Suicide or accident? A call for expansion of psychological autopsy studiesAccording to the Centers for Disease Control and Prevention, suicide is the 11th leading cause of death in the US, while unintentional injuries ranks 4th.1 Differentiation between these categories is difficult without a stated motive, often in the form of a suicide note, and is further complicated when multiple lethal methods are used. Lethal methods that can obscure the determination of suicide can include overdosing on medications, lethal actions taken while under the influence of drugs or alcohol, and/or motor vehicle deaths. Lack of standardization in this process contributes to inaccurate measurements of suicide data and suicide risk factors, which can impact the efficacy of suicide prevention policies. This note advocates for an expansion of psychological autopsies in cases for undetermined deaths with undocumented motives.2
The purpose of psychological autopsies is to gather information about the circumstances of a person’s death.3 Investigators attempt to obtain information on the deceased’s life, personality, psychological and physical health, and treatments preceding death. This method is based on a combination of interviews of those closest to the deceased and evidence from sources such as medical records or social work reports. Arriving at the correct cause of death is an insufficiently-studied problem and remains an issue, given that local and national suicide prevention policies rely on accurate data collection.
Since the 1950s, medical examiners have struggled to differentiate deaths related to suicide or accidents and tend to categorize them as accidental when there is any doubt about the case.4 One study published in 2021 investigated road traffic fatalities in Sweden between 2010-2019 classified as either accidents or suicides. They showed a 63% increase in the number of identified suicides after incorporating the psychosocial background of the deceased.5 This could be due to the fact that mental health risk factors in individuals who died by suicide also tend to be present in deaths reported as accidents.6 Given the significant overlap in risk factors in both the accident and suicide groups, psychological autopsies could be a tool to further separate these distinct groups.
Expansion of psychological autopsies should require increased involvement from health care providers during cause of death evaluations. Psychiatric reports could show that mental health issues may have contributed to death, which can impact both the family of the deceased and improve how suicides are categorized. The testimony of medical witnesses has historically had limited influence as juridical proof when distinguishing suicides from accidents,7 which should not be the case. Increased collaboration with health care professionals can strengthen psychological autopsies to ensure that suicides are correctly documented and that their documentation is further standardized.
Current retrospective studies have demonstrated an unclear understanding as to how suicides have been categorized, which can hinder the development of suicide prevention policies. Expanding psychological autopsies to include collaboration by physicians would be a major step towards a more accurate evaluation of suicide in the United States and other countries, which has been long overdue.
References
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1 Centers for Disease Control and Prevention. Suicide and self-inflicted injury [Internet]. 2023 Jul 21 [cited 2023 Sep 24]. https://www.cdc.gov/nchs/fastats/suicide.htm
» https://www.cdc.gov/nchs/fastats/suicide.htm - 2 Oquendo MA, Volkow ND. Suicide: A silent contributor to opioid-overdose deaths. N Engl J Med. 2018; 378:1567-9.
- 3 Knoll JL. The psychological autopsy, part I: Applications and methods. J Psychiatr Pract. 2008;14:393-7.
- 4 Palmer BS, Bennewith O, Simkin S, Cooper J, Hawton K, Kapur N, et al. Factors influencing coroners’ verdicts: an analysis of verdicts given in 12 coroners' districts to researcher-defined suicides in England in 2005. J Public Health (Oxf). 2015;37:157-65.
- 5 Andersson A-L, Sokolowski M. Accident or suicide? Improvement in the classification of suicides among road traffic fatalities in Sweden by extended psychosocial investigations, during the years 2010-2019. J Safety Res. 2022;80:39-45.
- 6 Gray D, Coon H, McGlade E, Callor WB, Byrd J, Viskochil J, et al. Comparative analysis of suicide, accidental, and undetermined cause of death classification. Suicide Life Threat Behav. 2014;44:304-16.
- 7 Richardson O, Breyfogle HS. Problems of proof in distinguishing suicide from accident. Yale Law J. 1947;56:482-508.
Edited by
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Handling Editor: Lucas Borrione
