Abstract
This is a beautifully presented book. The layout of the chapters is clear, subheadings are generous and help orientate the reader. The book ‘… is directed at the “busy clinician”’ as well as ‘… groups such as the police, probation officers and teachers’. It achieves this aim admirably. Unfortunately it may be too basic for many psychiatrists. However, we all have our areas of relative ignorance and those who have belatedly woken up to public concern about suicide prevention may find this book a handy little primer.
The editor Danuta Wasserman is a prominent researcher from Stockholm which is a WHO collaborating centre on suicide research and prevention. Her authors are well respected, but I couldn't help noticing that she herself features solely or in combination with others in 17 of the 32 chapters. The chapters are orientated in eight sections. The first on epidemiology is clear but superficial. The next includes a theoretical model of suicidal behaviour which is neat from a medical perspective but does not do justice to socio-cultural issues. The chapter on neurobiology of suicide is clear but provides few clues as to what accounts for the unfavourable neurobiology other than genes. It is time biological psychiatrists looked beyond their test tubes to factors that activate genetic and biochemical potential. For example, amongst bees, workers and queens have the same genes at birth. Environmental factors determine whether they develop as workers or become totally reproductively orientated queens.
The third section has a number of chapters on the basic psychological disorders associated with suicide. Unfortunately for psychiatrists, this involves introductions to the various disorders that we are all familiar with and then superficial coverage with respect to suicide. One chapter on adjustment disorders and suicide is only two pages long with almost one of them being a case history. Such brevity limits the depth of coverage. A chapter on the suicidal patient – doctor relationship needs to be applauded. Few texts discuss this most important aspect of suicide prevention. The chapter on psychological treatment of suicidal patients is another highlight. It examines cognitive behaviour therapy, dialectical behaviour therapy and interpersonal therapy in a simple but clear way.
Coverage on pharmacological management was less impressive with the author seemingly having greater success with benzodiazepines than I can attest to. The chaos of disinhibition, not to mention dependency, that I encounter in the few patients I risk these agents with, seems not a problem in his practice. He also unfortunately advocates thioridazine which might put one at risk of litigation. Suicide in the elderly provides a balanced coverage of this area in contrast to the chapter on adolescent suicide which is excessively clinical.
Coverage of examples of successful suicide prevention in psychiatry is a breath of fresh air. At times it appears that nothing really works when often this impression may be a product of research difficulties. It emphasises the efficacy of Lithium with respect to reducing suicide mortality in major affective disorders. Clozapine looks promising in reducing suicide schizophrenia. Hopefully, some of the less dangerous atypicals may also offer promise in this respect. The need for long-term treatment as distinct from past overemphasis on crisis intervention is justified. Successful innovations including letter writing, telephone support for the elderly and others, illustrate the potential of imagination.
The section on when to hospitalise a suicidal patient may further strain the collapsing Australian medical indemnity industry as it appears to suggest that all patients with major depression with anxiety and agitation or psychoses warrant immediate hospitalisation.
A chapter on perestroika in the former USSR was illuminative showing the encouraging decline in suicide rates associated with Gorbachev's early reforms, characterised by openness and freedom. Unfortunately this did not last and as unofficial alcohol production rose strikingly, so did suicide rates. It is notable that 8 of the 10 nations with the highest suicide rates in the world are from the former Soviet Empire.
The final section entitled ‘Public Health Perspective’ is striking for its lack of consideration of this. Fleeting mentions of public health approaches do occur earlier in the text, but it is notable that in the index basic terms such as ‘primary, secondary and tertiary prevention’ are nowhere to be found – nor are synonyms eg. early intervention.
Psychiatrists preferring a more in depth text would be better advised to try The International Handbook of Suicide and Attempted Suicide edited by Hawton and van Heeringen.