Psychological autopsy studies as diagnostic tools: are they methodologically flawed?

One of the most established "truths" in suicidology is that almost all (90% or more) of those who kill themselves suffer from one or more mental disorders, and a causal link between the two is implied. Psychological autopsy (PA) studies constitute one main evidence base for this conclusion. However, there has been little reflection on the reliability and validity of this method. For example, psychiatric diagnoses are assigned to people who have died by suicide by interviewing a few of the relatives and/or friends, often many years after the suicide. In this article, we scrutinize PA studies with particular focus on the diagnostic process and demonstrate that they cannot constitute a valid evidence base for a strong relationship between mental disorders and suicide. We show that most questions asked to assign a diagnosis are impossible to answer reliably by proxies, and thus, one cannot validly make conclusions. Thus, as a diagnostic tool psychological autopsies should now be abandoned. Instead, we recommend qualitative approaches focusing on the understanding of suicide beyond mental disorders, where narratives from a relatively high number of informants around each suicide are systematically analyzed in terms of the informants' relationships with the deceased.