Suicide investigation: Psychological autopsy

According to the WHO, approximately 800,000 people take their life each year, and many others try to do so. Each suicide is a tragedy that affects families, communities and countries, having long-lasting effects on the relatives of the deceased. People of all ages can commit suicide. In 2015, it was the second biggest cause of death in the 15–29 age group worldwide.¹

In Spain, according to the National Statistics Institute (INE), suicide was the biggest external cause of death in 2015, with 3602 deaths caused by suicide compared to 1880 as a result of road accidents.²

In view of the indubitable relevance of the issue of suicide, and therefore treating it as a topic within its scope of action, suicide has always been a key focus of research in legal and forensic medicine.

However, despite all the efforts made to date from all fields of medicine, including legal and forensic medicine, it is undeniable that research into suicidal behaviour still leaves much to be desired.³ Therefore, by means of making our own personal contribution with the aim of identifying and resolving the different problems posed, the SPANISH JOURNAL OF LEGAL MEDICINE (REML) has always been committed to suicide research, paying special attention to the publication of works that have tried to shed light on this multidisciplinary problem from various perspectives. Proof of this is the December 2012 publication of a monograph (volume 38, number 4) dedicated exclusively to this topic.^4–9 Besides this monograph, which was also published in the REML, and always in accordance with the need for a multidisciplinary approach to suicide, various published studies have tackled aspects exclusively related to forensic pathology, in relation to suicide methods and the keys for its correct diagnosis,^10–14 whereas others have emphasised a purely psychiatric approach to the problem.^15,16 Other publications, meanwhile, have focused on some aspects that bear a greater relationship to public health and the use of suicide mortality statistics.^17,18 In this sense, multidisciplinary collaboration initiatives have been developed with public health specialists aimed at gaining greater knowledge about deaths due to suicide. This has been done while considering the frequent tendency to under-declare or poorly classify suicide deaths in official mortality statistics,^19–21 emphasising the aforementioned studies in which medical-forensic sources provide standard reference data regarding death by suicide.^20,21

On the other hand, and assuming that suicide is a major public health issue, the WHO has advised that this issue, arising from the phenomenon of suicide, can be prevented through appropriate interventions based on reliable and often low-cost data. The WHO also points out that, in order for national responses to be efficient, a multi-sector and comprehensive suicide prevention strategy is required.¹ Consistent with these guidelines indicated by the WHO, and in line with the efforts carried out from within other medical specialities, several investigations have been launched that try to identify the best suicide prevention strategies. These studies reflect, primarily, collaborations between specialists from the field of psychiatry with those of forensic medicine.

In this sense, several collaborations have taken place in recent years between the Institutes of Legal Medicine and Forensic Science and specialists in the field of psychiatry in suicide prevention programmes, whether to determine the existence of psychiatric disorders in cases of suicide in a given area²² or, for example, to identify space-time clusters in cases of suicide.²³ Several collaborations have taken place, such as those already established in the year 2006, between the LMAFS and the Universities of Seville and Granada.⁹ Likewise, to facilitate these collaborations in the field of research and considering the need to formulate a common implantation plan in the research strategies, a few years ago the Institute of Legal Medicine and Forensic Science of Catalonia (IMLCFC) created a Multidiscipline Group for Suicide Research (GMIS) within the institute itself, containing professionals from all branches of legal and forensic medicine, serving as an umbrella and as a base for the standardisation of different investigations in the field of suicide that may arise from the institution itself.

Following this multidisciplinary approach, in this volume of REML, Naudó-Molist et al.²⁴ have written an article entitled Análisis descriptivo de los suicidios y la aplicación del método autopsia psicológica durante el período 2013-2015 en la comarca de Osona (Barcelona, España) [Descriptive analysis of suicides and the application of the psychological autopsy method during the period of 2013–2015 in the Osona region (Barcelona, Spain)], which counted on the participation of mental health and IMLCFC specialists. The same research nucleus had already previously published their experience of the prevention of suicidal behaviour in the Osona region in REML.⁴ In this new publication, however, they have added an analysis of the psychological autopsy technique to their objective of describing the profile of deaths by suicide. It should be noted that the use of this methodology in the research they submitted is of particular importance, given that its use in analysing suicide deaths is very limited in Spain.

Psychological autopsy, the term coined by Schneidman in the middle of the twentieth century, is the scientific method that has been proven to be the best way of collecting data to help obtain a profile that is as close as possible to that of the person committing suicide. It may be carried out by psychologists, psychiatrists and forensic doctors who are especially well-trained in this area, and it has a dual use: forensic investigation and clinical research into suicide.⁹

As pointed out by the authors of the Osona study,²⁴ psychological autopsy was initially used to try to shed light on and help clarify what is now known as ‘suspicious deaths’, therefore being able to apply the NASH code (Natural, Accidental, Suicide, Homicide) on the death certificate. Nowadays, however, it is internationally considered to be the best method for studying suicides. Within this group of studies, retrospective case-control appears to be the best method for avoiding inclusion bias and untimely assessment, thus making it possible to extrapolate data to the general public.⁹

Therefore, despite the limitation posed by the relatively small sample size of the research presented in this edition of the REML, Naudó-Molist et al.’s study²⁴ shows that psychological autopsy represents (even in our setting) an efficient tool for describing and obtaining suicide-related data that may be relevant and useful in the design and implementation of prevention programmes. It would be desirable for other suicide research groups from our area to include this methodology in their future research projects, in a regulated and standardised manner, which would allow for comparative studies with large sample sizes to be conducted in the future.