Author's reply

There is little doubt that depression has a major role in suicide, being identifiable in approximately 50% of cases (Andersen et al, 2001). For this reason, depression is a target in all the national plans that I am aware of.

The role of depression in suicide has been well known since antiquity (Van Hooff, 2000) and this understanding has been largely responsible for the decline in a punitive attitude towards those exhibiting suicidal behaviour since the Englightenment. Consequently, the ‘fundamental discovery’ at the end of the 1950s of the role of affective disorders in suicide was far from revolutionary. It is worth remembering that in the vast majority of cases, fortunately, depression does not culminate in suicide. The relative risk for suicide across the life-span has been recently revised downwards (see, for example, Bostwick & Pankratz, 2000). In addition, a significant percentage of patients who die by suicide appear to have been adequately treated (25% in the experience of Andersen et al, 2001). A World Health Organization (1998) technical report has pointed out that optimal treatment of clinical depression would have little impact on global suicide rates, leaving the field open to speculations around more powerful factors in suicide prevention. In any case, the ‘medical paradigm’ is, in my view, only one of many possible perspectives, and needs to be integrated with other disciplines. Clearly, it is not the different prevalence of depression among countries that helps to explain the enormous diversity in rates of suicide that I mentioned in my editorial. Religious, cultural and social factors play very relevant roles in suicidal behaviour. It is in this light that the World Health Organization has correctly endorsed an ecological model, to help both understand and prevent/intervene in suicidal behaviours.

I am aware that Isacsson and Rich, through their research, strongly support the role of the newer antidepressants in preventing suicide. But others are a bit more hesitant in accepting this hypothesis (see, for example, Van Praag, 2002), and maybe lithium has shown more consistent (and convincing) effects, so far, on suicidal behaviour (Tondo et al, 2001).

With regard to the comments about a possible overemphasis on the complexities of suicidal behaviour, I am afraid that the philosopher Albert Camus, if he came back to life, would die again on hearing that!