Looking for Why
Psychological autopsies of young people who died by firearm suicide may help to identify risk factors and inform prevention.
In the summer of 2022, the Office of the Chief Medical Examiner of Maryland sent identical letters to 100 sets of parents, all of whom experienced the same unimaginable tragedy: They had lost a child who took their own life using a firearm.
The letter asked the parents to consider helping to advance the understanding of suicide by talking with Bloomberg School and School of Medicine researchers leading a study to find ways to prevent suicide in young people.
Nine families, who lost sons and a daughter between ages 17 and 21 to suicide, agreed. Over the next several months, the researchers, whose focus was on firearm suicides by young people, met individually with the parents, siblings, and friends—those closest to the young person who had died—to conduct “psychological autopsies.” Led by psychiatrist and suicide researcher Paul Nestadt, MD, associate professor in Psychiatry and Behavioral Sciences at the School of Medicine with a joint appointment in Mental Health at the Bloomberg School, their goal was to construct detailed psychosocial biographies—essentially a timeline from childhood to the months, weeks, days, hours, and minutes that precede the suicide. The aim is to identify common themes and risk factors in this specific population to inform suicide prevention efforts—and fill in gaps not covered by surface-level information collected by medical and law enforcement authorities such as cause of death, location, or presence of drugs or alcohol in the system.
“No single risk factor explains any suicide. It’s usually an aggregate of any number of bad things happening to somebody who’s vulnerable to be suicidal,” says psychologist, Alan “Lanny” Berman, PhD, a psychological autopsy expert and adjunct professor in Psychiatry and Behavioral Sciences at the School of Medicine. “But we know very little about the last days of life for people who take their life.”
One main reason is that much of the research into suicide is based on accounts by suicide attempt survivors, who are “not a very good proxy for suicide death,” says Nestadt. While survivors of suicide attempts are able to provide information, such as their thought process between deciding to end their life and taking action, survivors and those who die by suicide are two very different populations, even from an epidemiological perspective. Suicide attempt survivors are typically women, and people who die by suicide are predominantly men, among other differences. Also distinguishing the two groups is the fact that death may not be the intent of some suicide attempts.
The psychological autopsy, says Nestadt, “is the only modality that helps us really understand what’s happening for people who die by suicide.”
Recent data on youth suicide and firearms illustrate the need for Nestadt’s focus on such deaths. Guns were the leading cause of death among youth (ages 1–19) in 2022. Suicide was the second-leading cause of death in young people in 2021, with firearm suicides making up nearly half of these deaths. And there are rarely survivors in suicide attempts by firearm.
“Youth suicides are maybe the most worrisome to me because kids are so impulsive,” Nestadt says of youth suicides by firearm. “I want to know, how do kids access these guns? Are there common themes in how the guns are being accessed? Is it an issue of parents who have guns not storing them safely? And maybe even most importantly, whose gun is it? Can we intervene there to prevent future deaths?”
Nestadt also plans to use the psychological autopsy format to investigate why suicides in Maryland’s Black population nearly doubled during the first wave of the pandemic, while suicide mortality nearly halved among whites, according to findings from his December 2020 study. Another project will employ psychological autopsies to help develop effective criteria to distinguish between accidental and intentional opioid overdoses in Maryland, where 75% of opioid overdose deaths are classified as undetermined compared to 10%–12% in the U.S. overall, giving the state an artificially low count of opioid-related suicides.
“We need actionable directions for policy, policy change, or preventive action that we can get in place—including programs and trainings. That’s what we’re looking for when we look across these interviews,” says Holly Wilcox, PhD ’03, MA, a professor in Mental Health, who is also leading psychological autopsy research at Hopkins. “Now that we have more nuanced data, we should be better informed on how best to prevent future deaths.”
The psychological autopsy was developed in the late 1950s by psychologist Edwin S. Shneidman, PhD, in response to a request from the Los Angeles Coroner’s Office for assistance in establishing manner of death. His first case: Determine the circumstances surrounding the death of a man whose body was discovered floating in the Pacific Ocean.
Shneidman, co-founder of the Los Angeles Suicide Prevention Center, sought information that the coroner didn’t have the training or resources to gather by interviewing individuals who knew the dead man, who was last seen sitting on the Santa Monica Pier. Based on these discussions, Shneidman concluded that the man had too much to drink and accidentally fell into the water. The coroner enlisted Shneidman’s help with a few more cases, eventually contracting with him to do more investigations into undetermined deaths.
At this point, Shneidman formalized the investigation model, calling it “psychological autopsy,” a technique that involves in-depth interviews with family members, friends, and others close to the deceased, with the goal of developing a profile to help explain the death. Over the next 10 years, the Suicide Prevention Center’s psychological autopsy work grew from about 50 cases a year to hundreds of cases, and gradually expanded into published suicide research, says Berman, who studied with Shneidman and other early practitioners of the method in Los Angeles, and in 2011 developed the only certification training course in psychological autopsy. The procedure also came to be used in court cases and insurance investigations, but only in the past two decades has it been widely employed in suicide research outside of the Los Angeles center, in part because more researchers are now focusing on suicide risk and prevention.
Simultaneous to its psychological autopsy work, the center continued to break new ground in the study and practice of suicide prevention. It developed the model of suicide crisis hotlines manned by paraprofessionals, and secured suicide research funding from the National Institute of Mental Health at a time when funding for this issue was uncommon.
Although the original psychological autopsy model is essentially unchanged, it can be easily adapted or modernized, depending on the research focus. For example, modifications in the firearms and youth suicide study included questions about gender identity, social media, and video games.
Berman, who trained Nestadt, Wilcox, and other Hopkins researchers in the psychological autopsy, describes it as “a dynamic biography, because you’re not just telling the story. You’re really putting it in the context of what is the developmental pathway from birth to an intentional death by one’s own hand?”
Key to the training is how to navigate a painful conversation with grieving parents, family, or friends while gathering information to draw a complete portrait of an individual lost to suicide. The protocol for the firearm suicide study—which is still ongoing, with 13 interviews completed—includes approximately 30 pages of questions and a written introduction; however, they are not intended to serve as a checklist and script. The interview is meant to flow organically, and the interviewer must make it clear to the parents that they can stop at any time to take a break, postpone the discussion to another day, or withdraw altogether.
Although it is recommended that the conversations interviews take place in person, Nestadt’s team conducted the interviews—which on average took about three hours—via Zoom, due to pandemic-related considerations.
“The major limitation of psych autopsies is that they are resource intensive, so you can’t collect 1,000 cases,” Nestadt says, explaining that the firearm suicide study required a support staff person and employed highly trained clinicians to do the hours-long interviews, which were then transcribed and discussed by the study team—factors that make the method more expensive than a self-reported survey. “They work best when it is a group that might have common risk factors, so you look at firearm suicide, or LGBTQ suicide in college, as examples.”
Navigating the Journey
Matthew Kelly, PhD, a Johns Hopkins medical student who conducted several of the psychological autopsies, says that he begins the process by emphasizing to the parents that “our conversation is a journey we will take together” and inviting them to begin the discussion by sharing stories of their child’s infancy and early years. But even at this stage, “the day” is very much present.
“I say that we’re not going to talk about that day for quite some time, and that we’ll get there when we both think that it’s the time,” Kelly says. “This way, we have a good amount of time to just allow them to bring to life their loved one who they lost. We talk about everything. It’s incredibly important for families, and important to the study because we’re trying to identify potential risk factors, and we don’t know what the risk factors are.”
Piecing together the chain of events leading up to the suicide is a key goal, says Wilcox. Researchers are seeking as many details as possible. The parents might share that their child was playing violent video games or spending a lot of time isolating. There may have been bullying or a breakup with a girlfriend or boyfriend. Taken together, these events and behaviors may reveal commonalities among the deaths that could inform opportunities for prevention.
In three cases, researchers learned that on the day of their deaths, the young people repeatedly allowed their characters in video games to be shot and killed, findings that could be useful in helping to understand the individual’s mindset leading up to the suicide.
As the conversation unfolds, the interviewer flags moments, events, and interactions that may take on more meaning as the discussion moves closer to the day of the suicide. “I might say, ‘Okay, let’s step back. You mentioned that 12 days before he died, there was a prom. Let’s talk about that,” says Nestadt. “Then, I might learn that he was alright for two or three days [after], and then what happened on the day [of the suicide].”
“The day of the death is always really difficult,” he says. “Typically, it’s a mother describing finding her child’s body.”
As part of the detail-gathering process, psychological autopsy interviewers are simultaneously assessing where parents are in their grieving process and can offer counseling or resources to access support services. Most parents reported that talking about their child’s death was therapeutic, as family and friends often avoid the topic due to stigma and discomfort around suicide.
“On several occasions, even after this very difficult discussion wherein we were talking about incredibly hard things,” Kelly observed, “the parents said, ‘Thank you, nobody will ever talk to me about any of this, so talking about it allows me to process it.’”
A Firearms Culture
After the Maryland psychological autopsies were completed, the conversations were transcribed and analyzed for common themes. This process yielded some valuable findings that allowed the team to better contextualize the deaths. (The research was presented at the American Psychiatric Association’s annual meeting in May.)
Researchers learned that family-owned firearms were used in more than two-thirds of the suicides. It also emerged during the discussions that in many cases the parents did not view having guns in the home as a source of danger, despite the fact that most of the young people had undergone mental health treatment, had suicidal ideation, or had a suicide plan.
Rather, eight of nine families interviewed said that firearms were an integral part of family tradition, culture, and identity—the passing down of a weapon through generations, trips to the shooting range, and father-son bonding on hunting trips. As one parent said in a psychological autopsy interview, their son “used to love shooting with his dad. That was something that they did together. It was a big point of connection for them.”
When the researchers asked the parents if they would have locked their guns up or stored them safely had a health care professional suggested it, most said yes. One parent remarked: “If someone would just have suggested, ‘You might want to take the guns out of the house,’ that’s what I would have done. … But we didn’t think, you know.”
Because of the sheer amount of qualitative data gleaned from the interviews in the firearms research, the final product is not limited to one paper, Kelly said. He noted that related projects are focused on understanding families’ engagement with firearm culture and on associations between youth suicide and breakups in romantic relationships.
Researchers say that these findings about a group with similar risk factors or common themes in their paths to suicide could inform policy changes and prevention and outreach programs, as well as clinical guidelines, around a polarizing topic. For example, the psychological autopsies on youth firearm suicides revealed that most of the suicides were carried out with a gun that belonged to the parents. Interventions or policies might be aimed at educating parents on the risks to children, especially when mental health issues or suicide risk factors are present, and strengthening child access prevention (CAP) laws—which differ by state. The findings also indicate that encouraging health professionals to broach the topic of gun safety with families is critical.
“I’m excited by the potential for the research to guide how clinicians engage families in discussions of firearms. I don't think that enough clinicians are talking to families about firearms, period, but I also recognize that it's understandably difficult to know how to do so,” Kelly says. “By listening to these families, and really benefiting from their perspective, I think it can transform the way we think about the topic. And by changing how we as clinicians think, it may change how we respond to this tragic epidemic.”