Platform, 393 pages). This book has been produced by St. Vincent's Psychogeriatric Mental. Health Service which is based in metropolitan New South Wales,.
0010.1177/1039856214562079Australasian PsychiatryBook reviews book-review2015
Australasian
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Book reviews
Australasian Psychiatry 2015, Vol 23(1) 81–83 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav apy.sagepub.com
Preventing suicide: a global imperative. World Health Organization: Geneva, 2014. ISBN 978 92 4 156477 9
prevention strategies. This explains some disappointment of the clinician reviewers, who hoped for practical advice.
92 pages, available free from http://www.who.int/mental_ health/suicide-prevention/world_ report_2014/en/
This document from the pre-eminent health authority (WHO) is revelatory and revolutionary. Key announcements are that there is no single cause of suicide, that there are multiple contributing factors, that risk factors are interactive and cumulative, and that there are multiple pathways to self-inflicted death.
Preventing suicide: a global imperative is the first World Health Organization (WHO) document of its kind. While it is repetitive and not beyond reproach, it corrects a misapprehension which has plagued psychiatry for half a century. Since the early 19th Century, medicine has (at its own request) ‘owned’ suicide. This ownership was strengthened after Dorpat and Ripley (1960) reported that 100% of 114 consecutive suicide completers suffered a psychiatric disorder.1 The consequent problems were that that psychiatrists became responsible for all suicide and contributions from other fields were not fostered. This document presents a balanced assessment of the triggers of suicide. The document begins with a Foreword from Dr Chan, the Director General (WHO). She states that suicide is a “major public health problem” and identifies “stigma” as an impediment to prevention. She states, “suicides are preventable”, that “the burden of suicide does not weigh solely on the health sector”, that prevention requires a “multisectoral approach”, and that the “way forward is to act together”. These ideas are frequently repeated thereafter. The Preface informs that the aim of the document is to encourage countries to establish comprehensive suicide
Gratifyingly, the list of risks factors is very broad and includes war, disaster, stress of acculturation (among indigenous or displaced people), discrimination, isolation, abuse, violence, conflictual relationships, harmful use of alcohol, financial loss, chronic pain, family history of suicide, personal history of suicidal behaviour, and psychological, social, cultural biological and environmental problems. These factors have been gathered under headings moving from ‘systemic’ to ‘individual’, suggesting an “ecological model” (page 30). The risks associated with mental disorders and harmful use of alcohol are mentioned, but they are buried in the host of factors mentioned above. There are caveats: “While the link between suicide and mental disorders is well established, broad generalizations of risk factors are counterproductive” (page 11). Eventually comes mention that mental disorders have been identified in 90% of people who die by suicide. This is followed by, “This risk factor should be approached with caution” (page 40). It is clear the authors are uncomfortable with these ‘facts’. The document contains
four full-page illustrations of placards bearing troublesome myths – one bears the statement “Only people with mental disorder are suicidal”, followed by the sanctioned statement “not all people who take their own lives have a mental disorder” (page 53). Thus, while mental disorder is acknowledged as a risk factor, WHO relegates it from its former position as the primary cause. Hopelessness (which is sometimes a component of depressive disorder) is considered important in its own right. Interestingly, the authority cited as support (O’Connor and Nock, 2014; page 73) states that while many risk factors have been identified, “they mostly do not account for why people try to end their lives”.2 Much is made of the importance of impulsivity (which received little attention in the past) and the potential prevention opportunity in restricting access to pesticides, firearms, charcoal which produces carbon dioxide, chemicals which produce hydrogen sulphide and erecting structural interventions at dangerous places such as high buildings, train tracks and bridges. The document claims to be evidence based, but no evidence was given to support this practice. Much is made also of the importance of responsible media reporting, and combating stigma; but again, there is no robust evidence indicated sustained positive effects. The risk factor attracting most attention was a previous suicide attempt. Unfortunately, this contention is meaningless, as “suicide attempt” was broadened to include “self-harm”
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which may or “may not have a fatal intent or outcome” (page 12). Prevention strategies are classified at three levels: ‘Universal’, ‘Selective’ (vulnerable groups) and ‘Indicated’ (vulnerable individuals). There is a large amount of cross-over between these levels. Actions are described in public health language and appear to lack practical application. In keeping with the words of the WHO Director General, that a multisectoral approach is required, assistance from many fields is suggested: health sector, education, employment, social welfare, judiciary, justice, labour, law, religion, transportation, agriculture, defence, politics and media. It is suggested that professional and non-professional groups participate. Non-specialized health professionals, self-help groups and trained volunteers (helplines) all have a place. The concept of ‘gatekeepers’ is introduced. A ‘gatekeeper’ is anyone “who is in a position to identify whether someone may be contemplating suicide” (page 38). Along with the more obvious candidates such as teachers and police, ‘community leaders’ and ‘human resources staff and managers’ are recommended. All need training. A personal belief system and “regular exercise and sport, adequate sleep and diet, consideration of the impact on health of alcohol and drugs, healthy relationships and social contact, and effective management of stress” (page 44) are recommended. “Upstream approaches” (page 44) refers to addressing risk factors in early life, and suggests imposed benevolence. There are statements with which the reader might take issue, such as, that an indicator of suicide prevention strategy success is “a decrease in the number of hospitalized suicide attempts” (page 9), and that suicide is never “an acceptable response to crisis or adversity” (page 32). There are some spectacular euphemisms, such as when debate is replaced by “meaningful ongoing academic dialogue” (page 12).
Nevertheless, Preventing suicide is a huge stride forward. It encourages us to think of suicide as the result of a host of often interacting and compounding triggers. Although it repeatedly states (starting with Dr Chan) “Suicides are preventable”, it does not provide a convincing key. Perhaps there is no such key. However, it contains much wisdom, such as, “the problem of suicide is different in every country” (page 58). References 1. Dorpat T and Ripley H. A study of suicide in the Seattle area. Compr Psychiatry 1960; 1: 349–359. 2. O’Connor R and Nock M. The psychology of suicidal behaviour. Lancet Psychiatry 2014; 1: 73–85.. 4
Saxby Pridmore and Stephane Auchincloss Hobart, TAS DOI: 10.1177/1039856214562079
St Vincent’s Hospital Handbook of Clinical Psychogeriatrics Burke, David and Burke, Ayse (2013, CreateSpace Independent Publishing Platform, 393 pages). This book has been produced by St Vincent’s Psychogeriatric Mental Health Service which is based in metropolitan New South Wales, Australia. This service commenced in 2003. The book aims to provide information on assessment and management of common presenting symptoms and mental health problems seen in older people, with inclusion of specialized topics relevant to the aging population. The initial chapter provides an introduction to the St Vincent’s Psychogeriatric service, and the importance of working within a multidisciplinary team. Then chapters follow which outline the major mental health problems commonly seen in the older age group. These include the “old favorites” such as acute presentations (suicide, drug and alcohol
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emergencies, and drug syndromes), delirium, dementia, and depression. These chapters have been coauthored by people from different disciplines so that a truly multidisciplinary perspective is given. Each major topic contains epidemiology, presenting symptoms, diagnostic and management information. There is nothing particularly ground-breaking or special in these chapters – a clinician can obtain information on these topics from any number of related “psychiatry of old age” textbooks. I note that there are no chapters dedicated to either personality changes/disorders in older age or drug and alcohol use. These two topics may become more relevant as the baby boomers are now aged 65 years, and many adult mental health patients are surviving into “old age” and are being transitioned to psychogeriatric services. The strengths of this handbook are the inclusion of specialized assessment topics which are not traditionally incorporated in small textbooks. There are chapters describing neuroimaging, neuropsychological assessment, and the oft-discussed topic of competence and capacity. I also found that the specialized management topics were informative. There is a chapter dedicated to psychotherapy, which is an area of neglect
