The International Handbook of Suicide Prevention, 2nd Edition, presents a series of readings that consider the individual and societal factors that lead to suicide, it addresses ways these factors may be mitigated, and presents the most up-to-date evidence for effective suicide prevention approaches. * An updated reference that shows why effective suicide prevention can only be achieved by understanding the many reasons why people choose to end their lives * Gathers together contributions from more than 100 of the world's leading authorities on suicidal behavior--many of them new to this edition * Considers suicide from epidemiological, psychological, clinical, sociological, and neurobiological perspectives, providing a holistic understanding of the subject * Describes the most up-to-date, evidence-based research and practice from across the globe, and explores its implications across countries, cultures, and the lifespan
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Notes on Contributors
Part I: Suicidal Determinants and Frameworks
1 Challenges to Defining and Classifying Suicide and Suicidal Behaviors
Challenges to Developing and Implementing a Standardized Nomenclature and Classification System
Terminology in Suicide Classification Systems
Examples of Definitional Obfuscation
Relevance to the General Population’s Understanding and use of Terminology
The Need for Sensitivity and Consistency
Recent Efforts to Clarify Suicidal Behaviors
2 International Perspectives on the Epidemiology and Etiology of Suicide and Self‐Harm
Extent of the Problem of Self‐Harm and Repetition
Prediction of Repeated Self‐Harm Across the Lifespan
Assessment of Risk of Repeated Self‐Harm
4 Major Mood Disorders and Suicidal Behavior
Suicidal Behavior in People With Mood Disorders
Clinically Detectable Suicide Risk Factors in People With Mood Disorders
Suicide Protective Factors in People With Mood Disorders
Key Achievements in Suicide Prevention: Interventions to Decrease Suicide in Patients With Mood Disorders
Challenges for the Future
5 Schizophrenia, Other Psychotic Disorders, and Suicidal Behavior
Suicide in Psychotic Disorders
The Risk of Suicide in Schizophreniaand Other Psychotic Disorders
Relationship with Other Suicide and Sociodemographic Characteristics
Characteristics of Psychotic Illness in Suicide
Insight into Psychotic Illness
Psychopathology, Personality Traits, and Family History of Suicidal Behavior
Treatment of Chronic Psychotic Disorders: Implications for Suicide Risk
6 Substance Use Disorders and Suicidal Behavior
Terms Used Throughout
Conceptual Model of Risk for Suicidal Behavior Among Individuals With SUDs
Evidence for the Conceptual Model: Research Showing that Individuals with SUDs are at Elevated Risk
Evidence for the Conceptual Model: Distal Risk Factors for Suicidal Behavior Among Individuals With SUDs
Evidence for the Conceptual Model: Proximal Risk Factors Among Individuals With SUDs
7 Personality Disorders and Suicidality
The Management of Suicidality in Borderline Personality Disorder
Conclusions and Implications for Practice
8 The Association Between Physical Illness/Medical Conditions and Suicide Risk
End‐Stage Kidney Disease
9 Relationships of Genes and Early‐Life Experience to the Neurobiology of Suicidal Behavior
Biological Alterations in Suicidal Behavior
Neural Circuitry of Suicidal Behavior
Developmental Factors Related to the Neurobiology of Suicide
Genes and Suicidal Behavior
Genes and Early‐Life Environment Interaction
Key Questions and Challenges for the Future
10 Understanding the Suicidal Brain
Neuropsychological Studies of Suicidal Ideation and Behavior
11 Visualizing the Suicidal Brain
Brain Imaging Findings in Suicide Attempters
Neuroimaging and Suicide Prevention
12 Present Status and Future Prospects of the Interpersonal–Psychological Theory of Suicidal Behavior
13 The Integrated Motivational‐Volitional Model of Suicidal Behavior
Brief Overview of Integrated Motivational‐Volitional Model of Suicidal Behavior
Conceptual and Empirical Rationale for IMV Model
Implications of the IMV Model for Research, Policy, and Practice
14 Sociological Perspectives on Suicide
Marital Integration and the Prevention of Suicide: A Review
An Empirical Study of Marriage, Religion, and Suicide: Analysis of an Integrated Model of Suicide Prevention
15 Inequalities and Suicidal Behavior
Socioeconomic Inequalities in Suicide: The Evidence
Empirical Investigation of Socioeconomic Inequalities in Suicide in Scotland
16 Economic Recession, Unemployment, and Suicide
Evidence of the Causal Nature of the Association Between Economic Recession and Suicide
Age‐ and Sex‐Specific Effects
Mechanisms to Explain the Rise in Suicide During Recessions
Interventions to Offset the Impact of Recession on Suicide
What Research Issues Remain Unanswered?
What Are the Key Achievements in Suicide Prevention Within This Area?
Part II: Intervention, Treatment, and Care
17 Evidence‐Based Prevention and Treatment of Suicidal Behavior in Children and Adolescents
Understanding Effective Prevention Through Changes in the Epidemiology of Youth Suicide
Risk Factors for Suicidal Behavior as Targets of Prevention and Treatment
Suicide Prevention in Children and Adolescents
18 Prevention and Treatment of Suicidality in Older Adults
Peculiarities of Suicidal Behavior in Older Age
Risk Factors for Suicide Among Older Adults
Treatment of Suicidality Among Older Adults
19 Therapeutic Alliance and the Therapist
Problems in the Communication of Suicidal Intent
Patient‐Oriented Versus Physician‐Oriented Approach
Therapeutic Assessment of Suicide Risk
Therapeutic Alliance: Some Basics
Therapeutic Alliance with the Suicidal Patient
Therapeutic Alliance in Treatments for Suicidality
Understanding Suicide as Goal‐Directed Behavior
Where the Truth Lies: The Patients’ Stories
The Provision of a Secure Base: Long‐Term Anchoring
20 Clinical Care of Self‐Harm Patients
What Can Be Learned From Studies of Service Users’ Attitudes Toward Self‐Harm Services?
What Can Be Learned From Studies of Staff Attitudes to Self‐Harm Patients?
What Do We Know About Effectiveness of Psychosocial and Physical Interventions for Self‐Harm Patients?
What Do We Know About Variations Between Services for Self‐Harm Patients?
What Can One Conclude From the Current Evidence About the Most Effective Design and Activities of a Service for Self‐Harm Patients?
21 After the Suicide Attempt—The Need for Continuity and Quality of Care
The Magnitude of the Problem
Follow‐Up Treatments for People Who Make a Suicide Attempt
Recommended Standards of Care and Aftercare After a Suicide Attempt
Adherence to Recommended Treatment Standards
The Norwegian Chain‐of‐Care Model
Conclusions and Recommendations for Policy and Clinical Practice
22 Management of Suicidal Risk in Emergency Departments
Why Is the Emergency Department an Important Setting for Suicide Prevention?
Why the Traditional Approach to Risk Management in Suicidal Patients is Unhelpful and Alternative Approaches to Managing Suicidal People in the Emergency Department are Required
23 Treating the Suicidal Patient
Dialectical Behavior Therapy
Comparison of CT and DBT for Suicide Prevention
Conclusions and Recommendations for Future Research
24 Lessons Learned from Clinical Trials of the Collaborative Assessment and Management of Suicidality (CAMS)
CAMS Therapeutic Philosophy
The CAMS Therapeutic Framework: Collaborative SSF Assessment
The CAMS Therapeutic Framework: Collaborative SSF Treatment Planning
Clinical Studies and Trials of the SSF and CAMS
Current RCTs of CAMS
Key Next Steps for CAMS
25 Modes of Mind and Suicidal Processes
Can Mindfulness Help?
The Effect of Mindfulness Training on Self‐Discrepancy
26 Brief Contact Interventions
What is a Brief Contact Intervention?
Content of BCIS
Evidence of Effectiveness From Reviews
Continuing Questions and Areas for Future Research
27 Delivering Online Cognitive Behavioral Therapy Interventions to Reduce Suicide Risk
Studies Targeting Depression With Suicide Ideation as Treatment Outcome
Study Targeting Suicidal Ideation: Living Under Control
28 Helplines, Tele‐Web Support Services, and Suicide Prevention
Conceptualization of Helplines and Tele‐Web Support Services
Discussion: Challenges and Future Directions
Part III: Suicide Prevention
29 Suicide Prevention in Low‐ and Middle‐Income Countries
Epidemiology of Suicide in LMICs
Risk and Protective Factors in LMICs
Prevention Efforts in LMICs
Preventing Suicides in LMICs
Evidence Gap and the Way Forward
30 Suicide in Asia
Setting the Context
The Challenge of Suicide Prevention in Asia
31 Cultural Factors in Suicide Prevention
How Does Culture Influence Suicidal Behavior?
32 Suicide Prevention Strategies
The Primary, Secondary, and Tertiary Prevention Model
The Institute of Medicine (IOM) Model
Suicide Prevention Programs and Actions Across the Globe
Dilemma of Evidence‐Based Suicide Prevention
33 Rurality and Suicide
Suicide in Rural Areas
Themes in Rural Suicide Epidemiology
Achievements in Rural Suicide Prevention
Models of Rural Suicide
Key Questions for the Future
34 Why Mental Illness is a Risk Factor for Suicide
Model 1: Suicide and Mental Disorders have a Common Etiology
Model 2: Some Mental Disorders are Alternatives to Suicide
Model 3: Suicide is a Direct Consequence of Mental Disorders
Model 4: Suicide is the Result of the Consequences of Living With a Mental Disorder
Model 5: Suicide Results from Treatment: It is “Iatrogenic” or Related to Inadequate, Inappropriate, or Incomplete Treatment
Model 6: Combined Model with the Addition of the Crisis Situation
Why the Suicide Risk for Different Mental Disorders Varies During the Course of the Disorder
Prevention Activities for Persons With Mental Disorders
35 Suicide Prevention Through Restricting Access to Suicide Means and Hotspots
Rationale and Evidence
Restricting Access to Suicidal Means and Hotspots in Suicide Prevention
36 Reducing Suicide Without Affecting Underlying Mental Health
Why Means Matter
Principles Guiding This Review
37 Surviving the Legacy of Suicide
The Problem of Terminology
The Number of Suicide Survivors
The Trajectory of the Bereavement Process
Models of Bereavement After Suicide
Grief Complications of Those Bereaved by Suicide
Helping the Bereaved by Suicide
Symbols and Other Substitutes for Remembering the Deceased
End of the Bereavement
Caregivers and Professionals Who Lose a Client to Suicide
38 Suicide Prevention Through Personal Experience
Introduction and Terminology
How Do You Measure the Impact of Personal Experience on Suicide Prevention?
Stigma: A Multifaceted Challenge
Impact of Experience‐Based Programs
Peer Support Programs
Challenges and Personal Experience
39 Time to Change Direction in Suicide Research
A Critical Look at Current Mainstream Suicide Research
The Kind of Research the Field Now Needs (More of)
40 Suicide Research Methods and Designs
Research Study Designs
Instruments and Informants
Conclusions and Suggestions for Future Research
41 School‐Based Suicide Prevention Programs
Awareness and Education Curricula
Culturally Adapted Programs
Key Achievements in School‐Based Suicide Prevention and Influence on the Evidence Base
Limitations of the Literature
42 Media Influences on Suicidal Thoughts and Behaviors
Suicide and Traditional Media
Suicide and Newer Media
Suggested Theoretical Underpinnings
Key Challenges for the Future
43 Suicide Clusters
Definition of Suicide Clusters
Ways in Which Suicide Clusters Are Investigated
Clusters of Self‐Harm and Suicide Attempts
Prevalence of, and Risk Factors for, Suicide Clusters
Mechanisms by Which Suicide Clusters Are Thought to Occur
The Role of the Internet and Social Media
Preventing and Managing Suicide Clusters
Key Questions and Future Challenges
44 Making an Economic Case for Investing in Suicide Prevention
The Use of Economic Evidence in Health Policy Making
Question 1: Assessing the Cost of Not Taking Action
Question 2: Assessing the Costs of Taking Action
Question 3: Assessing Value for Money
Question 4: Incentivizing Investment in Suicide Prevention Actions
Conclusions: How Can the Economic Evidence Base Be Strengthened?
End User License Agreement
Table 8.1 Main Suicide Risk and Prognostic Factors
Table 8.2 Risk Factors Associated with Suicidal Behavior in those with HIV
Table 10.1 Brief Summary of Findings in Association with Suicidal Ideation or Behavior per Neuropsychological Domain
Table 11.1 Summary of Findings in Suicide Attempters, by Brain Region
Table 13.1 Selected Predominant Models of Suicidal Behavior from the Past 30 Years
Table 14.1 Hierarchical Linear Regression Results of the Effect of Marital and Religious Integration on Suicide Acceptability, World Values Surveys, 1999–2000
Table 16.1 Approaches to Mitigating the Impact of the Economic Crisis on Suicide
Table 18.1 Ubiquitous Causes of Underreporting of Suicide Mortality Data in Older Adults
Table 22.1 Five Reasons why the Emergency Department is Important in Suicide Prevention
Table 22.2 Examples of Assessment Tools for Assessing Future Risk of Suicide
Table 25.1 Decentered Meta‐Awareness of Thoughts and Feelings as Reasons for Not Self‐Harming
Table 29.1 Epidemiological Differences Between LMICs and HICs
Table 29.2 Multisector Approach to Suicide Prevention in LMICs
Table 30.1 Selected Asian countries: Estimated Numbers and Age‐Standardized Suicide Rates (per 100,000) 2012
Table 30.2 Suicide Rates of Women in Cities/Districts of Selected Asian Countries
Table 31.1 The Influence of Culture on Suicidal Behavior
Table 35.1 Studies Published between (Jan 2001–Feb 2015) Examining Changes in Suicide Trends Following Restriction of Methods and Proposed Method‐Specific Measures for Future Research
Table 36.1 Case Fatality Ratios for Selected Methods Commonly Used in Intentional Self‐Harm
Table 38.1 Suicide Attempt Survivor Core Values Compared to Recovery Principles
Table 44.1 Estimates of the Average Cost per Completed Suicide U.S. Purchasing Power Parity (PPP) $ (2014 prices)
Figure 2.1 Age‐standardized suicide rates in 2012 for selected countries based on most recent data from the WHO.
Figure 2.2 Age‐standardized suicide rates in 2012 in low‐ and middle‐income regions.
Figure 2.3 (a) Increase (percentage change) in suicide rates between 2000 and 2012 in selected countries .
Figure 2.4 (a) Average percentage method of suicide for males across 56 countries.
Figure 2.5 Male:female ratio of suicide rates by age group and income level of country, 2012.
Figure 6.1 Model of suicidal behavior among individuals with SUDs.
Moderating effects are depicted by a broken arrow and mediating effects by unbroken arrows.
Figure 12.1 A visual representation of the primary predictions of the IPT.
Figure 13.1 Integrated motivational‐volitional (IMV) model of suicidal behavior.
Figure 13.2 Predictors of repeat suicidal behavior.
The boxes surrounding past suicide attempt and entrapment indicate that these are significant predictors in the multivariate analyses.
Figure 13.3 The probability of self‐harm between Time 1 and Time 2 as a function of acute life stress and socially prescribed perfectionism .
Figure 15.1 Suicide rates by social class, males, Scotland, 1989–1995 and 1996–2002.
Figure 15.2 Standardized mortality ratios (SMRs) by population‐weighted deprivation quintile, all persons, Scotland, 1989–1995 and 1996–2002.
Figure 15.3 Male suicide rates by deprivation quintile and social class, 1989–1995, Scotland.
Figure 15.4 Male suicide rates by deprivation quintile and social class, 1996–2002, Scotland.
Figure 15.5 Male suicide rates by deprivation quintile and social class, 1989–2002, Scotland: relative risks (multilevel analysis).
Figure 16.1 The Great Depression: Trends in the number of male suicides (solid line) and number of unemployed males (dotted line) in 1923–1947.
Figure 16.2 The Russian economic crisis: Trends in age‐standardized male suicide rates in former Soviet Union countries.
Figure 16.3 The Asian economic crisis (1997–1998): Trends in age‐standardized suicide rates in Japan, Republic of Korea, and Taiwan; the gray bar highlights the years of the economic crisis.
Figure 16.4 The Great Recession from 2008: Trends in age‐standardized suicide rate in new EU, old EU, and non‐EU countries, weighted by population size. the gray bar highlights the years of the economic crisis.
Figure 16.5 Trends in the number of research articles indexed on Medline with key words relating to suicide and mental health in relation to the economy or employment 2004–2013. [Key words: (Econom?? Or unemployment) and (suicide? Or mental?)]
Figure 18.1 Suicide mortality rates (per 100,000) by sex and age, 1992–1995/2004–2009; 62 selected countries .
Figure 18.2 Suicide mortality variation (%) by sex and age, 1992–2009; 62 selected countries
Figure 24.1 CAMS course of care.
Figure 25.1 Escalation of negative cognitions into suicidal crisis fueled by rumination and avoidance.
Figure 25.2 Proportion of participants surviving without a further readmission to hospital for self‐harm over follow‐up (Y axis) as a function of performance on the Means‐End Problem Solving Task. Each drop in the survival curve indicates one or more readmissions to hospital.
Figure 29.1 Rates of suicide by age and region.
. Based on data from
Preventing suicide: A global imperative
, WHO (2014) as per WHO regional classification.
Figure 31.1 The Inglehart‐Welzel cultural map of the world. http://www.worldvaluessurvey.org/images/Cultural_map_WVS6_2015.jpg
Figure 33.1 A conceptual model of suicide in rural areas.
Figure 33.2 An example of the use of the conceptual model.
Figure 34.1 Model 1: Suicide and mental disorders have a common etiology.
Figure 34.2 Model 2: Some mental disorders are alternatives to suicide.
Figure 34.3 Model 3: Suicide is a direct consequence of mental disorders.
Figure 34.4 Model 4: Suicide is the result of the consequences of living with a mental disorder.
Figure 34.5 Model 5: Suicide results from treatment; it is “iatrogenic” or related to inadequate, inappropriate, or incomplete treatment.
Figure 34.6 Model 6: Combined model with the addition of the crisis situation.
Figure 34.7 Implications of (a) Model 1 (Suicide and mental disorders have a common etiology) and (b) Model 3 (Suicide is a direct consequence of mental disorders) for prevention.
Figure 34.8 Implications of Model 4 (Suicide is the result of the consequences of living with a mental disorder) for prevention.
Figure 34.9 Implications of Model 6 (Combined model with the addition of the crisis situation) for prevention.
Figure 36.1 Pathways through which reductions in access to lethal means may result in lower suicide rates.
Figure 43.1 The Circles of Vulnerability model.
Table of Contents
For two people who made me a better person.
Dr Clare Cassidy (1968–2008)
I continue to be inspired by Clare’s memory daily.An amazing friend and colleague.
“But then with autumn upon us, so breezy and cruel,Clare left us in Paris, heartbroken and cool.But we remember Clare’s grace, her beauty, her light;Her kindness, her smile and sadness, its might.”(RO’C, 2008)
Professor Noel Sheehy (1955–2011)
One day in the summer of 1994 Noel asked me whether I might be interested in undertaking a PhD on suicide—without hesitation I jumped at the chance. Without him, I would never have embarked on a career in suicide research. He took a chance on me. For this (and many other things besides) I will always be grateful. So kind and generous.
In my thoughts
Rory C. O’Connor
Rory C. O'Connor and Jane Pirkis
This second edition first published 2016© 2016 John Wiley & Sons, Ltd
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Library of Congress Cataloging‐in‐Publication Data
Names: O’Connor, Rory C., editor. | Pirkis, Jane, editor.Title: The international handbook of suicide prevention / edited by Rory C. O’Connor and Jane Pirkis.Description: 2nd Edition. | Hoboken : Wiley, 2016. | Revised edition of International handbook of suicide prevention research, policy and practice, 2011. | Includes bibliographical references and index.Identifiers: LCCN 2016021173 (print) | LCCN 2016022004 (ebook) | ISBN 9781118903278 (cloth) | ISBN 9781118903230 (pdf) | ISBN 9781118903247 (epub)Subjects: LCSH: Suicide–Prevention–Research. | Suicidal behavior–Research.Classification: LCC HV6545 .I594 2016 (print) | LCC HV6545 (ebook) | DDC 616.85/8445–dc23LC record available at https://lccn.loc.gov/2016021173
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Cover image: Gettyimages/Kenichi Sotozaki / EyeEm
To all those who have been affected by suicide and to those who struggle daily to stay alive.
To Suzy, Poppy, and Oisin for all their continued support
Karl AndriessenSchool of PsychiatryUniversity of New South WalesRandwick NSWAustraliaAlan ApterFeinberg Child Study CenterSchneider's Children's Medical Center of IsraelPetach Tikvah and Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsraelElla ArensmanNational Suicide Research FoundationDepartment of Epidemiologyand Public HealthWHO Collaborating Centre for Surveillance and Research in Suicide PreventionUniversity College CorkCorkIrelandUrška ArnautovskaAustralian Institute for Suicide Research and PreventionWHO Collaborating Centre on Research and Training in Suicide PreventionGriffith UniversityAustraliaNargis AsadDepartment of PsychiatryAga Khan UniversityKarachiPakistanDeborah AzraelHarvard Injury Control Research CenterHarvard T.H. Chan School of Public HealthBoston, MassachusettsUSAAlan L. BermanDepartment of PsychiatryJohns Hopkins School of MedicineBaltimore, MarylandUSAStijn BijttebierUnit for Suicide ResearchGhent UniversityGhentBelgiumLisa A. BrennerVA Veteran Integrated Service Network 19 – Mental Illness Research Education, & Clinical CenterDenverColoradoUSAGregory K. BrownDepartment of PsychiatryUniversity of PennsylvaniaPennsylvaniaUSAGregory L. CarterCentre for Translational Neuroscience and Mental HealthFaculty of Health and MedicineUniversity of Newcastle, CallaghanAustraliaFrançois ChagnonCentre for Research and Intervention on Suicide and Euthanasia andPsychology DepartmentUniversité du Québec à MontréalMontréal, QuébecCanadaLai Fong ChanDepartment of PsychiatryUniversiti Kebangsaan Malaysia [National University of Malaysia]Kuala LumpurMalaysiaNadine A. ChangDepartment of Psychiatry Mount Sinai St. Luke’s HospitalNew YorkUSAShu‐Sen ChangInstitute of Health Behaviors and Community Sciences andDepartment of Public HealthCollege of Public HealthNational Taiwan UniversityTaiwanYing‐Yeh ChenTaipei City Psychiatric Center Taipei City Hospital &National Yang‐Ming UniversityTaipeiTaiwanSeonaid CleareSuicidal Behaviour ResearchLaboratoryInstitute of Health & WellbeingUniversity of GlasgowGlasgowScotlandUKKatherine Anne ComtoisDepartment of Psychiatry and Behavioral Sciences andDepartment of Psychology Harborview Medical CenterUniversity of WashingtonSeattleWashingtonUSAKenneth R. ConnerUniversity of Rochester Medical CenterRochesterNew YorkUSAVA VISN 2 Center of ExcellenceCanandaiguaNew YorkUSAPaul CorcoranNational Suicide Research FoundationDepartment of Epidemiology andPublic HealthNational Perinatal Epidemiology CentreWHO Collaborating Centre for Surveillance and Research in Suicide PreventionUniversity College CorkCorkIrelandCatherine CraneOxford Mindfulness CentreDepartment of PsychiatryUniversity of OxfordEnglandUKAmy CunninghamCentre for Acceptance and ChangePennsylvaniaUSADianne CurrierCentre for Epidemiology and BiostatisticsMelbourne School of Population and Global HealthUniversity of MelbourneMelbourneAustraliaDiego De LeoAustralian Institute for Suicide Research and PreventionWHO Collaborating Centre on Research and Training in Suicide Prevention and Life PromotionClinicGriffith UniversityAustraliaAntoine DesîletsMcGill Group for Suicide StudiesDouglas Mental Health University InstituteMcGill UniversityMontrealCanadaPeter DömeLaboratory for Suicide Research and PreventionNational Institute of Psychiatry and AddictionsBudapestHungaryNadine DougallNMAHP Research UnitSchool of Health SciencesUniversity of StirlingStirlingScotlandUKDanielle S. DugganOxford Mindfulness CentreDepartment of PsychiatryUniversity of OxfordEnglandUKSarah EschleSuicidal Behaviour ResearchLaboratoryInstitute of Health & WellbeingUniversity of GlasgowGlasgowScotlandUKAlberto ForteDepartment of Neurosciences, Mental Health and Sensory Organs Suicide Prevention CenterSant'Andrea HospitalSapienza University of RomeItalyJoseph C. FranklinDepartment of PsychologyVanderbilt UniversityNashvilleTennesseeUSABergljot GjelsvikOxford Mindfulness CentreDepartment of PsychiatryUniversity of OxfordOxfordEnglandUKCatherine R. GlennDepartment of Clinical and Social Sciences in PsychologyUniversity of RochesterRochesterNew YorkUSAOnja T. GradCentre for Mental HealthUniversity Psychiatric HospitalLjubljanaSloveniaEve GriffinNational Suicide Research FoundationWHO Collaborating Centre for Surveillance and Research in Suicide PreventionUniversity College CorkCorkIrelandDavid GunnellSchool of Social and Community MedicineUniversity of BristolEnglandUKPeter M. GutierrezVA Veteran Integrated Service Network 19 – Mental Illness Research, Education and Clinical CenterDenverColoradoUSAYari GvionDepartment of PsychologyBar Ilan UniversityRamat GanIsraelGergö HadlaczkyNational Centre for Suicide Research and Prevention of Mental lll‐Health (NASP)Karolinska InstitutetStockholmSwedenChristopher R. HaganLaboratory for the Study and Prevention of Suicide‐Related Conditions and BehaviorsDepartment of PsychologyFlorida State UniversityUSAEmily HargusOxford Mindfulness CentreDepartment of PsychiatryUniversity of OxfordOxfordEnglandUKSimon HatcherDepartment of PsychiatryUniversity of OttawaOttawaCanadaKeith HawtonCentre for Suicide ResearchDepartment of PsychiatryUniversity of OxfordEnglandUKSilvia R. HepburnDepartment of Clinical Health PsychologySt Mary's HospitalEnglandUKHeidi HjelmelandDepartment of Social Workand Health ScienceNorwegian University of Science and TechnologyTrondheimNorwayChristina W. HovenDepartment of Epidemiology and Division of Child PsychiatryChild Psychiatric Epidemiology Group, College of Physicians andSurgeons andMailman School of Public Health, Columbia UniversityNew York State PsychiatricInstituteNew YorkUSAIsabelle M. HuntCentre for Suicide PreventionCentre for Mental Health and SafetyUniversity of ManchesterManchesterEnglandUKShari Jager‐HymanAaron T. Beck Psychopathology Research CenterUniversity of PennsylvaniaPennsylvaniaUSAMark A. IlgenVA Serious Mental Illness Treatment Research and Evaluation Center & University of MichiganDepartment of PsychiatryAnn ArborMichiganUSADavid A. JobesSuicide Prevention LabDepartment of PsychologyThe Catholic University of AmericaDepartment of PsychologyWashington, DCUSAThomas E. JoinerLaboratory for the Study and Prevention of Suicide‐Related Conditions and BehaviorsDepartment of PsychologyFlorida State UniversityUSANavneet KapurCentre for Suicide PreventionCentre for Mental Health and SafetyUniversity of ManchesterManchesterEnglandUKLaurence Y. KatzDepartment of PsychiatryUniversity of ManitobaWinnipegCanadaJaclyn C. KearnsNational Center for PTSDVA Boston Healthcare SystemBostonMassachusettsUSAAd KerkhofDepartment of Clinical, Neuro, and Developmental Psychology and the EMGO Institute for Health and Care ResearchFaculty of Behavioural and Movement SciencesVU UniversityAmsterdamThe Netherlands Murad M. KhanDepartment of PsychiatryAga Khan UniversityKarachiPakistanOlivia J. KirtleySuicidal Behaviour Research LaboratoryInstitute of Health & WellbeingUniversity of GlasgowGlasgowScotlandUKBirthe Loa KnizekDepartment of Applied Social SciencesDepartment of Social Work and Health ScienceNorwegian University of Science and TechnologyTrondheimNorwayLynda KongDepartment of PsychiatryUniversity of ManitobaWinnipegCanadaAugustine J. KposowaDepartment of SociologyUniversity of CaliforniaRiversideUSAMyriam LabossièreMcGill Group for Suicide StudiesDouglas Mental Health University InstituteMcGill UniversityMontrealCanadaDorian A. LamisDepartment of Psychiatry and Behavioral Sciences Emory University School of MedicineAtlantaGeorgiaUSAElizabeth C. LanzilloDepartment of PsychologyBrown UniversityRhode IslandUSADeQuincy A. LezinePrevention CommunitiesFresnoCaliforniaUSADonald J. MandellInternational Center for Child Mental HealthNational Center for Disaster PreparednessMailman School of Public HealthColumbia UniversityNew York State Psychiatric InstituteNew YorkUSAManiam ThambuDepartment of PsychiatryUniversiti Kebangsaan Malaysia [National University of Malaysia]Kuala LumpurMalaysiaJ. John MannDivision of Molecular Imaging & NeuropathologyDepartment of PsychiatryCollege of Physicians and SurgeonsColumbia UniversityNew York State Psychiatric InstituteUSADavid McDaidPersonal Social Services Research UnitLSE Health and Social CareLondon School of Economics and Political ScienceLondonUKAlexander McGirrDepartment of PsychiatryUniversity of British ColumbiaVancouverCanadaLars MehlumNational Centre for Suicide Research and PreventionInstitute of Clinical MedicineUniversity of OsloOsloNorwayKonrad MichelUniversity Hospital of PsychiatryUniversity of BernBernSwitzerlandMatthew J. MillerDepartment of Health SciencesNortheastern UniversityBostonMassachusettsUSAAllison J. MilnerMelbourne School of Population and Global HealthUniversity of MelbourneMelbourneAustraliaCentre for Mental Health ResearchSchool of Population and Global HealthThe University of MelbourneMelbourneAustraliaBrian L. MisharaCentre for Research and Intervention on Suicide and Euthanasia and Psychology DepartmentUniversité du Québec à MontréalMontréalQuébecCanadaErlend MorkNational Centre for Suicide Research and PreventionInstitute of Clinical MedicineUniversity of OsloOsloNorwayKatherine MokCentre for Mental HealthMelbourne School of Population and Global HealthUniversity of MelbourneMelbourneAustraliaMatthew K. NockDepartment of PsychologyHarvard UniversityCambridgeMassachusettsUSAMerete NordentoftPsychiatric Center CopenhagenUniversity of CopenhagenCopenhagenDenmarkRory C. O’ConnorSuicidal Behaviour Research LaboratoryInstitute of Health & WellbeingUniversity of GlasgowGlasgowScotlandUKStephen S. O’ConnorDepartment of Psychiatry and Behavioral SciencesUniversity of LouisvilleLouisvilleKentuckyUSAMaria A. OquendoMolecular Imaging & Neuropathology Division (MIND)Department of PsychiatryCollege of Physicians and SurgeonsColumbia UniversityNew York State Psychiatric InstituteUSAJoel ParisInstitute of Community and Family PsychiatryMcGill UniversityMontrealQuebecCanadaMichael PhillipsSuicide Research and Prevention CentreShanghai Jiaotong University School of Medicine and Emory University School of MedicineShanghaiChinaJane PirkisCentre for Mental HealthMelbourne School of Population and Global HealthUniversity of MelbourneMelbourneAustraliaStephen PlattUsher Institute of Population Health Sciences & InformaticsUniversity of EdinburghScotlandUKMaurizio PompiliDepartment of Neurosciences, Mental Health and Sensory OrgansSuicide Prevention CenterSant'Andrea HospitalSapienza University of RomeItalyZoltán RihmerLaboratory for Suicide Research and PreventionNational Institute of Psychiatry and AddictionsBudapestHungaryJessica D. RibeiroVanderbilt UniversityNashvilleTennesseeUSAVincent RiordanWest Cork Mental Health Services, Cork, Ireland andCentre for Rural Health Research and PolicyInvernessScotlandUKJo RobinsonOrygen, The National Centre of Excellence in Youth Mental HealthMelbourneVictoriaAustraliaJitender SareenDepartment of PsychiatryUniversity of ManitobaWinnipegCanadaKate E. A. SaundersDepartment of PsychiatryUniversity of OxfordWarneford HospitalEnglandUKMorton M. SilvermanDepartment of PsychiatrySchool of MedicineUniversity of ColoradoDenverUSASteven StackDepartments of Criminology, and Psychiatry & BehavioralNeuroscienceWayne State UniversityDetroitUSABarbara StanleyDivision of Molecular Imaging & NeuropathologyDepartment of PsychiatryCollege of Physicians and SurgeonsColumbia UniversityNew York State Psychiatric InstituteUSACameron R. StarkDepartment of Public HealthNHS Highland, InvernessCentre for Rural HealthUniversity of AberdeenAberdeenScotlandUKSarah SteegCentre for Suicide PreventionCentre for Mental Health andSafetyUniversity of ManchesterManchesterEnglandUKKatherin SudolFrank H. Netter, M.D.School of MedicineQuinnipiac UniversityNorth Haven, ConnecticutUSAEhsanullah SyedDepartment of PsychiatryPenn State Milton S Hershey Medical CenterPenn State College Of MedicineHersheyPennsylvaniaUSAGustavo TureckiMcGill Group for Suicide StudiesDouglas Mental Health University InstituteMcGill UniversityMontrealCanadaKees van HeeringenUnit of Suicide Research and Flemish Suicide Prevention CentreGhent UniversityGhentBelgiumBregje van SpijkerNational Institute for Mental Health ResearchResearch School of Population HealthThe Australian National UniversityAustralia Capital TerritoryAustraliaLakshmi VijayakumarVoluntary Health ServicesSNEHA Suicide Prevention CentreIndia & University of MelbourneChennaiIndiaYun WangHong Kong Jockey Club Centre for Suicide Research and PreventionUniversity of Hong KongHong KongCamilla WassermanChild Psychiatric EpidemiologyDepartment of Child and Adolescent PsychiatryColumbia UniversityNew York State Psychiatric InstituteNew YorkUSADanuta WassermanNational Centre for Suicide Research and Prevention of Mental lll‐Health (NASP)Karolinska InstitutetStockholmSwedenKaren WetherallSuicidal Behaviour ResearchLaboratoryInstitute of Health & WellbeingUniversity of GlasgowGlasgowScotlandUKJ. Mark G. WilliamsOxford Mindfulness CentreDepartment of PsychiatryUniversity of OxfordOxfordEnglandUKKirsten WindfuhrCentre for Suicide PreventionCentre for Mental Health and SafetyUniversity of ManchesterManchesterEnglandUKAlan WoodwardLifeline Research FoundationLifeline AustraliaCanberraAustralian Capital TerritoryAustraliaKevin Chien‐Chang WuDepartment and Graduate Institute of Medical Education and BioethicsNational TaiwanUniversity College of MedicineDepartment of PsychiatryNational TaiwanUniversity HospitalTaiwanClare WyllieResearch & EvaluationSamaritansUKPaul S. F. YipCentre for Suicide Research and Prevention & Department of Social Work and Social AdministrationUniversity of Hong KongHong Kong
Rory C. O’Connor and Jane Pirkis
Since the publication of the first edition of the International Handbook of Suicide Prevention in 2011 (O’Connor, Platt, & Gordon, 2011), Preventing Suicide: A Global Imperative has been published by the World Health Organization (World Health Organization [WHO], 2014). This landmark publication, the first ever world suicide prevention report, highlighted the scale of the task of suicide prevention. At least 804,000 people take their own lives each year across the globe, which translates into a death every 40 seconds. The report also touches on many of the issues that we examine in detail herein, including the epidemiology of suicide and how best to intervene to prevent it. We are delighted that many of those who contributed to the WHO report have authored chapters for the second edition of this Handbook.
There are a number of changes in this edition of the Handbook. First, there is a change in editorship. Rory C. O’Connor has been joined by Jane Pirkis from University of Melbourne as coeditor, and Jane takes the place of Stephen Platt and Jacki Gordon, who were coeditors of the first edition. Second, we have expanded the Handbook; in terms of chapters, it is now 20% longer, which has allowed us to include more hot topics in suicide research and prevention. Third, given that the majority of the world’s suicides occur in Asia and low‐ and middle‐income countries, additional chapters have been dedicated to better understand suicide across different countries and cultures. Fourth, the majority of chapters end with a section describing up to 10 key resources. These resources include a selection of journal articles, books, reports, or online resources that the authors believe the reader would benefit from reading.
As in the first edition of the Handbook, we have tried to understand why people attempt suicide and what can be done to reduce suicide by harnessing the expertise of more than 110 suicidologists from across the world. The Handbook offers kaleidoscopic views on the complex multitude of factors that may explain suicidal behavior and the array of approaches to suicide prevention. It should appeal to anyone with an interest in trying to comprehend suicide and, ultimately, prevent it. To this end, one of the guiding principles of this volume is to improve our understanding of the relationship between attempted suicide and deaths by suicide. A more comprehensive understanding of this relationship is important not only for theoretical and conceptual reasons but also because secondary prevention interventions are frequently directed at those who attempt suicide. Any national or international suicide prevention strategy, to be effective, must be able to engage those who have attempted suicide. Although this may seem self‐evident, it is crucial, given the universal recognition that maintaining patients who have attempted suicide in treatment is fraught with difficulties. Further, it is sobering to note that the best predictor of future suicidal behavior (and suicide) is past suicidal behavior. Therefore, if we can intervene with those who have previously tried to take their own lives, we should be able to prevent at least some of the future deaths by suicide. Consequently, nonfatal suicidal behavior and suicide receive equal attention in this Handbook. As suicide attempt and self‐harm are often used interchangeably in the research literature (also see the following text), where we use the term suicide attempt/suicidal behavior in this Introduction, we are referring to self‐injurious behavior with evidence of suicidal intent. Self‐harm is used to describe all self‐harming behaviors where suicidal intent is not explicitly ascertained.
The overarching aim of this Handbook is to bring together the different exponents of suicide research and prevention irrespective of country of origin or professional background, because only through learning and working together internationally and across disciplines will we rise to the challenge of reducing suicidal behavior in every country. Suicidology, defined as the science of suicide and suicide prevention (Maris, 1993), is little over 55 years old, and embraces researchers, practitioners, and policy planners whose disciplinary backgrounds include psychology, psychiatry, epidemiology, sociology, social work, health economics, nursing, emergency medicine, ethics, law, and public health. This heterogeneity is a major strength, as the whole (i.e., the discipline of suicidology) is much greater than the sum of its constituent disciplines. We continue to learn from each other’s difficulties and successes, and to exchange a broad range of theoretical and methodological perspectives. However, one of the challenges of working in an interdisciplinary manner is that there are inevitable differences in emphasis, which can lead to difficulties in how we communicate about self‐injurious behavior across countries and professions. Although there have been several efforts to reach consensus on definitions and nomenclature (see Chapter 1 by Silverman), as a discipline we have yet to agree on a common definition of suicidal behavior. This renders the comparison of studies difficult. One study may include a heterogeneous sample of patients, some of whom are reporting suicidal intent and some of whom are not, whereas another may include only individuals who have engaged in potentially lethal suicide attempts, with explicit and high suicidal intent. Despite our best efforts, we are unlikely to achieve an agreed definition of suicidal behavior for some considerable time. Indeed, an inspection of the international literature still yields a myriad of different terms to describe the broad spectrum of self‐injurious thoughts and behaviors (e.g., self‐harm, attempted suicide, suicidal behavior, nonsuicidal self‐injury; see Chapter 1 by Silverman). Consequently, we asked each contributing author to make explicit early in their chapter how they operationalized and defined suicidal behavior therein.
Additional aims of the book are to showcase the state of the science in terms of research, policy, and practice, to share insights and expertise, and to enhance mutual learning. In this Handbook, we present the latest research on determinants of suicidal behaviors and the most promising interventions, treatments, and ways of caring for those at risk. We also describe the challenges of translating research, policy, and practice into saving lives. The extent to which suicidologists meet this latter challenge will determine, in large part, whether or not the universal goal of reducing suicide rates across the globe is attained. In short, this Handbook addresses the key questions of why people attempt suicide, what the best interventions are for those at risk, and what the key international challenges are in our pursuit of suicide prevention. In addressing these questions, it is important to recognize that the evidence base is, by and large, limited and that it must be understood in terms of the specific characteristics of a study population or the particular context of an intervention. Encouragingly, though, there have been major advances in our understanding of how best to treat and prevent suicidal behavior since the publication of the first edition.
As before, this edition of the Handbook is organized into three parts. Part I is concerned with the determinants and frameworks that inform our understanding of suicide and attempted suicide. Part II focuses on treatment, intervention, and care, and Part III reviews a range of suicide prevention issues that span research, policy, and practice. Chapters 1 to 3 provide the foundations for many of the subsequent chapters. In Chapter 1, for example, Silverman provides an overview of how the international community defines, classifies, and communicates about self‐injury with and without suicidal intent. As noted earlier, these remain contested issues within the field with much of the recent debate stimulated by the inclusion of nonsuicidal self‐injury and suicidal behavior disorder in DSM 5 as areas requiring further research (e.g., Kapur, Cooper, O’Connor, & Hawton, 2013; Oquendo & Baca‐Garcia, 2014). In Chapter 2, Windfuhr, Steeg, Hunt, and Kapur endeavor to bring together the research literature on the factors associated with suicidal behavior from different disciplines, and in Chapter 3, Arensman, Griffin, and Corcoran consider the specific challenge of predicting repetition of self‐harm. These are followed by four chapters (Chapters 4–7) that summarize the research and clinical literature on the relationship between suicidal behavior and psychiatric illness (depression [Chapter 4 by Rihmer and Dome], schizophrenia and other psychotic disorders [Chapter 5 by Desîlets, Labossière, McGirr, & Turecki), substance user disorders [Chapter 6 by Conner and Ilgen], and personality disorders [Chapter 7 by Paris]). The Handbook also considers the extent to which the treatment of these disorders can reduce suicide and attempted suicide. The risk of suicide in medical conditions is described in Chapter 8 (by Pompili, Forte, Berman, and Lamis).
The neurobiological and neuropsychological substrates that underpin suicidal behavior are considered in Chapters 9 and 10. In Chapter 9, Mann and Currier review the role of the serotonergic and noradrenergic neurotransmitter systems and the hypothalamic–pituitary–adrenal axis. They highlight the importance of studying the interaction between genetic vulnerability and environmental adversity in early life as a means of understanding how the effects of developmental changes in neurobiological systems can persist into adulthood and affect suicide risk. Chapter 10 by van Heeringen and Bijttebier investigates how changes in brain function are mediated by neuropsychological factors to increase the risk of suicide in response to stressors. In a new addition to this edition, the research findings and clinical implications of magnetic resonance imaging (MRI), diffusion tensor imaging, functional MRI (fMRI), positron emission tomography, and single photon emission computed tomography studies in suicide attempters are reviewed in Chapter 11 by Sudol and Oquendo.
The central role of psychology in understanding suicide risk is highlighted in Chapters 12 and 13. For example, the interpersonal‐psychological theory of suicidal behavior is described by Hagan, Ribeiro, and Joiner in Chapter 12, together with its history, its current status, as well as suggestions for further directions. The integrated motivational‐volitional model of suicidal behavior, a tripartite model that maps the relationship between background factors and trigger events and the development of suicidal ideation/intent into suicidal behavior is outlined by O’Connor, Cleare, Eschle, Wetherall, and Kirtley in Chapter 13. In the final three chapters (Chapters 14–16) of Part I, the focus shifts to the social context of suicide. In Chapter 14, Stack and Kposowa consider sociological perspectives, including the role of marital and religious integration. The powerful effects of inequalities, economic recession, and unemployment on suicide rates across the globe receive detailed analyses in Chapters 15 and 16. Lower socioeconomic status (at an individual level) and socioeconomic deprivation (at an area level) are both risk factors, although the evidence presented by Platt in Chapter 15 suggests that the “area effect” is compositional (rather than contextual). The complicated relationship between an economic recession and suicide risk is emphasized by Gunnell and Chang in Chapter 16: levels of debt, house repossession, relationship difficulties, alcohol misuse, pressures on those remaining in work and job insecurity, and cuts in mental health services ought to be considered in addition to unemployment.
Part II begins with two chapters that review the evidence‐based treatment and care of suicidal children and adolescents (Chapter 17 by Gvion and Apter) and older adults (Chapter 18 by De Leo and Arnautovska). In the former, the interplay between biological, genetic, environmental, social, and psychological factors in the etiology and course of suicidal behavior is considered alongside the effectiveness of prevention and treatment among children and adolescents. Chapter 18 highlights the age‐specific and gender‐specific risk and protective factors in old age as well as reviewing the efficacy of existing treatment and preventative strategies. The fundamental role of the therapist and the importance of the therapeutic alliance are considered in Chapter 19 by Michel. The subsequent six chapters (Chapter 20–25) also address clinical issues concerning treatment of patients who have attempted suicide, are actively suicidal, or who have presented to hospital following self‐harm. Recent systematic reviews of studies of attitudes of self‐harm patients toward clinical services and staff attitudes toward self‐harm patients are included in Chapter 20 (by Hawton and Saunders), as is a study of service provision with recommendations for the clinical management of self‐harm patients. Results of a systematic review of aftercare interventions are also summarized in Chapter 20. The authors conclude that there is now robust evidence that short‐term psychological therapy should be routinely offered to patients following self‐harm. After reviewing the literature, with a particular focus on clinical practice, Mehlum and Mork’s Chapter 21 suggests a set of requirements to ensure the continuity of care of suicide attempters, and makes recommendations for policy and clinical practice. In another new chapter, Hatcher presents a systems approach (adopted elsewhere in medicine and in other industries) applied to the management of suicide risk in emergency departments (Chapter 22).
Chapters 23–25 focus on key psychological processes in suicidality and emphasize how a better understanding of such processes is integral to a range of psychotherapeutic treatments. Cognitive Therapy, Dialectical Behavior Therapy, and the Collaborative Assessment and Management of Suicidality are reviewed in Chapters 23 (by Chang, Jager‐Hyman, Brown, Cunningham, and Stanley) and 24 (by Jobes, Comtois, Brenner, Gutierrez, and O’Connor). Chapter 25 (by Williams, Duggan, Crane, Hepburn, Hargus, and Gjelsvik) explores the conditions under which suicidal ideas may persist and escalate. It also describes mindfulness training and presents preliminary evidence that such training may be beneficial to those at risk of suicidal ideation and behavior. In the final three chapters of Part II (Chapters 26–28), different types of interventions adopting alternative modes of delivery are examined. Because it is often difficult to engage suicidal patients in treatment, interest in brief contact interventions has grown in recent years, with studies yielding promising findings in some subgroups (Chapter 26 by Milner and Carter). The role of online interventions to reduce suicide risk is considered by Kerkhof and van Spijker in Chapter 27. The authors ask whether the high expectations around online interventions have been met and highlight a number of challenges for future research. The significance of helplines in suicide prevention is explored by Woodward and Wyllie in Chapter 28. Although crisis helplines have been a mainstay of many national suicide prevention activities for decades, the authors review the evidence for their efficacy, noting the difficulties of evaluating their benefits.
Part III of the Handbook
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