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Adolescent Suicide: Assessment and Intervention, Second Edition
Reviewed by Lawrence Adler
Am J Psychiatry 2006;163:1116-1117.
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by Alan L. Berman, Ph.D., David A. Jobes, Ph.D., Morton M. Silverman, M.D., Washington, DC, American Psychological Association, 2005, 456 pp., $69.95.

This book has many strong points and is an excellent first stop for any clinician seeking a good integration of what has been reported about adolescent suicide, including the problems of gathering accurate data. The authors begin with a chilling dose of reality, “the increasing rate of youth suicide over the last part of the 20th century…led the U.S. Department of Health and Human Services to establish specific federal health objectives to lower the suicide rate among 15–24 year-olds by certain target years. Epidemiologic studies have defined our failure to meet these objectives in 1990 and 2000, leading to reestablished goals for the year 2010 …” (p. 13). The challenge and the tragedy lie in the fact that despite years of research, theories, and therapies, there has been little or no significant decrease in U.S. adolescent suicide. This book presents an accurate snapshot, particularly in the psychosocial approach, of both the strengths and limitations of what we know and the work that we have yet to do.

It is in the sections on assessment and treatment that the authors stand out. The importance of accurate assessment, establishment of a therapeutic alliance with the patient and the patient’s family, risk assessment, safety plans, and diagnosis is emphasized. In addition, the authors present a good summary of basic interpersonal, cognitive, and family approaches. I did find the section on pharmacology to be too brief; however, one cannot necessarily find fault with the authors. There is a dearth of double-blind placebo controlled studies of psychotropic medication in children and adolescents for disorders other than attention deficit hyperactivity disorder (ADHD), too few on mood disorders, and even fewer specifically examining the effect on suicidality. Further, it has taken decades to produce studies of the decreased suicide risk with increased duration of use for patients taking lithium. Similarly, it has taken many years to produce studies of the reduced suicide risk in adults taking clozapine. One hopes that there will be more objective data by the third edition of this book. If, by that time, social theorists have not yet produced a way of predicting lethality in an individual, molecular biologists and neuroscientists will probably have yet to discover any single diagnostic test that would predict suicidality, although there are correlations with dysregulation in the serotonergic system and with serotonin transporter alleles. Nonetheless, it seems less likely that we will see a specific biological test for suicidality than we will for a specific psychiatric disorder.

The authors stress the utter uselessness of a “no suicide contract” and, instead, emphasize developing a safety plan with contingencies. Here also, the experienced clinician can only nod his or her head when the authors note that more may be gleaned by the process of the adolescent’s interaction and strength of relationship with the clinician than with any specific single indicator. There are apt reminders of the importance of continuity of care, communication between caregivers, limiting access to firearms, and particularly high-risk time intervals such as the first week after psychiatric admission and the weeks after discharge from an inpatient unit. One might have hoped for more detailed recommendations concerning partial hospitalization, but this is an alternative that is becoming less available. However, the authors have eminently practical sections on evaluating suicidal ideation and plan, risk assessment, and practical approaches. An unusual omission is that although the authors review cognitive treatments in detail, they do not review more recent data arising from neuropsychological and cognitive neuroscience suggesting that impaired executive functioning is highly correlated with suicidal behaviors, particularly in bipolar disorder. In spite of the relative lethality of particular axis I disorders— schizophrenia, bipolar disorder, major depression, panic disorder, posttraumatic stress disorder, and alcohol abuse—there are very limited discussions of how treatment should differ. Similarly, the problems of the adolescent with neurocognitive impairment (e.g., traumatic brain injury [often underdiagnosed but associated with increased risk of suicide], ADHD, learning disabilities, or developmental disorders) are barely mentioned. While this may be due to a lack of space, it may also reflect partiality toward viewing adolescence from a psychosocial bias. Another area that few molecular biologists would neglect is the simple expedient of drawing a family tree and obtaining information from the parents about first- or second-degree relatives with histories of substance abuse, suicide, psychosis, or affective symptoms. This alone can greatly aid the assessment of risk and diagnosis and is perhaps just as important as checking for physical or sexual abuse.

The authors provide illustrative cases—some emphasize the different interpersonal issues of a suicide attempt, some emphasize evaluation, others describe treatments that went awry. The examples the authors present illustrate their arguments well, but one can’t help feeling that in the interests of making a specific point, the complexity of a case may have been de-emphasized. This is particularly true of the description of Columbine High School’s Harris and Klebold, which, if anything, illustrates the complexity of the interaction of social pressures, access to firearms, failure of the legal system, the role of peer groups, and, more than likely, the presence of a serious psychiatric disorder.

On standards of care and malpractice, chapter 7 is full of practical and useful suggestions for ensuring good treatment and includes a frank discussion of pitfalls that can result in losing a malpractice suit. Unfortunately, although the chapter is permeated with the same kinds of useful tables and diagrams that are prevalent throughout the book, the practice of labeling tables as Exhibit 8.5 instead of Table 8.5 might alarm the public-sector clinician who is drowning in a caseload of 600 or more patients and who is exceedingly unlikely to have the time or support to carry out the detailed recommendations for documentation described. Here also is a discussion that could have been more detailed. If the final responsibility is that of the individual clinician, then what should a dedicated clinician do when confronted with the necessity of establishing treatments for high-risk adolescents in underfunded communities? Refuse to treat these patients? Work hundreds of extra hours, ignoring their own families in order to do what is necessary to minimize their legal risk? Worse yet, there is no guarantee that one particular treatment will prevent suicide.

All in all, this is still the classic text on adolescent suicide and one of the best places to begin for anyone who wants to review what is known and what is not yet known on the subject. The book accurately reflects the literature in the field.

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