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The Psychological Autopsy: Methodological Considerations for the Study of Adolescent Suicide
The Psychological Autopsy: Methodological Considerations for the Study of Adolescent Suicide DAVID A. BRENT, M.D., JOSHUA A. PERPER, M.D., L.L.B., M.Sc., DAVID J. KOLKa, PH.D ., JANICE P. ZELENAK, PH.D .
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Abstract. Methodological issuesin the use of the psychological autopsy technique to study adolescentsuicide victims were addressed in a study of 27 adolescent completed-suicide victims and a comparison group of 56 suicidal psychiatric inpatients. This report concludes that: (I) parent/parent figure descriptions of suicide victims were unaffected by the presence or severity of affective symptomatology in the informant at the time of the interview; (2) parent reports were unaffected by the time interval between the death and the interview, within a time span of 2 to 6 months; and (3) the asymmetry of informant sources must be considered in the interpretation of odds ratios for psychiatric disorder comparing compieters to a live control group. In light of these findingsand the convergence of several psychological autopsy studies with each other and with prospective studies, the psychological autopsy is thought to yield reliableand valid results for the study of adolescent suicide. J. Am. Acad. Child Adolesc. Psychiatry, 1988,27, 3:362-366. Key Words: suicide, psychological autopsy. The psychological autopsy is an intensive interview, or series of interviews, designed to reconstruct the social and psychological features and circumstances circumscribing the death of an individual (Schneidman and Faberow, 1961). Although this technique was originally developed in the Los Angeles Coroner's Office as a method of expanding the standard investigation of undetermined deaths (Curphey, 1968), the psychological autopsy has been used by several groups of psychiatric investigators to characterize the psychological profile of adult and adolescent suicide victims (Barraclough et al., 1974; Dorpat and Ripley, 1960; Fawcett and Clark, 1987; Fawcett et al., 1987; Rich et al., 1986; Robins et al., 1959; Shaffer and Gould, 1984; Shafii et al., 1984, 1985). Although the recent concern about suicide among youth has prompted a renewed interest in the application of this method to the study of adolescent suicide, there is a paucity of investigations into the reliability and validity of the data derived from psychological autopsy studies. A review of the literature on the application of the psychological autopsy technique reveals several methodological concerns (Barraclough et al ., 1974; Fisher and Shaffer, 1984) . First and foremost is the influence of the suicide on the quality and quantity of data obtained from a bereaved informant. The literature is unclear as to how the acute and subacute symptoms of grief may influence the report of parents (or other informants) about the suicide victims. A second and related issue has to do with the reliability and Accepted February I . 1988. Dr. Brent is Assistant Professor. Child Psychiatry. Western Psychiatric Institute and Clinic, 381 I O 'Hara St ., Pittsburgh, Pennsylvania 152 I 3. Dr. Perper is Clini cal Professor, Epidemiology. Graduate School ofPublic Health , University of Pittsburgh. and Chief Coroner. Allegheny County. Dr. Kolko is Assistant Professor. Child Psychiatry. Western Psvchiatric Institute and Clinic. Dr. Zelenak is Research Coordinator, ESSA Y Project. Western Psychiatric Institute and Clinic. Reprint requests to Dr. Brent. This work was supported by NIMH Contract No. 278-85-0026 (OD) and prepared for presentat ion at the NIMH Workshop on Strategies for Studying Suicide and Suicidal Behavior. April 30-May I. 1987. Additional support for this work was provided by the Health and Research Services Foundation No. AA-81. the W. T. Grant Foundation No. 86-1063-86. and an NIMH Clinical Investigator Award No. K08 MII0058I. The editorial comments of Drs. David Clark. Madelyn Gould. and Mohammad Shafii were greatly appreciated. Ms. Shari Adams aided in the preparation ofthi s manuscript. 0890-8567/88/2703-0362$02.00/0 © 1988 by the American Acad-
emy of Child and Adolescent Psychiatry.
stability of recall of informants who are interviewed weeks to months after the death of the suicide victim. Although parental and other informants should be interviewed before too much time has elapsed after the suicide, these informants may not be able to tolerate an interview about the suicide victim while in the throes of acute grief. An exploration of the relationship between the postmortem interval (time from death to interview) and the quality and quantity of information obtained might clarify the optimal time to approach and interview the families of suicide victims. A third, as yet unresolved, issue relates to the integration of data gleaned from multiple informants about the suicide victim into a "best-estimate" diagnosis and the comparability of these best-estimate diagnoses on suicide victims with diagnoses obtained on groups comprised of live subjects. For example, the psychological autopsy study ofShafii et al. (1985) compared matched pairs of adolescent suicide victims and surviving friends and contrasted the two groups on the basis of best-estimate diagnoses. Although Shafii et al. gathered extensive information from friends, teachers, parents, and physicians of the suicide victims, it is unclear as to the degree to which the best-estimate diagnoses derived from all these informants are comparable with best-estimate diagnoses on the live control group of surviving friends, which are heavily influenced by these survivors' self-reports. This is a particularly critical issue because estimates of suicidal risk will be derived from comparisons between live groups (e.g., suicide attempters) and suicide cornpleters, and such estimates are likely to be influenced by the asymmetry of information sources intrinsic to psychological autopsy studies. These methodological issues were explored in a study of 27 adolescent suicide victims and 56 adolescent suicidal inpatients. Specifically, the following questions were addressed: (I) How does the affective symptomatology in the informants during the period of bereavement influence their description of the suicide victim? (2) How does the time interval between the death and the interview affect the informants' reports about the suicide victims? (3) How does the asymmetry of information sources affect comparisons between suicide victims and a live centro] group? Method Sample Suicide completers. The suicide-completion sample was drawn from a consecutive series of adolescent suicide victims
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over a time period from February 1984 through June 1986. in Allegheny, Butler, and Westmoreland Counties, an area that includes and surrounds metropolitan Pittsburgh. Onl y families of adolescents aged 19 and under who recei ved a definite verdict of suicide were identified for study. The families of the suicide victims were contacted by mail 6 to 12 weeks after the death and then by phone I week later to schedule an interview. The acceptance rate was high; of 35 families approached, 27 (77 %) agreed to participate in the study. Interviews generally took place about 6 months after the death (5(= 176.0 days; S.D .= 112.3 days). Primary informants consisted of parents (92.5%) or a parental figure (7.5%; e.g., an older sister or a foster parent) in all cases, and peers or siblings in 20 of 27 cases. The majority of the interviews were performed in the homes of the families (81.5 %). with the remainder taking place at the office of the senior author. Suicidal inpatient s. Suicidal inpatients were recru ited from the Adolescent and Young Adult Module inpatient un it at Western Psychiatric Institute and Clinic. The inclusion criteria were: an age of 13 to 19, and the reason for admission to hospital including suicidal ideation with an intent to die . suicidal threat, gesture (i.e., a threat with the method to attempt suicide present, such as holding pills in hand), or attempt. Exclusion criteria were mental retardation (lQ < 70) and inability to cooperate with the interview because of psychiatric condition (e.g.• del irium, psychosis). The latter exclusion most frequently applied to patients with psychosis who were too disorganized to be interviewed but allowed for the inclusion of seven patients who were psychotically depressed. The acceptance rate was quite high ; 56 of 58 patients who were approached agreed to participate in the study (97 %). The sample of suicidal inpatients consisted of 38 patients who had made suicide attempts (referred to as "attempters") and 18 who showed suicidal ideation with a plan, suicidal threats. or gestures (referred to as "ideators"). Four of the 18 ideators had made a previous attempt. The attempters and ideators were compared and found to be similar with respect to demographics, psychiatric diagnoses, treatment history, family history of psychiatric disorder and suicide, exposure to suicidality, and availability of firearms. Based upon thi s and previous results supporting a similarity between patients with suicidal ideation and those who have engaged in actual suicidal behavior (Brent et al., 1986, in press) . these two subgroups were pooled for all subsequent analyses. The patients and their families were usually evaluated within the first 6 weeks after admission to psychiatric hospital (X=28 .6 days ; S.D.=21.0 days). Informants for the suicidal inpatients were the index patient and a parental figure. Informed consent was obtained from all informants in both groups in accordance with the guidelines of the Psychosocial Institutional Review Board of the University of Pittsburgh. This sample is described in detail elsewhere (Brent et aI., in press) .
Specific Assessment M easures Suicidal intent. The Beck Suicidal Intent Scale (Beck et al., 1974) was used to assess suicidal intent in suicide com pieters and suicidal inpatients who engaged in suicidal behavior. This study reports on only the first nine items that were adrninis-
tered to the informants for both groups. whereas the latter six items, designated for pat ient self-report. were administered onl y to inpatient suicide attempters. Psychiatric sym ptomatology and diagnoses. The K-SADSE (Orvaschel et al., 1982) was used to assess lifetime and current psychiatric symptomatology and corresponding DSM-lll diagnoses among suicide-compieters and suicidal inpatients. In addition. the affecti ve disorders portion of the K-SADS-P (Chambers et aI., 1985; Puig-Antich , 1978) was employed to rate the severity of depressive and manic symptoms at the time of the suicidal episode. Past and current psychiatric treatment were also ascertained through this interview schedule. Family history of psychiatric disorder. The lifetime prevalence of psychiatric disorders (only before the suicidal episode) was ascertained by use of the Family History-RDC (Andreasen et aI., 1977), with diagnostic criteria modified from RDC to DSM-lIl. A median of two first-degree relat ives were interviewed directly from each famil y. In addition to diagnostic information, data on past psychiatric treatment and suicidal behavior were also ascertained. Data analysis. Data analytic techniques include the assessment of intersource agreement by use of the kappa coefficient (Fleiss, 1981) and an examination of the correlations between interview variables (e.g., time from death to interview) and outcome variables (e.g.• suic idal intent, inde x subject diagnoses) by use of the nonparametric correlation coeffic ient, Spearman's rho . Results
Influence ofAffective Symptomatology on Informants ' Reports During Bereavement Parents (or parental figures) of suicide victims were dichotomized into those who met criteria for an affective disorder (e.g., minor depression, dysthymia. major depressive episode) at the time of the interview versus those that did not. There was no relationship between the presence of an affective disorder at the time of the interview and the parent's report of the adolescent's su icide intent, number of psychiatric diagnoses, or specific diagnoses of an affective, conduct, anx iety, or substance abuse disorder (Spearman's rho ranged from rho=-0.24 to 0.16, all N.S.). The presence of a current affective disorder in the parents of suicidal inpatients was similarly unrelated to these variables (rho's from -0.13 to 0.11 . all N.S.). There was also no relationship between the severity of affective symptomatology (O=no affecti ve disorder. I=minor depression or dysth ymia. 2=major depression) and the aforementioned variables in either group. Therefore. it appears that the extent or severit y of affecti ve symptomatology during the period of bereavement did not substantially influence the report of parental informants about their adolescent offspring who committed suicide. nor did affective symptomatology influence the report of parents of hospitalized suicidal adolescents.
Influence ofthe Tim e Interval Between the Suicidal Episode and Interview There was some variability as to the interval between the death and the time when families of suicide victims were
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interviewed. To consider the possible influence of this methodological variable, the correlations between the time interval and the parental report of suicidal intent, number of diagnoses, and diagnoses of affective, anxiety, substance abuse, or conduct disorder in the adolescent suicide victim were examined. No significant correlations (Spearman's rho ranged from rho=-0.20 to 0.17, all N.S.) were found. Although the interviews with parents of adolescent inpatients took place much sooner after the suicidal episode, the relationship of post-episode interval and the aforementioned variables was also not significant (rho's ranged from -0.13 to 0.23, all N.S.). Parent versus best estimate diagnoses. In this study, best estimate diagnoses for suicide victims were derived from an integration of various data sources: parents or parental adults (100%), siblings or nonrelated peers (74%), teachers or school records (41%), and medical records (41%). The absence of school records in many of the suicide victims was related to the high proportion of victims who had either dropped out or graduated from high school. Similarly, many suicide victims had had no regular medical care so, often, no records were available. For suicidal inpatients, best-estimate diagnoses were derived from parental informants and the index subjects (all 100%). Although it is clear that parent-derived diagnoses were comparable across groups, determining whether best-estimate diagnoses were also comparable was also a concern. Therefore, the K coefficient of agreement between parent and best-estimate diagnoses for both groups was computed (see Table I). For com pieters, the agreement between parent and bestestimate diagnoses was quite high (K=O. 96; p<0.0 1),indicating that parental information was much more contributory than other sources to the best-estimate diagnoses of suicide victims. For suicidal inpatients, K were lower (K=0.74, p<0.01), and this was almost entirely attributable to the tendency for the parents of suicidal inpatients to underestimate disorders of affect and substance abuse in their offspring. Presumably, parents of suicide victims also underestimated these disorders in their children. Augmentation of information about the suicide victims from parents with interviews from friends, siblings, and other informants did not appear to make up for the absence of self-report in the suicide victim. Table 2 illustrates the best-estimate and parent-derived odds ratios (OR) for several disorders in suicide victims relative to suicidal inpatients. It is apparent that the OR are lower in TABLE I. Kappa Coefficients 0/ Agreement Between Parent and Best-Estimate Diagnoses/or Adolescent Suicide Completers and Suicidal Inpatients
Diagnosis Mania/hypomania Majordepressive disorder Affective disorder with nonaffective comorbidity Substance abuse Conductdisorder Attention deficit disorder N= 27. b N ~ 56.
Q
Cornpleters" (K ± S.E.) 0.88 ± 0.20
1.00 1.00 0.85 ± 0.18
1.00 1.00
Suicidal Inpatients" (K ± S.E.) 0.48 ± 0.19 0.72±0.13 0.69 ± 0.12 0.61 ± 0.13 0.88 ± 0.13
1.00
TABLE
2. A Comparison 0/ Odds Ratios" Derived from Parental and Best Estimate Diagnoses
Diagnoses
Best Estimate
Parental
Bipolar disorder 5.0 b Affective disorder 1.1 with nonaffective comorbidity Substance abuse 3.2 b Conductdisorder 0.7 Attention deficit 3.6 b disorder Unadjusted for age or sex. b Significantly different than unity.
7Y 2.2 b 4.1 b
0.8 3.6b
Best Estimate + Parental 0.65 0.50
0.78 0.88
1.00
Q
best-estimate to best-estimate comparisons for diagnoses of substance abuse and the affective disorders, compared with parent-derived comparisons (best-estimate OR are 50 to 78% of parent OR). Given the major contribution of self-report to the best-estimate diagnoses of suicidal inpatients, the authors conclude that the relative risks based on best-estimate diagnoses are likely to be underestimates of the true relative risks. Discussion This paper demonstrates that: (I) the report of the parent does not appear to be influenced by the presence or severity of affective symptomatology at the time of the interview; (2) the report of the parent is not likely to be influenced by the time between death and the interview within a span of 2 to 6 months; and (3) the odds ratios for psychiatric disorder comparing com pieters and a live control group, based on parentderived diagnoses, are likely to be more accurate than those based upon best-estimates. Each of these conclusions will be discussed in tum.
Effectofthe Suicide on Parental Report Barraclough et aI. (1974) suggested that the suicide of a loved one might have one of two antipodal effects on a surviving informant: (1) either the informant might attempt to idealize the victim and deny any evidence of psychopathology; or, conversely, (2) the informant might exaggerate the extent of psychopathology because of the suicide. The present findings, and those of others who have performed psychological autopsies on adolescent and adult suicide victims, belie the first possibility. Over 90% of suicide victims in every reported series have been found to have at least one major psychiatric disorder (Barraclough et aI., 1974; Brent et aI., in press; Dorpat and Ripley, 1960; Rich et aI., 1986; Robins et aI., 1959; Shafii et aI., 1985). On the other hand, it is harder to determine whether the parents' grief or knowledge of the suicide led them to exaggerate their offspring's psychopathology. Although no correlation between affective symptomatology in the parental informant and a wide variety of psychiatric diagnoses was found, parental grief or affective symptomatology was not measured through use of dimensional or self-report instruments that might have more readily detected such a relationship. This may account for the differences between the present findings and those of Breslau et aI. (in press) and Griest et aI.
METHODOLOGY OF THE PSYCHOLOGICAL AUTOPSY
(1979), who found that affective symptomatology in mothers tended to increase the likelihood that they would report symptomatology in their child. On the other hand, Kashani et al. (1985) found that depressed parents tend to report oppositional and conduct problems in their children that the children themselves see as depression. Therefore, given the controversy in the literature and the present finding of a lack of relationship between parental affective symptomatology and diagnostic variables in the index subjects, further exploration of this interrelationship is warranted.
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equivalent to self-report, which means that the odds ratios comparing the two groups' best-estimates will be lower than the odds ratios comparing the two groups' parental diagnoses. An interpretation of these two sets of odds ratios may be that comparisons that are significant for both best-estimate and parental sources are most likely to be statistically and clinically important, and that comparisons that are significant for parental source only are also likely to be clinically relevant. However, comparisons that are significant only between bestestimate diagnoses may be attributable to asymmetry of sources and, therefore, should be regarded with skepticism.
Effect of Time Interval Between Death and Interview
Despite the fact that the psychological autopsy technique has been in use for nearly three decades, there has been no previous systematic effort to evaluate the impact of the time interval between the death and the interview on the quality and quantity of information elicited through the psychological autopsy procedure. Often, this time interval has been unspecified (e.g., Barraclough et al., 1974; Dorpat and Ripley, 1960; Robins et al., 1959), and in other reports, the time interval has been quite variable. For example, Shafii and colleagues (1984, 1985) began interviewing friends, siblings, and parents of adolescent suicide victims within a week of the suicide and continued to both gather information and provide support during the subsequent year-long follow-up. In other studies of adult and adolescent suicide victims, the family was contacted and interviewed between 1 and 6 months after the suicide (Fawcett and Clark, 1987; Fawcett et al., 1987; Rich et al., 1986; Shaffer and Gould, 1984). The present findings suggest that between 2 and 6 months after the death, there is no significant relationship between the amount of time lapsed and the report of informants. However, the authors' experience and that of others (e.g., Cantor, 1975) indicates that parents of youthful suicide victims are likely to refuse to be interviewed if substantially longer than 6 months has transpired between the death and the first approach to the family. Asymmetry ofIn/ormation Sources
Although previous psychological autopsy studies have employed a case-control design with live control groups (Barraclough et al., 1974; Shafii et al., 1985), the issue of the obvious asymmetry of informants has never been addressed. Previous studies of adolescent psychiatric nosology have indicated that, particularly for affective symptomatology, the child report is more closely related to the best-estimate diagnosis than is the parental report and that reliance on parental report alone will underestimate the prevalence of affective disorders (Cham bers et al., 1985; Herjanic and Reich, 1982; Reich et al., 1982; WeIner et al., 1987). It is therefore reasonable to assume that the parental description of the suicide victims will also underestimate these specific domains of psychopathology. Furthermore, although adjunctive data sources (e.g., teachers, peers, and siblings) are likely to confirm parental report, these sources do not appear to contribute much additional information to the best-estimate diagnoses, in contrast to the contribution of child reports to the best-estimate diagnoses in the live control group of suicidal inpatients in this study. The adjunctive data sources for the com pieters are probably not
Conclusion The most clinically significant question about data derived from psychological autopsy studies is: Are these data reliable and valid? The lack of relationship to parental affective state and to time elapsed after the death within a restricted time range support the reliability of the data gathered in this study. Moreover, the predominance of affective disorders and substance abuse in this series of youthful suicide victims (Brent et al., in press) is similar to other reports of youthful (Rich et al., 1986; Shafii et al., 1985; Shafii, 1986) and older (Barraclough et al., 1974; Dorpat and Ripley, 1960; Robins et al., 1959) suicide completers. Moreover, these results are convergent with those obtained from prospective studies of high risk youth (Otto, 1972; Weiner et al., 1979). Therefore, it appears that the psychiatric diagnoses derived from psychological autopsy interviews of suicide victims are probably both reliable and valid. These results appear encouraging and support the use of the psychological autopsy technique in further investigations of adolescent suicide. References Andreasen, N., Endicott, J., Spitzer, R. & Winokur, G. (1977), The family history method using Research Diagnostic Criteria: reliability and validity. Arch. Gen. Psychiatry, 34:1229-1235. Barraclough, B., Bunch, J., Nelson, B. & Sainsbury, P. (1974), A hundred cases of suicide: clinical aspects. Br. J. Psychiatry, 125:355-373. Beck, A., Schuyler, D. & Herman, J. (1974), Development of suicidal intent scales. In: The Prediction ofSuicide, eds. A. Beck, H. Resnck & D. Letierri. Bowie, Md.: Charles Press. Brent, D. A., Kalas, R., Edelbrock, C, Costello, A. J., Dulcan, M. K., & Conover, N. (1986), Psychopathology and its relationship to suicidal ideation in childhood and adolescence. J. Am. Acad. Child Psychiatry, 25:666-673. - - Perper, J. A., Goldstein, C E., et al. (in press), Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Arch. Gen. Psychiatry. Breslau, N., Davis, D. G., & Prabudic, K. (in press), Depressed mothers' reports of psychopathology in their children overstate familial risk. Psychiatry Res. Cantor, P. (1975), The effects of youthful suicide on the family. Psychiatrist's Opinion, 12:6-11. Chambers, W., Puig-Antich, J., Hirsch, M., et al. (1985), The assessment of affective disorders in children and adolescents by semistructured interview: test-retest reliability of the K-SADS-P. Arch. Gen. Psychiatry, 42:669-674. Curphey, T. J. (1968), The psychological autopsy: The role of the forensic pathologist in the multidisciplinary approach to death. Bulletin ofSuicidology, July:39-45. Dorpat, T. L. & Ripley, H. S. (1960), A study of suicide in the Seattle area. Compr. Psychiatry, 1:349-359. Fawcett, J. & Clark, D. (1987), A psychological autopsy study 0/
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adolescent suicide. Unpublished investigation funded by the Fry Foundation, The W. T. Grant Foundation, and the Arie and Ida Crowne Memorial. - - Rosman, M. & Clark, D. (1987), Substance abuse. teen suicide. and physician involvement. Unpublished grant proposal submitted to NIDA by the American Medical Association and Rush-Presbyterian-St. Luke's Medical Center. Fisher, P. & Shaffer, D. (1984), Methods for investigating suicide in young children and adolescents: an overview. In: Suicide in the Young, eds. H. S. Sudak, A. B. Ford & N. B. Rushforth. Littleton, Mass.: John Wright PSG, pp. 139-257. F1eiss, J. L. (1981), Statistical Methods for Rates and Proportions. New York: Wiley. Griest, D., Wells, K. C. & Foreland, R. (1979), An examination of predictors of maternal perceptions of maladjustment in clinicreferred children. J. Abnorm. Psychol., 88:277-282. Herjanic, B. & Reich, W. (1982), Development of a structured psychiatric interview for children: agreement between child and parent on individual symptoms. J. Abnorm. Psychol., 10:307-324. Kashani, J. H., Orvaschel, H., Burk, J. P., & Reid, J. C. (1985), Information variance: the issue of parent-child disagreement. J. Am. Acad. Child Psychiatry, 24:437-441. Orvaschel, H., Puig-Antich, J., Chambers, W., Tabrizi, M. & Johnson, R. (1982), Retrospective assessment of prepubertal major depressive episode with the K-SADS-E. J. Am. Acad. Child Psychiatry, 21:392-397. Otto, Y. (1972), Suicidal acts by children and adolescents: a followup study. Acta Psychiatr. Scand. [Suppl.], 233:1-123. Puig-Antich, J. (1978), The Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS). New York: New York State Psychiatric Institute. Reich, W., Herjanic, B., Weiner, Z. & Gandhy, P. R. (1982), Devel-
opment of a structured psychiatric interview for children: agreement on diagnosis comparing child and parent interviews. J. Abnorm. Child Psychol., 10:325-336. Rich, C. L., Young, D. & Fowler, R. C. (1986). San Diego study: I. young vs. old subjects. Arch. Gen. Psychiatry, 43:577-582. Robins, E., Murphy, G. E., Wilkinson, R. H., Gessner, S. & Kayes, J. (1959), Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. Am. J. Public Health, 49:888-899. Schneidman, E. S. & Faberow, N. L. (1961), Sample investigations of equivocal deaths. In: The Cry for Help, ed. N. L. Faberow & E. S. Schneidman. New York: McGraw-Hill, pp. 118-129. Shaffer, D. & Gould, M. (1984), A study ofcompleted and attempted suicide in adolescents. Unpublished study, NIMH Grant ROI MH38198. Shafii, M. (1986, Oct.), Psychological autopsy study of suicide in adolescents. Paper presented at the Child Depression Consortium, S1. Louis, Mo. Carrigan, S., Whittinghill, J. R. & Derrick, A. (1985), Psychological autopsy of completed suicide in children and adolescents. Am. J. Psychiatry, 142:1061-1064. - - Whittinghill, J. R., Dolen, D. C; Pearson, Y., Derrick, A. & Carrigan, S. (1984), Psychological reconstruction of completed suicide in childhood and adolescence. In: Suicide in the Young, eds. H. S. Sudak, A. B. Ford & N. B. Rushforth. Littleton, Mass.: John Wright PSG, pp. 271-294. Weiner, A., Weiner, Z. & Fishman, R. (1979), Psychiatric inpatients: eight-to-ten year follow-up. Arch. Gen. Psychiatry, 36:698-700. Weiner, Z., Reich, W., Herjanic, B., Jung, K. G. & Amado, H. (1987), Reliability, validity, and parental-child agreement studies of the Diagnostic Interview of Children and Adolescents (OICA). J. Am. Acad. Child Adolesc. Psychiatry, 26:649-653.
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Abstract. Methodological issuesin the use of the psychological autopsy technique to study adolescentsuicide victims were addressed in a study of 27 adolescent completed-suicide victims and a comparison group of 56 suicidal psychiatric inpatients. This report concludes that: (I) parent/parent figure descriptions of suicide victims were unaffected by the presence or severity of affective symptomatology in the informant at the time of the interview; (2) parent reports were unaffected by the time interval between the death and the interview, within a time span of 2 to 6 months; and (3) the asymmetry of informant sources must be considered in the interpretation of odds ratios for psychiatric disorder comparing compieters to a live control group. In light of these findingsand the convergence of several psychological autopsy studies with each other and with prospective studies, the psychological autopsy is thought to yield reliableand valid results for the study of adolescent suicide. J. Am. Acad. Child Adolesc. Psychiatry, 1988,27, 3:362-366. Key Words: suicide, psychological autopsy. The psychological autopsy is an intensive interview, or series of interviews, designed to reconstruct the social and psychological features and circumstances circumscribing the death of an individual (Schneidman and Faberow, 1961). Although this technique was originally developed in the Los Angeles Coroner's Office as a method of expanding the standard investigation of undetermined deaths (Curphey, 1968), the psychological autopsy has been used by several groups of psychiatric investigators to characterize the psychological profile of adult and adolescent suicide victims (Barraclough et al., 1974; Dorpat and Ripley, 1960; Fawcett and Clark, 1987; Fawcett et al., 1987; Rich et al., 1986; Robins et al., 1959; Shaffer and Gould, 1984; Shafii et al., 1984, 1985). Although the recent concern about suicide among youth has prompted a renewed interest in the application of this method to the study of adolescent suicide, there is a paucity of investigations into the reliability and validity of the data derived from psychological autopsy studies. A review of the literature on the application of the psychological autopsy technique reveals several methodological concerns (Barraclough et al ., 1974; Fisher and Shaffer, 1984) . First and foremost is the influence of the suicide on the quality and quantity of data obtained from a bereaved informant. The literature is unclear as to how the acute and subacute symptoms of grief may influence the report of parents (or other informants) about the suicide victims. A second and related issue has to do with the reliability and Accepted February I . 1988. Dr. Brent is Assistant Professor. Child Psychiatry. Western Psychiatric Institute and Clinic, 381 I O 'Hara St ., Pittsburgh, Pennsylvania 152 I 3. Dr. Perper is Clini cal Professor, Epidemiology. Graduate School ofPublic Health , University of Pittsburgh. and Chief Coroner. Allegheny County. Dr. Kolko is Assistant Professor. Child Psychiatry. Western Psvchiatric Institute and Clinic. Dr. Zelenak is Research Coordinator, ESSA Y Project. Western Psychiatric Institute and Clinic. Reprint requests to Dr. Brent. This work was supported by NIMH Contract No. 278-85-0026 (OD) and prepared for presentat ion at the NIMH Workshop on Strategies for Studying Suicide and Suicidal Behavior. April 30-May I. 1987. Additional support for this work was provided by the Health and Research Services Foundation No. AA-81. the W. T. Grant Foundation No. 86-1063-86. and an NIMH Clinical Investigator Award No. K08 MII0058I. The editorial comments of Drs. David Clark. Madelyn Gould. and Mohammad Shafii were greatly appreciated. Ms. Shari Adams aided in the preparation ofthi s manuscript. 0890-8567/88/2703-0362$02.00/0 © 1988 by the American Acad-
emy of Child and Adolescent Psychiatry.
stability of recall of informants who are interviewed weeks to months after the death of the suicide victim. Although parental and other informants should be interviewed before too much time has elapsed after the suicide, these informants may not be able to tolerate an interview about the suicide victim while in the throes of acute grief. An exploration of the relationship between the postmortem interval (time from death to interview) and the quality and quantity of information obtained might clarify the optimal time to approach and interview the families of suicide victims. A third, as yet unresolved, issue relates to the integration of data gleaned from multiple informants about the suicide victim into a "best-estimate" diagnosis and the comparability of these best-estimate diagnoses on suicide victims with diagnoses obtained on groups comprised of live subjects. For example, the psychological autopsy study ofShafii et al. (1985) compared matched pairs of adolescent suicide victims and surviving friends and contrasted the two groups on the basis of best-estimate diagnoses. Although Shafii et al. gathered extensive information from friends, teachers, parents, and physicians of the suicide victims, it is unclear as to the degree to which the best-estimate diagnoses derived from all these informants are comparable with best-estimate diagnoses on the live control group of surviving friends, which are heavily influenced by these survivors' self-reports. This is a particularly critical issue because estimates of suicidal risk will be derived from comparisons between live groups (e.g., suicide attempters) and suicide cornpleters, and such estimates are likely to be influenced by the asymmetry of information sources intrinsic to psychological autopsy studies. These methodological issues were explored in a study of 27 adolescent suicide victims and 56 adolescent suicidal inpatients. Specifically, the following questions were addressed: (I) How does the affective symptomatology in the informants during the period of bereavement influence their description of the suicide victim? (2) How does the time interval between the death and the interview affect the informants' reports about the suicide victims? (3) How does the asymmetry of information sources affect comparisons between suicide victims and a live centro] group? Method Sample Suicide completers. The suicide-completion sample was drawn from a consecutive series of adolescent suicide victims
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over a time period from February 1984 through June 1986. in Allegheny, Butler, and Westmoreland Counties, an area that includes and surrounds metropolitan Pittsburgh. Onl y families of adolescents aged 19 and under who recei ved a definite verdict of suicide were identified for study. The families of the suicide victims were contacted by mail 6 to 12 weeks after the death and then by phone I week later to schedule an interview. The acceptance rate was high; of 35 families approached, 27 (77 %) agreed to participate in the study. Interviews generally took place about 6 months after the death (5(= 176.0 days; S.D .= 112.3 days). Primary informants consisted of parents (92.5%) or a parental figure (7.5%; e.g., an older sister or a foster parent) in all cases, and peers or siblings in 20 of 27 cases. The majority of the interviews were performed in the homes of the families (81.5 %). with the remainder taking place at the office of the senior author. Suicidal inpatient s. Suicidal inpatients were recru ited from the Adolescent and Young Adult Module inpatient un it at Western Psychiatric Institute and Clinic. The inclusion criteria were: an age of 13 to 19, and the reason for admission to hospital including suicidal ideation with an intent to die . suicidal threat, gesture (i.e., a threat with the method to attempt suicide present, such as holding pills in hand), or attempt. Exclusion criteria were mental retardation (lQ < 70) and inability to cooperate with the interview because of psychiatric condition (e.g.• del irium, psychosis). The latter exclusion most frequently applied to patients with psychosis who were too disorganized to be interviewed but allowed for the inclusion of seven patients who were psychotically depressed. The acceptance rate was quite high ; 56 of 58 patients who were approached agreed to participate in the study (97 %). The sample of suicidal inpatients consisted of 38 patients who had made suicide attempts (referred to as "attempters") and 18 who showed suicidal ideation with a plan, suicidal threats. or gestures (referred to as "ideators"). Four of the 18 ideators had made a previous attempt. The attempters and ideators were compared and found to be similar with respect to demographics, psychiatric diagnoses, treatment history, family history of psychiatric disorder and suicide, exposure to suicidality, and availability of firearms. Based upon thi s and previous results supporting a similarity between patients with suicidal ideation and those who have engaged in actual suicidal behavior (Brent et al., 1986, in press) . these two subgroups were pooled for all subsequent analyses. The patients and their families were usually evaluated within the first 6 weeks after admission to psychiatric hospital (X=28 .6 days ; S.D.=21.0 days). Informants for the suicidal inpatients were the index patient and a parental figure. Informed consent was obtained from all informants in both groups in accordance with the guidelines of the Psychosocial Institutional Review Board of the University of Pittsburgh. This sample is described in detail elsewhere (Brent et aI., in press) .
Specific Assessment M easures Suicidal intent. The Beck Suicidal Intent Scale (Beck et al., 1974) was used to assess suicidal intent in suicide com pieters and suicidal inpatients who engaged in suicidal behavior. This study reports on only the first nine items that were adrninis-
tered to the informants for both groups. whereas the latter six items, designated for pat ient self-report. were administered onl y to inpatient suicide attempters. Psychiatric sym ptomatology and diagnoses. The K-SADSE (Orvaschel et al., 1982) was used to assess lifetime and current psychiatric symptomatology and corresponding DSM-lll diagnoses among suicide-compieters and suicidal inpatients. In addition. the affecti ve disorders portion of the K-SADS-P (Chambers et aI., 1985; Puig-Antich , 1978) was employed to rate the severity of depressive and manic symptoms at the time of the suicidal episode. Past and current psychiatric treatment were also ascertained through this interview schedule. Family history of psychiatric disorder. The lifetime prevalence of psychiatric disorders (only before the suicidal episode) was ascertained by use of the Family History-RDC (Andreasen et aI., 1977), with diagnostic criteria modified from RDC to DSM-lIl. A median of two first-degree relat ives were interviewed directly from each famil y. In addition to diagnostic information, data on past psychiatric treatment and suicidal behavior were also ascertained. Data analysis. Data analytic techniques include the assessment of intersource agreement by use of the kappa coefficient (Fleiss, 1981) and an examination of the correlations between interview variables (e.g., time from death to interview) and outcome variables (e.g.• suic idal intent, inde x subject diagnoses) by use of the nonparametric correlation coeffic ient, Spearman's rho . Results
Influence ofAffective Symptomatology on Informants ' Reports During Bereavement Parents (or parental figures) of suicide victims were dichotomized into those who met criteria for an affective disorder (e.g., minor depression, dysthymia. major depressive episode) at the time of the interview versus those that did not. There was no relationship between the presence of an affective disorder at the time of the interview and the parent's report of the adolescent's su icide intent, number of psychiatric diagnoses, or specific diagnoses of an affective, conduct, anx iety, or substance abuse disorder (Spearman's rho ranged from rho=-0.24 to 0.16, all N.S.). The presence of a current affective disorder in the parents of suicidal inpatients was similarly unrelated to these variables (rho's from -0.13 to 0.11 . all N.S.). There was also no relationship between the severity of affective symptomatology (O=no affecti ve disorder. I=minor depression or dysth ymia. 2=major depression) and the aforementioned variables in either group. Therefore. it appears that the extent or severit y of affecti ve symptomatology during the period of bereavement did not substantially influence the report of parental informants about their adolescent offspring who committed suicide. nor did affective symptomatology influence the report of parents of hospitalized suicidal adolescents.
Influence ofthe Tim e Interval Between the Suicidal Episode and Interview There was some variability as to the interval between the death and the time when families of suicide victims were
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interviewed. To consider the possible influence of this methodological variable, the correlations between the time interval and the parental report of suicidal intent, number of diagnoses, and diagnoses of affective, anxiety, substance abuse, or conduct disorder in the adolescent suicide victim were examined. No significant correlations (Spearman's rho ranged from rho=-0.20 to 0.17, all N.S.) were found. Although the interviews with parents of adolescent inpatients took place much sooner after the suicidal episode, the relationship of post-episode interval and the aforementioned variables was also not significant (rho's ranged from -0.13 to 0.23, all N.S.). Parent versus best estimate diagnoses. In this study, best estimate diagnoses for suicide victims were derived from an integration of various data sources: parents or parental adults (100%), siblings or nonrelated peers (74%), teachers or school records (41%), and medical records (41%). The absence of school records in many of the suicide victims was related to the high proportion of victims who had either dropped out or graduated from high school. Similarly, many suicide victims had had no regular medical care so, often, no records were available. For suicidal inpatients, best-estimate diagnoses were derived from parental informants and the index subjects (all 100%). Although it is clear that parent-derived diagnoses were comparable across groups, determining whether best-estimate diagnoses were also comparable was also a concern. Therefore, the K coefficient of agreement between parent and best-estimate diagnoses for both groups was computed (see Table I). For com pieters, the agreement between parent and bestestimate diagnoses was quite high (K=O. 96; p<0.0 1),indicating that parental information was much more contributory than other sources to the best-estimate diagnoses of suicide victims. For suicidal inpatients, K were lower (K=0.74, p<0.01), and this was almost entirely attributable to the tendency for the parents of suicidal inpatients to underestimate disorders of affect and substance abuse in their offspring. Presumably, parents of suicide victims also underestimated these disorders in their children. Augmentation of information about the suicide victims from parents with interviews from friends, siblings, and other informants did not appear to make up for the absence of self-report in the suicide victim. Table 2 illustrates the best-estimate and parent-derived odds ratios (OR) for several disorders in suicide victims relative to suicidal inpatients. It is apparent that the OR are lower in TABLE I. Kappa Coefficients 0/ Agreement Between Parent and Best-Estimate Diagnoses/or Adolescent Suicide Completers and Suicidal Inpatients
Diagnosis Mania/hypomania Majordepressive disorder Affective disorder with nonaffective comorbidity Substance abuse Conductdisorder Attention deficit disorder N= 27. b N ~ 56.
Q
Cornpleters" (K ± S.E.) 0.88 ± 0.20
1.00 1.00 0.85 ± 0.18
1.00 1.00
Suicidal Inpatients" (K ± S.E.) 0.48 ± 0.19 0.72±0.13 0.69 ± 0.12 0.61 ± 0.13 0.88 ± 0.13
1.00
TABLE
2. A Comparison 0/ Odds Ratios" Derived from Parental and Best Estimate Diagnoses
Diagnoses
Best Estimate
Parental
Bipolar disorder 5.0 b Affective disorder 1.1 with nonaffective comorbidity Substance abuse 3.2 b Conductdisorder 0.7 Attention deficit 3.6 b disorder Unadjusted for age or sex. b Significantly different than unity.
7Y 2.2 b 4.1 b
0.8 3.6b
Best Estimate + Parental 0.65 0.50
0.78 0.88
1.00
Q
best-estimate to best-estimate comparisons for diagnoses of substance abuse and the affective disorders, compared with parent-derived comparisons (best-estimate OR are 50 to 78% of parent OR). Given the major contribution of self-report to the best-estimate diagnoses of suicidal inpatients, the authors conclude that the relative risks based on best-estimate diagnoses are likely to be underestimates of the true relative risks. Discussion This paper demonstrates that: (I) the report of the parent does not appear to be influenced by the presence or severity of affective symptomatology at the time of the interview; (2) the report of the parent is not likely to be influenced by the time between death and the interview within a span of 2 to 6 months; and (3) the odds ratios for psychiatric disorder comparing com pieters and a live control group, based on parentderived diagnoses, are likely to be more accurate than those based upon best-estimates. Each of these conclusions will be discussed in tum.
Effectofthe Suicide on Parental Report Barraclough et aI. (1974) suggested that the suicide of a loved one might have one of two antipodal effects on a surviving informant: (1) either the informant might attempt to idealize the victim and deny any evidence of psychopathology; or, conversely, (2) the informant might exaggerate the extent of psychopathology because of the suicide. The present findings, and those of others who have performed psychological autopsies on adolescent and adult suicide victims, belie the first possibility. Over 90% of suicide victims in every reported series have been found to have at least one major psychiatric disorder (Barraclough et aI., 1974; Brent et aI., in press; Dorpat and Ripley, 1960; Rich et aI., 1986; Robins et aI., 1959; Shafii et aI., 1985). On the other hand, it is harder to determine whether the parents' grief or knowledge of the suicide led them to exaggerate their offspring's psychopathology. Although no correlation between affective symptomatology in the parental informant and a wide variety of psychiatric diagnoses was found, parental grief or affective symptomatology was not measured through use of dimensional or self-report instruments that might have more readily detected such a relationship. This may account for the differences between the present findings and those of Breslau et aI. (in press) and Griest et aI.
METHODOLOGY OF THE PSYCHOLOGICAL AUTOPSY
(1979), who found that affective symptomatology in mothers tended to increase the likelihood that they would report symptomatology in their child. On the other hand, Kashani et al. (1985) found that depressed parents tend to report oppositional and conduct problems in their children that the children themselves see as depression. Therefore, given the controversy in the literature and the present finding of a lack of relationship between parental affective symptomatology and diagnostic variables in the index subjects, further exploration of this interrelationship is warranted.
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equivalent to self-report, which means that the odds ratios comparing the two groups' best-estimates will be lower than the odds ratios comparing the two groups' parental diagnoses. An interpretation of these two sets of odds ratios may be that comparisons that are significant for both best-estimate and parental sources are most likely to be statistically and clinically important, and that comparisons that are significant for parental source only are also likely to be clinically relevant. However, comparisons that are significant only between bestestimate diagnoses may be attributable to asymmetry of sources and, therefore, should be regarded with skepticism.
Effect of Time Interval Between Death and Interview
Despite the fact that the psychological autopsy technique has been in use for nearly three decades, there has been no previous systematic effort to evaluate the impact of the time interval between the death and the interview on the quality and quantity of information elicited through the psychological autopsy procedure. Often, this time interval has been unspecified (e.g., Barraclough et al., 1974; Dorpat and Ripley, 1960; Robins et al., 1959), and in other reports, the time interval has been quite variable. For example, Shafii and colleagues (1984, 1985) began interviewing friends, siblings, and parents of adolescent suicide victims within a week of the suicide and continued to both gather information and provide support during the subsequent year-long follow-up. In other studies of adult and adolescent suicide victims, the family was contacted and interviewed between 1 and 6 months after the suicide (Fawcett and Clark, 1987; Fawcett et al., 1987; Rich et al., 1986; Shaffer and Gould, 1984). The present findings suggest that between 2 and 6 months after the death, there is no significant relationship between the amount of time lapsed and the report of informants. However, the authors' experience and that of others (e.g., Cantor, 1975) indicates that parents of youthful suicide victims are likely to refuse to be interviewed if substantially longer than 6 months has transpired between the death and the first approach to the family. Asymmetry ofIn/ormation Sources
Although previous psychological autopsy studies have employed a case-control design with live control groups (Barraclough et al., 1974; Shafii et al., 1985), the issue of the obvious asymmetry of informants has never been addressed. Previous studies of adolescent psychiatric nosology have indicated that, particularly for affective symptomatology, the child report is more closely related to the best-estimate diagnosis than is the parental report and that reliance on parental report alone will underestimate the prevalence of affective disorders (Cham bers et al., 1985; Herjanic and Reich, 1982; Reich et al., 1982; WeIner et al., 1987). It is therefore reasonable to assume that the parental description of the suicide victims will also underestimate these specific domains of psychopathology. Furthermore, although adjunctive data sources (e.g., teachers, peers, and siblings) are likely to confirm parental report, these sources do not appear to contribute much additional information to the best-estimate diagnoses, in contrast to the contribution of child reports to the best-estimate diagnoses in the live control group of suicidal inpatients in this study. The adjunctive data sources for the com pieters are probably not
Conclusion The most clinically significant question about data derived from psychological autopsy studies is: Are these data reliable and valid? The lack of relationship to parental affective state and to time elapsed after the death within a restricted time range support the reliability of the data gathered in this study. Moreover, the predominance of affective disorders and substance abuse in this series of youthful suicide victims (Brent et al., in press) is similar to other reports of youthful (Rich et al., 1986; Shafii et al., 1985; Shafii, 1986) and older (Barraclough et al., 1974; Dorpat and Ripley, 1960; Robins et al., 1959) suicide completers. Moreover, these results are convergent with those obtained from prospective studies of high risk youth (Otto, 1972; Weiner et al., 1979). Therefore, it appears that the psychiatric diagnoses derived from psychological autopsy interviews of suicide victims are probably both reliable and valid. These results appear encouraging and support the use of the psychological autopsy technique in further investigations of adolescent suicide. References Andreasen, N., Endicott, J., Spitzer, R. & Winokur, G. (1977), The family history method using Research Diagnostic Criteria: reliability and validity. Arch. Gen. Psychiatry, 34:1229-1235. Barraclough, B., Bunch, J., Nelson, B. & Sainsbury, P. (1974), A hundred cases of suicide: clinical aspects. Br. J. Psychiatry, 125:355-373. Beck, A., Schuyler, D. & Herman, J. (1974), Development of suicidal intent scales. In: The Prediction ofSuicide, eds. A. Beck, H. Resnck & D. Letierri. Bowie, Md.: Charles Press. Brent, D. A., Kalas, R., Edelbrock, C, Costello, A. J., Dulcan, M. K., & Conover, N. (1986), Psychopathology and its relationship to suicidal ideation in childhood and adolescence. J. Am. Acad. Child Psychiatry, 25:666-673. - - Perper, J. A., Goldstein, C E., et al. (in press), Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Arch. Gen. Psychiatry. Breslau, N., Davis, D. G., & Prabudic, K. (in press), Depressed mothers' reports of psychopathology in their children overstate familial risk. Psychiatry Res. Cantor, P. (1975), The effects of youthful suicide on the family. Psychiatrist's Opinion, 12:6-11. Chambers, W., Puig-Antich, J., Hirsch, M., et al. (1985), The assessment of affective disorders in children and adolescents by semistructured interview: test-retest reliability of the K-SADS-P. Arch. Gen. Psychiatry, 42:669-674. Curphey, T. J. (1968), The psychological autopsy: The role of the forensic pathologist in the multidisciplinary approach to death. Bulletin ofSuicidology, July:39-45. Dorpat, T. L. & Ripley, H. S. (1960), A study of suicide in the Seattle area. Compr. Psychiatry, 1:349-359. Fawcett, J. & Clark, D. (1987), A psychological autopsy study 0/
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adolescent suicide. Unpublished investigation funded by the Fry Foundation, The W. T. Grant Foundation, and the Arie and Ida Crowne Memorial. - - Rosman, M. & Clark, D. (1987), Substance abuse. teen suicide. and physician involvement. Unpublished grant proposal submitted to NIDA by the American Medical Association and Rush-Presbyterian-St. Luke's Medical Center. Fisher, P. & Shaffer, D. (1984), Methods for investigating suicide in young children and adolescents: an overview. In: Suicide in the Young, eds. H. S. Sudak, A. B. Ford & N. B. Rushforth. Littleton, Mass.: John Wright PSG, pp. 139-257. F1eiss, J. L. (1981), Statistical Methods for Rates and Proportions. New York: Wiley. Griest, D., Wells, K. C. & Foreland, R. (1979), An examination of predictors of maternal perceptions of maladjustment in clinicreferred children. J. Abnorm. Psychol., 88:277-282. Herjanic, B. & Reich, W. (1982), Development of a structured psychiatric interview for children: agreement between child and parent on individual symptoms. J. Abnorm. Psychol., 10:307-324. Kashani, J. H., Orvaschel, H., Burk, J. P., & Reid, J. C. (1985), Information variance: the issue of parent-child disagreement. J. Am. Acad. Child Psychiatry, 24:437-441. Orvaschel, H., Puig-Antich, J., Chambers, W., Tabrizi, M. & Johnson, R. (1982), Retrospective assessment of prepubertal major depressive episode with the K-SADS-E. J. Am. Acad. Child Psychiatry, 21:392-397. Otto, Y. (1972), Suicidal acts by children and adolescents: a followup study. Acta Psychiatr. Scand. [Suppl.], 233:1-123. Puig-Antich, J. (1978), The Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS). New York: New York State Psychiatric Institute. Reich, W., Herjanic, B., Weiner, Z. & Gandhy, P. R. (1982), Devel-
opment of a structured psychiatric interview for children: agreement on diagnosis comparing child and parent interviews. J. Abnorm. Child Psychol., 10:325-336. Rich, C. L., Young, D. & Fowler, R. C. (1986). San Diego study: I. young vs. old subjects. Arch. Gen. Psychiatry, 43:577-582. Robins, E., Murphy, G. E., Wilkinson, R. H., Gessner, S. & Kayes, J. (1959), Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. Am. J. Public Health, 49:888-899. Schneidman, E. S. & Faberow, N. L. (1961), Sample investigations of equivocal deaths. In: The Cry for Help, ed. N. L. Faberow & E. S. Schneidman. New York: McGraw-Hill, pp. 118-129. Shaffer, D. & Gould, M. (1984), A study ofcompleted and attempted suicide in adolescents. Unpublished study, NIMH Grant ROI MH38198. Shafii, M. (1986, Oct.), Psychological autopsy study of suicide in adolescents. Paper presented at the Child Depression Consortium, S1. Louis, Mo. Carrigan, S., Whittinghill, J. R. & Derrick, A. (1985), Psychological autopsy of completed suicide in children and adolescents. Am. J. Psychiatry, 142:1061-1064. - - Whittinghill, J. R., Dolen, D. C; Pearson, Y., Derrick, A. & Carrigan, S. (1984), Psychological reconstruction of completed suicide in childhood and adolescence. In: Suicide in the Young, eds. H. S. Sudak, A. B. Ford & N. B. Rushforth. Littleton, Mass.: John Wright PSG, pp. 271-294. Weiner, A., Weiner, Z. & Fishman, R. (1979), Psychiatric inpatients: eight-to-ten year follow-up. Arch. Gen. Psychiatry, 36:698-700. Weiner, Z., Reich, W., Herjanic, B., Jung, K. G. & Amado, H. (1987), Reliability, validity, and parental-child agreement studies of the Diagnostic Interview of Children and Adolescents (OICA). J. Am. Acad. Child Adolesc. Psychiatry, 26:649-653.