Working Paper of Public Health Volume 2012 - Azienda Ospedaliera ...

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Azienda Ospedaliera Nazionale“SS. Antonio e Biagio e Cesare Arrigo”Working Paper of Public Healthnr. 6/2012We have recently operationalized predicament suicide (OPS) by an arrangement of 4categories, which may assist in the conceptualization and classification of triggers/drivers ofsuicide (Pridmore et al, in press): Category (Cat) A. A mental illness is clearly or probably present, and probably playeda major role in triggering the suicide. No environmental/social (non-mental illness)stressor played a major role. Cat B. An environmental/social (non-mental illness) stressor/s is clearly or probablypresent, which probably played a major role in triggering suicide. No mental illnessplayed a major role. For current purposes, terminal illness and intractable pain areconsidered as ‘external’ stressors. Cat C (combined).Mental illness and environmental/social (non-mental illness) stressors are bothpresent, and both probably played a role in triggering the suicide. In thesecircumstance it is difficult to decide which (if either) was the main trigger for thesuicide. If the influence of one is clearly predominant and the other is clearly trivial,another category may be chosen. Cat U (unclassifiable).There is insufficient or contradictory information. Also, if there is no evidence foreither mental illness or environmental/social (non-mental illness) stressor, this is theappropriate designation. Cat U can be used when dealing with uncertainty.As a result of subsequent investigations, we are considering adding a 5 th category, Cat P, toaccommodate protest suicide. However, although there are over 100 cases of protest/politicalsuicide on the public record, they are extremely rare and none have been encountered in theclinical experience of the first author.In Pridmore et al (in press), 18 experienced psychiatrists (from six different countries) read 12coroner’s reports and categorized them according to the OPS. There was acceptablecorrelation and the raters found the OPS had face validity and was easy to use. It is hoped theOPS will give people the opportunity to take a broader view of suicide, and ease them awayfrom the belief that all those who suicide do so as a result of mental disorder (although, ofcourse, mental disorder is often an important trigger).6. Discussion7
Azienda Ospedaliera Nazionale“SS. Antonio e Biagio e Cesare Arrigo”Working Paper of Public Healthnr. 6/2012This is an account of the thinking about suicide of a small group of people over a period oftwo decades. The central theme is that the current social science view that all or almost allthose who suicide do so as a consequence of mental disorder. While mental disorder is animportant factor, it is not the only factor, and focusing on the medical approaches will notserve the community well. As expected, suicide prevention strategies which focus on medicalaspects have failed to reduce suicide rates anywhere around the world (De Leo & Evans,2004; Page et al, 2012). It is time to rethink the role of mental illness in suicide (Phillips,2010).We have introduced the concept of predicament suicide, which holds that individuals usesuicide to escape (in rare instances, change) unacceptable predicaments/circumstances.We have given evidence of people taking their lives to avoid loss of reputation, loved ones,health, and finances. Our methods of using the public record (historical texts through tonewspapers and electronic resources) can be criticized as not being sufficiently ‘scientific’,which is to say, there is no place in science for common sense. Such records contain a vastvolume of valuable information.We have developed an objective system (Operationalized Predicament Suicide; OPS) whichcan be used to classify suicide, it has 4 categories, one of which allows the suicide to beclassified as due to social factors. It is hoped the existence of the OPS will encourage scholarsand clinicians to take a broader view of suicide other than the predominant suicide-is-alwaysdue-to-mental-disorderview.AcknowledgmentWe are indebted to Dr Piantato Ennio for his support.ReferencesAbondo M, Masson M, Le Gueut M, Milleet B. [Psychiatric autopsy: its uses and limits inFrance.] (French). Encephale 2008; 34:343-346.Bertolote J, Fleischmann A, De Leo, D, Wasserman D. Psychiatric diagnoses and suicide:revisiting the evidence, Crisis 2004; 25:147-155.Biffl, E. Psychological autopsies: do they belong in the courtroom? American Journal ofCriminal Law 1996; 24: 123-146.8
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