1 Qualitative Research & Suicide Seminar University of Cardiff 2 July 2007 The psychological autopsy method of studying suicide: qualitative approaches Christabel Owens Hon. Senior Research Fellow

2 Outline Brief history of the psychological autopsy Psychological autopsy study of suicide in people outside the care of mental health services: Analysis using quantitative techniques Analysis using qualitative techniques What difference does it make? Study of social networks – a sociological autopsy?

3 Brief history of the psychological autopsy Term coined by Edwin Shneidman in late 1950s Original purpose to assist coroner in determining mode of death (intentional or unintentional) Clinical interview with those close to the deceased Assessment of behaviour and mental state in the period leading up to death Research potential recognised

4 Barraclough et al, 1973 (classic British psychological autopsy study): Virtually all the suicides studied were mentally ill… Mental illness is an essential component of suicide; our findings… suggest that in Western society suicide in the healthy person is a rare event.

5 Rates of mental illness found in previous psychological autopsy studies: Robins et al, 1957 (St Louis): 98% Dorpat & Ripley, 1960 (Seattle): 100% Not one case was found to have been without psychiatric illness. Barraclough et al, 1973 (S. England): 93% Runeson, 1989 (Sweden): 97% Foster et al, 1997 (N. Ireland): 86% Cavanagh et al, 1999 (Scotland): 96% Isometsa, 2001: Overall, more than 20 major psychological autopsy projects have documented that, with rare exceptions, the presence of a mental disorder is a necessary although not a sufficient condition for a completed suicide to occur.

6 Psychological autopsy study of suicide in people outside the care of mental health services Case-controlled study 100 suicides; 100 age-sex matched living controls semi-structured interviews with relatives or others close to deceased/control aimed to identify factors that differentiate those who took their own lives from the general population

7 Analysis using quantitative techniques Risk factors, risk factors, risk factors… Cases significantly more likely than controls to have: been unemployed (OR=9.0; 95%Ci= ) been living alone or with strangers (OR=7.4; Ci= ) attempted suicide in past (OR=39.0; Ci= ) exhibited symptoms in last month warranting diagnosis of depression (OR=29.0; Ci= ) alcohol or substance abuse (OR=25.0; Ci= ) personality disorder (OR=19.0; Ci= ) had past mental health service contact (OR=19.3; Ci= ) …

8 Whats wrong with risk factors? Far too general to be of any practical use (Murphy, 1983) Designed to aid clinical assessment of risk What about the 50% who do not come into contact with health professions? What is the lay equivalent?

9 Analysis using qualitative techniques Few relatives told illness stories; accounts of suicide dominated by moral as opposed to medical categories Relatives and friends played a key role in determining whether suicidal individuals sought medical help Many did not consult GP because no-one around them was aware of seriousness of distress or saw it as medically significant We left her alone. We assumed shed just get over it in her own time. (Father: female aged 24)

10 What difference does it make? Quantitative: Takes data at face value Aims to penetrate mind of deceased Privileges psychiatric explanations Creates cases of sickness by imposing diagnostic overlay – to what end? Informs macro-level prevention strategies Qualitative: Acknowledges conditions under which accounts are constructed Aims to understand the situation from viewpoint of those close to deceased Interested in meanings that informants attach to events Provides better basis for lay and community-based approaches to prevention

11 Study of social networks – a sociological autopsy? Aims to discover: who was in regular contact with the deceased person how aware each was of his/her distress how each one interpreted what was going on whether and in what way they intervened what additional information and support might have been helpful to them in managing the situation Design: Qualitative study using in-depth interviews Sample: 30 cases; 3-4 informants per case

12 Sibling 1 Suicidal individual Sibling 2 Parent 1 Parent 2 Friend Grandparent GP Partner Colleague Other colleagues

13 Couples, they break up all the time. You dont think, Oh, is he going to commit suicide? You just dont. ( Mother: male aged 24)