Letter

In Reply: We thank Dr. Hubbeling for her response, and we are happy to clarify our choice of the APA guidelines. First, no Dutch national guidelines for the treatment of suicidal patients exist. Therefore, we knew beforehand that we could expect that the inspectorate's notifications and responses would not follow any existing guidelines. However, we needed a standard of good clinical care for suicidal patients so that we could evaluate the inspectorate's responses. For this reason we conducted a literature search and screened all guidelines available internationally. The review was published in Dutch in 2007 ( 1 ).

Because the APA guidelines are the most extensive that we know of and are partly evidence based, we chose them as a gold standard, as Dr. Hubbeling observed. However, it is important to note that it was our intention to use only the most global recommendations and not to compare the inspectorate's responses with every detail in the APA guidelines. Most of the primary and general points in the APA guidelines, such as continuity of care and systematic risk assessment, are very much in line with major recommendations in the other guidelines that we reviewed.

We agree that there are many more important aspects to suicide prevention, such as checking for the absence of ligature points in inpatient facilities and other more detailed recommendations for specific treatment settings. Also, we agree that further research on good clinical practice is necessary to develop and maintain an up-to-date standard as a reference for the inspectorate's responses. Partly as a consequence of our study of the suicide notification procedure, a multidisciplinary guideline for the treatment of suicidal patients, which will be used by the inspectorate, is being developed in the Netherlands.