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Book Forum: Suicide   |    
Suicide: Biopsychosocial Approaches
DONALD D. DENTON, JR., D.MIN., L.P.C.
Am J Psychiatry 1999;156:966-966.
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edited by Alexander J. Botsis, Constantin R. Soldatos, and Stefanis N. Costas. Amsterdam, Elsevier, 1997, 278 pp., $188.50.

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This volume is a compendium of well-researched, tersely written articles on the topic of suicide. The book is divided into four sections: Epidemiology in General and Special Populations, Etiopathogenic Considerations, Clinical Issues, and Conceptual and Ethical Issues. A preface, index of authors, and brief keyword index round out the volume. The articles draw from data as recent as 1996. The volume covers the topic with clarity and sensitivity, providing the reader with more technical data than most readers can absorb or use but also wrestling with topics as contemporary as the daily newspaper.

Depression, exacerbated by physical suffering or accelerated by drug use, is the primary contributor to suicide. Strong values, whether religious or cultural, tend to be inhibitors of suicide. Although these are not new conclusions, the research that supports these conclusions is overwhelming in detail. Robert Plutchik’s chapter, "Suicide and Violence: The Two-Stage Model of Countervailing Forces," provides an excellent model for understanding suicide as a function of aggression and violence under situations of great stress. This model attempts to weigh variables that are amplifiers of aggression and are likely to lead toward suicide and variables that are attenuators and are likely to reduce the risk of suicide. The strength of this model is its capacity to help clinicians focus interventions on concrete events or tasks (attenuators) that appear to be able to reduce the risk of suicide. In a later essay, Plutchik argues for further research on this model.

One of the most clinically helpful chapters is "Clinical Problems in Assessing Suicide Risk." Those of us who supervise students in addition to maintaining a clinical practice will not be comforted by either the research indicating the virtual inability to predict suicide accurately or the sobering comment that "judging risk seems so much easier with the benefit of hindsight." What makes this chapter useful is its relative precision in identifying those populations most likely to commit suicide, "separated into four diagnostic groups known to be at high risk and to certain defined periods of time."

Not surprisingly, a number of articles address the topic of "assisted suicide" or "euthanasia." These articles provide a reasoned, compassionate voice on a topic too often tried in the newspapers. One article explores the "right to die" concept as practiced in the Netherlands. This article provides the criteria that are applied to assisted suicide once "a terminal illness with nearness to death has been diagnosed." Although the authors of this essay take a stance that is permissive regarding a person’s right to die with dignity, they underscore the responsibility of health professionals to assist the person in exploring all possible alternatives to death. They suggest that once a clinician has urged a patient to consider all the alternatives before embarking on the road of assisted suicide, the clinician becomes ethically bound to help with the patient’s self-murder if an honest exploration of alternatives to death is unsuccessful in managing the patient’s pain and fear.

This volume is likely to be most useful to educators and researchers in the field of suicidology and euthanasia, primarily because of its format and the tone of the chapters, rather than its content. This is not a book one can digest quickly or easily, in part because of the distressing nature of the subject but more because the writing, even in the clinical chapters, is quite technical in presentation. One chapter was significant by its absence: what do you say, as a pastor or counselor, to the living who remain at the grave site or in the consulting room? So often, years later, the children of people who committed suicide struggle to understand why someone who was so powerful, who gave them the gift of life, chose to leave this life in a premature and apparently premeditated fashion.

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