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BMC PsychiatryBMC Psychiatry1471-244XBioMed Central London 1471-244X-4-371552750210.1186/1471-244X-4-37Research ArticlePsychiatric diagnoses in 3275 suicides: a meta-analysis Arsenault-Lapierre Geneviève 1genevieve.arsenault-lapierre@elf.mcgill.caKim Caroline 1caroline.kim@elf.mcgill.caTurecki Gustavo 1gustavo.turecki@mcgill.ca1 McGill Group for Suicide Studies, Douglas Hospital Research Centre, Department of psychiatry, McGill University, Montreal, Canada2004 4 11 2004 4 37 37 13 4 2004 4 11 2004 Copyright © 2004 Arsenault-Lapierre et al; licensee BioMed Central Ltd.2004Arsenault-Lapierre et al; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background
It is well known that most suicide cases meet criteria for a psychiatric disorder. However, rates of specific disorders vary considerably between studies and little information is known about gender and geographic differences. This study provides overall rates of total and specific psychiatric disorders in suicide completers and presents evidence supporting gender and geographic differences in their relative proportion.

Methods
We carried out a review of studies in which psychological autopsy studies of suicide completers were performed. Studies were identified by means of MEDLINE database searches and by scanning the reference list of relevant publications. Twenty-three variables were defined, 16 of which evaluating psychiatric disorders. Mantel-Haenszel Weighted Odds Ratios were estimated for these 16 outcome variables.

Results
Twenty-seven studies comprising 3275 suicides were included, of which, 87.3% (SD 10.0%) had been diagnosed with a mental disorder prior to their death. There were major gender differences. Diagnoses of substance-related problems (OR = 3.58; 95% CI: 2.78–4.61), personality disorders (OR = 2.01; 95% CI: 1.38–2.95) and childhood disorders (OR = 4.95; 95% CI: 2.69–9.31) were more common among male suicides, whereas affective disorders (OR = 0.66; 95% CI: 0.53–0.83), including depressive disorders (OR = 0.53; 95% CI: 0.42–0.68) were less common among males. Geographical differences are also likely to be present in the relative proportion of psychiatric diagnoses among suicides.

Conclusions
Although psychopathology clearly mediates suicide risk, gender and geographical differences seem to exist in the relative proportion of the specific psychiatric disorders found among suicide completers.
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Background
Suicide is an important public health problem that is among the leading causes of death in Western countries [1]. Over the last years, the relationship between suicide and mental disorders has been the focus of several studies and has generated important debate [2]. This relationship has been investigated by different strategies, but particularly by the psychological autopsy method [3], which is generally considered the method of choice to retrieve postmortem information on psychopathology. The psychological autopsy procedure entails the retrospective psychiatric assessment of the deceased by variable methodologies, but generally by means of proxy-based interviews. This procedure is also frequently completed by having access to medical and other relevant dossiers from the subject on whom the psychological autopsy is carried out [4,5].

It is well established that psychopathology is an important predictor of suicide completion [6], but there is considerable variability between studies in rates of total and specific psychiatric disorders [7]. One of the most consistent findings in suicidology is the excess of male suicides observed in most countries [8], with a few notable and important exceptions, such as China [1,9]. Geographic origin is another important source of variation [1]. However, the possibility that clinical and other behavioural factors could at least partly mediate gender and geographic differences in suicide rates has been little explored. The aim of this study was to carry out quantitative syntheses of overall and specific psychiatric diagnoses found in suicide studies and to explore possible gender and geographical differences in the distribution of psychiatric disorders among suicide completers.

Methods
Study identification
To identify studies for this review, the National Library of Medicine (NLM) PubMed database was searched up to December 2002 using English language and human study limits. The Medical Subject Heading (MeSH) terms "suicide AND psychological autopsy", "suicide AND psychopathology", "suicide AND (postmortem diagnoses OR postmortem diagnosis)", and "(mental disorders/*epidemiology) AND prevalence AND ((suicide/*statistics & numerical data) NOT suicide attempts)" were used. Finally, in order to find other articles not obtained through electronic searches, reference lists from original studies as well as from not independent studies were screened.

Study selection
The inclusion criteria for considering articles for this review were as follow. Studies had to: 1) be original, 2) be published in English, 3) contain information on diagnostic distribution, 4) include suicide completers unselected according to specific mental disorders, 5) use of a psychological autopsy method, which for the purpose of this review was considered as the process of reconstructing psychiatric diagnoses based either on interviews with informants (regardless of the specific diagnostic instrument methodology) or on review of multiple official records that contained interviews with informants such as general practitioners, other professionals and relatives or friends, 6) use of standard diagnostic criteria (any versions of the Diagnostic and Statistical Manual of Mental Disorders, the International Classification of Diseases or the Research Diagnostic Criteria).

Studies were excluded if: 1) their sample was not independent from that investigated in another study (see below for criteria on which one was included), 2) they were reports on suicide in one specific diagnostic category and 3) if diagnoses were simply extracted from medical records without review of multiple sources of information.

A single reviewer (G.A.L.) made a prior screening to identify and select articles. When titles and abstracts were deemed adequate or when they remained too obscure to reach a verdict, full texts were retrieved for further evaluation in conformity with the inclusion and exclusion criteria.

Study assessment
A total of 23 variables were defined, three of which relate to demographic information, four other concern the method of diagnosis, and 16 evaluate the presence of psychiatric diagnoses. To obtain the latter 16 variables (shown in table 1; see additional file), every diagnostic term used in the original studies was categorised into one of the 16 pre-defined groups. So diagnoses such as "intermittent depressive disorder" or "neurotic depression" reported in some studies were coded under "depressive disorders' variable and diagnoses such as "alcohol use", "alcohol misuse" and "alcohol abuse" were coded as "alcohol problems". All substances noted as other than alcohol were coded under "other substances problems". These two variables were then recoded as "any substance problems". The same was achieved with the "depressive disorders" and "bipolar disorders" which were recoded as "any affective disorders".

Disorders labelled as "other" or as a subset of various disorders without further specification were left aside. For all studies the most specific diagnosis was considered. That is, when the authors broke down general diagnosis such as "affective disorder" into "depressive disorders" and "bipolar disorders", only these more specific diagnoses were noted and accounted for in our study.

When two studies or more were carried on the same population, the study with the largest sample and the most informative report was consistently selected. When multiple diagnoses and principal diagnoses (those deemed by the investigators as more related to the suicide) were reported, preference was given to the former. In four cases, secondary diagnoses were added to principal diagnoses to obtain multiple diagnoses [10-13]. Studies for which controls were selected among psychiatric in-patients or matched to suicides by mental diagnosis, only suicide cases were included in our analysis [12,14]. In the study by Graham and Burvill [15], controls were older suicide completers, and so they were included in our suicide group. In the study by Hawton et al. [10], only diagnoses for suicides obtained by means of an interview were included. In three case-control studies [16-18], not all suicide cases were matched to a control. In these cases, we considered the full suicide sample in the descriptive analyses, but only the control-matched suicides in the quantitative analyses.

Statistical analysis
Descriptive analyses and homogeneity tests were carried out before pooling the data. In order to determine the risks of having had a disorder, suicides and controls were recorded in 2 × 2 tables. These data were then stratified by the 16 outcome variables and Mantel-Haenszel Weighted Odds Ratios (OR) and 95% confidence intervals (95% CI) were estimated. Gender differences were also explored by means of Odds Ratios. Major disorders were then compared between the different demographic areas by means of χ2 to assess variations in the diagnostic distribution across these demographic areas. All statistical analyses were carried out using Epi Info 6, version 6.04d (C.D.C., U.S.A.; W.H.O., Geneva, Switzerland).

Results
A total of 152 studies were initially identified. After selection according to inclusion/exclusion criteria, 27 studies were included in this review. The most common reasons for exclusion were that a) no diagnostic distribution was provided (n = 46) [6,19-63], b) samples were pre-selected according to a psychiatric disorder (n = 30) [64-93], c) there was another report on the same sample that either included more subjects or was more informative (n = 29) [3,94-121]. Four other studies were about non-completers [122-125]. Another was not in English [126], and others reported only on one type of disorder [127,128], and therefore, they were all excluded. Additional 14 studies [7,129-141] were excluded because the diagnostic criteria were either unspecified or not standard.

The studies by Rich et al. [99] and by Foster et al [142] were not independent from, respectively, Rich et al. [143] and Foster et al. [144]. Although non-independent, these studies provided information of different quality, and thus, were included in our review. Accordingly, Rich et al. [99] and Foster et al. [142] were considered, respectively in the gender difference analysis and the case-control comparisons, whereas the study by Rich et al. [143] and Foster et al. [144] were considered for the descriptive analysis.

Methodological assessment
Among the 27 studies that were retained, 52% (14/27) were case-control studies. Eighty-one percent (22/27) of the studies were published after 1990. Sixty-seven percent of the studies (18/27) used DSM diagnostic criteria, whereas only 22% (6/27) and 11% (3/27) used the ICD and RDC diagnostic criteria respectively. Multiple diagnoses were investigated in 63% (17/27) of the studies, whereas principal diagnoses only were given for the other 10 studies. A description of the demographic and methodological features of these 27 studies is shown in table 2.

Table 2 Description of the 27 studies included in this meta-analysis

Study	Year	Origin	Diagnostic criteria	Methods	Number of diagnoses	n Suicide	With a Dx (%)	n Control	with a Dx (%)	Matched	
Appleby et al.[151]*	1999	England	ICD-10	Official records and interviews	Multiple	84	76 (90%)	64	17 (27%)	Living ± 5 year and sex	
Apter et al.[145]*	1993	Israel	DSM-III	Official records and interviews	Principal	43	35 (81%)				
Asgard U.[147]*	1990	Sweden	RDC	Official records and interviews	Principal	104	99 (95%)				
Cavanagh et al.[14]	1999	Scotland	DSM-III	Official records and interviews	Principal	45	44 (98%)				
Cheng et al.[16]*	1995	Taiwan	DSM-III-R	Official records and interviews	Multiple	116	114 (98%)	226	130 (58%)	Living ± 5 years, sex, area of residence	
Conwell et al.[156]*	1996	USA	DSM-III-R	Official records and interviews	Multiple	141	127 (90%)				
Foster et al.[142,144]	1997/1999	Ireland	DSM-III-R	Official records and interviews	Multiple	118	106 (90%)	117	30 (26%)	List of deceased's GP Age, gender, marital status	
Harwood et al.[17]*	2001	England	ICD-10	Official records and interviews	Multiple	100	93 (93%)	54	N/A	Natural deaths Age and sex	
Hawton et al.[10]	2002	England	ICD-10	Official records and interviews	Multiple	42	38 (90%)	84	6 (7%)	Living nurses ± 10 years, specialty and seniority	
Henriksson et al.[11]	1993	Finland	DSM-III-R	Official records and interviews	Multiple	229	225 (98%)				
Houston et al.[12]	2001	England	ICD-10	Official records and interviews	Multiple	47	40 (85%)				
Lesage et al.[150]	1994	Canada	DSM-III-R	Official records and interviews	Multiple	75	69 (92%)	75	N/A	Living Neighbourhood, age, marital status and occupation	
Phillips et al.[9]*	2002	China	DSM-IV	Interviews with informants	Principal	519	325 (63%)	536	93 (17%)	Accidental deaths Geographical areas	
Rich et al.[143]	1986	USA	DSM-III	Official records and interviews	Multiple	283	258 (91%)				
Runeson B.[153]	1989	Sweden	DSM-III-R	Official records and interviews	Principal	58	57 (98%)				
Shaffer et al.[18]*	1996	USA	DSM-III	Official records and interviews	Multiple	119	108 (91%)				
Shaffi et al.[13]*	1988	USA	DSM-III	Official records and interviews	Multiple	21	20 (95%)	21	11 (52%)	Living friends Sex, age, race, education, religion, income, and father's education	
Vijayakumar et al.[159]*	1999	India	DSM-III-R	Official records and interviews	Principal	100	88 (88%)	100	14 (14%)	Living SES, sex and ± 2 years	
Waern et al.[154]*	2002	Sweden	DSM-IV	Official records and interviews	Multiple	85	82 (96%)	153	28 (18%)	Living Sex, ± 2 years	
Boardman et al.[152]	1999	England	ICD-10	Multiple official records	Multiple	212	151 (71%)	212	40 (19%)	Unnatural deaths ± 5 years and sex	
Cantor et al.[157]	1989	Australia	DSM-III-R	Multiple official records	Principal	47	41 (87%)				
Groholt et al.[149]*	1997	Norway	DSM-III-R	Multiple official records	Multiple	121	90 (74%)				
Thacore et al.[158]	2000	Australia	ICD-9	Multiple official records	Principal	75	46 (65%)				
Graham et al.[15]	1992	Australia	DSM-III	Multiple official records	Multiple	136	120 (88%)				
Brent et al.[148]	1999	USA	DSM-III	Interviews with informants	Multiple	140	115 (82%)	131	32 (24%)	Living Age, race, gender, country and SES	
Cerel et al.[155]	2000	USA	RDC	Interviews with informants	Multiple	15	13 (87%)	201	70 (35%)	Non-suicide bereaved family	
Arato et al.[146]*	1987	Hungary	RDC	Interviews with informants	Principal	200	162 (81%)				
* Based on axis I disorders only.

N/A – information not available or not clear

Demographic features
A total of 3275 suicides were included in our study with a mean number of 121 (standard deviation (SD) 103) suicides per study. There were 11 studies where diagnoses were given by gender for a subtotal of 933 males and 462 females [10,11,18,99,144-150]

There were 14 studies [10-12,14,17,142,145-147,149,151-154] carried out in Europe, including one in Israel [145]. These 14 European studies comprised a total of 1488 suicides. Seven studies were from North America [13,18,143,148,150,155,156] with 794 suicides, three others were from Australia [15,157,158] with 258 suicides and, finally, three were from Asia [9,16,159]. with 735 suicides.

Diagnostic distribution
The mean percentage of suicides with a psychiatric diagnosis was 87.3 % (SD 10.0 %). However, only 14 of the 27 studies reported both axes I and II disorders (see table 2). The remaining 13 studies only assessed axis I diagnoses. The mean percentage of controls with a diagnosis was, as expected, lower (34.9 % SD 25.1 %). As a comparison, among studies not included because the diagnostic criteria were not specified or not standard, the mean percentage of suicides with a diagnosis was not statistically different from that of the studies included in this review (78.7% SD 21.0%, χ2 : 2.27, p = 0.13).

On average, 43.2% (SD 18.5%) of suicide cases were diagnosed with any affective disorders (including depressive and bipolar disorders) and 25.7% (SD 14.8%) with other substance problems. In these groups, respectively, depressive disorders and alcohol problems were the most frequent. Finally, personality disorders represented 16.2% (SD 8.6%) of the suicide diagnoses and psychotic disorders, including schizophrenia accounted for 9.2% (SD 10.2%).

The samples from the 14 case-control studies were found homogeneous for the 16 outcome variables according to a homogeneity test (results not shown), allowing us to pool the individual studies and determine overall risks.

Table 1 (see additional file) shows that, with the exception of organic disorders and adjustment disorders, suicide cases had a higher risk of being diagnosed than controls with each of the diagnoses considered. Of these diagnoses, the risks for psychotic disorders were the highest (OR = 15.38; 95% CI: 3.53–97.82) followed by the variable "at least one psychiatric disorder" (OR = 10.50; 95% CI: 9.60–13.56). The risk for schizophrenia was also particularly high (OR = 5.56; 95% CI: 3.12–10.24). This is due to the fact that there were only 15 control subjects altogether diagnosed with schizophrenia and two with psychotic disorders.

Statistically significant differences were found when male and female suicide cases were compared (see table 3). However, gender-based comparisons should be considered cautiously as, when available, demographic information indicated that female suicides included in the studies reviewed tended to be older than males (table 5). Nevertheless, even considering this potential limitation, the results are interesting. The risks for alcohol (OR = 2.19; 95% CI: 1.63–2.95), other substance problems (OR = 2.02; 95% CI: 1.32–3.10), and any substance problems (OR = 3.58; 95% CI: 2.78–4.61), personality disorders (OR = 2.01; 95% CI: 1.38–2.95) or childhood disorders (OR = 4.95; 95% CI: 2.69–9.31) were greater in male as opposed to female suicides. On the other hand, the risks of having depressive disorders (OR = 0.53; 95% CI: 0.42–0.68) or any affective disorders (OR = 0.66; 95% CI: 0.53–0.83) were lower in males.

Table 3 Odds Ratios for major outcome variables across sexes

Disorders	n for females	n for males	OR (95% CI)	χ2	p-value	
Any psychiatric disorders	398	801	0.98 (0.70–1.36)	0.02	0.881	
Schizophrenia	17	44	1.30 (0.71–2.39)	0.79	0.373	
Other psychotic disorders or psychosis NOS	15	40	1.33 (0.71–2.56)	0.88	0.347	
Somatoform, anxiety and neurotic disorders	33	83	1.27 (0.85–1.97)	1.24	0.265	
Bipolar disorders	26	43	0.81 (0.48–1.38)	0.68	0.409	
Organic disorders	6	15	1.24 (0.45–3.60)	0.20	0.656	
Adjustment disorders	31	64	1.02 (0.64–1.64)	0.01	0.917	
Disorders more likely if male						
Alcohol problems	73	272	2.19 (1.63–2.95)	29.57	0.000	
Other substances problems	32	122	2.02 (1.32–3.10)	11.89	0.001	
Any substances problems	110	436	3.58 (2.78–4.61)	110.18	0.000	
Personality disorders	41	153	2.01 (1.38–2.95)	14.60	0.000	
Childhood disorders	13	117	4.95 (2.69–9.31)	34.57	0.000	
Disorders more likely if female						
Depressive disorders	199	268	0.53 (0.42–0.68)	28.56	0.000	
Any affective disorders	272	454	0.66 (0.53–0.83)	12.91	0.000	
Other disorders	16	12	0.36 (0.16–0.82)	7.44	0.006	
Table 5 Descriptive analysis of the age and sex of subjects

	Age (mean ± SD)	n [Studies]	
All regions			
♂	28.5 ± 12.8	880 [11,18,143,145,148-150,158]	
♀	34.5 ± 17.8	333 [11,18,143,147-149,158]	
Both sexes*	41.6 ± 17.8	794 [11,14,17,149,151,154,157,158]	
American Studies			
♂	26.0 ± 12.3	491 [18,143,148,150]	
♀	27.3 ± 18.9	127 [18,143,148]	
Both sexes*	N/A	N/A	
European Studies			
♂	27.2 ± 15.4	314 [11,145,149]	
♀	37.9 ± 18.9	191 [11,147,149]	
Both sexes*	42.3 ± 20.8	672 [11,14,15,17,151,154]	
Australian Studies			
♂	42.5	491 [158]	
♀	45.7	15 [158]	
Both sexes*	39.5 ± 5.2	122 [157,158]	
Asian Studies			
♂	N/A	N/A	
♀	N/A	N/A	
Both sexes*	N/A	N/A	
N/A – information not available

* Both sexes refers to studies in which information on age by sex was not provided, and thus, only mean age for the whole sample was available.

Analysing the data according to geographic areas, the diagnostic distribution of the key diagnoses found in suicides differed significantly between world regions (see table 4), but as mentioned above, potential age-related biases may apply (table 5). The American suicides were more often diagnosed with a psychiatric disorder than suicides in the other regions of the world; 89.7 % (SD 4.2 %) of the American suicides had at least one diagnosis, whereas 88.8 % (SD 8.9 %) of the European suicides, 83.0 % (SD 18.4 %) of the Asian suicides and 78.9 % (SD 15.3 %) of the Australian suicides had at least one psychiatric diagnosis.

Table 4 Diagnostic distribution across different regions of the world

	European (%)	North American (%)	Australian (%)	Asian (%)	χ2	
Affective disorders	753 (48.5)	390 (33.6)	71 (32.7)	335 (51.3)	11.3*	
Substances-related disorders	390 (18.6)	573 (40.1)	106 (24.1)	135 (26.7)	12.1*	
Schizophrenia and other psychotic disorders or psychosis NOS	125 (7.5)	42 (4.2)	29 (24.3)	53 (8.4)	24.1*	
Personality disorders	197 (16.8)	75 (13.4)	75 (17.7)	20 (17.7)	1.2n.s.	
At least one Diagnosis	1298 (88.8)	710 (89.7)	207 (78.9)	527 (83.0)	6.4n.s.	
* Significant at p ≤ 0.01

n.s.Non significant

Discussion
Total psychopathology
Since the first psychological autopsy studies by Robins et al. [139] in North America and by Barraclough et al. [7] in Europe, a relatively small number of studies have been carried out. These original studies were descriptive in nature, and only more recently case-control studies have been performed. The data from these studies have consistently suggested a clear relationship between mental disorders and suicide. Here we systematically reviewed these studies and pooled their results whenever possible. Our results show that, on average, 87.3 % of the subjects who committed suicide had a mental disorder. On the other hand, an average of 14.0 % of these subjects was not diagnosed with a psychiatric disorder. A possible explanation is that a diagnosis failed to be detected due to various methodological shortcomings. This possibility is concrete, as psychological autopsy studies rely on informants and/or available medical information to generate diagnostic data. In some cases, the informant has little information on the last weeks or months of life of the subject. Therefore, it is possible that the overall rate of psychopathology observed is still underestimated. This is consistent with findings from recent studies by our group focusing on suicides without an axis I diagnosis [160].

Specific diagnoses
This review confirms the overall impression from individual studies that affective, substance-related, personality and psychotic disorders account for most of the diagnoses among suicides. The two single most common diagnostic categories among suicide completers were any affective disorders (diagnosed in 43.2 % of suicide cases), and any substance disorders (present in 25.7 % of suicide cases). Recent studies on comorbidity indicate that suicide completers are more likely to have more than one psychiatric diagnosis [142,161]. In a comparison with matched community controls, Foster et al. [142] found a significant increase in suicide risk in the presence of Axis I-Axis II comorbidity (OR = 346.0, p < 0.0001). Our group [161], investigating male completers and controls from the general population, found that suicide cases had an average of 2.36 diagnoses and that comorbidity in completers tended to be of three different patterns, according to mean number of diagnoses (range 1.19 – 4.05) and presence of impulsive-aggressive behaviours. Thus, it would have been interesting to assess overall levels of comorbidity in this review, as well as to investigate what is the amount of overlap between the different diagnoses investigated. However, very little, if any, information about comorbidity was present in the original studies reviewed and this information was impossible to retrieve from the published data.

Gender differences
The investigation of gender differences in rates of psychopathology associated to suicide should be regarded in light of the methodological limitations of this review, which are primarily related to difficulties in comparing studies carried out using different methodological procedures, diagnostic instruments and criteria, in addition to potential differences in sample characteristics, including age distribution. However, given the important effect that gender seems to have as a suicide risk moderator and the relative lack of appropriate investigation focusing on gender differences in suicide completion, the observed differences in rates of psychopathology in male and female suicides are interesting and should be considered for validation in future studies. Our results indicate that the risk of substance-related disorders, personality disorders and childhood disorders are significantly higher in male suicides, whereas, the risk of affective disorders, specifically, depressive disorders, are greater in female suicides. On average, any substance problems represented 41.8 % (SD 21.1 %) of the male diagnoses and 24.0 % (SD 16.5 %) of the female diagnoses (χ2 7.29 p = 0.007), whereas affective disorders represented 59.4 % (SD 13.9 %) of the female diagnoses and 47.4 % (SD 12.7 %) of the male diagnoses (χ2 2.88 p = 0.089).

Although there has been much discussion on possible factors that could help explain gender differences in suicide rates, most of the studies have primarily focused on psychosocial and demographic risk factors. There is very little data on the possible role of psychiatric and/or behavioural characteristics, which may also mediate gender differences in suicide risk. This study suggests that the underlying psychiatric morbidity may be different in male and female suicide completers. An important question that follows is whether or not the differences found in this study between male and female suicides are the consequence of gender differences in the prevalence of psychiatric disorders in the general population. Although possible, it is unlikely that differences in population rates of psychiatric disorders could explain the different distribution of psychiatric disorders observed in this study, as the gender-specific risks found were not consistently reflecting gender-differences observed in prevalence rates (for instance, schizophrenia and psychotic disorders) and they were not always in the same direction (for instance, personality disorders).

An interesting finding of this study was precisely the absence of gender differences in schizophrenia. This is not necessarily inconsistent with suggestions that most of the suicide cases in schizophrenia are males [162-164], as our findings basically indicate that there are no relative differences between genders in the proportion of suicide cases that are diagnosed with schizophrenia. However, our findings are inconsistent with the common generalization that schizophrenics tend to commit suicide early in the course of the disease because, given gender-differences in the age at onset in schizophrenia [165], with males more likely to have the onset at younger ages, one would expect a considerably higher proportion of schizophrenia among male completers, even if the age distribution in our sample suggests that women in general seemed older than men. In summary, despite the potential methodological limitations discussed above, our results in gender differences in clinical correlates of suicide are interesting and should be further investigated.

Geographic differences
We also found differences in rates of psychiatric disorders in studies from different geographic origins. This finding may indicate social and cultural factors influencing how one views and interprets suicide and cultural biases towards or against specific diagnoses. Alternatively, as discussed for gender-based comparisons, demographic (age, rural vs. urban samples, socioeconomic and educational level, etc.) differences between the samples could explain some of these results. In view of that, similar limitations, as those for the analysis of gender differences, apply to the analysis of geographical differences in rates of psychopathology associated to suicide (see table 5). American women seem younger than in any other region, Australian women and men appear older than those in the other regions, and no Asian studies provide age means for their sample. In spite of these limitations, our review suggests that, although psychopathology mediates suicide worldwide, there seem to be differences across different parts of the world in the relative proportion of the specific psychiatric disorders found among suicide completers. As mentioned above, these differences may be attributed to variance in psychological autopsy methodologies between countries, or yet, to important differences in the prevalence of psychiatric disorders. Although it is possible that methodological differences between studies play a certain role explaining some of the differences found, it is unlikely that they accounted for all differences found as the studies included in these regional comparisons used similar methods and diagnostic criteria, whereas the differences found were substantial. It is not likely either that diversity between countries in prevalence of psychiatric disorders account for all the observed regional differences, as for some of these disorders, such as schizophrenia, it is thought that there is little variation in prevalence rates between different populations [166]. Thus, the geographical differences observed in the relative proportion of psychiatric disorders among suicide completers is an interesting issue that should be further explored.

Most limitations of this study are common to all quantitative systematic reviews. In particular to this study, one should take into account that the quantitative review was carried out with studies that, although published in a relatively short period of time (from 1986 to 2002), have variation in diagnostic criteria used and have different methodological rigor. Moreover, it is possible that between-study variation in the distribution of a series of demographic variables could have had an impact on our findings. We chose not to control for these methodological differences as given the diverse sources of possible variation, doing so would have considerably limited the number of studies included in the review. Therefore, we opted to be more inclusive and consider the results of this review as preliminary and providing information to be further investigated.

Over the course of this study, a report on another meta-analysis of psychological autopsy studies was published. This study, by Cavanagh et al. [167], reviewed the literature on psychological autopsies and yielded similar overall results. However, there are differences between the study by Cavanagh et al [167] and ours, both in methodology and major aims. While they identified studies through a larger number of library databases, they included only studies up to June 2000. Moreover, they did not investigate risks attributed to specific diagnostic categories, but rather risks attributed to mental health disorders, presence of an affective disorder and comorbidity. They also investigated the role of a few social variables and did not carry out analyses exploring a possible gender and geographic difference in relative rates of psychopathology.

Conclusions
Our study carried out a systematic review of psychological autopsy studies of suicide and indicates that overall, 87.3% of suicide cases have a history of psychiatric disorders. We also found that male suicides have a different psychiatric profile than female suicide cases and that the relative proportion of psychiatric disorders in suicide completers tends to vary according to geographical region.

Competing interests
The author(s) declare that they have no competing interests.

Authors' contributions
GAL carried out the search, extraction of data, analysis and drafted the manuscript. CK helped with the design of the review, and the statistical analysis. GT conceived the study and participated in the design and coordination. All authors read and approved the final manuscript.

Pre-publication history
The pre-publication history for this paper can be accessed here:



Supplementary Material
Additional File 1
Table 1 – Mantel-Haenszel Weighed Odds Ratio. This table gives Mantel-Haenszel Weighed Odds Ratio for the 14 case-control studies included in this meta-analysis for the 16 variables of psychiatric disorders.

Click here for file

 Acknowledgment
This study was partly funded by CIHR grant MOP-38078 and a NARSAD grant. GT is a CIHR scholar.
==== Refs
WHO  World Health Report 2000 Health System: Improving Performance 2000 Ref Type: Report 
Tanney BL  Marris RW, Berman AL, Sylverman MM  Psychiatric diagnoses and suicidal acts In Comprehensive textbook of suicidology 2000 New York: The Guilford Press 311 341 
Farberow NL Shneidman ES Neuringer C  Case history and hospitalization factors in suicides of neuropsychiatric hospital patients J Nerv Ment Dis 1966 132 32 44 5931169 
Hawton K Appleby L Platt S Foster T Cooper J Malmberg A Simkin S  The psychological autopsy approach to studying suicide: a review of methodological issues J Affect Disord 1998 50 269 276 9858086 10.1016/S0165-0327(98)00033-0 
Isometsa ET  Psychological autopsy studies – a review Eur Psychiatry 2001 16 379 385 11728849 10.1016/S0924-9338(01)00594-6 
Lonnqvist JK Henriksson MM Isometsa ET Marttunen MJ Heikkinen ME Aro HM Kuoppasalmi KI  Mental disorders and suicide prevention Psychiatry Clin Neurosci 1995 49 S111 S116 9179954 
Barraclough B Bunch J Nelson B Sainsbury P  A hundred cases of suicide: clinical aspects Br J Psychiatry 1974 125 355 373 4425774 
Heuveline P Slap GB  Adolescent and young adult mortality by cause: age, gender, and country, 1955 to 1994 J Adolesc Health 2002 30 29 34 11755798 10.1016/S1054-139X(01)00329-9 
Phillips MR Yang G Zhang Y Wang L Ji H Zhou M  Risk factors for suicide in China: a national case-control psychological autopsy study Lancet 2002 360 1728 1736 12480425 10.1016/S0140-6736(02)11681-3 
Hawton K Simkin S Rue J Haw C Barbour F Clements A Sakarovitch C Deeks J  Suicide in female nurses in England and Wales Psychol Med 2002 32 239 250 11866319 
Henriksson MM Aro HM Marttunen MJ Heikkinen ME Isometsa ET Kuoppasalmi KI Lonnqvist JK  Mental disorders and comorbidity in suicide Am J Psychiatry 1993 150 935 940 8494072 
Houston K Hawton K Shepperd R  Suicide in young people aged 15–24: a psychological autopsy study J Affect Disord 2001 63 159 170 11246092 10.1016/S0165-0327(00)00175-0 
Shafii M Steltz-Lenarsky J Derrick AM Beckner C Whittinghill JR  Comorbidity of mental disorders in the post-mortem diagnosis of completed suicide in children and adolescents J Affect Disord 1988 15 227 233 2975295 10.1016/0165-0327(88)90020-1 
Cavanagh JT Owens DG Johnstone EC  Suicide and undetermined death in south east Scotland. A case-control study using the psychological autopsy method Psychol Med 1999 29 1141 1149 10576306 10.1017/S0033291799001038 
Graham C Burvill PW  A study of coroner's records of suicide in young people, 1986–88 in Western Australia Aust N Z J Psychiatry 1992 26 30 39 1580884 
Cheng AT  Mental illness and suicide. A case-control study in east Taiwan Arch Gen Psychiatry 1995 52 594 603 7598636 
Harwood D Hawton K Hope T Jacoby R  Psychiatric disorder and personality factors associated with suicide in older people: a descriptive and case-control study Int J Geriatr Psychiatry 2001 16 155 165 11241720 10.1002/1099-1166(200102)16:2<155::AID-GPS289>3.0.CO;2-0 
Shaffer D Gould MS Fisher P Trautman P Moreau D Kleinman M Flory M  Psychiatric diagnosis in child and adolescent suicide Arch Gen Psychiatry 1996 53 339 348 8634012 
Sanborn DE Sanborn CJ Cimbolic P  Two Years of Suicide: A Study of Adolescent Suicide in New Hampshire Child Psychiatry and Human Development 1973 4 234 242 
Cattell H Jolley DJ  One hundred cases of suicide in elderly people Br J Psychiatry 1995 166 451 457 7795915 
Litman RE Curphey T Shneidman E Farberow NL Tabachnick N  Investigations of Equivocal Suicides JAMA 1996 184 924 929 
Sainsbury P  Suicide in later life Gerontol Clin (Basel) 1962 4 161 170 14496074 
McCarthy PD Walsh D  Suicide in Dublin Br Med J 1966 5500 1393 1396 5932735 
Hartelius H  A study of suicides in Sweden 1951–63, including a comparison with 1925–1950 Acta Psychiatr Scand 1967 43 121 143 6077781 
Jacobson S Jacobson DM  Suicide in Brighton Br J Psychiatry 1972 121 369 377 5077093 
Ottosson JO Perris C  Multidimensional classification of mental disorders Psychol Med 1973 3 238 243 4715856 
Amir M  Suicide among minors in Israel Isr Ann Psychiatr Relat Discip 1973 11 219 269 4520333 
Dizmang LH Watson J May PA Bopp J  Adolescent suicide at an Indian reservation Am J Orthopsychiatry 1974 44 43 49 4809584 
Miller JP  Suicide and adolescence Adolescence 1975 10 11 24 1124679 
Bagley C Jacobson S Rehin A  Completed suicide: a taxonomic analysis of clinical and social data Psychol Med 1976 6 429 438 996203 
Pitts FN JrSchuller AB Rich CL Pitts AF  Suicide among U.S. women physicians, 1967–1972 Am J Psychiatry 1979 136 694 696 434249 
Hagnell O Rorsman B  Suicide in the Lundby study: a controlled prospective investigation of stressful life events Neuropsychobiology 1980 6 319 332 7443006 
Hegde RS  Suicide in rural Communities Ind J Psychiatry 1980 22 368 370 
Bourque LB Kraus JF Cosand BJ  Attributes of suicide in females Suicide Life Threat Behav 1983 13 123 138 6659008 
Shafii M Carrigan S Whittinghill JR Derrick A  Psychological autopsy of completed suicide in children and adolescents Am J Psychiatry 1985 142 1061 1064 4025622 
Angst J Clayton P  Premorbid personality of depressive, bipolar, and schizophrenic patients with special reference to suicidal issues Compr Psychiatry 1986 27 511 532 3780193 10.1016/0010-440X(86)90055-6 
Beratis S  Suicide in southwestern Greece 1979–1984 Acta Psychiatr Scand 1986 74 433 439 3812005 
Lindesay J  Trends in Self-Poisoning in the Elderly 1974–1983 Int J Geriatr Psychiatry 1986 1 37 43 
Thompson TR  Childhood and adolescent suicide in Manitoba: a demographic study Can J Psychiatry 1987 32 264 269 3496950 
Poteet DJ  Adolescent suicide. A review of 87 cases of completed suicide in Shelby County, Tennessee Am J Forensic Med Pathol 1987 8 12 17 3578199 
Diekstra RF  Suicidal behavior in adolescents and young adults: the international picture Crisis 1989 10 16 35 2786795 
Banerjee G Nandi PN Nandi S Sarkar S Boral GC Ghosh A  The vulnerability of Indian women to suicide. A field Study Ind J Psychiatry 1990 32 305 308 
King E Barraclough B  Violent death and mental illness. A study of a single catchment area over eight years Br J Psychiatry 1990 156 714 720 2095949 
Thorslund J  Suicide among Inuit youth in Greenland 1977–86 Arctic Med Res 1991 299 302 1365135 
Duberstein PR Conwell Y Caine ED  Age differences in the personality characteristics of suicide completers: preliminary findings from a psychological autopsy study Psychiatry 1994 57 213 224 7800770 
Gaylord MS Lester D  Suicide in the Hong Kong subway Soc Sci Med 1994 38 427 430 8153746 10.1016/0277-9536(94)90442-1 
McClure GMG  Suicide in children and adolescents in England and Wales 1960–1990 Br J Psychiatry 1994 165 510 514 7528624 
Rich CL Runeson BS  Mental illness and youth suicide Am J Psychiatry 1995 152 1239 1240 7625487 
Arieli A Gilat I Aycheh S  Suicide among Ethiopian Jews: a survey conducted by means of a psychological autopsy J Nerv Ment Dis 1996 184 317 319 8627279 10.1097/00005053-199605000-00009 
Grabbe L Demi A Camann MA Potter L  The health status of elderly persons in the last year of life: a comparison of deaths by suicide, injury, and natural causes Am J Public Health 1997 87 434 437 9096548 
Malmberg A Hawton K Simkin S  A study of suicide in farmers in England and Wales J Psychosom Res 1997 43 107 111 9263937 10.1016/S0022-3999(97)00114-1 
Rothberg JM  The Army psychological autopsy: then and now Mil Med 1998 163 427 433 9640042 
Marshall D Soule S  Accidental deaths and suicides among Alaska Natives, 1979–1994 Int J Circumpolar Health 1998 57 497 502 10093332 
Pitkala K Isometsa ET Henriksson MM Lonnqvist JK  Elderly suicide in Finland Int Psychogeriatr 2000 12 209 220 10937541 10.1017/S1041610200006335 
Di Nunno N Costantinides F Bernasconi P Di Nunno C  Suicide by hara-kiri: a series of four cases Am J Forensic Med Pathol 2001 22 68 72 11444667 10.1097/00000433-200103000-00014 
Weller EB Weller RA  Suicide in youth Depress Anxiety 2001 14 155 156 11747124 10.1002/da.1060 
Bateman C  Doctor burnout silent and fatal S Afr Med J 2001 91 98 100 11288406 
Miller M  Geriatric suicide: the Arizona study Gerontologist 1978 18 488 495 263566 
Guze SB Robins E  Suicide and primary affective disorders Br J Psychiatry 1970 117 437 438 5481206 
Sainsbury P  Clinical aspects of suicide and its prevention Br J Hosp Med 1978 19 156 162 638293 
Shaffer D Fisher P  The epidemiology of suicide in children and young adolescents J Am Acad Child Psychiatry 1981 20 545 565 7310021 
Carlson GA Miller DC  Suicide, affective disorder, and women physicians Am J Psychiatry 1981 138 1330 1335 7294189 
Spellman A Heyne B  Suicide? Accident? Predictable? Avoidable? The psychological autopsy in jail suicides Psychiatr Q 1989 60 173 183 2813651 
Seager CP Flood RA  Suicide in Bristol Br J Psychiatry 1965 111 919 932 5833604 
Hoberman HM Garfinkel BD  Completed suicide in children and adolescents J Am Acad Child Adolesc Psychiatry 1988 27 689 695 3198553 
Krupinski J Polke P Stoller A  Psychiatric Disturbances in Attenpted and Completed Suicides in Victoria During 1963 Med J Aust 1965 2 773 778 5852205 
Edwards JE Whitlock FA  Suicide and attempted suicide in Brisbane. 1 Med J Aust 1968 1 932 938 5654810 
Flood RA Seager CP  A Retrospective Examination of Psychiatric Case Records of Patients who subsequently Committed Suicide Br J Psychiatry 1968 114 443 450 5656263 
Rorsman B Hagnell O Lanke J  Mortality psychiatric specialist care in the Lundby study. Age-standardized death rates in different forms of psychiatric services in a total population investigated during a 25-year period Neuropsychobiology 1983 9 2 8 6888706 
Lindekilde K Wang AG  Train suicide in the county of Fyn 1979–82 Acta Psychiatr Scand 1985 72 150 154 3876689 
Babigian HM Lehman A Reed S  Suicide in psychiatric and non-psychiatric populations Acta Psychiatr Belg 1986 86 528 532 3825563 
Conwell Y Rotenberg M Caine ED  Completed suicide at age 50 and over J Am Geriatr Soc 1990 38 640 644 2358625 
Kettl P Bixler EO  Alcohol and suicide in Alaska Natives Am Indian Alsk Native Ment Health Res 1993 5 34 45 8130312 
Milne S Matthews K Ashcroft GW  Suicide in Scotland 1988–1989. Psychiatric and physical morbidity according to primary care case notes Br J Psychiatry 1994 165 541 544 7804672 
Harris MR Holman J Bates AA DeLima Z Howard ES Ivanenko A Lunsford RJ James WA el Mallakh RS  Completed suicides and emergency psychiatric evaluations: the Louisville experience J Ky Med Assoc 2000 98 210 212 10835836 
Mortensen PB Agerbo E Erikson T Qin P Westergaard-Nielsen N  Psychiatric illness and risk factors for suicide in Denmark Lancet 2000 355 9 12 10615884 10.1016/S0140-6736(99)06376-X 
He XY Felthous AR Holzer CE IIINathan P Veasey S  Factors in prison suicide: one year study in Texas J Forensic Sci 2001 46 896 901 11451074 
Boothroyd LJ Kirmayer LJ Spreng S Malus M Hodgins S  Completed suicides among the Inuit of northern Quebec, 1982–1996: a case-control study CMAJ 2001 165 749 755 11584562 
Schmidt P Müller R Dettmeyer D Madea B  Suicide in children, adolescents and young adults Forensic Science International 2002 127 161 167 12175945 10.1016/S0379-0738(02)00095-6 
Beskow J  Suicide in mental disorder in Swedish men Acta Psychiatr Scand Suppl 1979 1 138 286500 
Nuttall EA Evenson RC Cho DW  A comparison of suicide and undetermined deaths in psychiatric patients Suicide Life Threat Behav 1980 10 167 174 7210103 
Rorsman B Hagnell O Lanke J  Mortality and hidden mental disorder in the Lundby Study. Age-standardized death rates among mentally ill 'non-patients' in a total population observed during a 25-year period Neuropsychobiology 1983 10 83 89 6674830 
Winokur G Black DW  Psychiatric and medical diagnoses as risk factors for mortality in psychiatric patients: a case-control study Am J Psychiatry 1987 144 208 211 3812790 
Cullberg J Wasserman D Stefansson CG  Who commits suicide after a suicide attempt? An 8 to 10 year follow up in a suburban catchment area Acta Psychiatr Scand 1988 77 598 603 3407429 
Vogel R Wolfersdorf M  Suicide and mental illness in the elderly Psychopathology 1989 22 202 207 2678211 
Allebeck P Allgulander C  Psychiatric diagnoses as predictors of suicide. A comparison of diagnoses at conscription and in psychiatric care in a cohort of 50,465 young men Br J Psychiatry 1990 157 339 344 2245261 
Allebeck P Allgulander C  Suicide among young men: psychiatric illness, deviant behaviour and substance abuse Acta Psychiatr Scand 1990 81 565 570 2378251 
Chandrasena R Beddage V Fernando ML  Suicide among immigrant psychiatric patients in Canada Br J Psychiatry 1991 159 707 709 1756350 
Marcus P Alcabes P  Characteristics of suicides by inmates in an urban jail Hosp Community Psychiatry 1993 44 256 261 8444437 
Ramsay L Gray C White T  A review of suicide within the State Hospital, Carstairs 1972–1996 Med Sci Law 2001 41 97 101 11368404 
Powell J Geddes J Deeks J Goldacre M Hawton K  Suicide in psychiatric hospital in-patients. Risk factors and their predictive power Br J Psychiatry 2000 176 266 272 10755075 10.1192/bjp.176.3.266 
Proulx F Lesage AD Grunberg F  One hundred in-patient suicides Br J Psychiatry 1997 171 247 250 9337978 
Dennehy JA Appleby L Thomas CS Faragher EB  Case-control study of suicide by discharged psychiatric patients BMJ 1996 312 1580 8664668 
Shaffer D  Suicide in childhood and early adolescence J Child Psychol Psychiatry 1974 15 275 291 4459418 
Kraft DP Babigian HM  Suicide by persons with and without psychiatric contacts Arch Gen Psychiatry 1976 33 209 215 1252097 
Miller M  A psychological autopsy of a geriatric suicide J Geriatr Psychiatry 1977 10 229 242 608940 
Hagnell O Rorsman B  Suicide in the Lundby study: a comparative investigation of clinical aspects Neuropsychobiology 1979 5 61 73 431800 
Rich CL Fowler RC Young D Blenkush M  San Diego suicide study: comparison of gay to straight males Suicide Life Threat Behav 1986 16 448 457 3798521 
Rich CL Ricketts JE Fowler RC Young D  Some differences between men and women who commit suicide Am J Psychiatry 1988 145 718 722 3369559 
Brent DA Perper JA Goldstein CE Kolko DJ Allan MJ Allman CJ Zelenak JP  Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients Arch Gen Psychiatry 1988 45 581 588 3377645 
Rothberg JM Fagan J Shaw J  Suicides in United States Army Personnel, 1985–1986 Mil Med 1990 155 452 456 2122283 
Thorslund J  Inuit suicides in Greenland Arctic Med Res 1990 49 25 33 2317242 
Conwell Y Caine ED Olsen K  Suicide and cancer in late life Hosp Community Psychiatry 1990 41 1334 1339 2276727 
Rich CL Sherman M Fowler RC  San Diego Suicide Study: the adolescents Adolescence 1990 25 855 865 2275442 
Conwell Y Olsen K Caine ED Flannery C  Suicide in later life: psychological autopsy findings Int Psychogeriatr 1991 3 59 66 1863707 10.1017/S1041610291000522 
Carlson GA Rich CL Grayson P Fowler RC  Secular trends in psychiatric diagnoses of suicide victims J Affect Disord 1991 21 127 132 1827640 10.1016/0165-0327(91)90059-2 
Marttunen MJ Aro HM Henriksson MM Lonnqvist JK  Mental disorders in adolescent suicide. DSM-III-R axes I and II diagnoses in suicides among 13- to 19-year-olds in Finland Arch Gen Psychiatry 1991 48 834 839 1929774 
Runeson B Beskow J  Borderline personality disorder in young Swedish suicides J Nerv Ment Dis 1991 179 153 156 1997663 
Brent DA Perper JA Moritz G Allman C Friend A Roth C Schweers J Balach L Baugher M  Psychiatric risk factors for adolescent suicide: a case-control study J Am Acad Child Adolesc Psychiatry 1993 32 521 529 8496115 
King EA Barraclough BM  Suicide Lancet 1993 342 744 745 8103850 10.1016/0140-6736(93)91737-7 
Marttunen MJ Henriksson MM Aro HM Heikkinen ME Isometsa ET Lonnqvist JK  Suicide among female adolescents: characteristics and comparison with males in the age group 13 to 22 years J Am Acad Child Adolesc Psychiatry 1995 34 1297 1307 7592267 10.1097/00004583-199510000-00014 
Henriksson MM Marttunen MJ Isometsa ET Heikkinen ME Aro HM Kuoppasalmi KI Lonnqvist JK  Mental disorders in elderly suicide Int Psychogeriatr 1995 7 275 286 8829433 10.1017/S1041610295002031 
Henriksson MM Isometsa ET Hietanen PS Aro HM Lonnqvist JK  Mental disorders in cancer suicides J Affect Disord 1995 36 11 20 8988260 10.1016/0165-0327(95)00047-X 
Gould MS Fisher P Parides M Flory M Shaffer D  Psychosocial risk factors of child and adolescent completed suicide Arch Gen Psychiatry 1996 53 1155 1162 8956682 
Isometsa E Heikkinen M Henriksson M Marttunen M Aro H Lonnqvist J  Differences between urban and rural suicides Acta Psychiatr Scand 1997 95 297 305 9150823 
Marttunen M Henriksson M Pelkonen S Schroderus M Lonnqvist J  Suicide among military conscripts in Finland: a psychological autopsy study Mil Med 1997 162 14 18 9002696 
Cheng AT Mann AH Chan KA  Personality disorder and suicide. A case-control study Br J Psychiatry 1997 170 441 446 9307694 
Duberstein PR Conwell Y Cox C  Suicide in widowed persons. A psychological autopsy comparison of recently and remotely bereaved older subjects Am J Geriatr Psychiatry 1998 6 328 334 9793581 
Groholt B Ekeberg O Wichstrom L Haldorsen T  Suicide among children and younger and older adolescents in Norway: a comparative study J Am Acad Child Adolesc Psychiatry 1998 37 473 481 9585647 10.1097/00004583-199805000-00008 
Conwell Y Lyness JM Duberstein P Cox C Seidlitz L DiGiorgio A Caine ED  Completed suicide among older patients in primary care practices: a controlled study J Am Geriatr Soc 2000 48 23 29 10642017 
Cheng AT Chen TH Chen CC Jenkins R  Psychosocial and psychiatric risk factors for suicide. Case-control psychological autopsy study Br J Psychiatry 2000 177 360 365 11116779 10.1192/bjp.177.4.360 
Gardner E Bahn A Mack M  Suicide and psychiatric care in the aging Arch Gen Psychiatry 1964 10 547 14159254 
Venkoba Rao A Mahendran N  One hundred female burn cases – a study in suicidology Ind J Psychiatry 1989 31 43 50 
Cole DA  Psychopathology of adolescent suicide: hopelessness, coping beliefs, and depression J Abnorm Psychol 1989 98 248 255 2768660 10.1037//0021-843X.98.3.248 
Iliev YT Mitrev IN Andonova SG  Psychopathology and psychosocial causes in adult deliberate self-poisoning in Plovdiv region, Bulgaria Folia Med (Plovdiv) 2000 42 30 33 11347333 
Tamakoshi A Ohno Y Yamada T Aoki K Hamajima N Wada M Kawamura T Wakai K Lin SY  Depressive mood and suicide among middle-aged workers: findings from a prospective cohort study in Nagoya, Japan J Epidemiol 2000 10 173 178 10860301 
Diekstra RF van Egmond M  Suicide and attempted suicide in general practice, 1979–1986 Acta Psychiatr Scand 1989 79 268 275 2711854 
Egeland JA Sussex JN  Suicide and family loading for affective disorders JAMA 1985 254 915 918 4021024 10.1001/jama.254.7.915 
Burvill PW  Suicide in Western Australia, 1967. An analysis of coroners' records Aust N Z J Psychiatry 1971 5 37 44 5291039 
Cattell H  Elderly suicide in London: an analysis of coroner's inquests Int J Geriatr Psychiatry 1988 3 251 261 
Chynoweth R Tonge JI Armstrong J  Suicide in Brisbane – a retrospective psychosocial study Aust N Z J Psychiatry 1980 14 37 45 6930258 
Dorpat T Ripley H  A study of suicide in the Seattle area Comprehensive Psychiatry 1960 1 349 359 13723963 
Eisele JW Frisino J Haglund W Reay DT  Teenage suicide in King County, Washington. II. Comparison with adult suicides Am J Forensic Med Pathol 1987 8 210 216 3673980 
Farberow NL Simon MD  Suicides in Los Angeles and Vienna. An intercultural study of two cities Public Health Rep 1969 84 389 403 4976803 
Holding TA Barraclough BM  Psychiatric morbidity in a sample of a London coroner's open verdicts Br J Psychiatry 1975 127 133 143 1182365 
Kelleher MJ Keohane B Corcoran P Keeley HS  Elderly suicides in Ireland Ir Med J 1997 90 72 74 9105133 
Kosky RJ Dundas P  Death by hanging: implications for prevention of an important method of youth suicide Aust N Z J Psychiatry 2000 34 836 841 11037371 10.1046/j.1440-1614.2000.00807.x 
Mishara BL  Suicide in the Montreal subway system: characteristics of the victims, antecedents, and implications for prevention Can J Psychiatry 1999 44 690 696 10500871 
Robins E Murphy GE Wilkinson RH Gassner S Kayes J  Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides Am J Public Health 1959 49 888 898 13661481 
Rorsman B Hagnell O Lanke J  Violent death and mental disorders in the Lundby Study. Accidents and suicides in a total population during a 25-year period Neuropsychobiology 1982 8 233 240 7133372 
Snowdon J Baume P  A study of suicides of older people in Sydney Int J Geriatr Psychiatry 2002 17 261 269 11921155 10.1002/gps.586 
Foster T Gillespie K McClelland R Patterson C  Risk factors for suicide independent of DSM-III-R Axis I disorder. Case-control psychological autopsy study in Northern Ireland Br J Psychiatry 1999 175 175 179 10627802 
Rich CL Young D Fowler RC  San Diego suicide study. I. Young vs old subjects Arch Gen Psychiatry 1986 43 577 582 3707290 
Foster T Gillespie K McClelland R  Mental disorders and suicide in Northern Ireland Br J Psychiatry 1997 170 447 452 9307695 
Apter A Bleich A King RA Kron S Fluch A Kotler M Cohen DJ  Death without warning? A clinical postmortem study of suicide in 43 Israeli adolescent males Arch Gen Psychiatry 1993 50 138 142 8427554 
Arato M Demeter E Rihmer Z Somogyi E  Retrospective psychiatric assessment of 200 suicides in Budapest Acta Psychiatr Scand 1988 77 454 456 3389182 
Asgard U  A psychiatric study of suicide among urban Swedish women Acta Psychiatr Scand 1990 82 115 124 2239354 
Brent DA Baugher M Bridge J Chen T Chiappetta L  Age- and sex-related risk factors for adolescent suicide J Am Acad Child Adolesc Psychiatry 1999 38 1497 1505 10596249 10.1097/00004583-199912000-00010 
Groholt B Ekeberg O Wichstrom L Haldorsen T  Youth suicide in Norway, 1990–1992: a comparison between children and adolescents completing suicide and age- and gender-matched controls Suicide Life Threat Behav 1997 27 250 263 9357080 
Lesage AD Boyer R Grunberg F Vanier C Morissette R Menard-Buteau C Loyer M  Suicide and mental disorders: a case-control study of young men Am J Psychiatry 1994 151 1063 1068 7503818 
Appleby L Cooper J Amos T Faragher B  Psychological autopsy study of suicides by people aged under 35 Br J Psychiatry 1999 175 168 174 10627801 
Boardman AP Grimbaldeston AH Handley C Jones PW Willmott S  The North Staffordshire Suicide Study: a case-control study of suicide in one health district Psychol Med 1999 29 27 33 10077291 10.1017/S0033291798007430 
Runeson B  Mental disorder in youth suicide. DSM-III-R Axes I and II Acta Psychiatr Scand 1989 79 490 497 2750550 
Waern M Runeson BS Allebeck P Beskow J Rubenowitz E Skoog I Wilhelmsson K  Mental disorder in elderly suicides: a case-control study Am J Psychiatry 2002 159 450 455 11870010 10.1176/appi.ajp.159.3.450 
Cerel J Fristad MA Weller EB Weller RA  Suicide-bereaved children and adolescents: II. Parental and family functioning J Am Acad Child Adolesc Psychiatry 2000 39 437 444 10761345 10.1097/00004583-200004000-00012 
Conwell Y Duberstein PR Cox C Herrmann JH Forbes NT Caine ED  Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study Am J Psychiatry 1996 153 1001 1008 8678167 
Cantor CH Hill MA McLachlan EK  Suicide and related behaviour from river bridges. A clinical perspective Br J Psychiatry 1989 155 829 835 2620210 
Thacore VR Varma SL  A study of suicides in Ballarat, Victoria, Australia Crisis 2000 21 26 30 10793468 10.1027//0227-5910.21.1.26 
Vijayakumar L Rajkumar S  Are risk factors for suicide universal? A case-control study in India Acta Psychiatr Scand 1999 99 407 411 10408261 
Ernst C Lalovic A Lesage AD Seguin M Trautman P Turecki G  Suicide and no axis I psychopathology BMC psychiatry 2004 4 
Kim C Lesage AD Seguin M Chawky N Vanier C Lipp O Turecki G  Patterns of comorbidity in male suicide completers 2002  
Breier A Astrachan BM  Characterization of schizophrenic patients who commit suicide Am J Psychiatry 1984 141 206 209 6691481 
Nyman AK Jonsson H  Patterns of self-destructive behaviour in schizophrenia Acta Psychiatr Scand 1986 73 252 262 3716842 
Rossau CD Mortensen PB  Risk factors for suicide in patients with schizophrenia: nested case-control study Br J Psychiatry 1997 171 355 359 9373425 
Konnecke R Hafner H Maurer K Loffler W an der HW  Main risk factors for schizophrenia: increased familial loading and pre- and peri-natal complications antagonize the protective effect of oestrogen in women Schizophr Res 2000 44 81 93 10867314 10.1016/S0920-9964(99)00139-5 
Jablensky A  Epidemiology of schizophrenia: the global burden of disease and disability Eur Arch Psychiatry Clin Neurosci 2000 250 274 285 11153962 10.1007/s004060070002 
Cavanagh JT Carson AJ Sharpe M Lawrie SM  Psychological autopsy studies of suicide: a systematic review Psychol Med 2003 33 395 405 12701661 10.1017/S0033291702006943

