Suicide risk management: A manual for health professionals

My brief goodreads review of the book, which I read yesterday (I gave it two stars):

“Closer to one star than three. Multiple spelling errors, no inline citations, questionable coverage of the literature, the authors frequently repeat themselves. Not recommended.”

This is a poor book, and I was close to giving it one star. I was considering modifying the review above today, as I got started blogging the book; when I wrote the review I’d assumed they’d just put the sources in the back of the book because the idea never crossed my mind that somone might decide to write a book like this without providing any sources (…I mean, that would be insane – and they’re psychiatry professors..). See more details about this aspect below. Normally spelling errors don’t bother me that much, but I spotted four of them in the first 50 pages alone (plus two words that were not separated by a space) and that’s just completely unacceptable; if you make that many mistakes which make it into the final publication then you don’t care enough about your book. I have had good experiences with the Wiley-Blackwell publications I’ve read, but the fact that they allowed this book through is a strong point against them.

The book is not heavy on data, but they do talk quite a bit about various findings from the literature. The problem is that you have to take everything they talk about on faith, and I’m just not that kind of person. No specific studies are mentioned (sentences like, ‘we base this on X&Y’s publication (20XX)’ are completely absent), the number of studies used to establish the conclusions are unknown, effect sizes are rarely talked about except in a very general sense (and you’ve no idea where the numbers are coming from so often such estimates are not actually helpful), limitations of the studies on which the conclusions are based are not covered in any amount of detail. I have the distinct impression that the authors are really bad at math, due to coverage of some specific conditions and the reported risks associated with them, but I won’t go into that in detail here as I consider those specific findings uninteresting (and if they knew basic probability theory, so presumably would the authors). Some of the findings they talk about I’m sure are correct as they are well known and -established in the literature, but there are other claims in the book which contradict what has been found in studies I’ve read in the past on the topic, so I certainly see no great need to just take it for granted that the authors are right. The fact that they won’t go into the details of which studies they are basing their conclusions on and so on frankly just make them look bad, especially considering the overall data quality one has to work with in this area and the limitations imposed by this data quality problem – basically what they’ve ended up with is a book filled with postulates. They don’t even include a literature overview in the final pages of the book, like say in an appendix – the book has an index, but no literature list, so basically they just decided to publish a book in which they don’t even tell you which sources they’re basing their conclusions on. From the point of view of someone who’d only consider evidence which you can test/verify to be valid, this book would be completely worthless as they may just have made it all up. I’m sure they haven’t, but this approach really stinks. One might argue that given that the book’s main focus is on the clinical perspective (how to deal with patients), not epidemiology, lack of sourcing may not be that big of a deal – one major problem here, however, is that writing textbooks this way certainly isn’t the way to promote evidence-based approaches in the future. Given the problematic history of mental health care, this is sure as hell not an area where you get points in my book for not dealing with the data in some detail and dealing with questions related e.g. to how we know what we know, and how and why those conclusions we’ve drawn may be wrong.

As usual when reading this kind of material, I was mildly annoyed by the fact that the authors take for granted the view that all suicides should be prevented. There’s such a thing as a good suicide. I’m not exactly surprised that this notion is absent from the book, but I am still a bit annoyed.

Some observations from the book below:

“based on available data, globally suicide is believed to account for an average of 10–15 deaths for every 100 000 persons each year, and for each completed suicide there are believed to be up to 20 failed suicide attempts.” [believed by whom, you ask? I have no idea] […] “in the USA and many other countries (particularly in wealthy or developed states), suicide continues to be one of the three leading causes of death in young people between the ages of 15 and 24.” […]

“The majority of studies on risk factors for suicide have been conducted in developed countries using the psychological autopsy methodology. Psychological autopsy studies in the West have consistently demonstrated strong associations between suicide and mental disorder, reporting that 90% of people who die by suicide have one or more diagnosable mental illness […] Using the same type of psychological autopsy methodology, studies conducted in developing countries have not demonstrated as robust an association between suicide and mental disorder as purported in the West.” […] Other identified significant risk factors include current or past suicide behaviour, availability of and access to lethal means, exposure to trauma or abuse, severe psychosocial stressors, interpersonal loss, family history of suicide and mental disorder, alcohol and drug misuse, lack of significant relationships and social isolation, chronic physical illness, disabling pain, lack of internal coping abilities, and lack of access to health and social services and supports.” […]

“In North America, studies indicate that the majority (up to two-thirds) of those who die by suicide have had contact with a health care professional for various physical and emotional complaints in the month before their death. […] individuals at risk are often never identified” […]

“In many parts of the world mental illness fails to be recognized as a legitimate health disorder and people with mental illness continue to be misunderstood as weak, lazy, attention seeking, crazy or stupid. Fear of being thought of or being labelled as mentally ill and fear of the ridicule, discrimination, social exclusion, loss of friends, loss of employment or loss of opportunity that may result likely contributes to the secrecy and silence that keeps people from reaching out and receiving help. […] Regardless of the reasons, many of those who die by suicide do not seek help and do not inform others of their plans. Moreover, some who are contemplating suicide or who are committed to completing suicide may not reveal their thoughts or plans even when directly asked.” […]

“Protective factors are those factors and experiences that are believed to reduce the risk for suicide and suicide behaviours and increase a person’s ability to cope with and manage stress and face life’s challenges. […] Protective factors are less well established than are risk factors and the scientific data to support their notation is generally not very strong. […] In the opinion of the authors of this manual, these factors have not been adequately demonstrated to prevent suicide. Many of them are simply negative restatements of known risk factors” […]

“A number of risk factors have been strongly linked to both suicide and suicide behaviours. Distal risk factors can be understood as predisposing factors that may increase a person’s vulnerability to suicide. […] Proximal risk factors include factors which augment current vulnerability for suicide as well as factors which may precipitate or trigger suicide or suicide behaviours.” […]

“In North America, Western Europe (including the UK) and most other countries for which data are available, suicide rates generally increase with increasing age. Projected on top of this trend are three peaks representing periods of increased risk: adolescence/young adulthood, middle age and old age. In general, suicide rates rise sharply in late adolescence and early adulthood, before leveling off through early midlife, then rising again in middle age and then again after age 70. In developed countries the highest suicide rates are found in the elderly. […] In general, suicide behaviours in the elderly are more likely to be lethal as compared to younger age groups. […] In most countries, suicide deaths occur more frequently in men than in women. In the United States, suicide rates are four times higher in men. […] In many Asian countries, including India for example, the rates of suicide death, particularly in rural areas, are almost equal for men and women. In China, female suicide rates are 25% higher than male suicide rates.” [Considering the kind of data likely to be available, I don’t trust this finding very much but I thought the observation was still interesting. Cultural factors causing differences in reported rates is one of many potential drivers here which should at least be considered a potentially contributing factor (e.g. greater shame associated with the suicide of a son (/an heir) than a daughter).] […]

“Suicidal ideation refers to thoughts, fantasies, ruminations and preoccupations about death, self-harm and self-inflicted death. Suicidal ideation can be both ‘passive’ and ‘active’. A person who is actively thinking about killing themselves and is having thoughts of initiating a suicide process that will lead to their death is experiencing active suicide ideation. A person who has thoughts about wanting to ‘disappear’, wishing they could just go to sleep and never wake up, or thoughts that they would rather not be alive, but who does not have thoughts of actively initiating a suicide process that would lead to their death, is experiencing passive suicide ideation. Active suicide ideation confers greater risk than passive suicide ideation and the greater the magnitude and persistence of the suicidal thoughts, the higher the risk for eventual suicide. […] Suicide ideation occurs along a continuum of frequency (fleeting to persistent), intensity (manageable to intolerable or uncontrollable), duration (chronic to acute) and persistence (intermittent to persistent), and can be associated with different levels of intent (no wish or desire to die to strong desire to die) as well as motivation.” […]

“In general, men tend to choose more violent means and women less violent means. Globally, hanging, firearms and poisoning are the most common lethal means for suicide – hanging being the most common in both genders. […] In developing countries, particularly in agricultural areas, ingestion of pesticides is the most common method of suicide. […] an estimated 30% of suicide deaths globally are attributable to the ingestion of pesticide.” […]

“Suicide attempts are 10–20 times more prevalent than completed suicides and up to 50% of those who die by suicide have made at least one previous attempt. These figures are likely underestimates of the true prevalence of suicide attempts as many attempts likely go undetected […] past suicide attempts are a major risk factor for suicide death. Up to one-fifth of people who attempt suicide will reattempt (most within a year) and reattempts are often associated with more lethal means, lower chance of rescue and survival, and higher likelihood of serious medical consequences.” […]

“the suicide rate among single adults is twice that of married adults, and rates among those who are divorced, separated or widowed are four to five times higher than those for married individuals.” […]

“Identification of ‘suicide risk factors’ does not allow a completely accurate prediction of when or if a specific individual will in fact die by suicide. Thus, suicide assessment scales that rely on the cataloguing of patient risk factors, although a useful clinical aid in the assessment of suicide risk, cannot by themselves be used successfully to predict who will commit suicide. […] It is the weighting and confluence of specific suicide risk factors rather than the number of risk factors present that must be considered in determining risk” […]

“Suicidal thoughts are relatively common amongst adolescents. […] Suicidal ideation in and of itself does not indicate psychopathology or need for intervention in teenagers. In children, however, expression of suicidal ideation warrants serious attention. Young children may not appreciate the ‘finality’ of death and therefore may unwittingly commit suicide, not realizing that they will not come back. […] Many […] warning signs are nonspecific and ambiguous, and taken separately may be just a normal part of growing up. On the other hand, if these warning signs represent a clear change in a young person’s personality, behaviour or functioning they may be signals of a serious underlying problem.” […]

“Although many universal and targeted interventions for suicide prevention have been implemented in countries and communities around the world, few have been empirically studied and evaluated in either developing or developed countries. Of those that have been evaluated, few have been shown to impact suicide rates. […] A number of interventions popularly considered to be very effective in reducing suicide rates, including suicide telephone hotlines and school-based suicide-education programmes, have shown little or no substantial positive effect on decreasing suicide rates.” […]

“suicide does not occur in a vacuum. Once the individual ends his or her life, there are clinicians, family members, friends and communities that may require support. […] Experience of shock and disbelief is normal in the first few hours or days following the loss of a loved one. Once the initial shock of the loss has dissipated, most people slowly begin the process of recognizing and accepting the loss. Feelings of intense sadness, anger, hopelessness, helplessness and guilt often wax and wane throughout the day, with periods of extreme intensity becoming less overwhelming and less persistent over time. Thoughts about not wanting to be alive anymore, that life is not worth living, and of wanting to reunite with the deceased are not uncommon […] After six months to one year, the pain associated with the grief generally becomes less intrusive, less intense and less persistent. Although there may be reexperiencing of intense grief when confronted with reminders of the loss, and periods of feeling sad, angry and empty, these grief experiences no longer prevent the person for moving on with their life and doing what they need to do, such as returning to work, returning to school, reconnecting in their personal relationships, participating in social and recreational activities, and caring for their families and children.” […]

“Often the most meaningful way to help someone who has experienced loss is to simply listen to them. […] Acknowledge and validate their feelings. […] Do not tell them not to cry or get angry. […] Do not tell them how you think they should feel. […] Give them space and time to talk about their loss. […] Assist problem-solving around practical issues and concerns.”

November 24, 2013 - Posted by | Books, health care, Psychology

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