Evidence-Based Practice in Suicidology: A Source Book

Sir Muir Gray in the foreword to this book defines evidence-based medicine as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual expertise with the best available external clinical evidence from systematic research. By individual clinical expertise [is meant] the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice.”

Empirical studies of suicide pose unique methodological and ethical problems, as the internationally renowned contributors to this edited volume address. Self-inflicted death is a multidetermined and, fortunately, a relatively rare event. Multiple factors interact to determine the morbid outcome. These include but are not limited to age, gender, marital status, religion, culture, sexual orientation, genetics, medical and psychiatric illness, developmental history, medicinal and recreational drug use, life events, impulsivity, and social matrix. The nature of the event studied—suicide—is such that one cannot withhold a treatment, no matter how limited in impact from a selected vulnerable sample to ascertain whether a novel intervention may be more efficacious. It is not ethically permissible to put an at-risk group for self-inflicted death in a double-blind placebo-controlled trial—the gold standard of evidence-based medicine. We therefore must integrate findings from other research strategies with lesser degrees of scientific validity, such as meta-analyses, systematic reviews, cohort studies, case-control studies, cross-sectional surveys, and case reports.

This volume commences with a series of papers descrbing research methods and their limitations at arriving at conclusions that may be generalized to larger populations. The contributors discuss ethical and methodological problems inherent in suicide research as well as the limitations of the best evidence we have to define a population at risk. Considerable discussion is given to the relative efficacy of interventions that have proven useful and strategies for risk reduction, including programs of public awareness, restriction of lethal means, and impact of media reporting of suicide. The benefits of individual-level strategies of prevention and follow-up care for suicide attempters are outlined. Attention is given in several chapters to institutional and professional interventions, including gatekeeper education, primary caregiver training, and educator and parental education, awareness, and screening.

Change in risk over the life cycle is addressed with specific chapters on youth and late-life suicide. Evidence of efficacy of cognitive-behavioral therapy, dialectical behavior therapy, and problem-solving training in management of suicidal patients is provided. Specific evidence-based psychopharmacologic interventions are enumerated in the context of biological understanding of self-directed violence. There are chapters on meta-analyses of efficacy of help lines and of community- and health care-based programs of prevention and on restriction of lethal means. There are chapters on suicide reduction specific to schizophrenia, major affective disorders, first-episode psychoses, and personality disorders. The book concludes with directions for further research in suicidology. A special feature of the volume is the remarkable up-to-date references to support the topics discussed.

In conclusion, evidence-based guidelines for evaluation of risk for self-inflicted death and institutional, professional, and community strategies for risk reduction are provided. The level of evidence may not be on a par with some medical interventions—such as to reduce risk of lung or colonic cancer—but the decision to die by one's own hand is not a simple molecular issue. Suicide results from a complex interplay of psychological, biogenetic, sociocultural, and existential variables. This book summarizes what we know and what we need to explore to know better how to help our patients and their families. It should be read by heath professionals, educators, and community leaders working with populations at risk to reduce the tragedy of life lost by suicide.