Previous suicide attempts, marital status, and employment status were significantly associated with a repeated suicide attempt within 6 and 12 months (p < 0.05). Alcohol misuse, employment status, and previous suicide attempts were significantly associated with a repeated attempt within 5 years (p < 0.05) while marital status became non-significant (p > 0.05). With each year of age, the risk of suicide increased by 3% (p < 0.05). CONCLUSIONS: The present study did not find any differences in the risk of fatal and non-fatal suicidal behavior between subjects who received treatment as usual combined with community assistance versus subjects who received only treatment as usual. However, assistance from the community team was mainly offered to attempters who were not receiving sufficient support from treatment as usual and was accepted by 50-60% of those deemed eligible. Thus, obtaining similar outcomes for individuals, all of whom were clinically judged to have different needs, could in itself be considered a desirable result.

Meaning-making through psychological autopsy interviews: the value of participating in qualitative research for those bereaved by suicide.

Too often ethical boards delay or stop research projects with vulnerable populations, influenced by presumed rather than empirically documented vulnerability. The article investigates how participation is experienced by those bereaved by suicide. Experiences are divided into 3 groups: (a) overall positive (62%), (b) unproblematic (10%), and (c) positive and painful (28%). The positive experiences are linked to processes of meaning-making, gaining new insight, and a hope to help others. Objective factors concerning the gender of participants, their relationship to the deceased, the method of suicide, and time since loss were largely unrelated to their experience of the interview.

Adolescent suicide attempts in Bærum, Norway, 1984-2006.

BACKGROUND: There are presently few international studies that examine adolescents' own experience of both triggering and the underlying reasons behind their suicide attempts. AIMS: To present the rates, triggering factors, and underlying reasons for such behavior. METHODS: The 23-year (1984-2006) surveillance study reported includes all general hospital-treated suicide attempters aged between 13 and 19 years (n = 254) living in the municipality of Bærum, a suburb on the outskirts of Oslo, Norway. RESULTS: Suicide attempt rates for both sexes decreased during the period of study. The female suicide attempt rate was on average 3.5 times higher than the male rate. An average of 8.2% of the suicide attempters made a repeat attempt within the following year. Overall, the most commonly reported trigger was a relational conflict (50.2%), and the most commonly reported underlying reason was a dysfunctional family situation (43.6%), followed by mental health problems (22.8%). The main gender difference for both triggers and underlying reasons was that relational conflicts were reported significantly more often by girls than by boys as triggers (55.0% versus 32.7%), and dysfunctional family issues were reported significantly more often by girls than by boys (47.1% versus 30.8%) as underlying reasons for the attempt. Mental health problems were reported less frequently as an underlying reason by girls than boys (21.2% versus 28.8%). CONCLUSIONS: A family-oriented intervention embracing the extended family system seems warranted in a majority of the cases in our study.

The relationship between sales of SSRI, TCA and suicide rates in the Nordic countries.

BACKGROUND: In the period 1990-2006, strong and almost equivalent increases in sales figures of selective serotonin re-uptake inhibitors (SSRIs) were observed in all Nordic countries. The sales figures of tricyclic antidepressants (TCAs) dropped in Norway and Sweden in the nineties. After 2000, sales figures of TCAs have been almost constant in all Nordic countries. The potentially toxic effect of TCAs in overdose was an important reason for replacing TCAs with SSRIs when treating depression. We studied whether the rapid increase in sales of SSRIs and the corresponding decline in TCAs in the period 1990-98 were associated with a decline in suicide rates. METHODS: Aggregated suicide rates for the period 1975-2006 in four Nordic countries (Denmark, Finland, Norway and Sweden) were obtained from the national causes-of-death registries. The sales figures of antidepressants were provided from the wholesale registers in each of the Nordic countries. Data were analysed using Fisher's exact test and Pearson's correlation coefficient. RESULTS: There was no statistical association (P = 1.0) between the increase of sales figures of SSRIs and the decline in suicide rates. There was no statistical association (P = 1.0) between the decrease in the sale figures of TCAs and change in suicide rates either. CONCLUSIONS: We found no evidence for the rapid increase in use of SSRIs and the corresponding decline in sales of TCAs being associated with a decline in the suicide rates in the Nordic countries in the period 1990-98. We did not find any inverse relationship between the increase in sales of SSRIs and declining suicide rates in four Nordic countries.