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Correspondence |
PO Box 1216, Noosa Heads, Queensland 4567, Australia
I am grateful to Eagles et al (2001) for their recent editorial on the role of psychiatrists in the prediction and prevention of suicide. I am a member of the Royal Australian and New Zealand College of Psychiatrists' working group on suicide, and we are currently deliberating how to vote on a proposal to disband our group and hand responsibilities back to the College — after all, suicide is part of mental health.
Eagles et al start with how traumatic it is for psychiatrists when their patients commit suicide. Is this not a bit self-indulgent? Our surgical colleagues dealing in trauma frequently contend with the death of ordinary people in the operating theatre. More importantly, the authors do not even mention the suffering of family members affected by suicide.
In their conclusions Eagles et al focus on four points: first, they advocate less epidemiology and more multi-centre treatment trials with suicidal people; second, they advocate more support for traumatised psychiatrists; third, they make a plea to politicians and health service planners to realise what a difficult task suicide prevention is for us; fourth, they note that prediction is a very limited art (I entirely agree), but claim that "all of our patients are at increased risk of suicide". Taking their first and last points together, perhaps if they were more aware of epidemiological data they would realise Blair-West et al's (1999) calculations have refuted the suggestion that 15% of people with depression eventually kill themselves: for this to be true, the annual number of suicides would have to be several times greater than it currently is. They recalculated the lifetime risk of suicide in people with depression as 3.4% with a lifetime risk of 7% for males and 1% for females.
As regards traumatised psychiatrists, I would simply say that all traumatised workers deserve support and that support should be in proportion to their trauma. I suspect that psychiatrists would rank well down the list, below fire, ambulance and police officers and many other medical workers — not to mention contemporary farmers in the UK!
The point relating to re-educating politicians and health planners about our limitations in influencing suicide rates has some validity. However, prevention is much more than that which might result from prediction. Nowhere in the editorial did I find any mention of basic public health concepts such as primary, secondary and tertiary prevention (Silverman & Maris, 1995). If general psychiatrists have not woken up to the fact that this is the basis of national suicide prevention strategies, I think I will have to vote in favour of retaining our local specialist-interest suicide prevention group.
REFERENCES
Blair-West, G. W., Cantor, C. H., Mellsop, G. W. et al (1999) Lifetime suicide risk in major depression: sex and age determinants. Journal of Affective Disorders, 55, 171-178.[CrossRef][Medline]
Eagles, J. M., Klein, S., Gray, N. M., et al
(2001) Role of psychiatrists in the prediction and prevention
of suicide: a perspective from north-east Scotland. British Journal
of Psychiatry, 178,
494-496.
Silverman, M. M. & Maris, R. W. (1995) The prevention of suicidal behaviours: an overview. Suicide and Life-Threatening Behavior, 25, 10-21.[Medline]
Royal Cornhill Hospital, Aberdeen AB25 2ZH, UK
Dr Cantor seems to have misconstrued the intended scope and content of our editorial. We did not set out to comment upon national suicide prevention strategies but, as the title suggested, we sought to discuss the role of psychiatrists specifically in attempting to prevent suicide among the patients we treat. We agree wholeheartedly that any strategy that focused exclusively on psychiatrists as the agents of suicide prevention would be absurd. Indeed, this was one of the main points we were trying to make.
Dr Cantor thinks that our ignorance of the epidemiological data makes us state that "all of our patients are at increased risk of suicide". This is in fact an epidemiological statement, which he interprets concretely. The fact that the lifetime risk of suicide among people with recurrent depression has been adjusted downwards actually renders statistical prediction of a rare event even more difficult. Largely for this reason we cannot predict which of our patients will commit suicide or when they might do so, and thus we must regard the entire cohort of patients we see as collectively at increased risk of dying by suicide and view their clinical management accordingly.
We take issue that it is "self-indulgent" to suggest that psychiatrists find the suicide of their patients to be traumatic. We know this to be the case from our survey in Scotland (Alexander et al, 2000) and from other, more qualitative accounts (Hendin et al, 2000). While valid comparisons among professional groups are difficult to make accurately, we in Aberdeen are more than a little interested in the impact of ‘critical incidents’ on colleagues in the caring and emergency services (e.g. Alexander, 1993; Alexander & Klein, 2001). One crucial difference between psychiatrists on the one hand and other doctors and other professionals on the other is the issue of blame. While, as we try to point out, it is often illogical for psychiatrists to take responsibility for the suicide of our patients, we frequently do, and this distinguishes it from the deaths that other professionals encounter. Finally, presumably we would wish our patients (and their families) to feel cared for and understood. Surely, as professionals in psychiatric services, we should accord the same opportunities to each other.
REFERENCES
Alexander, D. A. (1993) Stress among police
body handlers: a long-term follow-up. British Journal of
Psychiatry, 163,
806-808.
Alexander, D. A. & Klein, S. (2001)
Ambulance personnel and critical incidents. Impact of accident and emergency
work on mental health and emotional well-being. British Journal of
Psychiatry, 178,
76-81.
Alexander, D. A., Klein, S., Gray, N. M., et al
(2000) Suicide by patients: questionnaire study of its effect
on consultant psychiatrists. BMJ,
320,
1571-1574.
Hendin, H., Lipschitz, A., Maltsberger, J. T., et al
(2000) Therapists' reactions to patients' suicides.
American Journal of Psychiatry,
157,
2022-2027.
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