Exploring paths to youth suicide and sudden violent death : a multimethod case-control investigation

Sammanfattning: Suicide and other forms of sudden violent death are the most common causes of death among young people worldwide. Both suicide and other forms of sudden violent death are more frequent among males than females. Risk factors, suicidal behavior, and help-seeking patterns differ between young women and men. Aims: To explore the hypothesis that there are similar backgrounds to both death by suicide and to other forms of sudden violent death among youths. The aims of the quantitative studies were: (1) to compare risk factors for youth suicide and for other forms of sudden violent death with matched living controls; (2) to examine associations between life events and coping strategies common in these three groups of young people. The aims of the qualitative studies were: (3) to build a generic conceptual model of the processes underlying youth suicide, grounded in the parents’ perspective; (4) to compare boys’ and girls’ suicidal processes. Material/Methods: In the prospective longitudinal case-control design, 63 consecutive cases of youth suicide and 62 cases of other forms of sudden violent death were compared with 104 matched control cases. Data were collected in 196 psychological autopsy interviews with parents and other relatives and 240 equivalent interviews in the control group. The interviews included DSM-IV-R criteria for selected psychiatric diagnoses and measures of adverse childhood experiences, stressful life events, and ways of coping. Statistical analyses were conducted using logistic regression, factor analysis, mediation analysis, and moderator analysis. Grounded theory methodology was applied in the qualitative studies in order to give voice to and make sense of the parent’s experiences. Results: (1) The number of recent stressful life events was the only common risk factor for suicide and other forms of sudden violent death. Specific risk factors for suicide were any form of addiction and being an inpatient in adult psychiatric care, whereas for other forms of sudden violent death, risk factors were poorer elementary school results, lower educational level, and abuse of psychoactive drugs. (2) Distinctive of the suicide and the sudden violent death group was significantly less Planful Problem-Solving, and more Escape-Avoidance and Confrontive Coping than among the controls. Between-group differences were partly mediated by differences in negative life events, early and late in life. (3) Family alliances, coalitions and secrets were intertwined with the young person concealing problems and “hiding behind a mask,” whereas the professionals did not understand the emergency. Several interacting factors formed negative feedback loops. Finding no way out, the young persons looked for an “emergency exit.” Signs and preparations could be observed at different times but were recognized only in retrospect. Typically, the young persons and their parents asked for professional help but did not receive the help they needed. (4) Different forms of shame were hidden behind gender-specific masks. Both the young men and women were struggling with issues of their gender identity. Five interwoven paths to suicide were found: being hunted and haunted, being addicted, being depressed, being psychotic, or—for the girls—having an eating disorder. Conclusions: The suicide group seems to have been more vulnerable and exposed to different kinds of stressors, whereas the sudden violent death group seems to have been more prone to acting out and risk-taking. Improved recognition and understanding of the interplay between life events, both in the far past and present, and coping styles, may facilitate the identification of young people at risk of suicide and other forms of violent death. Both groups must be the subject of prevention and intervention programs. Future preventive programs need to address barriers to communication among all parties involved: the young people, parents, and community support agencies. Understanding and making use of the parents’ tacit knowledge can contribute to better prevention and treatment. Keywords: Suicide, sudden violent death, case-control study, psychological autopsy, multiple logistic regression, grounded theory, risk factors, youth, adverse childhood experiences, stressful life events, coping strategies, barriers to help, prevention.