Psychological Autopsy in Adolescent Suicide: Evaluating Risk Factors and Research Methods
Article information
Abstract
Objective
The primary purpose of this literature review is to explore and integrate findings from various psychological autopsy (PA) studies to identify critical risk factors associated with adolescent suicide and evaluate the methodologies employed in these investigations.
Methods
A systematic review of 15 studies reporting psychological autopsies of adolescent suicides was conducted. Data sources included databases such as PubMed, Google Scholar, and RISS. Studies were selected based on empirical research focused on adolescent suicides, conducted since 1970, and written in English. Two reviewers independently screened and selected studies, with a third reviewer resolving any disagreements. The studies were analyzed for sample characteristics, included variables, and specific features of the PA methodology.
Results
The review identified consistent findings across studies, highlighting the significant role of mental illnesses and sociodemographic factors in adolescent suicides. Methodological variations were noted in interview timing, source selection, and the use of semi-structured interviews. The review also emphasized the importance of comprehensive data collection, including social network and mobile activity data, to better understand suicide risk factors. Key challenges identified include retrospective data bias and cultural differences affecting the generalizability of findings.
Conclusion
The review underscores the need for standardized PA procedures, particularly tailored to adolescents, to improve the reliability and validity of findings. The consistent association of psychiatric disorders with suicide risk emphasizes the urgent need for effective mental health interventions. Future research should focus on developing ethical, culturally sensitive, and methodologically rigorous approaches to enhance the understanding and prevention of adolescent suicide.
INTRODUCTION
Psychological autopsy (PA) is a methodological approach aimed at understanding the reasons behind suicide by examining the psychological and behavioral changes exhibited by individuals before their deaths [1,2]. This analytical endeavor is executed through a meticulous examination of declarations and documents provided by individuals who were intimately acquainted with the decedent. In cases of suicide, comprehensive data about the deceased are collected through interviews with close acquaintances and are systematically analyzed to understand the factors contributing to the suicide [2]. PA generally encompasses interviews directed at family members or acquaintances who maintained proximity to the deceased, alongside the accumulation of all pertinent documentation, which includes but is not limited to medical and psychiatric records [3].
Suicidal behavior is a continuous and complex concept encompassing suicidal thoughts, intentions, attempts, and death. Traditional suicide studies have primarily targeted individuals with suicidal thoughts or those who have attempted suicide. However, risk factors for suicidal thoughts and attempts may differ significantly from those for actual suicide. Therefore, PA studies are essential to prevent such deaths [4].
Suicide is a global issue, affecting not only adults but also adolescents. The proportion of adolescent suicides among all suicides is increasing, and the age at which adolescents are committing suicide is getting younger [5]. Although various preventive policies targeting adolescent suicide have been implemented, this trend does not seem to be improving. Therefore, identifying the causes of adolescent suicide and understanding both risk and protective factors is crucial for establishing effective suicide prevention policies and on-site interventions [1]. Brent proposed that psychological autopsies in adolescents are particularly advantageous because comprehensive interviews with their family, friends, teachers, and health professionals are more feasibly conducted than interviews in adult suicides [6]. Despite this advantage, the relatively infrequent occurrence of adolescent suicides compared to adult suicides has resulted in a scarcity of studies dedicated exclusively to PA methods and procedures tailored to adolescents [7].
Recent studies continue to emphasize the importance of PA in that it can lay the groundwork for effective policy making for suicide prevention by building data on which psychological and social situations an individual makes the extreme choice of suicide through PA [8,9]. In the case of adolescent suicide, a social and psychological context different from that of adults should be included in the autopsy procedure, and a customized investigation method is needed for adolescents [9]. In adolescent suicide, interpersonal problems, family conflicts, and relationships with school or peers are the main risk factors, and, unlike adult suicide, interpersonal problems are pointed out as important differences [10]. In addition, adolescents need to collect information from various sources, such as friends, siblings, and school officials, as well as their parents, even information provider selection. Because adolescents have developmental characteristics in which interaction with their peers is important, information from friends and school staff is particularly important, which is differentiated from the way adolescent autopsies obtain information primarily from family and spouses [11]. This can lead to a deeper understanding of adolescent suicide and the establishment of customized prevention strategies [8].
One of the main challenges in conducting psychological autopsies in adolescents is obtaining consent and cooperation for interviews. Families often feel stigmatized and may conceal the suicide [12]. Additionally, accessing cases after suicide can be difficult, and the high cost and time required for these autopsies make studies even more complicated. Despite these obstacles, the importance of PA remains clear. Creating a database of psychosocial factors surrounding adolescent suicide can help develop effective prevention policies. To date, these procedures have focused primarily on adults. However, adolescent suicides occur in different social and psychological contexts and require tailored investigation methods. This review examines reported cases of psychological autopsies in adolescents and explores effective methods for studying these suicides, aiming to reduce youth suicide rates over time [13].
METHODS
Information sources and search strategies
To identify the studies included in the review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic review. In this study, we identified the relevant literature by applying keywords such as psychiatric autopsy, suicide, and youth or adolescents using the PubMed, Embase, Web of Science, Google Scholar, and RISS databases. As a result, 180 papers were initially retrieved. The inclusion criteria of this systematic review were: 1) empirical studies focused on the PA of adolescents (10–19 years old) who died by suicide, 2) studies conducted after 1970, 3) studies in English, and 4) studies that provided a detailed methodology for performing PA. Exclusion criteria included: 1) studies with unclear or insufficient descriptions of the PA method, 2) studies including a significant number of adults (e.g., age range extending beyond adolescence) without separately reporting adolescent-related data, 3) non-empirical studies such as literature reviews or theoretical papers, and 4) case studies without sufficient generalizability. Based on these criteria, a total of 15 studies were selected for further analysis.
Selection process
Two reviewers independently screened studies based on the inclusion criteria. The abstracts of the articles were then reviewed for secondary screening, and the final selected studies were subjected to expert review. In cases of disagreement, a third reviewer assessed the articles to reach a consensus on inclusion or exclusion.
Ethics
This study was approved by the Institutional Review Board of Sungkyunkwan University, Seoul, Republic of Korea (IRB no.SKKU-2021-12-002-002). Informed consent was obtained from all participants at the time of enrollment.
RESULTS
After removing redundancies, 166 records were analyzed to exclude studies that did not meet the eligibility criteria, resulting in the selection of 15 studies for inclusion in this systematic review, as shown in Figure 1.
PRISMA flowchart of study selection for a review on psychological autopsy studies in adolescents.
The purpose of this review was to describe the methodology used for the application of psychological autopsies and to synthesize the main results. First, we provide an overview of the main findings of the analyzed studies. Then, we present a detailed description of the methodology, focusing on study design, sample characteristics, included variables, and specific features of psychological autopsies.
Main findings of the included studies
Table 1 summarizes the main goals and findings of the studies considered in this review. In this section, we focus on reporting the main findings, and each study investigated the risk factors related to suicide through PA.
Main results of the included studies
Abdullah et al. [14] found that a significant proportion of youth suicide victims in Pakistan were unmarried and had not completed primary education, with common methods being firearms for boys and pesticides for girls. Major psychiatric disorders included depression and other risk factors, such as psychotropic drug misuse, self-harm thoughts, irritability, aggression, low self-esteem, non-compliance with treatment, family conflicts, and financial difficulties. Appleby et al. [15] found significant social, interpersonal, and clinical differences between individuals who died by suicide and the control group under the age of 35 years in Greater Manchester. Higher rates of severe mental illness and alcohol and drug misuse were observed among individuals who died by suicide, along with unemployment, being single, lack of friends, recent negative life events, parental divorce, and child abuse.
Aquila et al. [16] highlighted the importance of using social networks and mobile technologies in PAs and found that incorporating these data provided better understanding and prevention strategies for suicide than traditional methods. Blanchard et al. [17] analyzed social and family factors influencing a Pueblo adolescent’s suicide and suggested issues such as family background, parental alcohol use, and cultural identity dissolution as contributing factors.
Balt et al. [18] explored the role of social media in adolescent suicide to identify both positive and negative effects. Social media provided peer support and recovery cases, but it also resulted in negative effects such as social comparison, suicidal behavior imitation, dependence, and cyber damage. These negative effects were more pronounced in girls affected by social comparisons and online triggers, with boys using social media more for real-world communication. Cyberbullying has in some cases been identified as a serious risk factor.
Several studies focused on gifted adolescents. Cook et al. [19] identified retroactive challenges and the need for institutional support in their autopsies on gifted adolescents who died by suicide, emphasizing the therapeutic effects of autopsies for the loved ones/acquaintances that remain after the person has died.
Lee et al. [20] found that 97.2% of adolescents who died by suicide had at least one major mental disorder, with depression being the most common. In addition, 80.6% of parents reported warning signs, such as verbal and emotional signals, before adolescents died. However, these signs were often difficult for families to recognize due to adolescent personality traits, such as avoidance and obedience.
Methodologies
Study design
The studies covered in this review had diverse study designs, as summarized in Table 2. Out of the 15 studies, 10 used a qualitative study design [14,16-19,21-25, and one used a quantitative design [26]. Four studies employed blended methods, incorporating both quantitative and qualitative methods [15,20,27,28].
Sample characteristics
Sample characteristics
The studies included in this review employed various research designs and had distinct characteristics in terms of inclusion criteria, region, sample size, gender distribution, and age range. Herein, we summarize the characteristics of the samples used in each study.
Abdullah et al. [14] conducted a study in Khyber Pakhtunkhwa, Pakistan, involving 63 individuals (38 boys and 25 girls) aged between 12 and 26 years, with data collected from at least two informants regarding deaths suspected to be suicides. This study highlighted regional variations and the importance of cultural contexts in understanding adolescent suicide.
In the UK, Appleby et al. [15] studied individuals under 35 years of age in Greater Manchester whose deaths had received a suicide or probable suicides between January 1995 and June 1996. Their sample included 84 suicides and 64 controls who were age- and gender-matched non-suicides obtained through the general practices often matched cases, emphasizing the role of young adults in suicide statistics. Similarly, Houston et al. [23] investigated 27 individuals (25 boys and 2 girls) aged 15 to 24 years whose deaths had received a suicide verdict, underscoring gender disparities in suicide cases.
In the Netherlands, Looijmans et al. [24] focused on 35 adolescents aged 14 to 19 years who died by suicide in 2017, providing insights into recent trends and preventive measures in Europe.
Several studies specifically targeted adolescent populations. Marttunen et al. [25] examined 116 officially classified suicide cases in Finland with a particular focus on 19 female individuals aged 13–22 years, thus shedding light on gender-specific risk factors and preventive strategies. In Norway, Freuchen et al. [27] analyzed 84 adolescents (42 suicide deaths and 42 accidental deaths) who died between 1993 and 2004, providing detailed age ranges and drawing comparisons between suicide and other accidental deaths. González-Castro et al. [22] conducted research in Mexico on 28 suicide cases involving equal numbers of boys and girls aged 10–17 years, contributing to our understanding of gender and age dynamics in suicide cases.
Several studies have explored suicides in unique populations and settings. In the US Midwest, Cook et al. [19] and Cross et al. [21] studied gifted students, with Cross et al. [21] focusing on a single gifted student named Daniel, aged 18 years, highlighting the pressures and mental health challenges faced by academically talented adolescents. Blanchard et al. [17] conducted a PA on a boy in the Pueblo community, illustrating the intersection of cultural identity and mental health. Aquila et al. [16] provided a detailed case study of a 17-year-old girl’s suicide in southern Italy, offering an in-depth analysis of individual and family dynamics in suicide cases. Finally, Gagnon et al. [26] studied suicide deaths and survivors in the Ottawa Valley/Outaouais region of Canada, including 29 individuals who died and 23 who survived aged between 14 and 25 years, emphasizing the regional characteristics and comparative aspects of suicide and survival.
Other variables included to support PA
When reviewing these studies, it is important to note the range of variables beyond psychiatric disorders, including sociodemographic factors and clinical characteristics. These factors include age, gender, education, marital status, educational history, work history, interpersonal relationships, financial and legal problems, and past and current mental and physical disorders. Many studies employed standardized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD) for psychiatric diagnoses, although some studies did not specify the criteria used. The variables considered in each study and the tools used for psychiatric assessment are summarized in Table 3.
Study characteristics
Several studies focused on sociodemographic and clinical factors. For example, Abdullah et al. [14] identified clinical factors such as depression, anxiety symptoms, and mental health service use history, along with psychosocial factors such as education level, and family and social relationships (DSM-5). Similarly, Freuchen et al. [27,28] examined socioeconomic factors, educational level, race, urban or rural residence, frequency of school changes, and diagnostic information from the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL), as well as suicide interest and suicidal ideation (DSM-IV). Blanchard et al. [17] used a range of psychological assessment tools to evaluate these factors, including the Rorschach test, Impulse-Ego-Superego scale, Bender Visual Motor Gestalt test, and Memory-for-Designs test.
Cyberbullying, social network activity, and family relationships were highlighted by Aquila et al. [16] as important factors in understanding suicide risk, although specific diagnostic criteria were not mentioned. Balt et al. [18] also did not use DSM diagnostics but highlighted the dual role of social media in providing positive support while also exacerbating negative effects such as cyberbullying, social comparison, and imitation of suicidal behaviors. They also emphasized gender differences, noting that girls were more vulnerable to the negative outcomes of online interactions.
Cross et al. [21] focused on identifying predictive factors for suicide, including methods of suicide, presence of suicide notes, psychological state before and after suicide, and substance use (DSM-5). González-Castro et al. [22] and Houston et al. [23] examined the methods and locations of suicide, sociodemographic characteristics, family dynamics, alcohol consumption, and psychiatric disorders (ICD-10).
Peer relationships and information provided by peers were examined by Looijmans et al. [24], who evaluated social relationships, bullying, school experiences, and social media use, emphasizing the value of peer insights for understanding the psychological state of adolescents.
Finally, Marttunen et al. [25] focused on family background, psychiatric disorders, psychiatric treatment history, psychosocial functioning, and previous suicide attempts, highlighting the complex interplay between these factors in adolescent suicide (DSM-III-R).
PA features
The characteristics of the protocols used to perform the PA are summarized in Table 4.
Psychological autopsy features
Informants and interview timing
All studies included family members as sources; however, there were differences between studies regarding sources other than family members. In addition, the timing of the PA interviews after suicide differed for each study.
Abdullah et al. [14] collected information from at least two sources: family, friends, villagers, and teachers. Interviews were conducted within four weeks of death. Appleby et al. [15] interviewed family, friends, general practitioners, and mental health staff with an average of 7.3 months (range 2–18 months) from death to interview. Blanchard et al. [17] included a variety of sources such as the parents of the deceased, social workers, school psychologists, social workers providing public health services, and dormitories staff at boarding schools. Interviews took place shortly after the suicide.
In some cases, informational sources other than people were used. Aquila et al. [16] conducted interviews by analyzing social network activities as well as using the family and friends of suicide victims as sources, and Cook et al. [19] included the victims’ medical, school life, and personal records. Cross et al. [21] conducted interviews with family, friends, teachers, and counselors, and analyzed school and health records.
González-Castro et al. [22] conducted interviews with family members within 30–60 days of the individual’s death. Houston et al. [23] conducted interviews with parents, spouses, brothers, and mental health nurses, but did not specify when they were interviewed. Marttunen et al. [25] conducted interviews with parents, relatives, friends, and school officials regarding suicides that had taken place within 1–3 months of the suicide.
Some studies conducted interviews a significant amount of time after death. Balt et al. [18] conducted interviews with colleagues and parents 2.5 years after the death, while Louijmans et al. [24] interviewed parents, friends, teachers, and health professionals an average of 1.5 years after the suicide. Freuchen et al. [27,28] reviewed parental interviews, hospital records, and police records from 1993 to 2004 and 2007 to 2009, at least 10 years after the deaths.
Interview duration and conduct
We examined the approach of each study and the level of expert involvement, summarizing the interview period reported in various studies and information about interviewers who participated in psychological autopsies.
Studies that specified interview duration and interviewer information
Abdullah et al. [14] held interviews for more than 60 minutes conducted by experienced mental health professionals, including physicians and clinical psychologists. Similarly, Appleby et al. [15] reported that experienced mental health nurses and psychiatrists conducted an average of 1.9 hours of interviews for suicide cases and 0.8 hours for control cases. Cook et al. [19] reported that a team of eight to 12 people, including graduate students and counseling psychology professors, conducted interviews for approximately two hours. Gagnon et al. [26] reported an average interview duration of 100 minutes conducted by trained clinical researchers, clinical psychologists, and psychiatrists. Houston et al. [23] reported that most interviews lasted two to three hours, with 20.4% lasting for more than three hours. A research team including a psychiatrist conducted the interviews. Looijmans et al. [24] conducted interviews with psychological experts with an average interview time of one hour.
Studies that did not specify interview duration or professional background
Blanchard et al. [17] did not mention the duration of the interview but reported that mental health experts and social workers participated. Cross et al. [21] did not mention the duration of individual interview sessions but reported that the entire interviewing period took about one year. Freuchen et al. [27,28] did not specify the duration of the interview but emphasized that the interviews were conducted by child and adolescent psychiatrists. González-Castro et al. [22] did not specify the interview time but stated that a psychologist from the Tabasco State Department of Health conducted the interview using a standardized questionnaire for PA. Marttunen et al. [25] did not specify the duration of the interview but noted that a psychiatrist conducted it.
Semi-structured interview types
Most studies employed semi-structured interviews to collect detailed information on various aspects of the deceased’s life and circumstances leading to suicide. For example, Cook et al. [19] used qualitative analysis to identify common and individual factors in the suicides of three students but did not specify their criteria. Freuchen et al. [27,28] utilized structured interview schedules to gather information on psychiatric diagnoses, interpersonal relationships, and sociodemographic factors using tools such as the K-SADS-PL.
Some studies incorporated data from various sources beyond direct interviews. Aquila et al. [16] combined traditional PA interviews with data from social networks and mobile activities to provide a comprehensive understanding of suicide cases. Similarly, Blanchard et al. [17] sought input from social workers, school psychologists, and public health service workers to enrich the data collected from family interviews.
Different studies employed various tools and methods to ensure thorough data collection. Freuchen et al. [27] recorded and cross-verified interviews to enhance reliability. Marttunen et al. [25] conducted in-depth interviews with family members, friends, and healthcare providers to gather detailed background information on deceased individuals. Lee et al. [20] went one step further by developing the Korean Youth Psychological autopsy checklist (K-PAC-A), which is designed specifically for adolescents. This checklist was created to provide a customized approach for the Korean youth population by systematically collecting clinical, developmental, and psychosocial factors that contribute to youth suicide.
DISCUSSION
This literature review synthesizes the results of several PA studies to identify key risk factors associated with youth suicide. One of our goals was to evaluate the studies’ methodologies. Key findings highlight the roles of psychiatric disorders and sociodemographic factors in adolescent suicide, and the importance of comprehensive data collection methods to gain a deeper understanding of suicide.
In the context of the PAs included in this review, the choice of informants and the time interval between the death and the PA interviews were crucial for researchers regarding the reliability and richness of the information. The role of informants in adolescent PA, such as school teachers, counselors, immediate family members, and friends, is significant due to the varying content and perspectives they provide based on their different relationships with the deceased. Similar to traditional PAs for adult suicidal individuals, family members were the main source of information in almost all studies, but the people around them, such as friends and neighbors, were also included. In some studies, the deceased were physicians [15,25], mental health workers [15], school psychologists, and social workers [17,21], health professionals [24], and personal records, such as diaries of deceased individuals [17,19]. Using informants who are close to a suicidal person may provide more information, but unreliable informants may be misleading and result in the gathering of incorrect information. It is important to consider that those close to the deceased are at greater risk of emotional involvement and memory bias [1].
In most PAs, the timing of interviews may not be as crucial as the informants. However, previous studies have suggested that PA reports should include a description of these time intervals and the investigators’ reasons for their selection [6,29]. Although it is worthwhile to keep the timing of PA consistent, there is little empirical data to guide PA researchers. Nevertheless, many PA practitioners have recommended conducting PA interviews 2 to 6 months after death [6,30,31], due to the interviewee’s crisis reaction [32] or psychopathology reports of suicide decedents [33].
The timing of interviews after death plays an important role [34]. After a long period, informants may provide vague or inaccurate details, and interviews that are too recent may not allow time for grieving. Therefore, it is important to consider timing when conducting interviews. Additionally, steps should be taken to reduce heterogeneity in interview timing as much as possible, compare differences in key measures (e.g., stressful life events and mental disorders) across interview times, and discuss the reasons for significant variability in timing when observed.
Most studies included in this review estimated the presence of psychiatric disorders in suicides based on the DSM and ICD and included trained clinical psychologists and psychiatrists as interviewers. Additionally, a semi-structured schedule was used to examine aspects of mental health as well as many other aspects of life. Psychiatric disorders, which have been consistently identified as major risk factors across studies, highlight the need for effective mental health interventions. Abdullah et al. [14] and Appleby et al. [15] showed a high prevalence of psychiatric disorders among suicide victims, which is consistent with the existing literature on the association between mental health problems and suicide risk [35]. These results suggest that the early detection and treatment of mental health conditions can reduce suicide rates [15].
Sociodemographic variables, such as age, gender, education level, marital status, and socioeconomic status, were frequently considered in these studies. Social and interpersonal differences were found between suicide and control deaths, and studies have shown that family problems, particularly parental mental health problems and a family history of suicide, are major risk factors. These results highlight the need for support programs to address not only mental health but also socioeconomic factors in at-risk populations [25]. Suicide among adolescents is associated with a combination of personality traits, psychiatric problems, and environmental factors [36].
When comparing PA in adolescents and adults, there is a marked difference in the role of mental illness and social factors, which seems to reflect the developmental context of each age group. According to Cavanagh et al. [35], approximately 91% of adult suicide cases include diagnosed mental illness, and substance abuse often acts as a significant comorbid condition. On the other hand, while mental illness is also an important factor in adolescent suicide, Marttunen et al. [37] emphasized that environmental stressors such as academic pressure, family conflict, and peer relations are more prominent in adolescents. Behavioral problems such as antisocial tendencies and substance abuse were also found to significantly contribute to the risk of adolescent suicide. These findings suggest that developmental and environmental contexts should be considered when establishing strategies for preventing adolescent suicide, as the stressors faced by adolescents differ significantly from those affecting adults [10].
In addition, the choice of informants in adolescent psychological autopsies is a critical factor that sets them apart from adult autopsies. Adolescents tend to confide their difficulties to peers rather than family members, so the collection of information from friends, teachers, and school counselors, is essential [11]. This is because peer interactions play a central role during adolescence, distinguishing adolescent autopsies from adult autopsies, which primarily gather information from family members or colleagues [8]. In addition, given the emotional vulnerability of adolescent informants, special measures are needed to protect them during the interview process, a consideration less prominent in adult’s PA. These factors highlight the need for a tailored approach in adolescent psychological autopsies to ensure the collection of accurate, comprehensive data and the development of effective, customized suicide prevention strategies [9].
The studies included in this review used a variety of methodological approaches, including qualitative, quantitative, and mixed methods. For example, Cook et al. [19] and Freuchen et al. [28] used semi-structured interviews to collect detailed information on individuals’ suicide backgrounds and circumstances. These interviews aimed to identify the causes of suicide from multiple perspectives and targeted family members, friends, and colleagues of the deceased. Aquila et al. [16] sought a more comprehensive understanding of suicide cases by combining traditional PA interviews with social network and mobile activity data. This approach leverages individuals’ digital footprints in modern society to identify the factors contributing to suicide more accurately.
However, some studies did not provide clear guidelines for how they conducted interviews. This lack of clarity can affect the consistency and reproducibility of the research, making it difficult to standardize PA procedures. In particular, there is a lack of clear guidelines on how psychological autopsies of adolescents should differ from those of adults. In cases of youth suicide, informants were often friends of the deceased. Fisher and Shaffer [8] acknowledged that PA interviews of adolescents are generally easier than those of adults, but highlighted the need for protective measures for informants such as friends. These considerations are important for developing strategies to protect the mental health of young informants during the PA process and minimize the trauma they may experience following a suicidal event.
In addition, to develop standard procedures for psychological autopsies, it is essential to establish safe and ethical methods for collecting data from informants in adolescent research. This effort can contribute to a deeper understanding of the complex social and psychological contexts surrounding youth suicide and the establishment of effective suicide prevention policies based on these insights.
Some studies did not clearly specify the criteria they used, which could have led to variability and potential bias. This lack of clarity can cause problems in the interpretation and application of the study results, making comparisons with other studies difficult. Studies that do not clearly specify standard diagnostic criteria limit reliability and reproducibility. However, Suominen et al. [38] improved the reliability of their findings by analyzing the association between major depressive disorder and suicide using DSM-III-R and ICD-9 criteria. Therefore, future research must specify and consistently apply standard diagnostic criteria to increase the reliability and validity of study findings. Additionally, methods such as recording interviews and performing cross-validation should be used to minimize potential biases in the diagnostic process.
Several challenges have been identified in performing psychological autopsies. These include reliance on retrospective data and bias among informants. These biases may arise from inaccurate memories and can affect the reliability of the data collected [39]. Additionally, reliance on retrospective data inherently involves limitations such as recall and selection bias, which can greatly affect the results of PA studies [40]. Previous research has noted that in adult PA, memory distortion or selective recall may occur depending on the time interval between death and interview, and similar caution should be taken because the same risk exists in adolescent autopsy [34]. There are alternative approaches that can be considered in future studies to reduce recall bias. The accuracy of the collected data can be improved by cross-referencing information from multiple informants and supplementing testimonies with objective data, such as medical or school records. In some cases, group interviews may help reduce this bias more effectively than individual interviews, as participants can assist each other in recalling events, thereby providing more reliable information and reducing the risk of selective recall.
Cultural and regional differences also play an important role in the generalizability of the research findings. For example, Abdullah et al. [14] found that the sociocultural context of suicide in Pakistan differed significantly from that in Western countries. These differences in cultural contexts may affect the applicability and effectiveness of intervention strategies in different regions [29]. Studies have shown that cultural factors can influence the prevalence and methods of suicide as well as interpretations and responses to suicidal behaviors [41]. For example, in studies on elderly suicide, life problems, physical illness, and interpersonal issues in specific regions and cultures were identified as major factors contributing to suicide [34]. This suggests that important risk factors may be overlooked if the cultural context is not considered when reviewing adolescents’ PA. Culturally accepted suicide methods or attitudes toward suicide may vary across regions, which can also influence suicide patterns and prevention strategies. Therefore, future PA studies should incorporate specific cultural backgrounds and regional characteristics to analyze suicide risk factors more comprehensively.
Another challenge lies in the selection process for informants participating in psychological autopsies. Most psychological autopsies attempt to include as many volunteer informants as possible; however, there is no clear agreement on who should be included as an informant. The choice of informants, such as teachers, friends, and neighbors, can vary greatly among studies, leading to potential problems with data consistency [42]. Establishing standardized guidelines for informant selection can alleviate these problems and improve the comparability of results across different studies [13].
In conclusion, the standardization process for PA should include a structured research design, validated interview protocols, and time frames for conducting interviews after suicide. In addition to organizing traditional information sources, utilizing more objective and less biased information sources such as digital footprints should also be considered [16,43,44]. Despite these limitations, our review thoroughly examined the increasing number of PAs in adolescent suicide and offers implications for future research and intervention directions.
Notes
Availability of Data and Material
Data sharing not applicable to this article as no datasets were generated or analyzed during the study.
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
Author Contributions
Conceptualization: Donghun Lee, Sangha Lee. Data curation: Sangha Lee. Formal analysis: Sangha Lee. Funding acquisition: Donghun Lee. Investigation: Sangha Lee, Seoha Kyung. Methodology: Donghun Lee, Sangha Lee. Project administration: Donghun Lee. Resources: Donghun Lee. Software: Seoha Kyung. Supervision: Donghun Lee. Validation: Sangha Lee. Visualization: Sangha Lee. Writing—original draft: all authors. Writing—review & editing: Sangha Lee, Seoha Kyung.
Funding Statement
This study was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (NRF) (NRF-2021S1A3A2A02089682).
Acknowledgments
None