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Physical disease among 21 suicide cases : Interviews of relatives and friends

Lars Gunnar Hrte, Richard Stensman and UllaBritt Sundqvist-Stensman Scand J Public Health 1996 24: 253 DOI: 10.1177/140349489602400405 The online version of this article can be found at: http://sjp.sagepub.com/content/24/4/253

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Scand J SOCMed, Vol. 24, No. 4

Physical disease among 21 suicide cases: Interviews of relatives and .friends

Lars Gunnar Horte, Richard Stensman* and UllaBritt Sundqvist-Stensman3
From the Departments of Forensic Medicine, zRehabilitatiori Medicine and 3Psycl~iatry, Uppsala University, Akadentiska sjukhuset. Uppsala. Sweden

f Physical disease anrong 21 suicide eases: interviews o relatives and friends, HBrte L.G., Stensman R., SundqvistStensman U.B. From the Departments of Forensic Medicine, Rehabilitation Medicine and Psychiatry, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden. Scand J Soc Med 1996,4 (253-258). In an earlier study made in Uppsala, it was found that in 17% of suicide cases there was a correlation between the suicidal act and serious physical disease. To obtain a deeper knowledge of this, an interview study among relatives and/or friends of 21 patients who had committed suicide was performed. Variables studied were: demographic data, somatic diagnoses, psychiatric diagnoses, contact with the medical sector, earlier suicidal signals, and the correlation between the suicidal act and the physical disease. The provision of inadequate medical treatment was sought. The persons who had committed suicide were allocated to one of three groups according to the degree of correlation between suicidal act and physical disease. Very strong correlation was found for five persons, !rather strong for nine persons, and weak for five persons. We found that physical disease was seldom decisive for the suicidal act. Medical treatment was experienced as inadequate in nine cases. Since there is reason to believe that physical disease is an important complicating risk factor for suicide, it is important to be aware of anxiety in patients and their relatives, give plenty of time for information, show empathy and give the care-providers a sense of security to avoid suffering and reduce suicidal acts. Key words: suicide, physical disease.

INTRODUCTION The background to a suicidal act is very complex and the reason for the final decision often remains unknown. Among the many risk factors discussed in connection with the process underlying a suicidal act, somatic disease is one of the life events of interest. A chronic physical disease might be the final decisive factor in a person with severe psychiatric illness such as depressive state and/or alcohol abuse. The suicide might also indicate inadequacy of medical care, greater attention perhaps being paid to technical
0 Scandinavian University

medical needs than to psychological and social aspects. In other cases, suicide may seem to be the only way out to the person who experiences his or her physical condition as desperate in spite of optimal care. In different studies, the frequency of somatic illness as an important factor for the suicidal act has been found to be 15 to 50% ( 1 , 2 , 3 , 4 , 5 ) . It is well known that physical disabilities sometimes cause depressive reactions and it is important to consider that this increases the risk of suicide (6, 7). Post stroke depression can be complicated by suicidal ideation though, according to Gordon et al, reports of suicide among stroke patients are rare ( 8 ) . Patients with chronic pain often experience depressive symptoms (9) and it is important to identify suicidal ideation among these patients (10). There is a tendency towards higher suicide rates among persons with diagnoses of cancer ( I I ) , and the background to suicide among cancer patients has been thoroughly studied (12, 13, 14). One way of obtaining more information about the suicidal process is to interview relatives and friends of the person who committed suicide. It has been shown in Swedish studies (15, 16, 17) that interviewing relatives is a method which is justified and accepted by the relatives. It is important that the time that elapses between the suicidal incident and the interview is not too long. According to Runesson (15), many interviewed persons have claimed to benefit by the interview. The validity of information obtained from the interviews with family members is confirmed by Brent et a1 (IS). The aim of the present study was, firstly, to gain more knowledge about the importance of physical disease and disability for the suicidal act by interviewing relatives and friends of persons with severe somatic disease who committed suicide. Secondly, we wanted to find out if the medical care had in any way been inadequate and thereby contributed to the suicidal process.
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L G. Horte et a!.
MATERIAL AND METHODS

the pcrsons were married (7 men, 5 women), one was living with his parents, 4 were single (3 men, 1 The registers for the years 1990-1993 kept at the woman) and 4 persons were divorced (4 men). Department of Forensic Medicine in Uppsala were scrutIn total. 29 interviews were performed. Of those inised and subjects classified as having committed suicide seven were with the spouse and five were with children and self-inflicted injury (E 950-59) and at the same time of the deceased. As to the man living with his parents, having a serious somatic disease constituted the present both parents and a sister were interviewed. For material. Thus, undetermined cases were excluded (E unmarried persons, parents, sisters, brothers, friends 980-89). and a sister-in-law were interviewed. Two ex-wives The material comprised 22 persons. Information from and/or children of the divorced men were interviewed. somatic and psychiatric records supplemented the information from the autopsy reports. The person named as close When more than one person was interviewed for the relative in the autopsy report was also contacted. Relatives same one deceased there were no discrepancies (husbands, wives, children) and friends of the subjects were between data given by different persons. The somatic diagnoses are described in Tables I-IV. first contacted by letter, in which information about the Alcohol abuse was found among six persons. study was given. We asked for an opportunity to meet and interview the person whiIe stressing that participation was Depressive disorder was the diagnosis for six persons, voluntary. Shortly thereafter, we telephoned this person to two of whom were also alcohol abusers. For 12 arrange a meeting or to conduct an interview by telephone. persons there were earlier signs of suicidal ideation. Our intention was to perform personal interviews with all They had talked about suicide or made suicide persons contacted, but practical reasons made this imposs- attempts. In one case, an 86-year-old man who ible. W e found that telephone interview provided sufficient intoxicated himself with carbon monoxide, and his information. Twenty-nine persons were interviewed, eleven wife had spoken about double suicide. The correlaof these by telephone. Only one person refused to tion between somatic diagnoses and the suicidal act participate. The interviews were performed 4-10 months after the was assessed according to information obtained from suicidal act. The variables studied were demographic fac- the interviews, medical records, and information in tors, somatic and psychiatric data, and signs of earlier the autopsy register. Three groups were identified. suicide attempts. These relatives and friends were asked to The correlations were judged to be weak, rather convey their own perceptions of the medical care received strong, or very strong. The groups are presented by the deceased. The seriousness and importance of the in Tables I-IV. physical disease for the suicidal act was judged according In two cases it was not possible to assess the to the impact of the disease on the activity of daily life. importance of the somatic disease. One man with Diseases with probably little significance were excluded, low back pain, 41 years old, with alcohol abuse, who such as fractures and cerebral trauma without sequelae and according to his wife, used the low back pain as an non-insulin dependent diabetes. Further excluded were diseases related to abuse such as Iiver dysfunction, pancreatitis, excuse to use analgesics. Another 41-year-old man, with knee trauma, operated upon several times, where and epilepsy due to abstinence. The judgement was based on information from case the wife did not agree that the man had committed records and police reports, comments by the patient to suicide, despite this being the mode of death accordpersons around them, information from relatives and ing to the death certificate. friends, and any existing farewell letters. The evaluation of As can be seen from the table, the correlation was the importance of the physical disease was made independ- judged to be very strong for five of the 21 persons. ently by two of the authors - one a psychiatrist and the The group very strong correlation seemed to be other a doctor of medical rehabilitation. This evaluation characterised by older men with the diagnosis of was,used in an earlier study, though in that study no malignant neoplasm. information from relatives or friends was available and it During the interview the relatives ivere asked to was only stated if there was importance or not (3). Since describe how they had interpreted the patients experiwe. now had more information and could discuss the importance of the disease with a close relative/friend we ence of his or her contact with medical staff and the found it reasonable to grade the importance weak, rather quality of the medical care. They were also asked strong or strong. It is, however, not possible to identify how they themselves had found the quality of the medical care to be. In nine of the 21 cases the a sharp demarcation between the groups. The study was approved by the Ethics Committee of the relatives described disappointment and characterised Faculty of Medicine, University of Uppsala, Sweden. the care as insufficient. RESULTS Among the 21 persons studied, 15 were men and 6 women. The age range was 20-86 years. Twelve of
Sand J SOC e d 24 N

DISCUSSION The number of persons studied was 21. The classification of the suicides was not re-evaluated, since

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Table I. Five suicide acts with strong correlation to physical disease. Some relevant irljbrriialioti
Age/Sex Somatic diagnoses Somatic function Psychiatric diagnoses Quality of contact with somatic care Insufficient Signals

32 M

Traumatic brain injury 12 months earlier

1. Cancer left knee op, probably radical, waiting for radiation 2. Tinnitus for 9 years

Training at work, allowed to drive a car ad 1. Crutches ad 2. No contact since 1987 Some help in her home, paid cataract operation herself Difliculties in breathing Severe pain

Slight alcohol problems, periods of slight depression No

Talked about suicide the days before None, but farewell letter

59 M

Insufficient

77 F

Cardiac ins.uK.; cataract; severe low back pain

No

Insufficient

Vague, but farewell letter

57 F 86 hl

Lung cancer, relapse Cancer of the colon with metastases

Relationship problem No

Sufficient Sufficient

None, but farewell letter Double suicide discussed

Table 11. Nine suicide acts with rather strong correlation to pliysical disease. Sonic relevant iirforitratioii
Age/sex Somatic diagnoses Somatic function Psychiatric diagnoses Quality of contact with somatic care Insufficient Signals

20 M

Bilateral heel fractures; fractures both hands

Slightly impaired function left hand

Depression 2-6 months earlier. Sensation seeker

Suicide attempt by cutting his wrists 6 months earlier None, but farewell letter Talked about suicide Suicide attempts Suicide attempt 6 months earlier Talked about suicide None None None

80 M
39 M

Hypernephroma with metastases Her. spastic paraplegia

Nothing remarkable Wheel chair, no daily help Severe pain Nothing remarkable

No Psychosis paranoides. Manic-depressive disorder Depression? Alcohol abuse? No Alcohol abuse No Alcohol abuse

Insufficient Suficient Insufficient Insuflicient

69 M
32 F

Ulcers of the lower part of the legs

Severe low back pain

23 M 43 M

Keratokonus Cancer of the kidney, OP. Cataract, vertigo, neck-ache Chronic ulceration in the colon, op. with stomy

Visus 1.0/0.3 corr.

Clin. metast, not verif. at autopsy Walked with a stick Trouble with the colostomy

Sufficient Insufficient Insufficient Sufficient

76 M
54 M

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L. G.Horte et al.

Table 111. Fire suicide acts with it.eak correlatioit to physical disease. Soiiie releraiit iiforniation
Agefsex Somatic diagnoses Somatic function Psychiatric diagnoses Quality of contact with somatic care Sufficient Signals

43 F

Severe low back pain for 16 years, accent. 3 years No op. Cataract; sciatica

Moderate pain

Severe manicdepressive disorder for 14 years Alcohol and depression Depression Mythomania, slightly mentally retarded Relationship problem

4 suicide attempts and farewell letter

75 F

Visus left eye 0,2; difficulties travelling Could cycle Nothing remarkable Slight pain

Insufficient

Talked about suicide Suicide attempts Suicide attempts Vague

74 M

Arthrosis of both hips Chronic benign painsusp. disease of connection tissue Crohns disease op. with stomy; inguinal pain postop

Suficient Sufficient

50 F

52 M

Sufficient

Table IV. Tivo suicide acts with iiistifficieitt infortnation concerttiiig correlation between suicide and physical disease. Some relevant ii formation
Agefsex
41 M
41 M

Somatic diagnoses

Somatic function Presented pain to get tablets Severe pain

Psychiatric diagnoses Alcohol abuse No

Quality of contact with somatic care ?

?

Signals None None

Low back pain

Knee trauma with pain, op several times; Psoriasis with chronic arthritis

the suicides were autopsied at the same institution and undetermined cases were excluded. Thus we have minimised the inter individual variation in the classification of suicides between different pathologists (19). There is a risk that the autopsy register of the Department of Forensic Medicine does not contain all cases of persons with severe somatic illness committing suicide. The death certificates may now be more possible to write without a forensic autopsy, since the person is well known by the health care system (20). Thus, the staff at the departments of Neurology, Medical Rehabilitation and Oncology, The Pain Centre and the diabetes ward were questioned but no further cases of suicide were reported. The interviews with relatives were easy to perform. The relatives and friends gave us lots of information about the complicated background to the suicidal act. We have also learned how relatives experience medical care and what is important in the communScand J SOC hfed 24

ication between medical staff and patients and their relatives. None of the interviewed persons expressed unease about the interview. In two cases we contacted the persons again for follow-up of possible problems caused by the interview. Neither reported such problems and our experience of interviewing relatives is in agreement with earlier research work (15, 16, 17). The interviews gave us the impression that the background to the suicidal act was verycomplicated. Serious somatic disease was of importance in many cases but only in a few cases decisive. The diagnosis in those cases was malignant neoplasm. The diagnosis malignant neoplasm was also the greatest homogeneous diagnostic group. We agree with Hietanen and Lonnquist saying that the health care system needs to pay greater heed to the psychological needs of cancer patients (14). The prevalence of chronic pain in the general population is high (21). The prevalence of this dia-

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257

gnosis in the material is therefore not unexpectedly high. Although the material is small, it is noteworthy that four persons had visual impairment and two persons colostomy. Psychiatric diagnoses were noted for 12 persons. Four persons had made suicidal attempts earlier. The psychiatric disorder was most probably an important factor behind the suicidal act for many of the persons. It is interesting to note, though, that in group A the psychiatric symptoms were not very serious and in this group there is nobody with earlier suicide attempts. Our assumption is that the somatic disease in this group was of strong importance for the suicidal act. We cannot take for sure that we are not biased in our classification since strong correlation is found among persons not having psychiatric symptoms. We have tried, though, to weigh together all the information from registers, relatives and friends as objectively as possible. Nine relatives said that the person who committed suicide and they themselves had experienced insufficient treatment from the medical staff. The impression was that this insufficiency of treatment consisted of at least two parts. One was the lack of information from the staff to the patients and to their relatives. Communication with the patient is often hampered by the patients anxiety, lack of knowledge about the human body and its functions and lack of knowledge about the disease and its implications. Secondly, the emotional implications of the disease for the patient and/or his or her relatives was not correctly interpreted by the medical staff. There was lack of empathic understanding and fertile soil for misunderstandings and dissatisfaction. There are always a certain number of persons who are disappointed at the care given. We have no reason to believe that the fraction of disappointed persons is greater among suicidal than among non-suicidal patients and their relatives. This does, however, not contradict that the information we got understates the importance of paying attention to this and to seriously listen to the dissatisfaction expressed. Finall), the study gives reason for some reflections:
- It is probably very unusual that somatic disease is

derstandings. It is also wise to check that the patient and his or her relatives have understood the information given. In that way, a lot of suffering can be avoided for the patient and his or her relatives, and suicidal acts reduced. ACKNOWLEDGEMENT
The study was supported by grants from the SoderstromKBnig Foundation.

REFERENCES
1. Beskow J. Suicide and mental disorder in Snedish men. Acta Psychiatr Scand 1979; Suppl 277. 2. Robins E. The final months. A study of the lives of 134 persons who committed suicide. New York: Oxford University Press, 1981. 3. Stensman R, Sundqvist-Stensman UB. Physical disease and disability among 416 suicide cases in Sweden. Scand J SOCMed 1988; 1 6 149-53. 4. Heikkinen hl, Aro H, Lonnqvist J. The partners views on precipitant stressors in suicide. Acta Psychiatr Scand 1992; 85: 380-4. 5. Heikkinen hl, Aro H, Lonnqvist J. Recent life events and their role in suicide as seen by the spouses. Acta Psychiatr Scand 1992; 86: 489-94. 6. Stenager EN, Stenager E. Suicide and patients with neurologic diseases. hfethodologic problems. Arch Neurol 1992; 49: 1296-1303. 7. Kyvik KO, Stenager EN, Green A, Svendsen A. Suicides in men with IDDM. Diabetes Care 1993; 17: 210-12. 8. Garden FH, Garrison SJ, Jain A. Assessing suicide risk in stroke patients: review of two cases. Arch Phys hfed Rehabil 1990; 71: 1003-5. 9. Fishbain DA, Goldberg M, RosomoKRS, Rosomoff H. Case report. Completed suicide in chronic pain. Clin J Pain 1991; 7: 29-36. 10. Livengood JM, Parris WCV. Case report. Early detection measures and triage procedures for suicide ideation in chronic pain patients. Clin J Pain 1992; 8: 164. Hakama I 11. Louhivouri & , M. Risk of suicide among cancer patients. Am J Epidemiol 1979; 109: 59-65. 12. Fox BH, Stanek EJ, Boyd SC, Flanery JT. Suicide rates among cancer patients in Connecticut. J Chron Dis 1982; 35: 89-100. 13. Bolund CI. Demographic and social characteristics of cancer patients who committed suicide in Sweden, 1973-1976. J Psychosoc Oncol 1985; 3: 17-30. 14. Hietanen P, LBnnqvist J. Cancer and suicide. Ann Oncol 1991; 2: 19-23. 15. Runeson B, Beskow J. Reactions of survivors of suicide victims to interviews. Acta Psychiatr Scand 1991; 83: 169-73. 16. Asgard U, Carlsson-Bergstrom hf. Interviews with survivors of suicides: procedures and follow-up of interview subjects. Crisis 1991; 12: 21-33.

the single factor behind the suicidal act. However, there is reason to believe that it is an important complicating risk factor. It is therefore necessary to be aware of somatic anxiety and the fact that the patient is anxious and cannot ask questions and assimilate the information from the medical staff in a meaningful way. It is important to spend plenty of time with the patient and to give comprehensible information about the situation so as to guard against misun-

3.:

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L. G. Harte et al.
21. Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sw.eden..Pain 1989; 37: 215-22.

sies: methods and ethics. Suicide and Life-Threatening Behaviour 1990; 20: 307-23. 18. Brent DA, Perper JA, Moritz G, Allman CJ, Roth C, Schweers J, Balach L. The validity of diagnoses obtained through the psychological autopsy procedure in adolescent suicide victims: use of family history. Acta Psychiatr Scand 1993; 87: 118-22. 19. HBrte L-G. Ovisshet-ett problem i suicidstatistiken. Hygiea 1983; 92: 251. 20. Veress B. Obduktionernas antal rninskar. Hot mot kunskapsktlla och rtttssskerhet. Ltkartidningen 1991;
91: 2685-7.

17. Beskow J, Runeson B, Asggrd U. Psychological a u t o p

Correspondence address: UllaBritt Sundqvist-Stensman, M.D. Department of Psychiatry, Uppsala University Akadcmiska sjukhusct S-751 85 Uppsala Sweden

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