Several findings stand out from this analysis. First, mental health disorders and substance abuse are equally prevalent in pregnant and non-pregnant women who commit suicide, and providers should be alert to these risk factors. Second, postpartum women were more likely to have been identified as having depressed mood in the two weeks prior to suicide than other women. Both pregnant and postpartum women were more frequently reported as having problems with a current or former intimate partner. Finally, postpartum women were more likely than other women to die via hanging, suffocation, or drowning, suggesting that when they committed suicide, they chose a relatively lethal method.
Depression is a known risk factor for suicide, and the high prevalence of depression as a mental health diagnosis among women in this study who committed suicide is consistent with prior findings. In a large study of pregnant women, almost 30% of those with screening scores consistent with probable major depression endorsed suicidal ideation.[13
] In our analysis, women within their first year postpartum were more likely to have been identified with depressed mood at the time of death compared with other women. It is not known why depressed mood might pose a higher risk in postpartum women compared to other groups, but lack of sleep and stress from infant care may play major roles.
The American College of Obstetricians and Gynecologists (ACOG) reports insufficient evidence to support a firm recommendation for universal antepartum or postpartum depression screening but does strongly encourage screening.[14
] ACOG also recommends that women with current depression or a history of major depression have close monitoring and evaluation during pregnancy and postpartum. Treatment guidelines for management of depression during pregnancy are available.[15
Although NVDRS reports extremely high rates of treatment among all victims with identified mental health disorders, we believe this reflects the NVDRS coding algorithm rather than true rates of treatment. One coding rule (NVDRS coding manual, 19-4, validation rule 0058) directs that patients with mental disorders should be assumed to also be receiving current treatment since “if the person had mental illness, it is unlikely that they did not have current treatment for mental illness.”[10
] Unfortunately, this is not consistent with current knowledge about mental health disorders and treatment in the United States. A recent study among women of reproductive age demonstrates that only half of women with current serious psychological distress were receiving medicine or treatment.[16
] Two studies which assessed depression during pregnancy reported even lower treatment rates of just 14 and 33%.[17
] In addition, many women who seek care have inadequate or suboptimal treatment.[18
Psychiatric disorders carry significant stigma and victims may hide the presence of such diagnoses or thoughts from relatives, colleagues, and even medical providers, leaving no trail for those attempting psychiatric autopsy.[19
] Mental health disorders frequently co-exist; the fact that few victims in NVDRS have more than one psychiatric diagnosis suggests significant underreporting of co-morbidities. Kessler (2007) reports that among individuals with a lifetime diagnosis of major depressive disorder, nearly three of four met criteria for another psychiatric disorder including almost 60% with a co-morbid anxiety disorder.[20
] Similarly, the 12 month prevalence of anxiety disorders in the U.S. is about 18%, roughly twice the reported rate among the population of suicide victims we examined in the NVDRS.[21
In our study, postpartum women in particular were noted to select more violent methods for suicide with lower rates of death by overdose. This may reflect less prescription medication consumption during pregnancy or may demonstrate greater intention on death as an outcome. There have been prior reports suggesting pregnant and postpartum women may choose more lethal methods of suicide.[5
Pregnant and postpartum suicide victims were more likely than non-pregnant women in this study to have been identified as having a problem with a current or former intimate partner. Intimate partner violence during pregnancy has been estimated to affect between 1 and 20% of women.[22
] It is difficult to ascertain exact incidence of intimate partner violence after a suicide since psychological or sexual violence may be underreported by the victim. Since our variable was defined by NVDRS as problems with an intimate partner rather than violence from an intimate partner, it is difficult to know the relationship between these two and whether information about conflict or friction with an intimate partner predicts or indicates violence. Women with current or recent pregnancy are more likely to have had interaction with an intimate partner than non-pregnant women so this finding may be simply related to greater prevalence of these relationships since we did not measure whether all suicide victims were currently or recently in a partnered-relationship. Alternatively, pregnant or postpartum women may be particularly vulnerable to threats of violence or control from a partner. ACOG recommends screening every pregnant woman for IPV during each trimester and postpartum .[22
] Asking about problems with an intimate partner may identify some women at risk or lead to further disclosure about violence, but this has not been investigated. Research is still identifying which interventions reduce rates of intimate partner violence in pregnant and postpartum women; while several studies have shown positive benefits from interventions, results are mixed.[23
This study has several limitations. First, the suicide victim cannot be interviewed after death, so it is impossible to assess for all current mental health disorders, thoughts about intent, or precipitating factors. Second, the toxicology data does not provide quantity of ingestion or whether a specific substance caused the death (i.e., whether the quantity would have been lethal). Third, multiple NVDRS abstractors may lead to differences in how variables are identified or coded. Fourth, since NVDRS assumes that victims with a mental health diagnosis are receiving treatment this variable is not useful in evaluating whether treatment offers any protection against self-harm. Fifth, our evaluation of intimate partner violence was limited to studying women with intimate partner problems which may or may not reflect violent or coercive behaviors. While the NVDRS offers a major advancement in terms of capturing pregnancy status, it likely underestimates early pregnancies which may not be publicly known and may miss postpartum women who do not have custody of their children or had an infant death. NVDRS does not provide data for the entire U.S. so results are not nationally representative.