Posts Tagged ‘suicide’

Impulsivity: Theory, Assessment, and Treatment

Impulsivity: Theory, Assessment, and Treatment

CD Webster and MA Jackson, editors

New York: Guilford Press; 1997. 462 pp. with index

ISBN 1-57230-225-9

Webster and Jackson have made a bold attempt at editing a multi-disciplinary book on the construct of impulsivity. The book focuses on impulsive individuals and their speed of judgement. It approaches the construct of impulsivity by covering a broad range of problematic behaviours that have impulsive components. The editors seem to take the view that, if several blindfolded individuals feel different body parts of a large animal such as an elephant, each will describe the respective body part, and the reader will then have a collection of descriptions that can be combined to form a holistic concept of the construct.

The first section of the book deals with the diverse theoretical perspectives on the construct of impulsivity. There are chapters on the clinical, social, sociological, legal and “cybonautical” (computer technologies involving cyberspace, virtual reality and information technology) perspectives on impulsivity. I singled out the chapter on “social perspectives,” in which the content, in my view, is incongruent with the focus of the book. The author seems to have an axe to grind about psychiatrists and the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for intermittent explosive disorder. He mistakenly takes the view that “psychiatrists” see “wife batterers” as individuals who have an intermittent explosive disorder. He then attempts to apply this psychiatric concept to 2 of his case studies of wife batterers. My concern lies in the author’s ludicrous view that the psychiatric explanation of all spousal assault lies in interpreting that these individuals fall within the boundaries of the DSM-IV diagnostic criteria for intermittent explosive disorder. The author also appears to be misinformed about such psychiatric terminology as the difference between a delusion and an overvalued idea.

The second section, on the foundations of impulsivity, provides 2 well-written chapters on the biology of impulsivity. The first chapter focuses on serotonin mediation of various neurophysiological processes. It traces the complex relations between the neurochemical substrates in the brain and impulsivity. The second chapter looks at the role of organic brain syndrome in impulsive violence. Researchers attempting to understand the nature of the connection between neurochemical factors and brain damage have concluded that these elements are mere components of a complex whole, rather than adequate explanations for certain types of behaviour. There is also a comprehensive and informative chapter on the measurement approaches used by researchers studying impulsivity. Unfortunately, the lack of definitional constructs has led to multiple self-reports and behavioural measures with poor and inconsistent inter-correlations. Unless we can overcome our definitional problems, we are unable to construct reliable and valid measurement instruments. The following 3 chapters look at major mental disorders, impulse-control disorders, and psychopathology. The relation of these 3 diagnostic groups provides the reader with insight into the complex interrelation between impulsivity and other psychopathology. The final chapter looks at a conceptual model for the study of violence and aggression. This author proposes the use of facet analysis to clarify the poor definitional issues that have plagued the study of risk research. A facet is defined as the basic unit of an enquiry into a specific phenomenon of interest. Facet analysis involves mapping the conceptually independant facets into a “mapping sentence/’ thereby enabling researchers to engage in a evolving dialogue on risk research.

The third section is entitled “Practise: Assessment” and focuses on assessment of violence. Empirically, we know that there is a link between impulsivity and violence. There is, however, a lack of clarity on the exact nature of this association and the operational definitions of the respective elements. There are 4 chapters addressing assessment of risk of violence to self, others and wives (spouses), as well as the risk of the patient committing sexual assault. These chapters are devoted mainly to descriptions of the respective authors’ assessment instruments or checklists. There is also a chapter giving some useful suggestions on how not to conduct a risk assessment.

The final section focuses on the treatment of patients with impulsive behaviour. The diverse chapters discuss effective services for offenders with mental disorders, pharmaco-logic approaches to impulsive and aggressive behaviour, and a case management system to approach people with “multiproblems” and “impulsive driven” people. In the final chapter, Webster ends on an upbeat note, remarking that, although the concept of impulsivity has not yet been adequately defined, researchers have accumulated enough information about impulsivity and disorders that involve impulsive elements to lead to better solutions than are now available. He provides a guide for professionals who are interested in creating treatment programs for people with problems related to impulsivity.

The lack of consensus on the definition of this construct is apparent from the diversity of chapters in this book. The authors address topics such as spousal abuse, violence and aggression, offenders with mental disorders, psychopathology, suicide and sexual violence. It is uncertain whether impulsivity is a behaviour, a symptom of a broad range of psychiatric disorders, or a component of many functional and dysfunctional behaviours. This book is therefore as much about these other topics as about impulsivity per se. Readers who are looking for a book focused on impulsivity will likely find this book a disappointment. This is not a criticism, but rather a reflection of the poor definitional and operational concepts when approaching such a task. For readers who want a good overview of the current state of knowledge of the concept, this book is an interesting read.

The Prevention of Mental Illness in Primary Care

The Prevention of Mental Illness in Primary Care

T Kendrick, A Tylee, P Freeling, editors

New York: Cambridge University Press; 1996. 398 p

This book describes the role of primary care physicians in the prevention of mental disorders. The literature consistently reports that 25% to 30% of patients presenting in primary care have significant psychological problems. The book is divided into 3 sections dealing with the major types of illness prevention: primary (risk factors), secondary (early identification and intervention), and tertiary (decreasing complications and recurrence). These distinctions are not consistently followed, but overlap between sections is avoided. Each chapter is well referenced, and most chapters cover the subject adequately. A preventive model of conceptualizing problems is employed, but the flaw in this approach to primary prevention is acknowledged. Many known risk factors, such as social, economic, and societal conditions and attitudes, cannot be modified by primary care professionals. Effort must be directed primarily at high-risk patients. The authors recognize that some physicians lack sufficient interest and ability to diagnose and manage psychiatric illness and throughout the book suggest ways to address this problem.

Chapters 1, 9, and 15 deal with primary, secondary, and tertiary prevention of childhood psychiatric disorders. Risk factors in the child, parenting, and environment, as well as protective factors, are very well described. Most children are seen regularly in primary care, which gives these practitioners a unique opportunity to employ all 3 types of prevention. When disorders are detected, care must be taken to avoid inappropriate reassurance and unnecessary pharmacotherapy. The role of the family in the management of chronically ill and disabled children is emphasized, along with the need to provide support to the parents. Chapter 3, on the relevance of life events in mental illness, relies mainly on the work of George Brown and his colleagues. A practical guide for intervention strategies is also included. Prevention of postnatal depression, a distinct diagnosis in British psychiatry, is discussed in Chapter 4. The unique opportunity for primary care physicians to detect this disabling condition is emphasized, but the suggested role for health care visitors is generally unavailable in this country. Chapter 5, on bereavement, has a good description of normal grief and an excellent discussion of risk factors for abnormal grief reactions. Practical suggestions for the appropriate use of counseling and medication are included.

Chapter 6, on prevention in ethnic minorities, is quite specific to British society, although the principles of how physicians perceive, interpret, and treat psychiatric problems in ethnic patients are universally applicable. The chapter on “learning disability” is initially confusing because in Britain, unlike North America, the term refers to developmental delay. The references suggest that 33% to 66% of children with “learning disability” have significant psychopathology. The important role of primary care practitioners in secondary prevention is discussed, but the use of a team for management is seldom feasible for Canadian family doctors. Chapter 8 contains a general discussion of the importance of good counseling skills but again assumes the existence of a primary care “team” of professionals.

Chapters 10, 16, and 17 describe secondary and tertiary prevention of depression. This common and treatable disorder is frequently unrecognized in general practice both because of the symptoms presented (often somatic) and the knowledge, skills, and attitudes of physicians. Ways to improve the detection rate are described, and an excellent section on long-term drug management is presented. The particularly important role of general practitioners in encouraging compliance is acknowledged. Discussion of psycho-therapeutic interventions in the management of depression is limited to a good description of cognitive therapy. Primary and secondary prevention of anxiety disorders is addressed in Chapter 11, which includes a discussion of the physical, behavioral, and environmental factors that maintain anxiety symptoms. The author recommends and briefly describes nonpharmacological management techniques, although the use of a team approach is again assumed. Chapter 12, on eating disorders, addresses the well-recognized problems in primary prevention that deeply ingrained societal attitudes are impossible to change and that prevention programs sometimes increase unwanted behaviors (for example, binging and purging). The physical consequences of these disorders are well outlined, but little reference is made to the psychological and social sequelae. Detection of eating disorders is a major responsibility of general practitioners but requires a high level of awareness of risk factors and signs and symptoms — these patients are often very secretive. Not discussed is the role of physicians in monitoring physical health or supportive counseling as an adjunct for their patients who attend specialized treatment programs. Chapter 13, on alcohol and drugs, describes the detection and management of alcohol abuse, as well as the primary prevention of medication abuse by judicious prescribing practices. Because drug seeking from multiple physicians is uncommon under the British system, the problem is not mentioned in this book. Psychosis, primarily schizophrenia, is discussed in Chapters 14, 18, 19, and 20. As in Canada, general practitioners are now expected to detect and treat 1st-episode psychosis, and the importance of early pharmacological treatment is emphasized. Increasingly, patients are managed for the long term in primary care, and physicians must be aware of the special physical, psychological, and social needs of this vulnerable group and be cognizant of the high suicide risk. Social management of patients with schizophrenia is well described, with emphasis on the role of families. In Canada, the functions proposed for primary caregivers are provided, if at all, by specialized mental health services. Finally, Chapter 21 briefly discusses suicide prevention in primary care. The major roles are to recognize patients at risk, provide treatment and/or referral, and offer support for staff and families when suicide occurs.

The authors of this book are academics from general practice and psychiatry backgrounds. The intended audience is primary care physicians and their teams, but the book should also be read by psychiatrists and mental health professionals who treat patients also seen by family doctors and who teach medical students and residents. In conclusion, this is a very readable volume which is well researched and which provides good recommendations, although some are not applicable to the Canadian system.

Handbook of Culture and Mental Illness: An International Perspective

Handbook of Culture and Mental Illness: An International Perspective

I Al-Issa, editor

Madison (CT): International Universities Press; 1995. 391 p

With the hectic pace of travel, migration, and social change of the modern world, psychiatrists, mental health professionals, and trainees can expect to see people from all continents and many cultures. Moreover, they are required to be knowledgeable about and sensitive to the different backgrounds of these people and to be able to make a diagnosis, understand the psychopathology, and conduct a treatment relevant to these cultures. This is a tall order. How can any single professional become acquainted with, let alone gain expertise about the predominant cultures in each continent? These are precisely the goals that the body of knowledge and practice called cultural psychiatry or transcultural or cross-cultural psychiatry has been pursuing over the past few decades. The burning question, then, is how far can Dr Al-Issa’s book advance the practitioners, teachers, or trainees in this field in their endeavors to understand and treat effectively people from all continents and main cultural groups with full awareness and systematic use of their background and experiences? The brief answer is that indeed this book advances the body of knowledge very significantly in this direction.

The volume has a simple and bold structure. Its main parts are dedicated to Africa, Asia, Australia, the South Pacific, Central and South America, and Eastern and Western Europe; within each part about 5 specific countries or cultures are presented in terms of historical background, epidemiology of illness, cultural context, psychopathology, and treatment practices. Ethnic groups and minorities, including immigrants and aboriginals, are dealt with in a special chapter at the end. The introductory chapter by Dr Al-Issa offers an international perspective on the main psychiatric syndromes, including somatization and alcohol abuse, and on ethnic and immigrant minorities. Dr Al-Issa shows both a command of the broad field of epidemiology, including the most recent studies of the World Health Organization and associate groups, and a critical focus on controversial issues, for example, somatization in Third World versus industrial societies, multiculturalism as potential neoracism, or the suggested incapacity of some “non-Indo-European languages to differentiate between some emotions” (p 21). It closes with about 150 well-selected references that would be extremely helpful to any trainee or researcher.

The chapters that follow are innovative and mark a new era in cultural psychiatry. All of the leading books on cultural psychiatry of the past 4 decades were wholly or partially written or edited by Western-trained and -rooted professionals such as Ari Kiev, Transcultural Psychiatry (1972); HBM Murphy, Comparative Psychiatry (1982); or even I Al-Issa’s previous book, Culture and Psychopathology (1982). By contrast, all 24 chapters of this volume are written singly or in coauthorship by professionals who, by all indications, practice or have roots in the culture on which they are reporting. Clearly, they are also highly trained in Western medicine and psychiatry and maintain ongoing contacts with Western ideas and practices. One or 2 exceptions might be the report on the Inuit in Greenland and possibly the Maoris from New Zealand. This knowledge of both worlds is manifest in the twin advantages of sophisticated Western epidemiological knowledge and intimate understanding of cultural dynamics, psychopathology, and native treatment modalities. In this respect, this volume is also politically correct: nobody could accuse the authors of “stealing a people’s voice,” since they are themselves of those peoples.

Africa is represented by Egypt, Nigeria, Tanzania, South Africa, and French West Africa. All are most interesting and well-documented chapters. Especially rich is the chapter on West Africa. To the pioneer work of Henri Collomb in Dakar and the psychoanalytical work of E and M-C Ortigues on the African oedipus is added a review of the work of Andras Zempleni on the transformation of persecutory ideas and agents into modes of control of individual anger and the development of inner self as a psychological space. Self psychologists would find these ideas of special interest.

The chapter on India is also exceptional. VR Varma, based on his own work in the Indian continent, addresses 2 frontline issues in the development of or controversy about cultural psychiatry: cultural formulation and basic or ethnic “modal” personality. The issues, of course, are not resolved but are considerably elucidated.

The chapter on Jamaica, or rather Jamaicans at home and abroad, deals with the perennial theme of culture and personality and attempts to explain the high rates of schizophrenia diagnosed in Western mental hospitals. It is a matter of some curiosity that this phenomenon has been well researched in Great Britain, but not in Canada, where, since the 1970s, some 100 000 West Indians have arrived. The chapter on immigrants and minorities in Great Britain shows excellent documentation on the Irish, Jewish, and West Indians, but a similar vacuum is left in the book with respect to minorities in Canada.

Mexico, Uruguay, and the Iberian Peninsula (primarily focused on Spain) are dealt with in terms of epidemiology and, rather weakly, cultural dynamics. Important in Spain are the high rates of alcoholism, migrant adaptation, and the burden on families of the “new chronic” mentally ill population after the poorly coordinated mental health reform of 1986.

The critical, often refreshing approach of the book is shown once more in the chapter on Germany where, applying to this industrial society the same standards as one would use on any Third World country, we discover that about half to one-third of the clergy believes in demonic possession and exorcism. Of course, the sad legacy of Nazism is briefly examined, revealing that much denial and avoidance apparently still persists among the medical profession.

The chapter on Hungary is a masterpiece on the epidemiology and dynamics of suicide, topics on which the authors, Buda and Furedi, are experts. The chapter on multicultural Australia, which reviews adequately the work of Krupinski and colleagues, should be of great interest to Canadians as we share the same British traditions and institutions, a recent multicultural immigrant community, and a native population.

The chapters on Egypt include references to the seminal contributions of Ahmed Okasha to the epidemiology and dynamic understanding of suicide, somatization, and the rituals of Zar. Including a chapter on Turkey, the book provides a good report on Islamic societies, never adequately treated in this type of volume until now. The chapter on Israel deals extensively with the issue of religion, intragroup variations, and posttraumatic stress disorder, referring to the comprehensive work of Dasberg on holocaust survivors and more recent civilian and military populations exposed to the trauma of war and armed conflict. South Korea, Singapore, and Bali (Indonesia) are Asiatic countries with epidemiological information limited to key issues: suicide, substance abuse, and culture-bound syndromes such as epidemic koro and hysteria, somatization, and illness behavior in various groups. In South Korea, a traditional country in the process of rapid modernization, the majority of people tend to use both traditional and modern therapies and remedies.

There are necessarily deficits or limitations to be found in a book of such ambitious scope. Russia or any country of the former Soviet Union, China, the United States of America, and Canada are not included. On various issues, however, the references to North America and China are plentiful, and one gets some idea of sociocultural variations in these regions. Dissociation is not listed in the subject index, although frequent references exist throughout the text when it deals with possession states and hysterical psychosis. Posttraumatic stress disorder, a major issue in refugee populations at present, has only a few references. There is not a single reference on psychopharmacology or biological studies among the various ethnic groups.

I would recommend this book to practitioners and trainees in psychiatry, psychology, and social work because the advances reported in the dynamic understanding of cultural groups will be helpful in clinical practice.

AIDS, HIV and Mental Health

AIDS, HIV and Mental Health

Michael B. King

New York NY: Cambridge University Press, 162 pp., 1993

ISBN 0 521 45294 (hardcover)

It is a pleasure to read AIDS, HIV and Mental Health by Michael B. King M.D., AIDS liaison psychiatrist at the Royal Free Hospital School of Medicine, London, UK. Published in 1993, this short book contains an excellent critical review of the relevant literature reported in this rapidly growing field through 1992. One of the distinguishing features of this text is Dr. King’s efforts to include studies from around the world, thus giving the reader a greater global perspective.

The text begins with a short medical overview of HIV disease and then moves into chapters on psychiatric disorders that develop over the course of HIV disease. There is an excellent discussion of predictive and protective factors associated with the development of psychiatric disorders that is clinically useful in evaluating which patients are at greatest risk for the development of a clear psychiatric disorder requiring psychiatric intervention. There is an excellent critical analysis of the complex relationship between stress, psychological morbidity and immunity which argues against often made simple explanations of their interplay and points out the limitations of many of the studies conducted in this field. The discussion of suicide and assisted suicide is coherent and thoughtful and draws on studies from the UK, US, Sweden and the Netherlands. Particularly informative is the review of some of the shortcomings in the practical implementation of the euthanasia legislation in the Netherlands which will be useful to other countries grappling with legislation in this controversial area. The chapter on neuropsychiatric manifestations of HIV disease is solid and usefiil to the clinician interested in the predictive power of diagnostic tests used in the evaluation of HIV-related cognitive impairment and noteworthy for pointing out the limitations of our understanding in this complex area. There are excellent chapters on sexual behavior and illicit drug use with an important discussion of the limitations of education on behavior change in the absence of addressing psychological variables and the consequences of substance related disorders. The work is inclusive and it is refreshing to see a discussion of behavior change that not only includes homosexual and bisexual men and heterosexual women, but also addresses the issues faced by prisoners and sex workers.

The sections on interventions are not as strong as the sections on epidemiology and clinical descriptions of neuropsychiatric and psychiatric disorders. In part, this may reflect the limited number of published studies reporting on psychiatric interventions. The discussion of psychopharmacology highlights all areas but lacks sufficient detail. However, it does establish a solid base which can be augmented by referring to the current HIV psychiatric literature which has seen a significant increase in intervention studies over the past two years. A discussion of theoretical strategies currently under investigation to slow down the progression of cognitive impairment would be a useful addition to the neuropsychiatry chapter so that clinicians could become familiar with neuroprotective agents that may become a reality in the near future. The discussion of psychotherapeutic and counselling techniques is also limited but contains an interesting description of studies from Zambia, Zaire and Uganda which highlight the need for culturally sensitive interventions.

What makes this one of the best texts in the field is the writing of Dr. King who gives a comprehensive, balanced, critical analysis of the reported literature supported by his valuable clinical impressions in areas where studies are lacking. He is able to write about the complexities of human behaviors in a calm and thoughtful manner and he has an ability to use science in a sensitive manner to guide his practice. The book is an easy read and should be on the curriculum for medical students and house staff. Family physicians, psychiatrists and nonpsychiatric mental health workers will find this to be an excellent reference to consolidate their knowledge base and it is hoped that they will be stimulated by the excellent appraisal of the literature to answer some of the important research questions that the author has generated.

Patient Encounters

Patient Encounters

James H. Buchanan

New York, NY: Henry Holt and Company Inc., 346 pp., 1991

Medical education has been under heavy attack in recent years for the dehumanizing effect it has on students. The strong emphasis on basic biological sciences, on physical procedures and treatments and the regimented nature of much of the curriculum all combine to make the student forget the person behind the disease. Despite the stress given to social sciences, psychiatrists have not been exempt from these influences. The emphasis on diagnostic labels and the sometimes mechanistic orientation of some teachers can have a similar effect on students and residents.

This book redresses that balance. It provides a series of case histories on patients with various serious diseases. These include amyotrophic lateral sclerosis, multiple sclerosis, lupus, AIDS, cancer, depression (with suicide) and voyeurism. A brief clinical and pathological description of the disease is provided after which the full personal history of one patient is given. These are written from the patient’s perspective and the author uses his imagination, though without overstating his case, to describe what patients are experiencing.

In the main the histories are based on individuals the author himself knew and the stories they recounted to him. A personal note is introduced by the description of the illness and death of his mother from lung cancer, and his own experience of having subacute bacterial endocarditis at the age of 8.

The author is a philosopher who has been involved in medical ethics and decision making. The book reads easily and is highly recommended as an antidote to the scientism of medicine and to the structured organization of medical education.

Suicide: Understanding and Responding

Suicide: Understanding and Responding

Douglas Jacobs, Herbert N. Brown

Connecticut: International Universities Press Inc., 505 pp., 1989

The editors’ intent was to develop “a clinically useful and broad-ranging book” on suicide, based on their planning of the Harvard Medical School Suicide Symposia which began in 1981 and are ongoing. The basis of this collective effort is the work of numerous internationally recognized experts in suicidology who have contributed to the symposia over the years. The contents of the book include review, provocative and new material.

The book begins with an interview between the editors and Erik Erikson who was the Department’s scholar — in residence in 1983. Erikson provided the guiding theme for this work, namely, that any study of human nature and behavior (including suicide) should include “biological, psychological and sociocultural influences.”

The book is divided into four sections. The first, “Foundations,” contains review material dealing with the psychological, biological and social aspects of suicide. The second, “Understanding,” is divided into general and specific assessment considerations. This latter section included coverage of child, adolescent and elderly suicide material, and more specifically, highlights women and suicide. The third section, “Responding,” include strategies and pitfalls, treatment and aftermath. “Philosophical and Larger Perspectives,” form the last section which is followed by “Reflections” by Karl Menninger.

The editors have successfully produced a cohesive, well-balanced and broad-based selection of pertinent and mostly contemporary suicide material. While the price of this 500 page synthesis is high ($60.00), the book is comprehensive and very readable. I would recommend it for all interested health professionals at varying levels of expertise.

Suicide in Children and Adolescents

Suicide in Children and Adolescents

George MacLean, editor

Toronto: Hogrefe & Huber Publishers, pp. 132, 1990

The frequency of suicide attempts in children and adolescents, along with substantial increases in the rate of completed suicides over the last several decades, have led to suicide becoming a major public health problem in Canada and in the United States. This in turn has led to a large number of studies and reviews on various aspects of the topic.

What sets this book apart from most such publications is the editor’s attempt to condense what is known about he topic to make it accessible for the nonspecialist clinician. Teachers, guidance counsellors, youth and child welfare workers, Big Brothers and Sisters are all involved with many children who subsequently make suicide attempts, often well before they are ever seen by a child psychologist or psychiatrist. If these gatekeepers could assess the risk of suicide in a given case, they could know better how to manage — and, even more important, when to refer for more specialized treatment — before, rather than after, a potentially dangerous attempt has been made. All too often, however, those groups listed above must manage these cases intuitively, since what is known about suicide and its prevention has not been pulled together and made accessible to them. It is no small feat that, in many ways, this book has achieved its intention.

The first of its five chapters, by Joffe and Offord, provides an epidemiological review of suicidal behavior in children and adolescents that is comprehensive, competent, organized and clear. While an excellent review of the epidemiology of suicide in this population, one the epidemiology of suicide in this population, one wonders if those to whom the book is addressed will be enlightened or overwhelmed by the implications of the often contradictory studies it places before them.

The chapter on clinical perspectives, one of two by the editor, is scholarly but, at times, loses sight of its objective. Its preoccupation with doing justice to the complexities and contradictions of psychoanalytic and cognitive psychological formulations for the concept of death takes the place of its integrating these in a way that summarizes their relevance to the reader. Similarly, in discussing psychodynamics, the author lists several overlapping and idiosyncratic formulations. However, he fails to provide a summary statement that numerous dynamics may lead to suicide attempts, and that any of the dynamic constellations described in the chapter should be cause for concern and, therefore, seriously and carefully evaluated. The author’s description of the dimensions to be surveyed routinely in assessing a potentially suicidal child is, because of its breadth, useful.

In the third chapter, “Depressive Disorders in Children and Adolescents,” the editor effectively reviews the scholarly controversy as to whether children are capable of being depressed, and then discusses the link between suicide and depression. While the importance of this link is undeniable, several studies quoted suggest that some children with conduct disorders, substance abuse and/ or personality disorders are also at risk for suicide. An attempts to integrate these studies ending in a statement of whether an inability to diagnose depression means that a youngster is not a suicidal risk would have been helpful for the intended audience. So would a comparison of the types of information obtained, and the advantages and limitations, of clinical interviews, semistructured interviews and rating scales.

The final two chapters best achieve the editor’s intent. In her chapter on risk factors, Pfeffer presents the concept of a spectrum of suicidal behaviors and demonstrates its usefulness for the nonspecialist in mental health. Her discussion of the assessment and predictive significance of individual risk factors is clear, relevant, and tightly organized. Her examination of the relationship of depression to suicide is tightly focussed; it provides the perspective looked for in the previous chapter. The discussions of adaptive mechanisms and interpersonal factors are of critical importance and extreme relevance in the evaluation of risk.

Davidson’s chapter on management is equally clear, well organized and appropriately focussed. Here we find the first mention of the “imitation effect” that can make poorly planned attempts at prevention dangerous. Throughout this chapter, the data on which the author bases his evaluation of their significance. His discussion of intervention clearly addresses teachers, youth workers and other nonspecialist clinicians directly and in language they will understand. He describes a spectrum of interventions from community management through emergency room to inpatient care, along with guidelines for appropriate management at each level. His examination of the value of integrating complementary forms of treatment and the qualities of a therapist needed to treat such cases is sound and straight-forward. The section on postvention therapy, so critical yet so often avoided not only with families but even in treatment institutions that should know better, is a must.

In summary, then, this is a compact, inexpensive and, for the most part, easily read book intended primarily for nonspecialist clinicians, but one from which residents in pediatrics, family practice and psychiatry can learn a good deal. So, too, can most psychiatrists or allied professionals, except for those who already have some expertise in this area. With its extensive bibliography, its annotated recommendations for further reading accompanying each chapter, its excellent use of headings, and a serviceable index, the book succeeds in achieving its purpose.