Commentary: Homicide-Suicide in

Older Adults—Cultural and

Contextual Perspectives
Carl C. Bell, MD, and Dominica F. McBride, PhD

The authors comment on “Domestic Homicide and Homicide-Suicide: The Older Offender” by Bourget et al., who
learned that after a domestic homicide in Canada, the older offender frequently commits suicide. The authors
comment on the ubiquity of single homicide-suicide across cultures, the incidence of single homicide-suicide in
various cultures, the common patterns and differences in single homicide-suicides across cultures, ethnic and
gender differences in single homicide-suicide within different cultures, characteristics of the phenomenon of mass
murder followed by suicide and ethnic differences within this type of homicide-suicide, and differences in suicidal
patterns in different cultures. Suicide and suicide preceded by homicide (single or multiple) are so rare, it is
currently impossible to draw any substantive conclusions about the incidence of these phenomena in various
contexts; however, ideas for consideration in addressing homicide-suicide are provided.

J Am Acad Psychiatry Law 38:312–17, 2010

Bourget and coauthors1 report that after a domestic the reason for and study and understanding of homi-
homicide, the older offender frequently commits sui- cide-suicide, including its antecedents and potential
cide. Accordingly, their article focused on the phe- preclusive mechanisms.
nomenon of homicide-suicide. Given the evolution-
ary propensity for the preservation and maintenance Cultural, Racial, Ethnic, and Gender
of life, the phenomenon of suicide is perplexing. Al- Patterns in Homicide-Suicide
though it is rare, suicide occurs regardless of location,
culture, gender, or age, and rates of suicide vary de- In their article Bourget and colleagues1 have con-
pending on these factors. The motivation for suicide tributed to a culturally nuanced discussion and
is determined by a set of complex dynamics, and added to our understanding of the complexity of
homicide-suicide is even more bewildering. Further- homicide-suicide dynamics. Their article highlights
more, homicide-suicide can involve only one homi- the characteristics of older spousal homicide-suicide,
cide victim or more than three victims, which classi- which have similarities and differences in the various
fies the event as a mass murder-suicide. Bourget et contexts and cultures. Although the incidence of ho-
al.1 endeavored to study one aspect of the puzzling micide-suicide is rare, it occurs across the globe in
occurrence of single homicide-suicide, providing a countries including, but not limited to Canada,1 the
cross-cultural picture of older spousal homicide-sui- United States,2 Scandinavia,3 South Africa,4,5
cide offenders in Canada. Contributing to the com- Greenland,6 China,7 England,8 Germany,9 Fin-
plexity of this phenomenon, these authors, among land,10 and France.11
others, demonstrate various aspects that confound
Rates of Homicide-Suicide in Different Countries
Dr. Bell is President and C.E.O. of the Community Mental Health In a review of the literature from 10 nations,
Council (CMHC), Inc.; Director of the Institute for Juvenile Re- Coid12 found the incidence of murder-suicide to be
search; and Professor of Psychiatry and Public Health, University of
Illinois at Chicago, Chicago, IL. Dr. McBride is Co-founder, Co- 0.2 to 0.3 per 100,000. Similarly, Marzuk et al.13
president, and an evaluation consultant with the HELP (Holism, Em- estimated the homicide-suicide rates in the United
powerment, Leadership, and Personhood) Institute, Chicago, IL. Ad-
dress correspondence to: Carl C. Bell, MD, 8704 S. Constance States to be 0.2 to 0.3 per 100,000 per year. In a
Avenue, Chicago, IL 60616. E-mail: [email protected]. comprehensive review of the current literature, Elia-
Disclosures of financial or other potential conflicts of interest: None. son14 examined the data on murder-suicide of Mar-

312 The Journal of the American Academy of Psychiatry and the Law
 Bell and McBride

zuk and colleagues,13 and found an incidence of physical illness in the victims.1 Other counties, cul-
murder-suicide under 0.001 percent. Specific to tures, and age groups display different trends. In the
country, Jena et al.4 found an annual rate of homi- United States, there was a history of domestic vio-
cide-suicide of 1.0 per 100,000 in Pretoria, South lence in most homicide-suicides involving intimate
Africa, between 1997 and 2001, while Roberts et al.5 couples; however, most were not elderly couples.14
reported an annual homicide-suicide rate of 0.89 per In China,7 most of the incidents were related to
100,000 in Durban, South Africa, between 2000 and spousal conflict or were completed for altruistic rea-
2001. Hansen6 reported a rate of homicide-suicide of sons. The main methods of killing were slashing with
1.33 per 100,000 in Greenland in the mid 1970s at a a weapon and carbon monoxide poisoning by char-
time when the total homicide rate was 15.6 per coal burning in a closed space. Homicide-suicide
100,000, and the suicide rate was an extraordinary trends in the three counties identified earlier (Can-
45 per 100,000 per year. Large et al.2 reported a rate ada, the United States, and China) show that there
of 0.313 per 100,000 within the United States. are variations in both country and age, which also
While these rates show that this incident happens demonstrates the dynamic complexity of this
around the world, they also demonstrate the rarity of phenomenon.
homicide-suicide and the complications involved in
Cultural, Racial, and Ethnic Differences in
prevention. Thus, more research should be con- Homicide-Suicide
ducted to gain a better understanding of the
phenomenon. Furthering these complications are ethnic differ-
ences related to homicide-suicide in South Africa and
Similar Characteristics of Homicide-Suicide in the United States. Regarding patterns of homi-
cide-suicide relationships, Jena et al.4 found two pro-
Thorough investigation shows commonalities in
the details of the spousal/couple homicide-suicide. files of typical perpetrators in Pretoria: a younger,
These similarities (or risk factors) usually include the single, black male shooting his girlfriend and himself
relationship between homicide victims and homi- at home and an older, married, Caucasian male
cide-suicide perpetrators (usually intimate), the sex shooting his wife and himself at home. In Durban,
of the homicide victim (usually female), the sex of the Roberts et al.5 reported that 91 percent of the perpe-
homicide-suicide perpetrator (usually male), the age trators and 87 percent of the victims were black,
of the victim (usually younger than the perpetrator), which proportionately represents the population.
the use of a weapon (usually a gun), and a history of Suicide Preceded by Mass Murder
mental illness in the homicide-suicide perpetrator Because homicide-suicide is an act of violence
(most often a male who is depressed). The resem- committed against another and then against oneself,
blances are universal and cut across national lines. In the topic of mass murder-suicide is included, with
Scandinavia,3 South Africa,4,5 China,7 and the interesting dynamics related to race and ethnicity.
United States,15 for example, most homicide-suicide Studying all forms of this trend (violence against oth-
perpetrators are male, with most of their victims be- ers and self), as well as aspects of it (e.g., suicide alone
ing female intimate partners who are killed violently or homicide alone) may help to illuminate underly-
by them with weapons. ing factors that contribute to mass murder-suicide.
Mass murder alone is usually defined as the killing
Dissimilar Characteristics of Homicide-Suicide of four or more people during one violent act or over
While these commonalities can be helpful in iden- a short time.16 Petee et al.17 provided a review of
tifying risk factors, further study of the broader phe- mass murder, including spousal homicide-suicide, in
nomenon of homicide-suicide renders more varia- public places. From their study, it became clear that
tion and difference within and between cultures and most offenders in anger/revenge- and domestic/ro-
age groups, complicating attempts at accurate tar- mantic-related mass murder are European Ameri-
geted prevention. The sample in the study by Bour- cans (Table 1).
get et al.1 consisted of 93 percent male perpetrators, In both motives for mass murder, there is a signif-
with all perpetrators older than 65 years. In this icant suicide dynamic. Thus, the authors suspect that
group, there were many Caucasians, a low prevalence these mass murders are actually suicides preceded by
of domestic violence history, and a high incidence of mass murder. Further, as these types of homicide-

Volume 38, Number 3, 2010 313

 Commentary

Table 1 Mass Murder Motives and Dynamics

Mass Murder Motive Mass Murder Dynamics European American, % Committed Suicide, %
Anger/Revenge Specific persons targeted 66.5 66.7
Specific place targeted 76.5 38.9
Diffuse target 80.0 30.0
Domestic/romantic 57.1 28.6
Direct interpersonal conflict 60.0 0.0
Adapted from Petee et al.17

suicide often involve tumultuous relationships, they also region, with Western states having the highest
seem quite different from the motives that Bourget et rates, crossing 21 per 100,000, compared with New
al.1 describe. Jersey, for example, with a rate of 6.4 per 100,000 in
1998.31 Saunderson and Langford32 believe popula-
Gender Differences in Homicide-Suicide tion density has a positive relationship with rate of
Differences based on the sex of the perpetrator suicide, as there are fewer incidents in heavily popu-
have also been studied in the United States. Infant lated areas in England and Wales. This pattern also
homicide followed by a suicide (filicide-suicide, holds true for the United States and, in part, seems
which is largely preventable by pre-empting postpar- due to the decrease in firearm suicides with urbaniza-
tum depression18) is one of two major homicide- tion,21 a finding supported by Brickmayer and
suicide patterns (the second being intimate partner Hemenway.33 Within the United States, ethnic dif-
homicide-suicide19). Logan et al.20 found that more ferences are also notable. The average rate of suicide
than half of filicide-suicides (51.5%) in their sample is 11 per 100,000; the lowest rate is among African-
were committed by females. American women: 2 per 100,000.21 The 2002 IOM
report found that United States’ rates of suicide are
Suicide Dynamics Within Patterns of exceptionally high among certain population groups
Homicide-Suicide (e.g., white males over 75 years of age and Native
Narrowing the focus, suicide alone also varies by Americans) and in certain professions (e.g. health
culture, race, and ethnicity, even within country, care and law enforcement).21 In the United States,
with some nations and cultural, racial, and ethnic European-American males older than 85 have the
groups within nations having higher suicide rates highest rate of suicide: 65 per 100,000.21 Suicide
than others. The seminal report of the Institute of among Native Americans is approximately 1.5 times
Medicine (IOM), “Reducing Suicide,”21 substanti- more prevalent than in the nation as a whole.21
ates that in the United States there are also cultural,
racial, and ethnic dynamics related to the overall pat- Motivational Differences Between Canada and
tern of suicide, with European Americans being the United States
more predisposed to completion of suicide and Afri- In almost every country and culture, males perpe-
can Americans being less predisposed. Thus, suicide trate homicide-suicide. The acts are most often com-
is a major form of violence within the European- mitted by men, the means are usually violent (involv-
American community, whereas homicide is a major ing weapons), and the victims are most frequently
form of violence within the African-American women. In a review, Scott34 lists 13 suggested moti-
community.22,23 vations for homicide-suicide, the first five of which
Suicide trends in some nations can also indicate are impending divorce, previous divorce, departure
focal points in other countries. For example, the sui- or perceived loss of a nonmarital partner, jealousy,
cide rate in China was 17 per 100,00024; however, and retaliation. This finding suggests pervasive and
the rates are higher in rural than in urban areas.25 pernicious patriarchy, sometimes called male entitle-
This regional pattern persists in various countries ment dysfunction,35 which should be urgently ad-
such as the United States,21 China,26 countries that dressed. Considering that domestic violence is a ma-
were in the former Soviet Union,27 Australia,28 jor motive for homicide-suicide in the United
Greece,29 and the Ukraine.30 The suicide rates in the States,14 it is surprising that a history of domestic
United States not only vary in area classification, but violence among the older couples was not found to

314 The Journal of the American Academy of Psychiatry and the Law
 Bell and McBride

be more prevalent by Bourget et al.1 This discrepancy Large sample sizes are required to provide statistical power
for studies of events with a low base rate. For example, to
could be attributable to the differences in national determine the overall incidence rate of suicide in a general
culture. The pattern of homicides in the United population within plus or minus five per 100,000 with 90
States is much different from that in Canada, with percent confidence, would require about 100,000 partici-
rates in the United States being about three times pants. Many statistical approaches exist that can be effec-
tively applied to the field of suicide [Ref. 21, p 411].
higher.36
As the homicide-suicide rates are even lower than
Complications in Studying Homicide-Suicide individual suicide rates, we believe that attempting to
Ostensibly, there is a broad range of research that base prevention efforts on the findings of these lim-
has been conducted in this area; however, this en- ited samples is problematic and typical of the current
deavor is fraught with complications and potential state of suicide prevention in Western countries.
inaccuracies. Bourget et al.1 identified two limita-
tions of their study: missing data and a small sample Prevention of Suicide in the Elderly
size. There are further limitations to the study of this In 1990, the United States had a suicide rate of
phenomenon. The Institute of Medicine Suicide 24.9 per 100,000 among men aged 75 to 84. In
Prevention report21 noted that coroners’ data in the 1998, the rate had risen to 42.0 per 100,000. Al-
United States are unreliable because of regional dif- though older individuals comprise approximately 10
ferences in requirements for the position of coroner, percent of the U.S. population, they account for 20
the definition and classification of suicide, training percent of completed suicides.40,41 Because the rates
and background, investigation of cases, and the qual- of suicide and homicide in the elderly are so low, it is
ity of data management. IOM gave various examples difficult to develop a profile of the perpetrators.
and stated: Given the apparent protective factors that are in
In the United States, the qualifications range from simply operation, profiling with the current limited infor-
having an interest in the job (e.g., Indiana) to specialized mation would be likely to yield frequent false posi-
training in forensic pathology (e.g., Oklahoma). Medico- tives.21 However, Bourget et al.1 provide informa-
legal officials may be elected, appointed or serve ex-officio
(e.g., elected county sheriffs). Investigations may be cen- tion to build a foundation for effective prevention.
tralized within a state (e.g., Rhode Island) or organized by These Canadian authors suggest that terminal illness
each county (e.g., Utah). Each of these factors affects the in a spouse (the usual victim) and depression in the
nature, extent, and quality of the investigation and the clas-
sification of deaths as suicide [Ref. 21, pp 380 –1]. other spouse (the usual perpetrator) may be risk fac-
tors for homicide-suicide in an older couple, propos-
These nuances can lead to inadvertently erroneous ing that it would be prudent to screen for such dis-
statements and confusion among researchers. orders to prevent suicide and homicide-suicide.
Religion and stigma leading to reporting bias can IOM stated:
confound the study of both suicide alone and homi-
Untreated or undertreated pain, anticipatory anxiety re-
cide-suicide. For instance, predominantly Catholic garding the progression of medical illness, fear of depen-
countries, in which the religion-related stigma on dence, and fear of burdening the family are the major con-
suicide is severe, are less likely to make explicit attri- tributing factors in the suicidality of elderly with medical
bution in the public record of deaths due to sui- illness [Ref. 21, p 44].
cide.37,38 The reported suicide rates in countries that Primary care physicians saw 70 percent or more of
are predominantly Muslim may also be influenced elderly suicide victims within 1 month of their
by this bias.39 It has been postulated that most, if not deaths.42– 44 It makes sense that if in Canada the
all, of the cases of death of undetermined cause are victims of homicide were gravely ill,1 individuals at
actually suicides.21 risk could be identified in primary care offices. Ac-
The rarity of suicide, as recognized by Bourget et cordingly, the problem of prevention of older-part-
al.,1 further complicates precise inquiry. The IOM ner domestic homicide-suicide1 could be approached
committee also noted that suicide is a rare event. in the same way as prevention of elderly suicide.
Despite these higher rates, the reality is that suicide Foley45 and Hendin46 found that elderly and cancer
and homicide have low base rates: 0.00011 and patients who once wanted to die found a stronger will
0.000062, respectively. Thus, if they are to yield sig- to live when their pain or depression was adequately
nificant results, studies must include large popula- treated and managed. Specifically, the Prevention of
tion samples. IOM asserted this necessity: Suicide in Primary Care Elderly (PROSPECT):

Volume 38, Number 3, 2010 315

 Commentary

Collaborative Trial47 proposed a way of identify- would have to study culturally, racially, and ethni-
ing at-risk perpetrators of suicide and providing cally diverse populations. In addition, they should
them with protective factors that keep their risk study continuity of care, treatment adherence, and
factors from becoming predictive of bad outcomes. access to services; the effects of reducing the sense of
PROSPECT48 found that patients in the interven- hopelessness in persons who are suicidal; the effec-
tion group had seven percent lower suicidal ideation tiveness of pharmacotherapies and psychotherapies;
than did those in conventional treatment. Further, neurological factors; genetics; the effects of hospital-
12 percent fewer patients expressed feelings of hope- ization; high-risk populations; short-term versus
lessness than those in conventional treatment. Bruce long-term treatment; and biopsychosocial factors.
et al.47 found that patients in PROSPECT experi- Unfortunately, this recommendation was never
enced a faster rate of decline of suicidal ideation than adopted within the United States, and the literature
did those in regular treatment. Alexopoulos et al.49 continues to publish useful but limited studies on the
similarly found that those in PROSPECT were more various aspects of suicide.
likely to receive psychotherapy or antidepressants The next step in progress and prevention is to
and to have a remission of depression than were those integrate research into practice, to apply the findings
in the treatment-as-usual group. The effectiveness of effectively. The status quo is that prevention science
this approach suggests that the same strategy could be takes an average of 14 years to be efficaciously inte-
used to prevent homicide-suicide in elderly couples. grated into practice.18 The cooperation of research-
Furthermore, although some homicide-suicide ers and practitioners is necessary to shorten this du-
patterns hold across cultures, there are culturally spe- ration and to address homicide-suicide more quickly
cific patterns as well (e.g., China’s homicide-suicide and comprehensively.
pattern of chopping or charcoal burning). Preven-
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