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Azienda Ospedaliera Nazionale“SS. Antonio e Biagio e Cesare Arrigo”Working Paper of Public Healthnr. 6/20123. Issues with the psychological autopsyThe psychological autopsy was seen as being ‘scientific’ and hence, unassailable. However,shortcomings have been reported.These are retrospective studies and retrospective studies are not accepted as being of highscientific value in any area of social science. Many (Robbins, 1984) did not include controlsamples. Those who gather and evaluate the information used in psychological autopsies havean investment in the outcome of these studies, and while we aspire to objectivity, avoidingbias is always a difficult task (Selkin & Loya, 1979). There are different types ofpsychological autopsy (Scott et al, 2006), leading some authors to state that one study cannotbe compared to another (Abondo, et al, 2008). Many authors have raised concern about thevalidity and reliability (Ogloff and Otto, 1993; Biffl, 1996; Hawton et al, 1998a; Werlang &Botega, 2003, Snider et al, 2006). In addition, Pouliot & De Leo (2006) state that “the vastmajority have used ill-defined instruments”, which means the formulas used to make thediagnoses of mental disorder in “the vast majority” studies were probably not valid.In view of these and other objections and the frequent findings in Asia that mental disorderwas frequently found to be absent in over 50% of completed suicides (Phillips, 2010), therehave been recommendations to standardize psychological autopsies (Conner et al, 2011&2012). While this may help in future studies, the impression is now created that the solutionto suicide is medical, and will take a long time to correct.3. Sociological/sociocultural autopsyEmile Durkheim (1897) wrote what may still be called the most important contribution tosuicide studies. While he acknowledged that in some cases, suicide was the result of mentaldisorder, he contended the major factors were sociological: the ability of society to give theindividual values and goals, and the degree of integration (attachment) gained by theindividual from society. He described ‘anomie’ a situation in society where the usual rulesand regulations do not apply and people lack a moral compass – he described this occurringduring the Industrial Revolution and other periods of social upheaval. It is seen withdevastating effect today in the high suicide rate of some disadvantaged indigenous people(Pridmore & Fujiyama, 2009).Durkheim (1897) also described egoistic suicide. This has been much misunderstood. Inegoistic suicide the individual has inadequate ‘integration’, meaning attachments and support3
Azienda Ospedaliera Nazionale“SS. Antonio e Biagio e Cesare Arrigo”Working Paper of Public Healthnr. 6/2012from society. This of course applies when there is social disorganization (anomie), however, itcan also be a function of the individual. Durkheim clearly stated people with neurasthenia(difficulty dealing with the stresses of life) were at greatest danger, he also advised against‘excessive individualism’ (an attitude of the individual rather than society, that exposes theindividual to lack of support and fellowship).Space does not allow a full discussion of the work of this genius. The important issue is thathe drew attention to the influence of society on the suicide rate. An issue which has beenassiduously ignored by those who promote mental disorder as the sole/major factor in suicide.Risk factors are of little use in predicting the suicide of the individual (Caine, 2010; Sher,2011, Large, 2011; Pridmore, 2011) but epidemiologically, risk factors for communitysamples can be identified. In addition to mental disorder, the risk factors include being male,single, unemployed, poor (in societies where there is misdistribution of wealth), elderly,physically unwell, excessive use of alcohol. The list of risk factors is extensive, and variessomewhat from one study to the next, but social factors are always found to be important.The breakdown of an important interpersonal relationship is a clear social risk factor (Wyderet al, 2008; Cupina, 2009; Vieira et al, 2009).Two decades ago, Shneidman (1993) concluded that suicide was not always the result ofmental disorder, but always the result of “intolerable psychological pain”. This could arisefrom a variety of factors, including social factors.Models have begun to emerge which take a broader view of suicide. The ‘Cry of pain/Entrapment’ model has been described by Stark et al (2011), in rural settings in Great Britain.Here, in addition to mental disorder and genetic factors, are described the particular stressorsrelated to rural life (such as isolation and social and political exclusion). A similar ‘StrainTheory’ of suicide has been described by Zhang et al (2011) in rural China. Here, the stressorsare listed as relative deprivation, unrealized aspirations and lack of coping skills. It isinteresting that these authors claim, “The strain theory of suicide forms a challenge to thepsychiatric model popular in the West”. Many in the West applaud such efforts.Recently a ‘Sociological Autopsy’ has been described by Scourfield et al (2010), which drawson the tradition of psychological autopsies. They recommend the use of coroner’s files, whichin spite of some limitations, contain a wealth of relevant information. This group (Shiner et al,2009) used the sociological autopsy to demonstrate that for mid-life men, that wheninvestments fail and social bonds are broken, suicide may offer a viable escape. A“Sociocultural Autopsy” was reported by Parkar et al (2009) to describe important factors in4
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