The International Handbook of Suicide Prevention ebook

Table of Contents

Cover

Title Page

Notes on Contributors

Introduction

References

Part I: Suicidal Determinants and Frameworks

1 Challenges to Defining and Classifying Suicide and Suicidal Behaviors

Introduction

Challenges to Developing and Implementing a Standardized Nomenclature and Classification System

Clarifying Terminology

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

Key Questions

Future Directions

Conclusions

References

2 International Perspectives on the Epidemiology and Etiology of Suicide and Self‐Harm

Introduction

Suicide

Self‐Harm

Conclusion

References

3 Self‐Harm

Introduction

Extent of the Problem of Self‐Harm and Repetition

Prediction of Repeated Self‐Harm Across the Lifespan

Gender Differences

Ethnicity

Assessment of Risk of Repeated Self‐Harm

Conclusions

References

4 Major Mood Disorders and Suicidal Behavior

Introduction

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

Conclusions

Key Resources

References

5 Schizophrenia, Other Psychotic Disorders, and Suicidal Behavior

Introduction

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

Conclusions

Key Resources

References

6 Substance Use Disorders and Suicidal Behavior

Introduction

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

Future Directions

Key Resources

References

7 Personality Disorders and Suicidality

Introduction

The Management of Suicidality in Borderline Personality Disorder

Conclusions and Implications for Practice

Key Resources

References

8 The Association Between Physical Illness/Medical Conditions and Suicide Risk

Introduction

Multiple Sclerosis

Epilepsy

Huntington’s Disease

Cancer

HIV

End‐Stage Kidney Disease

Diabetes Mellitus

Stroke

Conclusions

References

9 Relationships of Genes and Early‐Life Experience to the Neurobiology of Suicidal Behavior

Introduction

Biological Alterations in Suicidal Behavior

Stress‐Response Systems

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

Conclusion

Acknowledgments

Key Resources

References

10 Understanding the Suicidal Brain

Introduction

Neuropsychological Studies of Suicidal Ideation and Behavior

Discussion

Conclusions

References

11 Visualizing the Suicidal Brain

Introduction

Brain Imaging Findings in Suicide Attempters

Discussion

Neuroimaging and Suicide Prevention

Conclusion

Key Resources

References

12 Present Status and Future Prospects of the Interpersonal–Psychological Theory of Suicidal Behavior

Introduction

Key Concepts

Main Predictions

Future Directions

Conclusion

Key Resources

References

13 The Integrated Motivational‐Volitional Model of Suicidal Behavior

Introduction

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

Conclusions

Key Resources

References

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

Results

Discussion

References

15 Inequalities and Suicidal Behavior

Introduction

Socioeconomic Inequalities in Suicide: The Evidence

Empirical Investigation of Socioeconomic Inequalities in Suicide in Scotland

Discussion

Conclusion

Key Resources

References

16 Economic Recession, Unemployment, and Suicide

Introduction

Epidemiological Evidence

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?

Conclusions

Key Resources

References

Part II: Intervention, Treatment, and Care

17 Evidence‐Based Prevention and Treatment of Suicidal Behavior in Children and Adolescents

Introduction

Understanding Effective Prevention Through Changes in the Epidemiology of Youth Suicide

Risk Factors for Suicidal Behavior as Targets of Prevention and Treatment

Assessment

Suicide Prevention in Children and Adolescents

Conclusions

References

18 Prevention and Treatment of Suicidality in Older Adults

Introduction

Peculiarities of Suicidal Behavior in Older Age

Epidemiological Trends

Risk Factors for Suicide Among Older Adults

Treatment of Suicidality Among Older Adults

Conclusions

Key Resources

References

19 Therapeutic Alliance and the Therapist

Introduction

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

Conclusion

Key Resources

References

20 Clinical Care of Self‐Harm Patients

Introduction

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?

Further Developments

Conclusions

Key Resources

References

21 After the Suicide Attempt—The Need for Continuity and Quality of Care

Introduction

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

Key Resources

References

22 Management of Suicidal Risk in Emergency Departments

Introduction

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

Key Achievements

Conclusion

Key Resources

References

23 Treating the Suicidal Patient

Introduction

Cognitive Therapy

Dialectical Behavior Therapy

Comparison of CT and DBT for Suicide Prevention

Conclusions and Recommendations for Future Research

Key Resources

References

24 Lessons Learned from Clinical Trials of the Collaborative Assessment and Management of Suicidality (CAMS)

CAMS Overview

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

Conclusion

Key Resources

References

25 Modes of Mind and Suicidal Processes

Introduction

Background

Empirical Evidence

Can Mindfulness Help?

The Effect of Mindfulness Training on Self‐Discrepancy

Conclusion

Key Resources

References

26 Brief Contact Interventions

Introduction

What is a Brief Contact Intervention?

Content of BCIS

Evidence of Effectiveness From Reviews

Continuing Questions and Areas for Future Research

Conclusion

Key Resources

References

27 Delivering Online Cognitive Behavioral Therapy Interventions to Reduce Suicide Risk

Introduction

Studies Targeting Depression With Suicide Ideation as Treatment Outcome

Study Targeting Suicidal Ideation: Living Under Control

Rationale

Effectiveness

Conclusion

Key Resources

References

28 Helplines, Tele‐Web Support Services, and Suicide Prevention

Introduction

Conceptualization of Helplines and Tele‐Web Support Services

Empirical Evidence

Discussion: Challenges and Future Directions

Conclusions

References

Part III: Suicide Prevention

29 Suicide Prevention in Low‐ and Middle‐Income Countries

Introduction

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

Conclusion

Acknowledgments

References

30 Suicide in Asia

Setting the Context

The Challenge of Suicide Prevention in Asia

Conclusions

Key Resources

References

31 Cultural Factors in Suicide Prevention

Introduction

How Does Culture Influence Suicidal Behavior?

Conclusions

Key Resources

References

32 Suicide Prevention Strategies

Introduction

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

Conclusion

Key Resources

References

33 Rurality and Suicide

Introduction

Suicide in Rural Areas

Themes in Rural Suicide Epidemiology

Achievements in Rural Suicide Prevention

Models of Rural Suicide

Key Questions for the Future

Conclusions

Key Resources

References

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

Conclusions

References

35 Suicide Prevention Through Restricting Access to Suicide Means and Hotspots

Introduction

Rationale and Evidence

Cognitive Availability

Restricting Access to Suicidal Means and Hotspots in Suicide Prevention

Conclusion

Key Resources

References

36 Reducing Suicide Without Affecting Underlying Mental Health

Introduction

Why Means Matter

Principles Guiding This Review

Empirical Studies

Conclusion

Acknowledgments

Key Resources

References

37 Surviving the Legacy of Suicide

Introduction

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

Conclusions

References

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

Research Directions

Challenges and Personal Experience

Conclusion

Key Resources

References

39 Time to Change Direction in Suicide Research

Introduction

A Critical Look at Current Mainstream Suicide Research

The Kind of Research the Field Now Needs (More of)

Conclusion

Key Resources

References

40 Suicide Research Methods and Designs

Introduction

Methodological Considerations

Research Study Designs

Instruments and Informants

Conclusions and Suggestions for Future Research

Key Resources

References

41 School‐Based Suicide Prevention Programs

Introduction

Awareness and Education Curricula

Screening

Gatekeeper Training

Skills Training

Culturally Adapted Programs

Key Achievements in School‐Based Suicide Prevention and Influence on the Evidence Base

Limitations of the Literature

Future Directions

Conclusion

Related Readings

Key Resources

References

42 Media Influences on Suicidal Thoughts and Behaviors

Suicide and Traditional Media

Suicide and Newer Media

Suggested Theoretical Underpinnings

Key Achievements

Key Challenges for the Future

Conclusions

Key Resources

References

43 Suicide Clusters

Introduction

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

Conclusions

Key Resources

References

44 Making an Economic Case for Investing in Suicide Prevention

Introduction

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?

References

Index

End User License Agreement

List of Tables

Chapter 08

Table 8.1 Main Suicide Risk and Prognostic Factors

Table 8.2 Risk Factors Associated with Suicidal Behavior in those with HIV

Chapter 10

Table 10.1 Brief Summary of Findings in Association with Suicidal Ideation or Behavior per Neuropsychological Domain

Chapter 11

Table 11.1 Summary of Findings in Suicide Attempters, by Brain Region

Chapter 13

Table 13.1 Selected Predominant Models of Suicidal Behavior from the Past 30 Years

Chapter 14

Table 14.1 Hierarchical Linear Regression Results of the Effect of Marital and Religious Integration on Suicide Acceptability, World Values Surveys, 1999–2000

Chapter 16

Table 16.1 Approaches to Mitigating the Impact of the Economic Crisis on Suicide

Chapter 18

Table 18.1 Ubiquitous Causes of Underreporting of Suicide Mortality Data in Older Adults

Chapter 22

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

Chapter 25

Table 25.1 Decentered Meta‐Awareness of Thoughts and Feelings as Reasons for Not Self‐Harming

Chapter 29

Table 29.1 Epidemiological Differences Between LMICs and HICs

Table 29.2 Multisector Approach to Suicide Prevention in LMICs

Chapter 30

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

Chapter 31

Table 31.1 The Influence of Culture on Suicidal Behavior

Chapter 35

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

Chapter 36

Table 36.1 Case Fatality Ratios for Selected Methods Commonly Used in Intentional Self‐Harm

Chapter 38

Table 38.1 Suicide Attempt Survivor Core Values Compared to Recovery Principles

Chapter 44

Table 44.1 Estimates of the Average Cost per Completed Suicide U.S. Purchasing Power Parity (PPP) $ (2014 prices)

List of Illustrations

Chapter 02

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.

Chapter 06

Figure 6.1 Model of suicidal behavior among individuals with SUDs.

Note.

Moderating effects are depicted by a broken arrow and mediating effects by unbroken arrows.

Chapter 12

Figure 12.1 A visual representation of the primary predictions of the IPT.

Chapter 13

Figure 13.1 Integrated motivational‐volitional (IMV) model of suicidal behavior.

Figure 13.2 Predictors of repeat suicidal behavior.

Note.

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 .

Chapter 15

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).

Chapter 16

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?)]

Chapter 18

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

Chapter 24

Figure 24.1 CAMS course of care.

Chapter 25

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.

Chapter 29

Figure 29.1 Rates of suicide by age and region.

Note

. Based on data from

Preventing suicide: A global imperative

, WHO (2014) as per WHO regional classification.

Chapter 31

Figure 31.1 The Inglehart‐Welzel cultural map of the world. http://www.worldvaluessurvey.org/images/Cultural_map_WVS6_2015.jpg

Chapter 33

Figure 33.1 A conceptual model of suicide in rural areas.

Figure 33.2 An example of the use of the conceptual model.

Chapter 34

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.

Chapter 36

Figure 36.1 Pathways through which reductions in access to lethal means may result in lower suicide rates.

Chapter 43

Figure 43.1 The Circles of Vulnerability model.

Guide

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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

The International Handbook of Suicide Prevention

Second Edition

Edited by

This second edition first published 2016© 2016 John Wiley & Sons, Ltd

Edition history: John Wiley & Sons, Ltd (1e, 2011)

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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

A catalogue record for this book is available from the British Library.

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

Notes on Contributors

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

Introduction

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