Coombs et al (1992) investigated the communication between professional caregivers and suicidal patients prior to attempting suicide. Clinicians often had failed to inquire about a potential suicide risk. When suicidality was addressed, clinicians tended to avoid further exploration of the suicidal thoughts, and rarely documented suicidal risk as a significant problem.

So far it has been virtually impossible to show that any aftercare strategy for suicide attempters effectively reduces the risk of further self-harm (see Hawton et al. 1998).

O'Sullivan et al (1999) found a 48% increase of uptake of hospital services in the year after the suicide attempt. This included visits to the emergency room as well as both general and psychiatric admissions and outpatient services. The authors write: "The significant increase in health service costs following acts of parasuicide ... further highlights the need to address the problem of parasuicide.... The dilemma faced by most clinicians and administrators is how to provide a quality service in the face of increasing demand and reduced resources". Rightly, the Surgeon General (1999) in his call to action recommends training for all health, mental health, and human service professionals concerning suicide risk assessment and recognition, treatment, management and aftercare interventions.

However, in spite of a large literature on risk factors it remains difficult to introduce special treatment strategies (such as strict supervision and intensive medical care) for individuals at risk for any length of time. Factors predictive of infrequent behaviour lead to large numbers of false-positive and false-negative cases and may give the wrong impression of scientific predictability (Murphy 1984, Pokorny 1983). Identifying the rare acute high risk patient seems rather like searching for the needle in the haystack, particularly considering that the average general practitioner is faced with a suicide of a patient once every three to five years.

Clearly, we need new ideas to try to become more effective in the treatment of suicide attempters and suicidal persons in general.

References

Coombs, D.W., Miller, H.L., Alarcon, R., Herlihy, C., Lee, J.M., Morrison, D.P. (1992) Presuicide attempt communications between parasuicides and consulted caregivers. Suicide and Life-Threatening Behavior 22(3), 289-302.

Hawton, K., Arensman, E., Townsend, E., Bremner, S., Feldman, E., Goldney, R., Gunnell, D., Hazell, P., van Heeringen, K., House, A., Owens, D., Sakinofsky, I., Träskman-Bendz, L. (1998) Deliberate self-harm: systematic review of efficacy of psychological and pharmacological treatments in preventing repetition. British Medical Journal 317: 441-7.

Murphy, G.E. (1984) The prediction of suicide: why is it so difficult? American Journal of Psychotherapy 38: 341-349.

O'Sullivan, M., Lawlor, M., Cocoran, P., Kelleher, M.J. (1999) The cost of hospital care in the year before and after parasuicide. Crisis 20/4,178-183.

Pokorny, A.D. (1983) Predicition of suicide in psychiatric patients: report of a prospective study. Archives of General Psychiatry 40: 249-257.

U.S. Public Health Service. The Surgeon General's Call To Action To Prevent Suicide. Washington, DC: 1999.

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