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Book Forum: MOOD DISORDERS   |    
Suicide: Individual, Cultural, International Perspectives
Howard S. Sudak, M.D.
Am J Psychiatry 1998;155:1127-1128.
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by Antoon A. Leenars, Ph.D., Ronald W. Maris, Ph.D., Yoshitomo Takahashi, M.D. New York, Guilford Publications, 1997, 151 pp., $25.00.

Book Forum

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This work represents a double reprise for a set of papers initially presented as the keynote core works from the 1996 Annual Meeting of the American Association of Suicidology. The conference theme was "Suicide: Individual, Cultural, International Perspectives." Following the conference, the papers were published as an issue of Suicide and Life-Threatening Behavior (volume 27, issue 1, Spring 1997), the official journal of the American Association of Suicidology, in exactly the same format as this hardcover book, published by Guilford Publications.

Most of the contributors to this edited work have a long affiliation with the American Association of Suicidology (Lanny Berman, Terry Maltsberger, Joe Richman, David Lester, as well as Leenars and Maris)—in fact, most have been awardees, officers, and board members—and are distinguished contributors in the field of suicidology. Maris, for example, was for years the editor of Suicide and Life-Threatening Behavior a journal now edited by Mort Silverman, M.D.

The present work, a slim volume, is rather uneven; the sections on cultural and international perspectives were of considerably more interest to me than the section on individual perspectives. Leenars sets the stage in the preface by reminding us that nomothetic and idiographic perspectives on suicide complement one another—indicating that these papers will embrace both. Berman begins the section on individual perspectives with a chapter on adolescent suicide that looks at both individual and cultural influences. Leenars follows with an interesting study of the "Richard Cory" type of suicide—i.e., an apparently clinically unpredictable suicide. He feels that this case is an example of a dissembler. An adult case is presented by Maltsberger, who employs an unorthodox bantering, teasing approach with an unusual patient. Richman offers a uniquely optimistic view of our changing age demographics, finding grounds for hope for our future, increasing elderly patients. This section concludes with a chapter on social suicide in which Maris attempts to meld individual and social perspectives.

What I find most disturbing about the section on individual perspectives is that the biological aspects of suicide and depression are merely mentioned. There is a clear emphasis on the psychological and a short-shrifting of the biological here. I understand that simple cause-and-effect reductionism does not do justice to the interdependence of biology and psychology, but, having treated so many severely depressed individuals over the years, it is hard for me not to feel that suicidal despair is generally more the product of patients' disordered neurochemistry than of their individual, developmental psychology—chickens and eggs notwithstanding. Certainly, not all suicidal individuals suffer from major depressive disorders and not all severely depressed patients kill themselves, but if we are significantly to decrease the appalling toll of suicides in youth and the elderly, a focus on depression and its optimal treatment by combined pharmacology and psychotherapy is required—not a minimization of the role of depression and biology. A public health campaign directed at better and earlier identification and treatment of depression holds the greatest promise for significant reduction of suicidal deaths.

In section 2, Cultural Perspectives, David Lester provides an overview with an interesting historical slant of diverse ethnic groups in the United States and their suicidal patterns. Marlene EchoHawk contributes a chapter on Native American suicide that is especially enlightening on traditional tribal structure. Little emphasis is given to the role of alcohol and other substance abuse, another public health problem that needs to be addressed. "African American Suicide as a Cultural Paradox," by Jewelle Taylor Gibbs, is a very good review article. More attention to the confounding of racial versus socioeconomic factors would have been welcomed, as well as more theorizing on the pattern of higher rates in 20–35-year-old African American men than in older African American men. Julia Shiang et al. contribute an excellent chapter on Caucasian compared with Asian groups in San Francisco. Notable are their disclaimers of necessary validity for their theories and their finding that Asian women older than age 85 have the highest rates of all age groups and races. Joseph Hover and Cheryl King's chapter on Mexican Americans is especially thoughtful regarding socioeconomic versus ethnic factors in this understudied population.

The first chapter in section 3, International Perspectives, is also by David Lester, who developed a small set of predictor variables that were "quite successful" in predicting the suicide rates of 17 industrialized nations. The description of "quite successful" (as cited in the abstract) was reduced to only "moderately successful" in the chapter's discussion section. More specifically, birth and divorce rates, alcohol consumption, percent of elderly in the population, and blood type generated an r of 0.69 in the multiple regression analysis. Sakinofsky and Leenars compared Canadian and U.S. data on suicide and found them generally similar, with slightly higher rates in Canada. Armin Schmidtke presents his perspective on Europe, revealing the apparent enormous differences across countries. He feels that national attitudes toward suicidal behavior are the most important reasons for these wide discrepancies. An interesting note is his reference to Rossow's 1993 article in the journal Addiction, showing that in Norway, from 1911 to 1990, alcohol consumption and divorce were independently and statistically significantly associated with male, but not female, suicide rates. This finding is at variance with Charles Rich's suggestion that the disparity between male and female completed suicide rates in the United States may best be accounted for by the far greater prevalence of alcohol abuse by males. The book's final chapter is by Takahashi, who writes of culture and suicide from a Japanese psychiatrist's perspective. He emphasizes the similarities of suicide across cultures rather than the differences and advocates a rather idiosyncratic clinical approach. His chapter is interesting, but it contains numerous grammatical errors.

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