American Journal of Orthopsychiatry Copyright 2005 by the Educational Publishing Foundation

2005, Vol. 75, No. 4, 676 – 683 0002-9432/05/$12.00 DOI: 10.1037/0002-9432.75.4.676

Completed Suicide and Psychiatric Diagnoses in Young

People: A Critical Examination of the Evidence
Alexandra Fleischmann, PhD, Annette Beautrais, PhD
José Manoel Bertolote, MD, and Christchurch School of Medicine
Myron Belfer, MD
World Health Organization
Suicide rates of young people are increasing in many geographic areas. There is a need to
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

recognize more precisely the role of specific mental disorders and their comparative importance
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for understanding suicide and its prevention. The authors reviewed the published English-
language research, where psychiatric diagnoses that met diagnostic criteria were reported, to
reexamine the presence and distribution of mental disorders in cases of completed suicide among
young people worldwide. The number and geographical distribution of cases were limited (N ⫽
894 cases). The majority of cases (88.6%) had a diagnosis of at least 1 mental disorder. Mood
disorders were most frequent (42.1%), followed by substance-related disorders (40.8%) and
disruptive behavior disorders (20.8%). Those strategies focusing exclusively on the prevention and
treatment of depression in young people need to be reconsidered. A comprehensive suicide
prevention strategy among young people should target mental disorders as a whole, not depression
alone, and consider contextual factors.

Keywords: suicide, psychiatric diagnosis, young people

Suicide in young people has been identified as a
serious public health problem worldwide. In many
countries, suicide rates among young people have
been increasing (Beautrais, 2000; Dudley, Kelk, Flo-
rio, Waters, Howard, & Taylor, 1998; Graham &
Burvill, 1992; Van Heeringen, 2001; World Health
Organization [WHO], 1999). Death due to suicide
ranks among the three leading causes of death for
those aged 15–34 years, resulting in personal and
economic loss to communities and societies world-
wide (Houston, Hawton, & Shepperd, 2001).
The WHO launched the Multisite Intervention
Study on Suicidal Behaviors (WHO, 2002) to better
understand the issues related to suicide and eventu-
ally to provide guidance on suicide prevention to
both developing and developed countries. This effort
follows on the earlier WHO/Euro Multicenter Study
on Suicidal Behavior (Schmidtke et al., 1996;
Alexandra Fleischmann, PhD, José Manoel Bertolote,
MD, and Myron Belfer, MD, Department of Mental Health
and Substance Dependence, World Health Organization,
Geneva, Switzerland; Annette Beautrais, PhD, Canterbury
Suicide Project, Christchurch School of Medicine,
Christchurch, New Zealand.
For reprints and correspondence: Alexandra Fleisch-
mann, 20 Evenue Appia, CH-1211, Geneva 27, Switzer-
land. E-mail: fleischmanna@who.int
Schmidtke, Bille-Brahe, De Leo, Kerkhof, & Was-
serman, 2001).
An important issue is the relationship between
suicide in young people and mental disorders. Al-
though the relationship has been widely discussed
and documented (Pfeffer, 2001; Rich, Young, &
Fowler, 1986; Runeson, 1989; Shaffer, Garland,
Gould, Fisher, & Trautman, 1988), it remains to be
conclusively demonstrated from a public health per-
spective. The relationship has important worldwide
implications for the development of programs to pre-
vent suicide among youth. The lack of understanding
of the relationship of diagnosable mental disorders,
especially in developing countries, represents a gap
in knowledge.
Method
A systematic study of all English-language reports on the
link between mental disorders and completed suicide was
undertaken. Precise attention was paid to the identification
in the reports of mental disorders meeting criteria estab-
lished by either the International Statistical Classification of
Diseases and Related Health Problems, Tenth Revision
(ICD-10; World Health Organization, 1992) or the Diag-
nostic and Statistical Manual of Mental Disorders (DSM,
4th ed.; American Psychiatric Association, 1994) criteria.
Relevant studies were located through searches in Medline
and Current Contents for the period from 1982 to 2001. A
search of the Lilac database (Latin America) did not reveal

676
 BRIEF REPORTS
appropriate material. The keyword combinations suicide
and adolescents, suicide and youth, suicide and young peo-
ple, suicide and psychological autopsy, suicide and psychi-
atric diagnosis, suicide and mental disorders, suicide and
epidemiology, and suicide and comorbidity were used.
Thirteen articles met the criteria and were included in the
review (see Table 1). All studies focused on young people
below the age of 30 years, although they used different age
brackets (e.g., 10 –19 years, 15–24 years). However, de-
tailed review, where possible, further narrowed the age
range for the purposes of reporting data in this article. As
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indicated in Table 1, studies applying an age bracket of up
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to 15–29 years were included. However, the majority of
cases in the overall analysis fell between 10 and 24 years of
age (84.9%). Each of the studies comprised all consecutive
completed suicides committed in a specific time period
(e.g., 1984 –1986) and in a specified area (e.g., a city, a
number of counties, a country).
The information about mental disorders present in the
deceased was gathered from all available information as
identified in the published journal article. Thus, information
came from interviews with key informants, such as family,
relatives and friends; from interviews with health profes-
sionals; from coroner’s records; and from medical records
and/or health records. The variability in report specificity is
evident, but in all instances this study adhered to the need
for the identification of DSM or ICD-10 criteria. The authors
of the resource articles used DSM third edition (American
Psychiatric Association, 1980) or revised third edition
(American Psychiatric Association, 1987) or ICD-10 crite-
ria (one article only). For the sake of the present analysis,
broad disorder labels (see Table 2), corresponding to spe-
cific disorder categories in both the DSM and the ICD-10,
were established on the basis of the equivalence (“cross-
walks”) between these classification systems. Articles that
concentrated a priori on specific disorders, such as depres-
sive disorders only, were not considered, because the result-
ing picture of the distribution of mental disorders in cases of
suicide would have been distorted.
In general, the studies referred to both sexes combined
and did not specify the psychiatric diagnoses by young men
and young women separately. As exceptions, one study
considered young women only and one study referred to
young men only (during compulsory military service).
Results
A total of 894 cases of suicide in young people met
review criteria. Although detailed breakdowns of age
were generally not recorded, it appeared from the
information available that the majority of cases were
below the age of 20 years. Of all cases, 72.1% were
up to 21 years old, 12.3% were in the 20 –29 years
age group, and 15.5% were in the 15–29 years age
group.
The majority of studies allowed for multiple diag-
noses, whereas three studies focused on a principal
677
diagnosis (see Table 1). Therefore, the number of
diagnoses exceeded the number of cases. In to-
tal, 1,409 diagnoses were established (including the
category “no diagnosis”) in 894 cases of completed
suicide. The overall results showed at least one men-
tal disorder diagnosed in 88.6% of the cases; the
category no diagnosis applied for 11.4% (see
Table 2).
Mood disorder was the most frequent diagnosis
(42.1%) of all 894 cases identified, followed by sub-
stance-related disorders with a similarly high propor-
tion (40.8%). The third most prominent diagnosis
was disruptive behavior disorder, which accounted
for 20.8% (see Table 2). If one considers only the
three articles that used principal diagnosis (183
cases), mood disorder was still the leading diagnosis,
with 30.1% of the cases.
When we take a different perspective and look at
the diagnoses and their distribution (excluding no
diagnosis), the results show that out of 1,307 multiple
psychiatric diagnoses established, the three most
prominent disorders (i.e., mood disorder, substance-
related disorder, and disruptive behavior disorder)
combined added up to more than two thirds of all
diagnoses (70.9%). Mood disorder accounted
for 28.0%, ranging from 5.1% to 58.1% of all diag-
noses in the various articles. If we take the fourth
most important diagnosis into account, which was
personality disorder, more than three quarters of all
diagnoses (78.9%) were covered.
Subcategories of the broad categories of mental
disorders were not identified in all articles. However,
the information that was available, including diag-
noses of comorbid disorders, is presented in the
following:
The broad category “mood disorders” comprised
major depressive disorder, minor depressive disorder,
dysthymia, mania, hypomania, bipolar disorder, and
mood disorders not otherwise specified. Of the 236
diagnoses that included information regarding the
subcategories, 56.4% were major depressive disor-
der, 22.0% were mood disorders not otherwise spec-
ified, and 16.5% were dysthymia.
Substance-related disorders were divided between
drug use disorders/drug abuse and alcohol depen-
dence/alcohol abuse. Of the 339 diagnoses, 53.7%
were alcohol dependence/abuse, and 46.3% ac-
counted for drug use disorders/drug abuse.
The broad category “disruptive behavior disor-
ders” included conduct disorder, attention-deficit dis-
order, oppositional disorder, and identity disorder.
Information on the subcategories was available for
156 diagnoses, of which 66.0% were attributed to
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678

Table 1
Articles Included in the Review
No. Young Young Age
Study Sample Country casesa men women (years)
Apter et al. (1993) Consecutive suicides during compulsory military service, Israel, mid-1980s Israel 43 43 0 18–21
Asgard (1990) All suicides in the city of Stockholm and the inner suburban area in 1982 Sweden 11 0 11 15–29
Brent et al. (1988) Consecutive suicides in three counties, including and surrounding metropolitan United States 27 21 6 ⬍ 20
Pittsburgh, from February 1984 to June 1986
Brent et al. (1993) Consecutive suicides in 28 counties of western Pennsylvania, from July 1986 to United States 67 57 10 ⬍ 20
August 1990
Brent et al. (1996) Consecutive suicides in 28 counties of western Pennsylvania, from July 1989 to United States 58 51 7 13–20
May 1994
Dudley et al. (1998) All suicides in New South Wales, from 1988 to 1990 Australia 114 10–19
Graham & Burvill All suicides in Western Australia over a 27-month period from 1986 to 1988 Australia 68 54 14 15–24
(1992)
Groholt et al. (1997) All suicides in Norway between January 1, 1990, and December 31, 1992 Norway 121 91 30 8–19
BRIEF REPORTS

Houston et al. (2001) All suicides in four counties that constituted the former Oxford Regional Health Britain 27 25 2 15–24
Authority between July 1993 and June 1995
Marttunen et al. (1991) All suicides in Finland, April 1, 1987, to March 31, 1988 Finland 53 44 9 13–19
Rich et al. (1986) All suicides in San Diego County, California, from November 1981 until June United States 128 97 31 15–29
1983
Runeson (1989) All suicides in the city of Gothenburg, Sweden, from July 1984 to June 1987 Sweden 58 42 16 15–29
Shaffer et al. (1996) Suicides in New York and its surrounding area between June 1984 and May 1986 United States 119 94 25 ⬍ 20
Note. Case control study (controls were suicidal inpatients; Brent et al., 1988); community controls (Brent et al., 1993, 1996); subjects from the study area (Groholt et al., 1997);
subjects from a self-report survey in schools (Shaffer et al., 1996). The principal diagnosis was used in the following three articles: Asgard (1990), Dudley et al. (1998), and Runeson
(1989). In all other articles, multiple diagnoses were made.
a
Total number of cases is equal to 894.
 BRIEF REPORTS 679

Table 2 orders with disruptive behavior disorders or person-

Mental Disorders in Cases of Suicide in Young ality disorders. Substance-related disorders often
People seemed to be secondary to other disorders. The com-
No. bination of mood, substance-related, and/or conduct
Disorder diagnoses % cases disorders was reported most frequently (see Table 3).
Two studies (Groholt, Ekeberg, Wichstrom, &
Mood disorders 376 42.1
Substance-related disorders 365 40.8 Haldorsen, 1997; Shaffer et al., 1996) provided a
Disruptive behavior detailed breakdown with regard to comorbidity, with
disorders 186 20.8 a total number of 240 cases. The breakdown identi-
Personality disorders 104 11.6 fied single diagnosis, comorbidity with mood disor-
Adjustment disorder 97 10.9
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Anxiety/somatoform
ders, other comorbidity, and no diagnosis. A brief
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disorder 68 7.6 analysis showed that 39.2% of the suicide cases were
Schizophrenia 44 4.9 diagnosed with two or more disorders. The combi-
Other DSM Axis I nations of mood/disruptive, disruptive/substance
diagnoses 42 4.7 abuse, and mood/disruptive/substance abuse disor-
Other psychotic disorders 21 2.3
Organic mental disorders 4 0.4 ders emerged as the most prominent ones. Together,
No diagnosis 102 11.4 these combinations amounted to 24.0% of all cases,
which was the same percentage attributable to mood
Note. The principal diagnosis was used in the following
three articles: Asgard (1990), Dudley et al. (1998), and disorders as a single diagnosis.
Runeson (1989). In all other articles, multiple diagnoses
were made. Because of multiple diagnoses, the number of Sex
diagnoses exceeded the number of cases (1,409 diagnoses
were made in 894 cases). DSM ⫽ Diagnostic and Statistical Five studies (Apter et al., 1993; Asgard, 1990;
Manual of Mental Disorders.
Groholt et al., 1997; Marttunen, Aro, Henriksson, &

conduct disorder, 16.0% fell under attention deficit Table 3

disorder, and 13.5% were disruptive behavior disor- Comorbidity of Mental Disorders in Cases of
ders (without further specification). Suicide in Young People
In the broad category “personality disorders,” of
the 62 diagnoses established, 38.7% fell under anti- No. cases % cases
Diagnosis (N ⫽ 240)
social personality disorder, and 35.5% were classed
as borderline personality disorder. The remaining Single diagnosis
were paranoid, narcissistic, anxious, and histrionic Mood 58 24.2
Disruptive 10 4.2
personality disorders; miscellaneous personality Anxiety 9 3.8
types; and personality disorders not otherwise spec- Substance 1 0.4
ified (all between 1.6% and 6.5%). It is important to Adjustment 10 4.2
note that 5 out of the 13 studies did not report on Psychosis or other 13 5.4
Mood comorbid
personality disorders at all, which might distort the Mood, disruptive 20 8.3
overall picture. Mood, anxiety 10 4.2
The broad category “anxiety/somatoform disor- Mood, substance 8 3.3
ders” comprised generalized anxiety disorder, obses- Mood, adjustment 1 0.4
sive– compulsive disorder, and somatoform disorder. Mood, other 3 1.3
Mood, disruptive, anxiety 2 0.8
The most prominent diagnosis was generalized anx- Mood, disruptive, substance 20 8.3
iety disorder. Mood, anxiety, substance 1 0.4
The broad category “other DSM Axis I diagnoses” Mood, disruptive, anxiety,
prominently included the spectrum of eating substance 5 2.1
Other comorbid
disorders. Disruptive, anxiety 2 0.8
Disruptive, substance 17 7.1
Comorbidity Disruptive, adjustment 3 1.3
Disruptive, anxiety,
Little information was provided as to comorbidity. substance 2 0.8
In general, the most common pattern seemed to be Other, not included 3 1.3
No diagnosis 42 17.5
that of mood disorders and/or substance-related dis-
 680 BRIEF REPORTS
Lonnqvist, 1991; Shaffer et al., 1996) out of the 13
provided information on psychiatric diagnoses disag-
gregated by sex. Two hundred seventy-two male
cases had 434 diagnoses, and 75 female cases had
111 diagnoses established. The differences in diag-
noses between young men and young women are
shown in Figure 1.
Mood disorders and other DSM Axis I diagnoses
were distinctly more common among young women.
The marked difference in other DSM Axis I diag-
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noses between the two groups might be due to the
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fact that eating disorders, being more prominent
among young women, were represented in this broad
category.
Young men had a pronounced dominance of dis-
ruptive behavior disorders and substance-related dis-
orders, which were the second and third most prom-
inent diagnoses for young women as well. It is inter-
esting that no diagnosis was the fourth most
prominent diagnosis for both young men and young
women.
Odds Ratio (OR) in Controlled Studies
Four out of 13 studies (see Table 1) applied case
control designs with community controls and thus
Figure 1. Psychiatric diagnoses in cases of suicide by sex, younger than 30 years. DSM ⫽
Diagnostic and Statistical Manual of Mental Disorders.
calculated and reported on ORs, which are recapitu-
lated here. Brent et al. (1988) used suicidal psychi-
atric inpatients as a control group, and that study is
not considered here. The OR is an estimate of how
many times more likely individuals with a diagnosis
of mental disorder are to complete suicide than those
without a diagnosis of mental disorder.
When we summarize the individual results of the
four studies, individuals who committed suicide and
had a diagnosis of major depression were character-
ized by an OR between 20 and 27. For those diag-
nosed with substance abuse, the odds ratio ranged
from 5 to 10 in the four studies considered. Cases
with conduct disorder were 6 to 11 times more likely
to commit suicide, and those with a diagnosis of
disruptive disorders had a risk 2 to 4 times higher
than those without diagnosis, according to the corre-
sponding studies. One study (Brent, Bridge, Johnson,
& Connolly, 1996) gave an OR for any anxiety
disorder (OR ⫽ 11) and for any personality disorder
(OR ⫽ 13).
The information on the ORs may be supplemented
by estimates of the population attributable risk
(PAR), which measures the percentage reduction in
the rate of suicide that would occur if the association
 BRIEF REPORTS
between the risk factor and suicide represented the
causal contribution of the risk factor and if the risk
factor were eliminated from the population. The es-
timation of the PAR requires information about the
OR between the risk factor and suicide and the frac-
tion of the population exposed to the risk factor.
Two studies (Brent et al., 1993; Shaffer et al.,
1996) provided the information necessary for the
estimation of the PAR. A reduction in the rate of
suicide of 36.8% and 45.7% in the two studies, re-
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spectively, would be possible if mood disorders were
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eliminated. The elimination of substance abuse dis-
orders would entail a reduction of 16.2% and 25.0%,
respectively. If conduct/antisocial disorders were
eliminated, suicide rates would be reduced by 16.6%
and 23.6%, respectively. There would be a reduction
of 11.4% (Brent et al., 1993) in the suicide rate if
anxiety disorders were eliminated. It should be noted
that the PAR tends to give an upper limit estimation
of the contribution of a risk factor to the rate of
suicide in the population, as it is based on strong
assumptions and is therefore subject to overestimation.
Discussion
Available Number of Cases
The present review of completed suicides in young
people reported in the scientific literature in which a
DSM or ICD-10 diagnosis had been made found a
smaller than expected number of cases. Only a lim-
ited number of studies recorded psychiatric diagnoses
that met defined criteria, and the studies themselves
were based on a small number of cases—that is, 128
cases maximum and 11 minimum (see Table 1).
Thus, it is important to note that current prevention
programs that are based on research evidence are
drawing conclusions from a small population. It is
evident that current public health preventive pro-
gramming, at best, either relies on a relatively small
number of cases with definable mental disorders or is
largely dependent on the case data from less rigorous
clinical studies or, at worst, relies purely on theory.
For the time being, one should proceed with caution
when recommending suicide preventive measures
and developing programs for suicide prevention on a
larger scale, in view of the small number of cases our
knowledge is based on.
Geographical and Cultural
Considerations
A limiting factor in the review is the fact that the
studies on psychiatric disorders in cases of completed
681
suicide originated mostly from Europe (n ⫽ 5) and
North America (n ⫽ 5) and to a lesser extent from
Australia (n ⫽ 2) and Israel (n ⫽ 1; see Table 1).
Studies from Africa, Asia, or South America that met
the criteria used for this review could not be identi-
fied (see Figure 2).
The findings of case-control studies of the adult
population in India (Vijayakumar & Rajkumar, 1999)
and East Taiwan (Cheng, 1995) suggest that risk
factors for suicide (e.g., mental disorders, previous
suicide attempts, recent life events, family history of
psychopathology) have a universal nature across
countries and cultures. However, there are indica-
tions that psychiatric disorders are not as prominent,
yet are present, in cases of suicide in China (Chan,
Hung, & Yip, 2001; Phillips, 2002; Phillips, Li, &
Zhang, 2002; Pritchard, 1996; Yip, 1996).
Considerations Regarding Psychiatric
Diagnoses
As demonstrated in a review of suicide and mental
disorders in the general population across all age
groups (Bertolote & Fleischmann, 2002), mood dis-
order was the diagnosis most frequently associated
with suicide. In the present review of studies on
suicide among young people, mood disorders took
the lead as well. However, the proportion of mood
disorders (42.1%) was lower than might have been
expected. Furthermore, substance-related disorders
(40.8% of all cases) were almost equally important as
mood disorders among young people. Disruptive be-
havior disorders emerged as the third most prominent
diagnosis. The results of an analysis of comorbidity
in young people further underline the need to prior-
itize mood disorders, substance-related disorders, and
disruptive behavior disorders as comorbid condi-
Figure 2. Geographical distribution of cases of suicide
(younger than 30 years).
 682 BRIEF REPORTS
tions, as combinations of those three disorders were
found most frequently.
The findings of the present review are generally
confirmed by studies of suicidal ideation and suicide
attempt behavior not limited to completed suicide
among young people (Andrews & Lewinsohn, 1992;
Beautrais, Joyce, & Mulder, 1998; Fergusson & Lyn-
skey, 1995; Joffe, Offord, & Boyle, 1988; Reinherz
et al., 1995). These studies provide an addi-
tional 4,289 cases in total to the database.
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The pattern and role of psychiatric diagnoses may
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vary between suicide and serious suicide attempt.
Beautrais (2001) found that these two groups formed
overlapping populations. However, completed sui-
cides were more common among men with a current
diagnosis of nonaffective psychosis, whereas those
who made medically serious suicide attempts— but
did not die—were more likely to have a current
diagnosis of anxiety disorder. These are findings for
people of all ages, and it has to be demonstrated to
what extent they apply to young people.
Implications for Prevention
The present review indicates that there is limited
information about the identification of psychiatric
disorders in cases of completed suicide in young
people. Those studies identified in Western countries
allow consideration of the implications for preven-
tion in that region, but caution is necessary in appli-
cation of these findings to program development in
Asian and developing countries. From a global per-
spective, a greater insistence on using more rigorous
data related to the diagnosis of specific disorders will
enhance the potential for developing programs with
greater specificity and permit more precise policy
development. Solid data related to mental disorders
will also permit a better evaluation of program effi-
cacy and effectiveness.
Beyond diagnosable mental disorders, the field
should take into consideration other components de-
pendent on the person’s constitutional predisposition
and on the social and physical environment and
should attempt to increase knowledge about psycho-
social risk factors (Wasserman, 2001) for suicide in
different cultures, encourage responsible media re-
porting about suicide, and restrict access to means of
suicide, such as toxic substances and guns (Bertolote,
Fleischmann, De Leo, & Wasserman, 2003; World
Health Organization, 1998). Psychosocial stressors,
independent of psychiatric diagnosis, must also be
considered as proximal determinants of suicide
(Chan et al., 2001). With the ultimate goal of pre-
vention in public health through a community focus
and broad applicability of measures for youth suicide
risk, the current need remains one of enhancing di-
agnostic precision and recognition, taking into ac-
count the culture-specific context.
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Received March 31, 2004
Revision received September 24, 2004
Accepted September 29, 2004 䡲