[Psychiatric autopsy: its uses and limits in France]

Abstract

Rationale: Within the framework of an evaluation program for the prevention of suicide in Brittany conducted by the academic department of psychiatry (University of Rennes, Brittany, France), we have addressed the issue of the potential usefulness of psychological autopsy as a tool for the better comprehension of suicide risk factors.

Method: We reviewed the appropriate literature in 30 articles found amongst those obtained from the "Medline" database. These articles were selected according to the quality of their methodology. For the Medline data retrieval search, the following keywords were used: "psychological autopsy", "psychiatric autopsy", "psychological autopsy and methodology", "psychiatric autopsy and methodology". This review's objective was to determine, firstly the nature and the content of psychological autopsies, secondly to evaluate their use as a methodological tool to assist the comprehension and prevention of suicide. Finally, it was also to assess its feasibility for use in France.

Results: The majority of the published studies using psychological autopsy for the evaluation of suicide expertise came from Scandinavian or Anglo-Saxon countries. Schneidman [Schneidman ES. The psychological autopsy. Suicide Life Threat Behav 1981;11:325-40], whose aim was to clarify the causes of sudden death related to psychological circumstances, focused on suicidal intentions and the symptoms exhibited. He coined the term: "psychological autopsy". Gradually, the definition of psychological autopsy has evolved and is now being used for the evaluation of death by suicide with a single goal in mind: to retrospectively identify any suicidal predictive and risk factors available at the time of the event. At present, no unequivocal definition of "psychological autopsy" has been put forth. However, this formerly only descriptive procedure is now becoming more analytical in nature (comparison of psychiatric profiles between pre- and postmortem assessments, research on precipitating factors, comorbidity studies...). Presently, it corresponds to a methodological tool to be used essentially for case reports that vary a great deal and do not permit cross-comparisons with other case-studies. For the past fifteen years, case-control studies in this field have become more frequent with various choices of control groups: healthy subjects with no psychiatric history, as well as attempted suicides, with or without a psychiatric history. Partial standardization of autopsy procedures is now possible with some data extracted from police inquiries, medical charts, or data gathered following interviews with the deceased patient's relatives.

Conclusion: In the aggregate, the literature review showed that the aims of psychological autopsy include understanding and prevention of suicide in a population-based sample. It seems difficult to generalize with results from other population references. In France, the use of psychological autopsy as a standardized tool for the assessment of suicidal behaviors would be difficult, due to the complexity of the procedures involved: data coming from external sources, such as medical sources, is nearly impossible to obtain. Practitioners would be required to overcome administrative rules and regulations, plus incurring the high costs of such procedures. They must also take into account ethical considerations that make such interviews with the deceased patient's relatives difficult to obtain. Be this as it may, the French Ministry of Health is presently attempting to find a solution in order to alleviate the all too frequent problem of suicide in the population at large and to promote suicide prevention in France.