A Concise Guide to Understanding Suicide: Epidemiology, Pathophysiology, and Prevention Edited by Stephen H. Koslow, Pedro Ruiz & Charles B. Nemeroff. Cambridge University Press. 2014. £67.50 (hb). 408 pp. ISBN 9781107033238

Suicide is a worldwide challenge; it represents a major public health problem, and suicide mortality across the globe accounts for almost one million deaths annually, leaving behind families, friends and colleagues struggling to recover from such a tragedy. Researchers have seen some significant progress in understanding suicide and interesting research is emerging.

The textbook contains 41 chapters, written by 88 internationally renowned researchers. The book is presented in six sections organised around common themes such as understanding suicide; special risk populations; treatment; and ending with suicide prevention. In recent years there have been a number of textbooks published on suicide, which usually present either public health or mental health perspectives. What I found most interesting in this book is the variety of perspectives with regard to the suicidal process. The different chapters examine aspects such as risk assessment, cognitive processes, and psychotherapy, as well as psychiatric, neuropsychobiological, pharmacological, and metabolic syndromes of suicide. Most of the chapters are concise, and adopt a multidimensional perspective on each specific theme. Many chapters offer graphics, tables and figures, all helpful, which allow the reader to identify specific areas of interest within the book. Each chapter is developed to explore one aspect of suicide behaviour and gives sufficient, state of the art information to the reader.

This book offers a wide perspective on suicide research, but there is an important focus on the detection of suicide potential. Of course, detection, evaluation and prediction of suicidal behaviours are important issues. In chapter 29, Davidson, Olson-Madden, Betz & Allan describe the steps to emergency department identification, assessment and management of suicidal patients. The chapter raises the question of who should be systematically screened for suicide risk in an emergency department setting, what type of clinical assessment and care should be offered for those patients presenting with low imminent risk of self-harm and what type of care is needed for some higher level of risk. This chapter offers a definition of different subgroups of suicidal behaviours, identifies major proximal and distal risk factors and proposes different risk levels, each accompanied by treatment recommendations. The authors suggest that a safety plan may be required for some patients before discharge. Stanley, Biggs & Brown present the safety planning to prevent suicidal behaviour in more detail in chapter 39. Safety planning is a strategy developed with the patient allowing identification of ways in which they could keep themselves safe during a suicidal crisis by recognising warning signs, employing different level of coping strategies during a suicidal crisis and, finally, restricting access to lethal means of suicide.

The safety plan differs from a no-suicide contract, which was used regularly in clinical settings for a long period. Reflecting on the advantages and iatrogenic effects of such no-suicide contracts in chapter 40, Miller highlights the historical use of these contracts, how and why the no-suicide contracts were used and the unintended negative consequences of these contracts. As an alternative to the use of no-suicide contracts, Miller suggests that clinicians encourage patients to communicate in detail about their suicidal thoughts, impulses, ideas and plans, and make a judgement about the state of the therapeutic alliance. Of course, the assessment of suicidal risk requires valid answers from patients, who may be ambivalent about their suicidal thoughts or afraid to disclose completely their suicidal plans or access to means. Therefore, the question of suicide assessment is of great importance. In chapter 4, Berman & Silverman take the reader step-by-step in the sensitive process of exploring the presence or absence of suicidal ideation, motivation, intent, planning and behaviour. The authors discuss the benefits and limitations of screening tools, and the importance of adding a face-to-face clinical interview in the process of making a clinical judgment based on sound systematic models of conducting a suicide risk assessment and a suicide risk formulation rather than intuition. The suicide risk formulation is based on the understanding of how multiple and different risk factors may interact in the life of one individual and play out differently for another person. The authors conclude by saying that ‘clinical judgement will always be necessary to the suicide risk formulation as purely actuarial models will never attain the level of specificity and sensitivity desired’.

There are a number of other chapters addressing suicide risk assessment, suicide treatment, especially pharmacological treatment, and the identification of mediators and moderators of biological markers. The editors suggest that research on suicide should focus on: the development of algorithms predicting suicide risk; biological markers; mapping neural circuitry and biological mechanisms; the development of effective pharmacological and psychotherapeutic treatments; and standardised assessment of suicide. While these are all worthwhile research avenues, the editorial choice of this book is mostly centred on the individual detection and biological markers of suicidal risk and on ‘indicated strategies’ for at-risk individuals, such as pharmacological treatments. Other strategies such as universal and selective strategies, which have been proven to be successful in suicide prevention, are less discussed in this textbook.

Overall, this textbook explores many extremely important aspects of suicide research and offers a perspective on the complex phenomena of suicide behaviours. While we still do not have a clear understanding of the difference between individuals who will plan a suicide, and those who will take their own lives, the multidimensional factors associated with suicide suggest that there is no single solution in dealing with suicide and we must remain open and responsive in light of new research perspectives and evidence.