Prevention and Treatment of Suicidal Behaviour

Making any choice creates in us a sense of being vulnerable. With each decision, we lose all the other choices that we did not make. What about the decision to die? Regardless of the cause of suicidal gestures or attempts, the individuals involved usually feel an intense sense of anxiety. One of the reasons is that deciding to die involves no further choices after that. It cannot be undone and people that have reached operational stages of thinking know that. In children, however, suicidality is more dangerous, as they have no or a limited sense of the irreversibility of dying. The majority of the successful acts of suicide are carefully planned in advance. It has been described as a process in which the persons develop suicidal thoughts without a plan but rather a passive desire to “not wake up.” Most often, this ideation disappears for a time or leads to one or several plans regarding the means to be used. This stage can lead to acquiring the means to accomplish this task. It can last for months (e.g., storing months’ worth of prescribed medication). In the time leading up to the act, many individuals go through a testing phase, mainly designed to decrease their anxiety (playing with the gun initially, cocking the gun without ammunition, buying the bullets, and loading the weapon, etc.). This interval often provides a prolonged window of time during which the individual can be identified as at risk by friends or physicians. This progression also might lead to reduction in anxiety about the final act. For example, some Golden Gate Bridge survivors did not report any anxiety symptoms as they fell, but others “changed their mind” about the act of dying.1 In light of the above conceptualization, we can hypothesize that the anxiety of “final choice” occasionally helps overturn the desire to die in some patients, at least for the time necessary to seek help. During this time, those caring for an individual at risk need to assure that the person is observed carefully to promote safety, assess protective and contributory factors, and develop a plan to anticipate and manage future attempts. Unfortunately, even with our best efforts, the rate of completed suicide is high in those who have had a previous attempt. Those in whom thoughts of suicide recur are not “exploring new ground” anymore. They have been there before. We have limited information since patients are often secretive about these thoughts and hide them even from close family and friends. The risk of suicide is highest after hospital discharge in psychiatric patients, particularly if there is a change in provider at the time of discharge. Proposed explanations include that patients return to the same environment that caused their suicidal symptoms, perceive loss of the supports available during hospitalization, perceive a sense of shame about being hospitalized, and perceive “inadequacy.” Therefore, immediate follow-up and close coordination between psychiatric and primary care services are necessary. In the book, Prevention and Treatment of Suicidal Behaviour: From Science to Practice, the editor has assembled a series of thought-provoking chapters exploring these phenomena and describes the related research data. He integrates new hypotheses and outlines future directions for research in a well-rounded structure. The authors discuss the devastating and long-lasting effects of suicidal acts not only as a burden to society but also on relatives, friends, and workmates. The book overall provides a balanced perspective on suicidal behavior without being too general or too specific, and without being too lengthy or too limited for use by a busy clinician. The first 6 chapters introduce the epidemiologic evidence from several large studies, carefully considering the time trends and the geographic differences in completed suicide. This gives the authors the opportunity to introduce several hypotheses and prevention measures (e.g., national policies controlling access to the most common lethal means of suicide resulting directly in decreased suicide rates). Is suicide a phenomenon in its own right or is it a secondary product of another illness? In the following chapters, the authors look at suicide from a different perspective. To deconstruct this phenomenon, the authors take a step back in Chapter 7, looking at the predictive value of the interplay of genes and environment. In Chapter 8, the emphasis is on traumatic stress and suicidal behavior, and in Chapter 9, the authors introduce a broad view of prevention. With this overview, the remaining chapters present data regarding other risk factors for suicidal behavior and paired suggestions for treatment and prevention. Many factors are important when discussing this phenomenon (e.g., access to means, influence of the media, and lasting effects on survivors). The approach to these concepts makes the book easy to read and understand, giving this book a particular elegance. In conclusion, the editor has assembled a cohesive text, easy to follow and well documented, which could be a valuable resource for practitioners and researchers working with suicidal patients. Historically, the fascination of death has been around for centuries. Freud's perspective is that the death drive is an urge of living things to restore the earlier state of things.2 How much more do we now understand about suicide compared with 100 years ago? As long as there still are patients completing suicide, certainly not enough. Robert G. Bota, M.D. University of Missouri, Kansas City, Missouri