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Suicidal Behaviour
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Table of Contents

Preface, Benedetto Saraceno; Introduction; Suicide prevention - Background, Problems, Strategies: Introductory Remarks - Wolfgang Rutz; The Who /Euro Multi-Centre Study on Suicidal Behaviour: Its Background, History, Aims and Design - Unni Bille-Brahe, Armin Schmidtke, Ad Kerkhof and Diego De Leo; Theoretical Aspects; Definitions of Suicidal Behaviour - Diego De Leo, Shelley Burgis, Jose M. Bertolote, Ad Kerkhof and Unni Bille-Brahe; Psychological Dimensions of Attempted Suicide: Theories and Data - Elene Chopin, Ad Kerkhof and Ella Arensman; The Psychobiology of Suicidal Behaviour - Cornelis Van Heeringen, Gwendolyn Portzky and Kurt Audenaert; Intentional Aspects of Non-Fatal Suicidal Behaviour - Heidi Hjelmeland and Keith Hawton; Research Findings; Socio-Demographic Variables of Suicide Attempters - Armin Schmidtke and Cordula Lohr; Negative Life Events and Non-Fatal Suicidal Behaviour - Ella Arensman and Ad Kerkhof; Repetition of Attempted Suicide: Frequent, but Hard to Predict - Ad Kerkhof and Ella Arensman; Marital Relations of Suicide Attempters - Cordula Lohr and Armin Schmidtke; Physical Illness and Suicidal Behaviour - Jacinta Hawgood, Kym Spathonis and Diego De Leo; Addiction and Suicidal Behaviour: Questions and Answers in the EPIS - Helen Keeley, Paul Corcoran and Unni Bille-Brahe; Sexual Abuse and Suicidal Behaviours - Ellinor Salander-Renberg, Sibylla Lindgren and Inger Osterberg; The Importance of Social Support - Unni Bille-Brahe and Borge Jensen; Imitation of Suicidal Behaviour - Armin Schmidtke, Cordula Lohr, Unni Bille-Brahe and Diego De Leo; Seasonality and other Temporal Fluctuations in Suicidal Behaviour: Myths, Realities and Results - Gert Jessen; Suicidal Behaviour in Special Interest Groups; Suicidal Behaviour Among Young People - Ella Arensman and Keith Hawton; Suicide and Suicidal Behaviour in Late Life - Diego De Leo and Kym Spathonis; Immigrants and Attempted Suicide in Europe - Halise Devrimci Ozguven, Isik Sayil, Bora Baskak and Unni Bille-Brahe; Clinical Aspects in Non-Fatal Suicidal Behaviour; Contacts with Health Care Facilities Prior to Suicide Attempts - Sandor Fekete, Peter Osvath and Konrad Michel; Suicide Attempters, Health Care Systems and the Quality of Treatments - Unni Bille-Brahe and Cordula Lohr; List of Contributors

Reviews

This new text presents clinicians with updated information that may prove vital to effectively preventing suicide. The research compiled in this text is the product of a study sponsored by the World Health Organization (WHO) that spanned fifteen years and involved data gathered from over forty European cities. Although the bulk of the research amassed in this book was done in Europe, the essays compiled within this text represent an important voice for those advocating the need for increased attention to an oft-ignored international public health concern. As the research demonstrates, the prevalence of suicidal behavior is seldom commensurate with the incidence of depression. While the authors acknowledge a relationship between risk factors such as depression and suicidal behavior, they demonstrate the need to look beyond simple risk-assessment analyses to understand this lamentable phenomenon on the one hand and working towards its prevention on the other. Understanding suicide is crucial to confronting the myriad public health, clinical, as well as economic costs burdening societies around the globe as they work towards prevention mechanisms to decrease the prevalence of such behavior. As one author suggests, "in order to mount effective prevention efforts, suicidal behavior must be understood" (pg 19). Understanding the nuances of suicidal behavior is a prerequisite to eradicating it, and the authors demonstrate that suicidal attitudes tend to mirror the society around them. Just as no society exists as a homogenous, monolithic entity, similarly, suicidal behavior cannot be classified according to a single, standardized definition. Indeed, as the authors suggest, suicidal behavior is, like many other social phenomena, indiscriminate in terms of the age, nationality, or gender of those it affects. For example, in the chapter entitled "Suicidal Behaviour Among Young People," authors Arensman and Hawton evaluate the incidence of suicidal behavior according to age-based criteria. Their research suggests that suicidal behavior is a problem that both young and old people need to confront since it affects both almost equally. Suicidal behavior among young people "has become a growing problem for many countries" (p.239), at a time when it has been concomitantly proven that "internationally, suicide rates increase with age" (p.255). Here we are confronted with a rather perplexing trend in which the young citizens of nations are being subjected to a "growing problem" while elderly people around the world are becoming increasingly susceptible to suicide with each passing year. The writers of this anthology tap various legal and economic sources to paint a lucid composite of suicidology. The introductory chapter sets the stage for the theme of the book which, as state previously, is enhancing the understanding of suicide as a means of facilitating its prevention. The analysis begins with an assessment of existing definitions of the word "suicide," which the authors find to be insufficient. The authors suggest that adopting a standard nomenclature of suicide is imperative for clinicians as it would enable a treatment system that is "applicable and usable both within and across all domains in which it is to be employed" (p.20). The lack of consistency in defining suicidality bodes ill for future clinicians in that it "contributes to a lack of comparability" (p. 22) between treatment modalities in different social and economic settings. The authors believe that this lack of comparability between studies is the largest impediment facing public health professionals in their struggle to stem the global threat of suicide. In the absence of a clearly-defined nomenclature, the ability of researchers and clinicians to confront suicide with the same uniformity doctors attack diseases bodes ill for governments around the world. Incidentally, the presence of a more comprehensive strategy for confronting suicidal behavior provides valuable clinical paradigms that clinicians can utilize. For example, if forced to abide by a uniform strategy, clinicians would be increasingly inclined to avoid adopting treatments that "may not prove effective or relevant for a particular patient" in favor of effective treatment modalities with proven effectiveness. Whether or not suicide prevention adopts universal standards is less important to the authors as the possibility of advancing "thoughtful and challenging debate" on the subject. The relationship between an individual's psychological disposition and the presence of suicidal behavior has been well documented. Nonetheless, according to the authors, current theories governing this relationship "only partially explain" the complex issues underlying suicidality and suicide attempts. The editors suggest that since multiple motives drive persons to attempt suicide, it would remiss not to dissect such motives from a multifaceted approach. For example, in the chapter entitled "Psychological Dimensions of Attempted Suicide: Theories and Data," the authors suggest that theories which regard suicidal behavior as "heterogeneous are more relevant since they can explain interpersonal as well as self-directed aspects of self-destructive behavior" (p.58). Nonetheless, the authors of this same chapter also advocate the need to "recognize and address specific subsets or dimensions" (p.58) of behaviors that result in increased suicide attempts. Conceptualizing suicidal behavior along individual dimensions would not only help us to better understand the etiology of attempted suicide but also, according to the authors, "would enable us to devise optimal treatments targeting specific needs" (p.58). This emphasis on individualized modes of treating patients offers promising results for future clinicians in that it forces us to treat suicide according to how it presents itself, thereby fostering the need for individualized treatment as well. If, for example, a patient's suicidal behavior were motivated by the fear of losing a loved one, then such a patient could be treated with relationship therapy. Conversely, a patient exhibiting suicidal behavior motivated by a life long avoidant personality-type, might respond better to self-esteem therapy. Overall, the text provides excellent insight into this ages-old problem for both global healthcare professionals and laymen interested in learning more about suicide. Review due to appear in Journal of the National Medical Association, November 2006

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