Mental disorders and suicide prevention
JOUKO K. LONNQVIST, MD, PHD,’ MARKUS M. HENRIKSSON, MD,’.’ ERKKI T. ISOMETSA, MD, PHD,’ MAURI J. MARTTUNEN, MD, PHD,’** MARTTI E. HEIKKINEN, M D , P H D , ” ~ HILLEVI M. ARO, MD, PHD’ AND KIMMO I. KUOPPASALMI, MD, P H D ~
‘National Public Health Institute, Department $ M e n d Health,’Department $Psychiatry, Helsinki University, Helsinki, Finland
In the research phase of the National Suicide Prevention Project, all suicides (n = 1397) in Finland between March 1987 and April 1988 were examined retrospectively using the psychological autopsy method. Careful retrospective diagnostic evaluation of the victims according to DSM-111-R criteria was done by weighing andintegrating all available information. A series of studies addressing the mental disorders among suicide victims, the treatment received before death and the life events is now reviewed. Among a random sample of suicide victims from the nationwide suicide population, at least one psychiatric diagnosis was made for 93% of the victims. The most prevalent disorders were depressive syndromes (66%) andalcohol dependence/abuse (43%). The prevalence of major depression was higher among women than among men. Major depression as the principal diagnosis was more common among the elderly suicides. Among adolescent victims, depressive syndromes were also the most prevalent disorders. Adjustment disorders were common (25%) among male adolescent suicides. The majority of suicide victims of all agessuffered from comorbid mental disorders. Among suicide victims who had had contact with a health carer before death, inadequacy of treatment for mental disorders seems to have been common. Of the major depressive victims only 3% were found to have received adequate psychopharmacological treatment, and only 7% received weekly psychotherapy by a trained therapist. The analysis of the massive databasecollected in the research phase of the National Suicide Prevention Project in Finland is still ongoing, and the implications of the findings for suicide prevention will be refined during the research process. The necessity to improve recognition and treatment for comorbid depressive disorders in all age groups seems evident already. alcoholism, comorbidity, depression, life events, suicide.
There is no single answer as to why some people choose to end their life by committing suicide. Every suicide has its own history with a unique set of predisposing, contributing and precipitating factors. One of the major figures in the field of suicidology, Edwin Shneidman,’ has formulated: ‘In suicide, there are no universals, absolutes, “alls”.’ There are some features,however, which are common in most suicides. Shneidman has described these features as C O ~ ~ O M I ities of suicide. From the viewpoint of a clinical psychiatrist, at least three of these commonalities are of special importance: (I) the common stimulus in suicide is intolerable psychological pain, (2) the common emotion in suicide is hopelessness/helplessness, (3) the common cognitive state insuicide is constriction. These features are very frequently associated with several types of mental disorders, particularly depression. In accordance with this, epidemiological and follow-up studies have shown that mental disorders are carrying a markedly heightened risk of suicide.2 Psychological autopsy studies from
Correspondence address: Jouko K. Lonnqvist, MD PHD, Department of Mental Health,National Public Health Institute, Mannerheimintie 166, Fin-00300 Helsinki, Finland.
many countries have found consistently that most people who commit suicide have suffered from diagnosable mental disorders. The most important diagnostic groups have always been depressive disorders and substance abuse, but the more detailed retrospective diagnostic picture has varied according to the age and...