Characteristics of suicide completers with a psychiatric diagnosis before death: A postmortem study of 98 cases

Abstract

The objective of this research was to classify the deaths of 98 victims of suicide in Tel Aviv, Israel between the years 2007 and 2010. This was done by examining background features and clinical characteristics among suicide completers with histories of a prior psychiatric hospitalization using logistic regression modeling. 34% of the sample (33/98) was given at least one psychiatric diagnosis upon discharge from a prior psychiatric hospitalization. Throughout their lifetime, those with psychiatric diagnoses were significantly more likely to have histories of mental health treatment (psychotherapy and psychotropic medication), psychopathology and suicidality among family members, prior suicide attempts and familial or emotional crisis as compared with those without a psychiatric diagnosis. During their last life phase, those with prior psychiatric diagnoses were also significantly more likely to have received psychotherapeutic treatment, expressed a lack of desire to live and presented with affective symptoms (e.g. depression, anxiety, adaptation difficulty and nervousness) as compared with those without such histories. Thus, focusing on high risk populations, such as those with psychiatric illnesses and deciphering the role of mental health treatment, familial predisposition, prior suicide attempt and sub-clinical symptoms in relation to suicide can inform future prevention practices.

Introduction

Numerous retrospective and psychological autopsy reports have consistently indicated that persons with mental illnesses experience mortality by suicide at rates significantly higher than their corresponding general population (Cheng, 1995, Conwell et al., 1996, Foster et al., 1997, Hawton et al., 1998, Isometsa, 2001). Clinical studies have also found that persons with schizophrenia and related disorders (e.g. major depression and substance abuse) are at increased risk for suicide throughout their lifetime (Caldwell and Gottesman, 1990, Westermeyer et al., 1991, Harris and Barraclough, 1997). The risk is particularly elevated among those recently discharged from a psychiatric in-patient facility (Rossau and Mortensen, 1997, Lawrence et al., 1999, Siris, 2001, Qin and Nordentoft, 2005) that are undertreated (Heila et al., 1999) or show poor adherence toward treatment (Hawton et al., 2005).

Despite ongoing research efforts, however, detection and management of those most vulnerable have remained elusive (Mann et al., 2005). These findings highlight the relevance of understanding suicide among those with psychiatric illnesses.

Prior studies of mortality in psychiatric populations have generally emphasized that those more likely to commit suicide are young males (Caldwell and Gottesman, 1990, Westermeyer et al., 1991, Pompili et al., 2005), that live alone (Drake et al., 1986), have higher educational attainment (Hawton et al., 2005), are unemployed (Drake et al., 1984), from a high socioeconomic background, with histories of substance abuse (Harris and Barraclough, 1997, Fenton, 2000) and prior suicide attempts (Harkavy-Friedman and Nelson, 1997, Fenton, 2000, Siris, 2001, Bakst et al., 2009, Hawton, 2010).

Accumulating evidence has also suggested the importance of cognitive, biological and psychosocial determinants underlying suicide in psychiatric populations (Fenton et al., 1997, Limosin et al., 2007, Pompili et al., 2007). This line of investigation has demonstrated that self-harming behavior (Foster et al., 1999, Hirokawa et al., 2012, Kuo et al., 2012, Nock, 2012), genetic vulnerability (e.g. parental psychopathology or a family history of suicidality (Gould et al., 1996; McGirr et al., 2006)), affective syndromes or behaviors (e.g. the psychological symptoms of depression (Drake and Cotton, 1986) or agitation (Hawton et al., 2005)) and family stress or emotional instability (Modestin et al., 1992) are associated with an increased risk for suicide. Indeed, these associations often cut across diagnostic categories and may be independent of diagnosis in their prognostic utility (Kaplan and Harrow, 1999, Hawton et al., 2005, Foster, 2011).

It has been hypothesized that the reciprocal effects of these determinants can influence personal tolerance against environmental exposures (e.g. lifestyle patterns and population characteristics) and lead to a fatal suicide attempt (Cheng et al., 2000, Isometsa, 2001).

Although considerable research has focused on socio-demographic and clinical factors for estimating suicide risk among psychiatric populations, the effects of other factors such as help-seeking behaviors are conceptually obscure; that is they are likely to vary by cultural specificities across regions and by methodological and design-related differences across studies (Yoshimasu et al., 2008, Milner et al., 2012).

To our knowledge, with the exception of the Israeli Defense Force (IDF) (Apter et al., 1993) this study represents the first to use data derived from an Israeli population based sample to delineate the psychiatric profiles of 98 victims of suicide and identify high risk subgroups. Specifically, we evaluate the contribution of potential exposures (cognitive, biological and psychosocial determinants) among those with and those without a history of a psychiatric hospitalization prior to the suicide.