The British Journal of Psychiatry (2002) 180: 190
© 2002 The Royal College of Psychiatrists
Understanding Suicidal Behaviour: The Suicidal Process Approach to Research, Treatment and Prevention
Gethin Morgan
Emeritus Professor of Mental Health, University of Bristol, St Michael's
Hill, Bristol BS2 8DZ, UK
EDITED BY SIDNEY CROWN and ALAN LEE
Edited by Kees van Heeringen. Chichester: John Wiley & Sons. 2001. 322
pp. £55.00 (hb). ISBN 0 471 988030
The aim of this book is to present a comprehensive explanation of
suicidality. This is postulated as a process that is based on personality
vulnerability, related to traits of impulsivity and aggressiveness. These in
turn are linked to hyposerotonergic functioning. The stress—diathesis
model suggests that in such vulnerable individuals, stress events such as
adverse life episodes, depression or other mental illness may lead to suicidal
behaviour in which the related neurochemical parameter is the
hypothalamic—pituitary—adrenal axis.
The first section presents supportive evidence from the fields of
psychopharmacology, epidemiology, ethology, neuropsychology and clinical
psychiatry. The text is on the whole clearly focused on relevant and
well-researched data, although at times the clinical heterogeneity of problems
subsumed under the category ‘attempted suicide’ introduces a
degree of ambiguity. Nevertheless, the hypothesis is set out in a systematic
and detailed way, which should facilitate further research towards eventual
replication or refutation of its various components.
The second section sets out the potential practical value of such a
hypothesis. First, a penetrating analysis of risk factors spells out starkly
their gross limitations as they are currently used in clinical practice.
Nevertheless, the relatively new discipline of risk-factor research appears to
have made an impressive start in clarifying the nature of risk factors and in
paving the way to improving their clinical usefulness. There follow several
chapters on social causation, the relevance of action theory, which focuses on
the goal-directed nature of the suicidal process, and the role of
pharmacological and psychotherapeutic approaches to treatment. Deliberate
self-harm is evaluated in detail on the basis of a recent meta-analysis of the
literature.
The hypothesis set out here should surely encourage us to review our
approach to the assessment and management of suicide risk, and to widen our
perspective on what is a tremendous clinical challenge. Personality traits of
impulsivity and aggression, and biased memory, which may encourage a sense of
entrapment and hopelessness, all have a claim to be considered carefully,
along with routine clinical method. It is surprising, though, to discover that
the stress—diathesis hypothesis accords depression and other mental
illnesses a peripheral stressor role in the process of suicidality. This seems
to run counter to clinical experience of severe and acute suicide risk.
However, there will be little dissent from the view expressed here that the
bedrock of any effective clinical approach to suicide prevention must depend
upon skills in face-to-face assessment, particularly with regard to the
individual significance of symptoms and behaviour. On reflection, did not
Adolf Meyer say this some time ago?
