Abstract
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The American Psychiatric Publishing Textbook of Suicide Assessment and Management approaches the topic of suicide from many perspectives. The order of the chapters is a natural progression. The book starts with five comprehensive chapters devoted to general suicide risk assessment. Included, in Chapter Two, is the Chronological Assessment of Suicide Events, or CASE Approach, by Shawn Christopher Shea. This flexible and unique technique allows clinicians to adapt their interviewing techniques to the individual they are assessing. Then, suicide is analyzed from the specific vantage points of different mental illnesses, treatment modalities, treatment settings, and specific populations, including children and adolescents. Other topics include, but are not limited to, the neurology of suicidal behavior, suicide and the Internet, suicide prevention, and, very intriguingly, the psychiatrist's reaction to suicide. The test questions at the end of the book review some of the key topics. This is a massive tome, but each chapter can be referenced individually, as needed, and can be understood independent of the other chapters. The strongest elements among the various chapters are the case examples that indelibly stamp the lessons of the chapter into the reader's mind.
The chapters that detail suicide assessment for specific mental illnesses are very effective in instructing readers on key elements particular to each illness. With regard to patients with personality disorders, this book instructs readers to differentiate suicide from acts of self-harm. More importantly, this chapter instructs readers to evaluate suicidal statements thoroughly and not mistake them for attention-seeking behavior. Other chapters break down suicide with regard to anxiety disorders, depressive disorders, substance-induced disorders, and bipolar disorder.
The case example brings the chapter on assessment of patients with schizophrenia to life. The case of CM illustrates the havoc that occurs when a highly functioning college student develops the symptoms of schizophrenia. Initially diagnosed with major depressive disorder, and treated with a trial of antidepressants, CM deteriorated until he could no longer function in college and required hospitalization. Despite improvement with antipsychotics, he became noncompliant when his symptoms improved. With this case, readers should sympathize with his understanding of his diminished functioning, which unfortunately led to his suicide via overdose on tricyclic antidepressants. CM had not once expressed suicidal ideation, but eventually died after overdosing on his psychotropic medication. This is a powerful case highlighting the high suicide risk time period of newly diagnosed schizophrenia. It is also a relevant case of a young adult with first break psychosis for a child and adolescent psychiatrist to review.
In the chapter about children, adolescents, and college students, readers are educated on important specifics in assessing this population. The chapter concurs with the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behavior. This includes assessment for the most common risk factors for completed suicide, and parameters for hospitalization of suicidal patients (AACAP 2001). The case of 15-year-old Stephanie, who overdosed on pills after her boyfriend ended their relationship, emphasizes evaluation of the youth's understanding of lethality of means. As Peter Ash states, “The clinician must consider that an attempt involving an overdose that was not pharmacologically dangerous might have seemed likely to the adolescent to cause death and some potential lethal attempts (such as aspirin overdose) might have seemed like a gesture to a youth who thought she was ingesting a fairly benign medication” (Simon and Hales 2012). The case of John, a 16-year-old, foster child facing imprisonment for assault, emphasizes the need to evaluate the strength of a patient's familial support and history of impulsivity, and the pending criminal charges, in risk assessment. Finally, the case of Jennifer, a 19-year-old suicidal college student, shows the unique atmosphere that she casts on her college friends who take turns watching her to make sure she does not harm herself. Readers learn about the standards to which schools must adhere for releasing information. For a health and safety emergency, the school can release the contents of a student's education record to parents, despite the student's objections.
All cases were informative; however, we would have liked more detail in the cases as well as more cases; for example, risk assessment in a preadolescent. Completed suicide occurs most commonly in adolescents, but it can also occur in very young children (AACAP 2001). Guidelines on developmentally appropriate interview techniques for children and techniques to assess their understanding of death would have been helpful as well.
Finally, the use of case examples is no better exemplified than in the chapter on suicide risk assessment in the elderly. Readers see this in the presentation of George Eastman, founder of the Eastman Kodak Company, who committed suicide on March 14, 1932, at the age of 77. With the incidence of suicide highest in the elderly population, the story of Eastman serves to instruct readers on the psychology and life stressors that are unique to this age group. The story of Eastman, a respected businessman and philanthropist, who in his later years became increasingly isolated and ultimately committed suicide, teaches readers to evaluate the unique later-year risks that lead to suicide, including multiple losses, physical illness, functional impairment, depression, and loss of meaning. Although this case was at the opposite end of the age spectrum of the patient population that we usually see, we felt that the Eastman case was another poignant case that cemented the lessons of the chapter in the readers' minds. We also could not help but compare the dichotomy of Mr. Eastman's depression and suicide resulting from loss of meaning and loss of function to an adolescent's potential depression and suicide resulting from a search for meaning and function in life.
The new chapter on suicide and the Internet in this edition was very appropriate. With regard to children and adolescents, this chapter contains topics such as cyber bullying and Internet suicide pacts. The Internet can spread information on how to commit suicide, but it also serves as an educational tool for families on how to help their troubled family members. The chapter continues to relate that a “young person's Internet use could be relevant to nearly every aspect of the psychiatric evaluation, and his or her risk for suicide is no exception” (Simon and Hales 2012). Readers learn that, in addition to seeking information on committing suicide, many young people turn to the Internet for support when they are in crisis, and this can either increase or decrease the risk of suicide, depending upon who responds.
The textbook ends with some intriguing points. “Trainees are more likely (one third to two thirds) to experience patient suicides than are more experienced psychiatrists” (Simon and Hales 2012). The book goes on to say “soon after the suicide, 25% of trainees met criteria for acute stress disorder and later 20% met criteria for post traumatic disorder” (Simon and Hales 2012). Suicide most directly impacts the patient and the patient's family, but at times, the impact that suicide has on the treating psychiatrist is minimized. This is a chapter we would like to see expanded. It highlights the importance of recognizing and treating reactions to patient suicide among healthcare professionals, whatever the specialty, especially those new to the field.
The American Psychiatric Publishing Textbook of Suicide Assessment and Management is an excellent book. It should be read by general psychiatrists and those in training. Child and adolescent psychiatrists would find this textbook useful as well. It is an excellent collection of relevant and up-to-date information about suicide assessment and management. The textbook is useful as a review, with the material from the chapters on assessment of adults relevant to assessment of children and adolescents. However, we felt that more information on assessment of children and adolescents, especially more emphasis on assessment in preadolescents and college-age young adults, would be beneficial to the readers working with these groups. Perhaps American Psychiatric Publishing (APP) will consider a companion text for clinicians working in child and adolescent mental health. This resource is not just for psychiatrists. Other professionals in the mental health field such as therapists, social workers, nurses, and psychologists would also benefit from reading this comprehensive book.
The American Psychiatric Publishing Textbook of Suicide Assessment and Management is both a thorough and also an engaging read. Not only is it a comprehensive review to be read cover to cover, readers can also pick and choose what chapter to read to suit their particular interest. The best feature of this text is the case examples specific to many chapters. The book covers many topics as aforementioned, including assessment across different mental illnesses, treatment modalities, settings, and age groups. Other relevant chapters, including those on suicide and the Internet and on psychiatrist reactions to patient suicide, contribute to the many different perspectives on suicide that this text strives to cover. The book is a good review of suicide assessment and management for psychiatrists and mental health professionals at any stage of their career.
Footnotes
Disclosures
Dr. Galanter is on the Scientific Steering Committee of the Primary Pediatric Psychopharmacology Fellowship of the REACH Institute and receives royalties from American Psychiatric Publishing, Inc. Dr. Trentacosta has no corporate or commercial relationships to disclose.