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 Table of Contents    
REVIEW ARTICLE  
Year : 2020  |  Volume : 62  |  Issue : 6  |  Page : 631-643
Psychological autopsy: Overview of Indian evidence, best practice elements, and a semi-structured interview guide


1 Department of Psychiatry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
2 Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Puducherry, India

Click here for correspondence address and email

Date of Submission11-Apr-2020
Date of Decision19-May-2020
Date of Acceptance29-Aug-2020
Date of Web Publication12-Dec-2020
 

   Abstract 


Background: No review has been attempted, so far, on Indian psychological autopsy (PA) literature. There is also a dearth of interview guides which is at the heart of a PA procedure.
Materials and Methods: Electronic searches of MEDLINE through PubMed, PsycINFO, and Google scholar databases were carried out from inception till February 2020 to identify relevant English language peer-reviewed articles from India, as well as global literature that provided information on best practice elements in PA. Abstracts generated were systematically screened for eligibility. Relevant data were extracted using a predesigned structured proforma, and a semi-structured interview guide was developed.
Results: A total of 18 original articles, one case report, and three reviews/expert opinion articles which tried to give a description of PA procedure were found from India. Most Indian studies are of suicide PA (SPA), done to assess risk factors associated with suicide. There was a wide variation in reported rates of psychiatric morbidity among suicide decedents, while the other major risk factor for suicide in the Indian setting was stressful life events. An optimal approach to PA involves systematically collecting information from key informants and other sources using a narrative interviewing method, supplemented with psychological measures, and is probably best carried out within 1–6 months after the death.
Conclusion: There have been limited attempts to standardize PA. Most Indian studies use SPA. We propose a semi-structured PA interview guide, suitable for both research and investigational purposes.

Keywords: Asia, autopsy, India, psychological autopsy, suicide

How to cite this article:
Menon V, Varadharajan N, Bascarane S, Subramanian K, Mukherjee MP, Kattimani S. Psychological autopsy: Overview of Indian evidence, best practice elements, and a semi-structured interview guide. Indian J Psychiatry 2020;62:631-43

How to cite this URL:
Menon V, Varadharajan N, Bascarane S, Subramanian K, Mukherjee MP, Kattimani S. Psychological autopsy: Overview of Indian evidence, best practice elements, and a semi-structured interview guide. Indian J Psychiatry [serial online] 2020 [cited 2021 May 17];62:631-43. Available from: https://www.indianjpsychiatry.org/text.asp?2020/62/6/631/303164





   Introduction Top


In its essence, psychological autopsy (PA) refers to a postmortem investigative procedure that seeks to uncover the intention of the decedent through a thorough retrospective evaluation through structured interviews of informants as well as a perusal of relevant records.[1] Originally devised for investigating, clarifying, and assisting police inquiries on the mode of death in equivocal deaths,[2] psychological autopsies have, in recent times, been more commonly used as a research tool for investigating risk factors for completed suicides. To a large extent, this has been driven by the accepted “truism” in suicide research that roughly 90% of suicide decedents have one or more diagnosable mental disorders.[3]

Although several PA studies have been published from India, thus far, there has been no attempt to systematically review the available literature. Further, currently accepted PA interview practices suffer from several limitations. Lack of standardized instruments or methods, informant bias, lack of interviewer training, recall bias (due to time elapsed between the event and the interview), and issues with selection of controls are some of the key methodological drawbacks[4] which have also, predictably, led to questions about the admissibility of PA evidence in courts.[5]

Against this background, the present review was carried out with three objectives; to review the Indian PA literature with a dual focus on methodological aspects as well as to summarize their key findings; to synthesize best practice elements of PA interview procedure and finally; and to outline a semi-structured PA interview guide to assist practice and research in this area.


   Materials and Methods Top


Search strategy and study selection

We performed an electronic search of databases such as MEDLINE through PubMed, PsycINFO, and Google Scholar databases from inception till February 2020 to identify relevant English language peer-reviewed articles on PA. For PubMed, we used the following combinations of MeSH and free text terms; ((((autopsies)) OR (autopsies[MeSH Terms])) AND (((((“autopsy”[MeSH Terms] OR “autopsy/instrumentation”[MeSH Terms] OR “autopsy/methods”[MeSH Terms] OR “autopsy/psychology”[MeSH Terms]) OR (autopsy)) OR (autopsy/instrumentation)) OR (autopsy/verbal)) OR (autopsy/methods)) OR (autopsy/psychology))) AND ((((((“interview”[Publication Type] OR “interviews as topic”[MeSH Terms]) OR “interview”[All Fields]) OR ((((“interview, psychological”[MeSH Terms] OR (“interview”[All Fields] AND “psychological”[All Fields])) OR “psychological interview”[All Fields]) OR (“interviews”[All Fields] AND “psychologic”[All Fields])) OR “interviews psychologic”[All Fields])) OR ((((“interview, psychological”[MeSH Terms] OR (“interview”[All Fields] AND “psychological”[All Fields])) OR “psychological interview”[All Fields]) OR (“interviews”[All Fields] AND “psychological”[All Fields])) AND (“suicide”[MeSH Terms] OR “suicide”[All Fields]) AND forensic[All Fields] AND (“autopsy”[MeSH Terms] OR “autopsy”[All Fields])).

For other databases, the search terms were adapted as appropriate. Two independent psychiatrists performed the literature search. A manual search of the reference lists of generated articles was also done to locate relevant articles.

A total of 2387 articles were generated initially. We included all articles involving PA-based research from India. We also included PA studies in literature that provided relevant information to synthesize best practices for the following key steps of PA procedure; how and whom to select as informants, contact/approach methods, timing, setting, and termination of the interview. Gray literature (such as conference proceedings) was not searched.

Based on these inclusion criteria and after removing duplicates, 184 articles were shortlisted for inclusion based on their title and abstracts. After further filtering, 156 articles were shortlisted for full-text examination, and finally, 39 articles were included for the present review. Two independent authors participated in the study selection and all authors reached a consensus on the studies to be included. Being a narrative review, we neither attempted computation of effect sizes nor performed a risk of bias assessment for included papers.

Data extraction

Selected studies were categorized under two headings; first, Indian studies using PA method and second, evidence for best practice elements in PA interview. Accordingly, the results of the current review are structured under these headings.

We extracted relevant data from the Indian studies and tabulated them under the following headings; author and year, sample size and participant characteristics, methodology used, main results, and any other special features. Data extraction was done independently by two authors.


   Results Top


Suicide psychological autopsy: Indian scenario

Original/case studies using psychological autopsy as method (n = 19)

Verbal Autopsy only to ascertain suicide rate (n = 8)

A series of papers from Vellore[6],[7],[8],[9],[10] used verbal autopsy to ascertain age-specific suicide rates in the same locality during different time periods. All these studies followed a similar methodology. Community health workers, health aides, and nurses independently visited the home, relatives, and neighbors of the deceased, traditional healers, and village leaders. Circumstances of the death were discussed with doctor and sometimes independently verified to check the accuracy of reporting.

Interestingly, they all reported a higher average annual suicide rate compared to the national average and conclude that suicide is largely underreported in the existing system. One of these studies[8] also found that stressful life events were reported by nearly all the decedents.

Two studies from Kerala[11] and Tamil Nadu[12] used verbal autopsy method to determine suicide rate and contribution of suicide to overall mortality. Trained health workers interviewed surviving spouses, close associates, or neighbors and wrote their verbal autopsy report. These were independently reviewed by one[11] or two[12] physicians to verify cause of death. Results from these studies showed that suicide underreporting varied between states.

A nationally representative survey[13] using nonmedical trained field workers and employing an augmented version of a verbal autopsy, called routine, reliable, representative, re-sampled household investigation of mortality with medical evaluation method (RHIME) found that suicide rates in India were among the highest in the world and suggested interventions such as restrictions on access to pesticides to control suicide.

Psychological autopsy with restricted information (n = 2)

Two studies[14],[15] used cross-sectional design to assess risk factors for completed suicide. Only relatives of the deceased were approached. Police records or additional information was not sought. A self-designed questionnaire with a special focus on recent stressful life events was used in one study,[14] while in the other,[15] relatives were approached 3-month postsuicide completion to enable the respondents to be out of the grief period and minimize recall bias while providing information.

Psychological autopsy involving extended information (n = 1)

When further evidence was collected through various sources such as suicide notes and circumstantial evidence from the police and the magistrate, the process of PA yielded valuable information such as gender-specific risk factors for completed suicide by hanging in Cuttack, Orissa.[16]

Psychological autopsy involving “key informant” relatives (n= 4)

In the earliest such PA study from India, authors used a detailed 178-item questionnaire with structured assessment of life events and psychiatric morbidity to interview key informants within 1–3 months after the death.[17] All interviews were done by a psychiatrist. A similar methodology, with structured instruments for psychiatric morbidity and life events and psychiatrist-led interviews, was followed in Kerala.[18]

Elsewhere, trained medical social workers and a counselor, who approached “key informant relatives” (defined as those who lived with the deceased for the past 2 years) used a self-designed semi-structured pro forma to conduct interviews.[19]

A study from Goa,[20] which involved “key informant relatives,” conducted the PA in the presence of 2–4 family members, against norm of one person at a time. Interviews were conducted using a semi-structured questionnaire in local language, evaluated stressful life events, and made diagnoses using the International Classification of Diseases-10th Edition.[21] A qualified psychiatrist performed the interviews after a gap of 1–3 months.

Psychological autopsy in special populations

Psychological autopsy of farmer suicides (n = 3)

Three PA studies have been carried out on this population. Two of them attempted to quantify risk factors for completed suicide among farmers in Wardha, Maharashtra. Structured pro formas were used in both. Results of one study were compiled as a monograph with little details on the methodology or results of the field study.[22] The other study[23] employed a case–control design and included the assessment of stressful life events for preceding 3 years, psychological antecedents, economic factors, CAGE questionnaire to screen for alcohol use disorder, and used Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV[24] for making psychiatric diagnoses. Interviews were carried out after a minimum gap of 3-month postsuicide.

A study on farmers from Vellore[25] assessed presumptive life events, generated diagnoses using Structured Clinical Interview for DSM-III-R,[26] and collected collateral information from traditional healers, village leaders, and health records. Relatives were approached after a minimum gap of 2-month postsuicide completion.

Psychological autopsy in emergency (n = 1)

A recent case report[27] of PA performed in the emergency room following death due to self-poisoning was characterized by a thorough clinical history including the context of attempt, past psychiatric history, substance abuse history, premorbid personality assessment, assimilating various caregivers' accounts of the deceased, and using DSM-5 for psychiatric diagnoses.

In the above section, we focused on the methodology adopted by Indian PA studies. [Table 1] summarizes their main findings.
Table 1: Summary of Indian studies using psychological autopsy method

Click here to view


Indian reviews/expert opinions on psychological autopsy as an investigative tool (n = 3)

An open review on the PA methods of equivocal death revealed that PA is usually required when the cause and mode of death is uncertain.[28] Usual indications for a PA were suspected suicide, impending criminal investigations, to acquire insurance claims (which are void if death occurred due to suicide within a certain period of policy issuance) and to appeal for malpractice suits. The recommended PA team included magistrate/coroner, medical officer, psychologist, psychiatrist, psychiatric social worker, police investigating officer, and law enforcement authorities. While the interviewer is usually any mental health professional, the interviewee can be persons from the family, friends, co-workers, neighbors, physicians, eyewitnesses, priests or religious figures, and other acquaintances, as appropriate.

Additional sources of information may include suicide notes, medical records, school records, military records, employment records, coroner's report, forensic medical results, police reports, and crime scene analyst reports. Focus areas for assessment include personal views about the deceased person, any behavioral or emotional distress noticed in the deceased, and perceived contextual reasons behind the death. Crucially, the process and outcome of PA are viewed as an expert opinion with probabilities.

A selective review on methods, ethics, and standardization of PA in India[29] identified two types of PA: the suicide PA (SPA) and the equivocal death PA (EDPA). While SPA (to ascertain reasons for suicide) is used in necessary circumstances, the EDPA (to clarify ambiguous deaths) is rarely used in India. The PA can also be used to determine the mode of death (suicide, natural, homicide, and accidental), means of death (head trauma, gunshot injury, heart attack, or suffocation, etc.) as well as the motivation behind death (intentional [on purpose], sub-intentional [an act was meant to harm but not kill], and unintentional [an accident]).

Recommendations included areas of inquiry based on Shneidman's 16 criteria, to conduct interviews within 2–6 months after the death, and to acquire informed consent while collecting information. Starting with information from the crime scene followed by review of police records, interviewing third parties, checking decedent's records (letters, e-mails, journal entries, cell phone records, audio or video recordings, bank accounts, student, or employee records), analyzing relationships, support systems, and the deceased person's occupation was the suggested workflow.

Pertinently, the review also reiterates the nonlegitimacy of PA in Indian courts and its importance in life insurance claims. Ongoing life insurance benefits could affect the quality and quantity of data provided by the informant. The absence of standard methodology, presence of recall bias in relatives, distorted versions from various relatives, and limited collateral records are discussed as further limitations of PA. In an attempt to address the lack of standardization of PA interview procedure,[30] a forensic expert has proposed a brief outline for PA.

Overview of best practice elements in psychological autopsy

Number and selection of informants

The primary choice of informants is always the next of kin; in other words, the spouses/parents/first-degree relatives. Other informants may include family, friends, co-workers, neighbors, and family physician/mental health-care provider, the last two in light of the large proportion of adults who visit a health-care provider within a month of their suicide.[31],[32],[33] In case of adolescent suicides, close friends should also be interviewed as they may confide their suicidal thoughts only to peers.[34],[35] Selection of informants often varies from case-to-case basis and becomes challenging when the individual is living alone.[36] Furthermore, when suitable medical records are available, relevant information from this also should be included.

Approaching informants and timing of interview

Different ways of approaching informants for a PA interview have been described. These include approaching at funeral home,[37] at the home “unannounced,”[31] by letter[35],[38],[39],[40] and by telephone.[41] In most of these, the compliance has been generally good (>80%). Telephone calls followed by a letter which contains the detailed information for the study and then visiting the home was suggested by Beskow et al.[42] This may ensure physical availability on the proposed day and has lower rejection rates.

The timing of PA interview has varied between studies, from between a week[37],[43] to 6–12 weeks[35],[44] after death. Whenever possible, one should avoid approaching informants and interviewing them close to the anniversary of death, birthday of the deceased, or at family occasions such as impending weddings/religious festivals.

In most Indian PA studies, the timing for interview was between 1 and 3 months after death,[15],[17],[20] while global literature suggests that the optimum time may lie between 2 and 6 months following death.[42]

Setting of interviews

Both setting and timing of interview needs to be flexible. Informed written consent should be obtained before the interview. The interviews usually take place at the informant's home or a neutral location, depending on mutual convenience. Interviews can last between 2 and 5 h; a single session with breaks or multiple sessions over subsequent days is ideal to minimize interview fatigue.[36] Sometimes, based on initial information, it may emerge that more people need to be interviewed. Accordingly, a second round of interviews may be planned.

Termination of the interview

The interview is usually terminated appreciating the informants for participation as the long interview process is taxing and their queries if anything after completion of the interview needs to be addressed. At times, they might go through grief or suffer from a mental disorder and help should be offered for the same.[3],[45]

Proposed semi-structured format for psychological autopsy interview

Lack of a standard format for interviewing informants in PA has raised legitimate concerns about the reliability/validity of the process. To our knowledge, only one previous study has outlined a detailed semi-structured interview format for PA.[46] A previous Indian study also attempted to draw up a preliminary outline for an interview,[47] whereas a few others[14],[17],[19],[20],[23],[25] used self-designed questionnaires with minimal elaboration. Drawing upon these, as well as the literature discussed in this article, we propose a comprehensive semi-structured format for the PA interview [Appendix 1]. The interview is divided into six parts and 13 items as follows and is designed to be used for each informant separately. A list of potential informants and supplemental measures are listed in [Table 2] and [Table 3], respectively.
Table 2: Potential sources of information for psychological autopsy interview

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Table 3: Supplementary measures/tools used in psychological autopsy studies

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Any conclusion about a PA should be restricted to opinions on whether the death was due to suicide or not, if the autopsy was conducted to classify an equivocal death, or probable cause/reasons for suicide if the autopsy was conducted to investigate the reasons behind suicide. Investigators should refrain from commenting on other possibilities such as accidental death or homicide.


   Discussion Top


Overview of Indian research using psychological autopsy

More than two decades after the earliest Indian PA study[17] was published, the volume of PA literature from India still remains very low. Further, all the available PA literature is related to suicide psychological autopsies, done on cases where the modality of death is not in question. No study or report so far has focused on EDPA.

Of the available 22 PA-related research articles from India, 18 were original research, three were reviews or expert opinions, and one was a case report. Of the 18 original PA studies, five studies[15],[17],[18],[23],[25] used a case–control design, while five were single group studies[14],[16],[19],[20],[22] on suicide deaths. Eight studies[6],[7],[8],[9],[10],[11],[12],[13] used the verbal autopsy method in selected villages to ascertain the average annual suicide rate while correcting for underreporting. One of these was a nation-wide study.[13]

Nearly all the verbal autopsy studies estimated that the average annual suicide rate is higher than the reported national average. As most of them were conducted many years ago, it may be worthwhile repeating these studies now, in light of changes in suicide-related legislation and practice.

Common risk factors noted for suicide in the five case–control studies[15],[17],[18],[23],[25] were the presence of mental illness, prior suicide attempts, interpersonal conflicts, substance use, financial loss, stressful life events, and solitary living arrangement. The demographic risk factor for suicides was not consistently observed.

Interestingly, there was a wide variation in observed prevalence rates of mental illness among the deceased; figures ranged from 37% to 88%.[17],[25] In general, studies that employed a structured diagnostic instrument noted higher prevalence rates than those without. Nonetheless, stressful life events were also a significant contributor to suicides in all these studies.

Five studies used single group (suicide) cross-sectional design.[14],[16],[19],[20],[22] Common findings were strikingly similar and included the occurrence of stressful life events among majority of attempters.[14],[16],[19],[20] Here too, the prevalence of mental illness was disparate; figures ranged from as low as 4.8%[16] to as high as 94%.[20]

Together, no clear conclusions can be drawn but average rates of mental illness among Indian suicide decedents appear to be comparable to pooled estimates from low- and middle-income countries.[82] It is also unclear whether the observed high rates of stressful life events among the deceased are a cause or effect of psychiatric morbidity, and further research is needed to answer this question. Nonetheless, it appears safe to conclude that suicide prevention efforts in the Indian setting must focus on both control of psychiatric morbidity and psychosocial risk factors.

Evidence informed methodological best practices for psychological autopsy

Regarding methodological aspects, available evidence suggests that selection of informants must be decided on a case-to-case basis based on proximity to deceased, especially in the days leading up to the death. All attempts must be made to collect information from as many sources as possible.

The optimal time for interviewing appears to be between 2 and 6 months after death to strike the right balance between grief resolution and recall bias. A single interview may last anywhere between 2 and 5 h but may extend longer depending on the informant's productivity. As interview fatigue may set in during this long period, it is advisable to pace it comfortably, give adequate breaks in between, or have multiple sittings. At all times, it is important to respect the integrity of the deceased, allow processing of emotions, and give informants adequate time to respond to questions.

PA generates sensitive information, and hence, safeguarding the confidentiality of the information generated is of paramount importance. As a confidence-building measure among informants, PA investigators can brief them upfront on the steps taken to ensure confidentiality, data safety, and anonymity. Steps include destroying any written information, audio or videotapes in case of telephonic interviews as well as case notes following completion of the report and analysis, limiting access to rooms where sensitive information is stored, and blinding other staff to the identity of the cases.[83] At all times, the privacy and confidentiality of the interviewee and the integrity of the deceased must be respected.[84]

There could be several barriers to accessing supplemental sources of information outlined in [Table 2]. In many jurisdictions, the medical records of the deceased are considered to be property of designated next of kin. Previous investigators have recommended approaching informants with a letter explaining the scope and nature of request along with the necessary approvals (ethics approval, if it is a SPA) and obtaining the consent of the kin to obtain their cooperation.[45] Even then, some agencies or systems involved may be reluctant to release information due to concerns about legal liability. Similar concerns may apply to other sources of information in PA interview [Table 2]. We are of the opinion that a collaborative approach with the informants and working with them to surmount administrative hassles required to obtain necessary records will be the optimal approach to a PA procedure.

Findings of the PA procedure could have implications for life insurance as well as health insurance. As discussed earlier,[28],[29] life insurance claims are not usually honored if the suicide occurred within a certain period of policy commencement. At present, most health insurance policies also do not honor medical claims for injuries due to suicidal attempt or self-harm; this is even after the Mental Health Care Act 2017[85] has come into force. By placing suicide or attempted suicide on record, the family members of the decedent in case of suicide, or the concerned individual and family in case of attempted suicide, may lose reimbursement claims from a health insurance policy, which could potentially be a serious financial blow. Hence, the need for a meticulous approach to performing PA cannot be overstated.

The proposed semi-structured format for PA interview has been prepared after going through the extant literature. It can be used for both suicide psychological autopsies as well as equivocal death autopsy and may assist investigators in delineating the probable mode and cause of death. The interview covers both static, stable, and dynamic risk factors as well as protective factors.[86] Investigators would be well advised not to base their conclusions on the probable mode of death (suicide, accidental death, homicide, or natural death) on any one or two factors, however important they may seem. Instead, they must follow a systematic approach including close examination of the circumstances surrounding death and the decedent, results of the physical (forensic) autopsy, physical examination of site of death, and the relative balance of risk and protective factors, supplemented by tools wherever necessary, similar to a structured suicide risk assessment process.[87] This will facilitate the formulation of structured professional judgment, which is what the proposed interview format seeks to espouse.

The items in the suggested guide must be viewed as question leads. It is important to allow respondents to build their narrative account of their relationship to the deceased and their understanding of the deceased's mental health condition and behavior in the days preceding death. Then, these narratives may be analyzed further to assist clinical impressions and reporting. The advantages of such a semi-qualitative approach to PA interviews and the perils of excessive standardization have been pointed out earlier.[4] It is for this reason that we have called it a semi-structured (and not a structured) interview guide.

The present review has certain limitations. We did not attempt a meta-analysis due to the heterogeneity in outcomes evaluated and methods employed across studies. It is quite possible that studies published in the gray literature or not indexed in the included databases may have been missed out, but every effort was made to include relevant studies by searching cross-references of included studies.


   Conclusion Top


PA is a useful investigative tool to ascertain the mode of death in equivocal deaths by examining the factors surrounding death and the mental health status of the deceased. However, in our country, it has more commonly been used as a research tool to examine risk factors associated with suicidal deaths and to determine the reason for committing suicide. Given the wide variations in rates of psychiatric morbidity among suicide decedents, the complex interplay between psychiatric morbidity and the other major risk factor for suicide in the Indian setting, namely, stressful life events, deserve more research attention.

From a reliability/validity perspective, it is hoped that the proposed semi-structured format will assist and encourage the use of PA as both an investigative and research tool. Future validation studies using this instrument will enhance its utility. This will also improve our understanding of the complex multidimensional behavior that is suicide and inform suicide prevention programs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


   Appendix Top


Appendix 1: Semi-structured psychological autopsy interview guide

Preamble

This format is meant to be administered separately to every informant. Information under each heading can be obtained either by interviews or by checking collateral sources/records.

Part – I (basic details)

1. Patient identification details – This section should include details such as name/age/sex/marital, educational and occupational status/current residential address

2. Informant name, age, residential address, contact number, and relationship of informant to the deceased

Part – II (details of death, circumstances, intent, and lethality)

3. Date, time, and location of death

4. Circumstances of death – This should include the following

  • Mode of death
  • Availability and access to lethal agents
  • Precautions taken against discovery versus options for rescue
  • Suicide note (if any, its origin and contents)
  • Intent/any privileged communication regarding suicide intent that the informant may have received
  • Discovery of death
  • Evidence of any planning or rehearsal
  • Any other relevant details.


Part III – Precipitants/stressors

5. Any precipitants/stressors

  • Recent stressors/any recent change in lifestyle or living arrangement
  • Recent loss (job/spouse/family member/financial debt/failed business investment or loss/self-esteem/prestige/crop loss or leasing out of land in case of farmers)
  • Any recent or anticipated life event, whether negative or positive (e.g., house mortgage/birth of family member/suicide of family member or acquaintances)
  • Change in activities of daily living (mobility/dependency issues particularly in elderly)
  • Recent exposure to suicidal behaviors among family members/neighborhood
  • Marital history – Length of marriage/any ongoing discord, estrangement or change in quality of relationship/threat of divorce or separation/current living arrangement/name, age, sex, and number of children
  • Change in daily activities/routines in the days preceding death
  • Occupational history – current job stress and satisfaction/expression of future goals/any impending promotion, retirement, or achievements
  • Recent troubles with the law/police
  • Possible anniversary reactions to loss.


Part IV – Changes in mental status

6. Recent alterations in mood, behavior, and thinking

  • Appearing sad/tearful/moody
  • Insomnia/hypersomnia/appetite changes/loss of libido
  • Ideas of hopelessness/worthlessness/pessimism/guilt
  • Anxiety/agitation/rage/anger outbursts/impulsive behavior
  • Preoccupation with death/overt or covert expressions of suicide ideation/plan
  • Indulgence in risk-taking behaviors
  • Acts that can be construed as preparatory to death – making/updating will, giving away personal belongings, “goodbye” messages to loved ones
  • Overt expressions of desire to reunite with deceased kith and kin/to be reborn
  • Mental status evidence of hallucinations/delusions/poor judgment/comprehension.


Part V – Relevant life history

7. Medical history

  • Recent diagnosis of any major/life-threatening illness or any recent change in health status
  • Nature and details of comorbidities (list each separately)
  • Ongoing treatments/compliance including any recent change
  • Recent change in functional capacity due to these conditions


8. Psychiatric history

  • Current or past diagnosis/treatment/compliance/response to treatment
  • Prior history of suicide attempt or self-harm (record as time, date, circumstances, intent, and lethality with provision of rescue for every such prior attempt)
  • Substance use history – Age at onset/dependent or not/recent change in consumption patterns/whether under influence of substance at the time of death/role of substance to the daily life and routines of deceased
  • Recent contact with mental health facility
  • Any other relevant psychiatric history
  • Personality assessment – impulsivity/emotional instability/violence or aggression/resourcefulness/tendency to conceal emotions/coping skills/attitudes to suicide.


9. Family history – Suicide or attempted suicide in the family/history of psychiatric illness/substance abuse/violence or aggression among family/interpersonal relationships with family members or significant others and any recent worsening of ties

10. History of childhood adversities – early loss of parental figure/trauma/emotional/physical or sexual abuse in childhood

11. Past history of legal troubles – brush with the law/criminal record/involvement in legal proceedings

12. Protective factors

  • Social support and attachments – Sources/current availability and accessibility of each potential source of support/ability to create and maintain ties/affiliation to religious organization/recent changes in support system or attachment patterns/recent expressions of feeling unsupported or helpless/attachment to hobbies or routines
  • Religious affiliation or attachment/involvement in religious groups (such as affiliation to groups that proscribe suicide; any recent changes in this also merits further exploration)
  • Overtly stated future goals/vision/future-oriented talk
  • Having young children/expressed sense of responsibility
  • Intact reality testing ability
  • Expressions of feeling hopeful about future
  • Stable marriage/relationships
  • Willingness to seek assistance for medical or psychiatric issues, if any.


Part – VI (supplementary information)

13. Interview may be supplemented by going through additional sources of information/records [Table 2] and the use of structured assessment tools [Table 3] to assess domains of interest in the preceding section.



 
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Correspondence Address:
Dr. Vikas Menon
Department of Psychiatry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_331_20

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