Psychological Autopsy Studies as Diagnostic Tools: Are They Methodologically Flawed?

Abstract

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.

Former suicidal inpatients’ experiences of treatment and care in psychiatric wards in Norway

“…Critical voices have been raised against diagnostic practices and the potential adverse effects of psychiatric medication (Gøtzsche, 2013; Whitaker, 2010), and several authors have questioned the overreliance on biomedical models with regard to how we understand and manage suicidality (Cutcliffe & Santos, 2012; Hjelmeland, Dieserud, Dyregrov, Knizek, & Rasmussen, 2014; Marsh, 2016; Webb, 2010). Even the assumption that 90% of all suicides are associated with mental disorders (Cavanagh, Carson, Sharpe, & Lawrie, 2003) is strongly challenged by researchers who argue that there is no valid evidence for this 90% statistic (Hjelmeland, Dieserud, Dyregrov, Knizek, & Leenaars, 2012). However, psychiatry continues to be heavily influenced by a biomedical ideology that in turn affects how mental health workers understand suicidality and approach suicidal patients (Hagen et al, 2017; Michel et al, 2002).…”

Risk factors for suicide attempts in the total population of Faroese eighth graders

“…In an attempt to identify risk factors for adolescent suicide attempts, the literature has also reported other variables, such as female gender, psychopathology, low tolerance for stress, and frustration and loneliness (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20). The majority of studies of suicide attempts, however, are based on small or convenience samples; only very few are based on national surveys (21).…”

Selvmord og psykiske lidelser

“…Dette går tydelig frem av Cavanagh og kollegers omfattende review-studie (3). Slike diagnoser er imidlertid basert på etterlattes subjektive oppfatninger, følelser og erfaringer, eller spekulasjoner om spørsmål de i mange tilfeller ikke har mulighet til å kunne svare sikkert på, på vegne av avdøde (5). Lar man derimot de etterlatte snakke fritt om det de tenker var sentralt for selvmordet, blir bildet et helt annet.…”

“…Evidensbasen for denne «90 %-sannheten» består hovedsakelig av en lang rekke psykologiske autopsistudier (PA-studier) (3), der man basert på intervjuer med etterlatte har stilt psykiatriske diagnoser på avdøde, ofte mange år etter selvmordet. Slike studier er imidlertid beheftet med alvorlige metodiske problemer (4), saerlig knyttet til den diagnostiske prosessen der man diagnostiserer noen (avdøde) basert på intervjuer med andre (etterlatte) (5). Det hevdes imidlertid at så lenge man bruker standardiserte diagnostiske instrumenter, er funn fra slike studier både reliable og valide (4,6).…”