Table 1.

Summary of Indian studies using psychological autopsy method

Author, year	Sample size and characteristics	Method used	Main findings	Special remarks
PA studies to determine suicide rates (n=8)
Joseph et al., 2003[6]	108,873	Verbal autopsy	Mean suicide rate for 6-year period was 95.2/100,000 (range: 83.7-106.3/100,000) and was stable during the period	These figures are much higher than the national average
Aaron et al., 2004[9]	108,000 (young people aged 10-19 years were included)	Verbal autopsy	The average annual suicide rate for young men and women was 58 and 148/100,000, respectively. Suicides were the leading cause of death in this age group	The very high rates noted call for urgent intervention in this group
Abraham et al., 2005[10]	108,873 (elderly i.e., more than 55 years were included)	Verbal autopsy	The average annual suicide rate was 189/100,000 for people over 55 years. Hanging and organophosphorous poisoning were the most common methods	These figures are very high and call for concerted efforts in this group
Prasad et al., 2006[8]	108,873	Verbal autopsy	Average suicide rate was 92.1/100,000. Hanging and organophosphorous poisoning were the most common methods. Acute or chronic stressful life events noted in nearly all subjects	These figures are 8-10 times higher than the national average. Study recommends setting up sentinel centers for suicide monitoring
Bose et al., 2006[7]	108,000	Verbal autopsy	Suicide constituted 11.3% of all deaths across age groups. Hanging and self-poisoning (with pesticides) were the preferred means of suicide	High burden of suicide was noted particularly in the 15-29-year age group
Gajalakshmi and Peto, 2007[12]	38,836 cases of suicide	Verbal autopsy	The average annual suicide rate for men and women were 71 and 53/100,000, respectively. Suicide contributed 9% of overall deaths. The most common mode was self-poisoning	Figures were higher than national average
Soman et al., 2009[11]	647	Verbal autopsy	Suicide constituted 6.6% of all deaths. Male-to-female suicide ratio was 1.7. Among females aged between 15 and 24, suicides constituted more than 50% of all deaths. Hanging was by far the most frequently used method (64%), followed by poisoning (10%)	Suicide underreporting in Kerala found to be less than in other states
Patel et al., 2012[13]	1,100,000	Enhanced verbal autopsy using routine, reliable, representative, RHIME method	About 3% of deaths in individuals aged 15 years or older were due to suicide. 40% of suicide deaths in men and 56% of suicide deaths in women occurred at ages 15-29 years. About half of suicide deaths were due to poisoning (mainly ingestions of pesticides)	Suicide death rates were higher in rural than in urban India Southern states have nearly ten-fold higher age-standardized suicide death rates than some of the northern states
PA studies to determine risk factors and cause of suicide a. Single group cross sectional studies (n=5)
Khan et al., 2005[14]	50 suicide cases, all aged between 15 and 35 years	Semi-structured, self-designed questionnaire. Demographic, clinical and psychiatric risk factors evaluated	Majority did not have psychiatric disorder (76%) or substance use (82%). The presence of precipitating factors and stressful life events are two important reasons for suicide	Most of the families of deceased (68%) had knowledge of their suicidal tendencies but could not prevent it
Behere and Behere, 2008[22]	Not mentioned. All farmers who committed suicide between January 2005 and March 2006 were included	Verbal autopsy method. Structured enquiry form with 52 questions (both open- and closed-ended questions) was used. Interview was done by trained doctor	Farmer suicides were found to be multifactorial. Social reasons and economic loss leading to family conflicts, depression, and substance use were found to be major drivers	Dedicated local communities for suicide prevention and farmer self-help groups proposed as possible interventions
Chavan et al., 2008[19]	101 suicide cases assessed	Semi-structured pro forma used to record sociodemographic profile, psychosocial variables, and treatment details. Interviews done by social worker and a qualified counselor (clinical psychologist)	High rates of suicide among migrant workers noted. Psychosocial stressors found in 60.3% of victims. Psychiatric illness diagnosed only among 33.6%	Prevention efforts in Indian context need to focus on migrants and psychosocial factors
Bastia and Kar, 2009[16]	104 cases of suicidal death by hanging (other modes of death not studied)	No details of proforma given. Information regarding suicide note and circumstantial evidence collected from police and magistrate records	Dowry stress, unemployment, financial and interpersonal conflicts were common reasons for suicide. Mental illness seen in only 4.8% of subjects	Social practices and perceptions are highlighted as priority areas for intervention
Srivastava et al., 2013[20]	100 cases of suicide	Semi-structured questionnaire based on ICD-10, including Life events scale to assess relevant life events (author used standardized Konkani version of the scale)	Psychiatric morbidity present in 94% of decedents. Contact with specialist mental health services and general health services was present in 40% and 50%, respectively	High rates of mental illness among suicide cases noted. Majority do not have a history of prior contact with health services
b. Case control studies (n=5)
Vijayakumar and Rajkumar, 1999[17]	100 completed suicide versus 100 neighborhood controls	Predesigned questionnaire with 178 items including Paykel Scale for Life Events. Psychiatric diagnosis made using SCID. Psychiatrist conducted all interviews	Presence of psychiatric morbidity, positive family psychiatric history, and recent life events were the risk factors identified. Psychiatric morbidity identified in 88% of suicide decedents	Conclusions were that risk factors for suicide are universal and not culture specific
Gururaj et al., 2004[15]	269 completed suicides versus 269 living controls	Semi-structured interview schedule was developed for the study. Four trained research officers with an educational background in sociology/social work/rural development involved in data collection	Previous suicide attempts, interpersonal conflicts, mental illness, economic loss, substance use and unemployment were observed risk factors for suicide. Psychiatric morbidity observed in 43% of cases. Personality disorder noted among 20%	Protective factors noted were good coping, problem solving and positive outlook to life
Manoranjitham et al., 2010[25]	100 completed suicides versus 100 living controls	Semi-structured interview schedule used. Psychiatric diagnosis made using SCID. Trained nurse practitioner and health-care worker conducted the interviews	Psychiatric diagnosis was present in 37% of deceased. Psychosocial stress and social isolation were bigger contributors to suicide than psychiatric morbidity	Psychosocial factors need greater focus in suicide prevention efforts in Indian context than psychiatric morbidity
Kumar et al., 2011[18]	166 completed suicides versus 166 living controls	Semi-structured interview schedule used. Psychiatric diagnosis made using SCID. PSLE used for life events. Two psychiatrists conducted the interview	Psychiatric morbidity seen in 66.7% of cases. Life events and social issues (migration and loneliness) emerged as significant risk factors for suicide
Bhise and Behere, 2016[23]	98 farmer suicide cases versus 98 living controls	Semi-structured interview schedule was used. CAGE questionnaire used to screen for alcohol-use disorder. Psychiatric diagnosis was made using DSM-5. Stressful life events in prior 3 years were enquired into	Economic issues, psychiatric illness, and stressful life events were found to be major drivers of suicide among farmers. Psychiatric morbidity present in 60% of cases, with most receiving no treatment	Socioeconomic and psychological issues are key risk factors among farmers
c. Case report (n=1)
Kulkarni et al., 2015[27]	Single case study	Thorough clinical history including context of attempt, past psychiatric history, substance abuse history, premorbid personality assessment, assimilating various caregivers’ accounts of the deceased, and using DSM-5 for psychiatric diagnoses	Major depressive disorder and inhalant abuse with marital strife was the precipitating factor.

RHIME – Re-sampled household investigation of mortality with medical evaluation; ICD-10 – International Classification of Diseases-10; SCID – Structured Clinical Interview for DSM-III-R; PSLE: Presumptive stressful life events scale; DSM – Diagnostic and statistical manual of mental disorders; PA – Psychological autopsy