Completed Suicide among Adolescents with No Diagnosable Psychiatric Disorder
Marttunen, Mauri J., Henriksson, Markus M., Isometsa, Erkki T., Heikkinen, Martti E., Aro, Hillevi M., Lonnqvist, Jouko K., Adolescence
The characteristics of male adolescent suicide victims with (n = 84) and without (n = 8) a diagnosable psychiatric disorder were compared. Using psychological autopsy methods--interviews with victims' family members and health care professionals, and review of records (e.g., medical, school, police)--data were collected on all adolescent suicides in Finland during a 12-month period. Compared with adolescents with a psychiatric disorder, those with no disorder tended to come from less disturbed families, had shown less antisocial behavior, and had less frequently utilized health care and social services. Adolescents with no disorder more often communicated suicidal thoughts for the first time just before the suicide, and difficulties with the law (discipline problems) were more common precipitants than among those with a disorder. It was concluded that the process leading to suicide seems to be relatively short among male adolescents with no diagnosable psychiatric disorder. Communication of suicidal intent an d problems with discipline are among the few clinical warning signs.
Completed suicide for all ages is strongly associated with mental disorders (Black & Winokur, 1990). In general, the more thorough the data collection, the higher the reported proportion of suicide victims with mental disorders. In studies of adolescent suicides based on report data (e.g., coroners' records), the frequencies of depressive symptomatology, substance abuse, or general psychiatric symptomatology have ranged from approximately 50% to 90% of the cases (Cosand, Bourque, & Kraus, 1982; Graham & Burvill, 1992; Hoberman & Garfinkel, 1988; Poteet, 1987; Thompson, 1987). The highest rates of mental disorders in representative samples of adolescent suicides have been reported in studies applying the psychological autopsy method (including informant interviews). Even in these studies, however, no evidence of any psychiatric disorder was found in 5% to 10% of the adolescents (Brent et al., 1988a; Marttunen et al., 1991; Shaffer et al., 1996; Shafii et al., 1988).
The influence of psychosocial stressors on suicidal behavior among adolescents has been emphasized (Brent et al., 1993b; Garrison et al., 1991; Shafii et al., 1988). The most commonly reported precipitating events in adolescent suicide have been interpersonal conflict, separation, rejection, and problems with discipline or the law (Brent et al., 1988a; Marttunen et al., 1993; Rich et at, 1990). Humiliating or shameful events may be particularly important as suicide precipitants (Apter et al., 1993; Shaffer, 1974).
Brent and associates (1993c) reported that adolescent suicide victims (under age 20) with no apparent psychopathology less often had histories of psychiatric treatment, suicide attempts, and other family members with affective illnesses, and had fewer interpersonal conflicts and total life stressors during their last 12 months, as compared with adolescent suicide victims with a psychiatric disorder. However, in comparison with a community control group with no mental disorders, suicide victims with no apparent psychopathology showed some evidence of psychiatric risk factors. Marttunen and associates (1994a) reported that 13- to 19-year-old adolescent suicide victims with adjustment disorders (including three without any disorders) seldom utilized psychiatric services but often had talked to somebody about their suicidal thoughts prior to committing suicide.
The present study analyzed data on all adolescent suicide victims in Finland during a 12-month period (see Marttunen et al., 1995). It sought to determine whether adolescents with no diagnosable psychiatric disorder differed from those with a psychiatric disorder (DSM-III-R axis I or II) in terms of family background, clinical characteristics, and suicide precipitants.
In the research phase of the National Suicide Prevention Project, all suicides (N = 1,397) committed in Finland between April 1, 1987, and March 31, 1988, were comprehensively analyzed using the psychological autopsy method (Clark & Horton-Deutsch, 1992; Litman et al. …