Introduction

Homicide followed by suicide is a rare incident which occurs with an incidence of 0.06/100,000 population, as reported in United Kingdom and Wales (Flynn et al. 2009) without sparing our country. However, the incidence of such an event cannot be determined, locally. On 11 September 2013, parents of three children were detained by police after their plan for filicide-suicide turned up to be a case of single homicide where only one life was claimed in the attempt. It was informed that the father had recent financial problems (Zolkepli 2013) with possibility of depression. This is to exemplify one of countless cases of homicide-suicide occurring worldwide. How could a depressed person decide to kill someone? Does homicide followed by suicide belongs to either one of the group (i.e. homicide or suicide) or it stands on its own category? In the present report, we relate a  case of depression associated with homicide-suicide. The theoretical approaches to understand homicide-suicide phenomenon are briefly discussed.

Case Report

Mr A was a 30-year-old gentleman and single. He was admitted to Hospital Bahagia Ulu Kinta (HBUK) for alleged murder of a lady six months prior to admission. Before the incident took place, he was never diagnosed with any psychiatric disorder. 

Retrospectively, he used to have few girlfriends and their courtships lasted for quite sometime ranging from 2 to 5 years. However, ultimately the relationships would end up unfavourably. Cheating due to extra-relationship affair and having one who was too difficult to manage due to time, these were the reasons given by him for the break-up with his previous girlfriends. 

About one year before the incident, he met a woman who within four months of courting became his beloved one. He spent rather much in terms of time and wealth for that relationship.  His savings sought from his five years job earnings were spent, if not all, for maintaining this relationship.  Their relationship was described as perfect and smooth without any disturbance and it lasted for one year. 

However, problems started to surface up when he suspected that she had someone else besides him. He self-investigated and with sufficient evidence had concluded that she was not loyal to him. He confronted her with the evidence he had but she denied it strongly. 

That episode did not end up with a break-up but what was more heart-breaking was yet to come. A few weeks before the murder took place; his mind was very much distraught. He felt threatened with the impending end in the relationship. He felt useless and hopeless ruminating about his previous failures in relationships. His sleep was disturbed and his appetite was reduced. He was not able to focus and think clearly as he used to do. Furthermore, he found a few other sensible evidences to suggest the on-going unfaithfulness from the girlfriend’s side (non-delusional).  

Apart from this, he also suffered from stress at workplace which predated the relationship problem. He was not in good terms with his superior and he worked alone, literally, in his department. With this, he felt rejected not only by his girlfriend but also at work.

A day before the incident took place, he started to write a death note recounting his plan to kill his girlfriend and subsequently committing suicide. He while staying at his girlfriend’s house left an important note to his family members with regard to his properties and wealth after his death. The next day, he carried out what he planned. Soon both of them were found unconscious and badly injured. However, he survived the suicidal attempt. 

During admission his mental state examination revealed  a young gentleman with psychomotor retardation. His speech was relevant but minimal with low tone and amount. His mood was low with suicidal ideation. There was no thought disorder and no perceptual disturbance. His cognitive and insight were good. He was diagnosed with major depressive disorder and treated with Escitalopram 20 mg daily. 

Discussion

Homicide-suicide can be defined as murder which is followed by perpetrator’s suicide in one week time (Eliason 2009). However, this definition is far beyond unison (Liem 2010). The incidence of homicide-suicide case varies depending on regions but remains low around 0.05 – 0.22/100, 000 population (Panzcak et al. 2013). Due to various reasons, the psychiatric literature on homicide-suicide remains scanty. This is primarily because it is dealt mainly by non-Psychiatrist (i.e. police). In addition, both the perpetrator and victim are dead (Eliason 2009). Except in a few cases where the perpetrator is well-known or as in this case, the patient escaped from any potentially fatal injury. 

Former views tend to view homicide-suicide as a variant of either homicide or suicide. However, in a recent systematic review and meta-analysis, the finding shows that homicide-suicide has a distinct characteristic differentiating it from suicide or homicide alone. It is often associated with “intimate partner strain and general psychological stress” (Panzcak et al. 2013).

Major depression, followed by substance abuse and psychosis are some of the commonest mental illnesses associated with homicide-suicide (Roma et al. 2012). In order to understand how depression leads to homicide-suicide, theorists have postulated numerous models aiming at understanding its manifestation. 

Despite the different approaches employed by theorists to explain homicide-suicide, in general they share a common theme i.e. aggression as the underlying force of homicide-suicide (Liem 2010).

The theories of aggression can be subdivided into three subcategories in terms of its origin, direction and outcome as expounded by Liem (2010) (Figure 1). While the biological factor may not be apparent in this case, the source of aggression as a result of frustration is explainable from the strain theories point of view. Three types of strains have been described using Agnew’s social stress and strain model to explain the source of aggression in homicide-suicide case. Any tension that prevents a person to achieve positively valued goal (i.e. sex, autonomy), removing or threatened removal of positively valued stimuli (i.e. loss of sexual partner) and real or threatened presentation of a noxious stimuli (i.e. rejection, abandonment) may lead to aggression (Harper & Voigt 2007). However, this theory fails to explain the direction of the aggression either towards homicide or suicide. While attributional study can explain the direction of aggression (either suicide or homicide), however it cannot explain why after homicide the perpetrator proceed with suicide. 

The end result of aggression that leads to homicide-suicide phenomenon can be explained from either psychodynamic or psychopathological perspectives (Liem 2010).

One of the earlier researcher in the field of homicide-suicide; Rosenbaum (1990) had the opinion that depression works as a defence to suppress the aggressive impulse. When a precipitating event, like a break-up in relationship which takes place, the defence would be broken and the aggressive impulse will be released (Rosenbaum 1990). Hendry and Short theorized that suicide is a result of strict superego, which prohibits an outward aggression. When a precipitating event take place i.e. break up, the defence is weakened and the impulse is directed outward as murder. Suicide may be undertaken as a form of self-punishment (Liem 2010).

As demonstrated in this case, patient’s former experience of rejection and current involvement with work-related stress and impending rejection in relationship, had led to frustration and aggression. However, patient might have suppressed his anger which then manifested as depression. However as the stress went on uncontrolled and failed his defence which resulted in him acting out the aggression leading to homicide. Unable to tolerate made him decide to take his life away.