It is generally thought that around 90% of people who commit suicide have a diagnosable mental disorder. Considerable geographical difference has been seen in this relationship. Psychological autopsy (PA) still remains a reasonably sound methodology to investigate this.How common is suicide in the absence of a mental disorder?
Allison Milner, Jerneja Sveticic and Diego De Leo report the results of a systematic review of the relationship between suicide among those with out mental illness. All studies published in or after 2000 using case control PA design were included. Identification of mental disorders needed to be reliant on objective assessment post- mortem, rather than possible diagnoses received when the subject was alive.
29 studies were included in the final analysis. All studies matched suicide cases with controls. Up to 68 % of suicide cases remained without diagnosis in those studies that only examined Axis I disorders. his varied widely from 6% to 68%. Studies from China , India and Italy reported higher rates of absence of mental disorder than American studies. It is possible that suicide in these areas might be related to social stress/ cultural attitudes. Stigma of reporting mental illness is another factor to consider.
36% of cases did not have an axis 1 or 2 disorders. Variation in definition of axis 2 and methods used to measure them is worth noting. China, Hungary and Colombia reported substantially lower personality disorder in suicide cases.
Cultural differences in the construct of personality disorder is likely to play an important part here. Classifying ‘sadness’ as an abnormal experience and making diagnosis of mental disorder when one experience distress and sadness- ‘pathologisation’ is probably more in American/European culture.
There has been little research into suicide deaths occurring in the absence of mental disorder in high-income western contexts. Available information indicate that atleast 10% of suicides occur in those without ant diagnosable mental disorder.
In many countries, good proportion of people committing suicide have no mental disorder. Even in countries where vast majority of those who commit suicide have diagnosable mental disorder (in retrospect , by PA methods) majority of suicides occur among people not in contact with mental health services ( in UK two thirds of suicide occur among those not in contact with mental health services in the past year). More research is required to understand the psychological processes and pathways involved in suicide occurring in those without detectable mental disorders in order to formulate appropriate prevention interventions.
Summary of the article:
Suicide in the absence of mental disorder? A review of psychological autopsy studies across countries.Milner A, Sveticic J, De Leo D. Int J Soc Psychiatry. 2013 Sep;59(6):545-54.