The International Handbook of Suicide Prevention

For two people who made me a better person.

Dr Clare Cassidy (1968–2008)

I continue to be inspired by Clare’s memory daily. An amazing friend and colleague.

“But then with autumn upon us, so breezy and cruel,Clare left us in Paris, heartbroken and cool.

But we remember Clare’s grace, her beauty, her light;Her kindness, her smile and sadness, its might.”

(RO’C, 2008)

Professor Noel Sheehy (1955–2011)

One day in the summer of 1994 Noel asked me whether I might be interested in undertaking a PhD on suicide—without hesitation I jumped at the chance. Without him, I would never have embarked on a career in suicide research.

He took a chance on me. For this (and many other things besides) I will always be grateful. So kind and generous.

In my thoughtsRory C. O’Connor

The International Handbook of Suicide Prevention

Second Edition

Edited by

Rory C. O’Connor and Jane Pirkis

This second edition first published 2016© 2016 John Wiley & Sons, Ltd

Edition history: John Wiley & Sons, Ltd (1e, 2011)

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Library of Congress Cataloging‐in‐Publication Data

Names: O’Connor, Rory C., editor. | Pirkis, Jane, editor.Title: The international handbook of suicide prevention / edited by Rory C. O’Connor and Jane Pirkis.Description: 2nd Edition. | Hoboken : Wiley, 2016. | Revised edition of International handbook of

suicide prevention research, policy and practice, 2011. | Includes bibliographical references and index.Identifiers: LCCN 2016021173 (print) | LCCN 2016022004 (ebook) | ISBN 9781118903278 (cloth) |

ISBN 9781118903230 (pdf) | ISBN 9781118903247 (epub)Subjects: LCSH: Suicide–Prevention–Research. | Suicidal behavior–Research.Classification: LCC HV6545 .I594 2016 (print) | LCC HV6545 (ebook) | DDC 616.85/8445–dc23LC record available at https://lccn.loc.gov/2016021173

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Cover image: Gettyimages/Kenichi Sotozaki / EyeEm

Set in 10/12pt Galliard by SPi Global, Pondicherry, India

1 2016

To all those who have been affected by suicide and to those who struggle daily to stay alive.

To Suzy, Poppy, and Oisin for all their continued support

Notes on Contributors xi

Introduction 1Rory C. O’Connor and Jane Pirkis

Part I Suicidal Determinants and Frameworks 9

1 Challenges to Defining and Classifying Suicide and Suicidal Behaviors 11Morton M. Silverman

2 International Perspectives on the Epidemiology and Etiology of Suicide and Self‐Harm 36Kirsten Windfuhr, Sarah Steeg, Isabelle M. Hunt, and Navneet Kapur

3 Self‐Harm: Extent of the Problem and Prediction of Repetition 61Ella Arensman, Eve Griffin, and Paul Corcoran

4 Major Mood Disorders and Suicidal Behavior 74Zoltán Rihmer and Peter Döme

5 Schizophrenia, Other Psychotic Disorders, and Suicidal Behavior 93Antoine Desîlets, Myriam Labossière, Alexander McGirr, and Gustavo Turecki

6 Substance Use Disorders and Suicidal Behavior: A Conceptual Model 110Kenneth R. Conner and Mark A. Ilgen

7 Personality Disorders and Suicidality 124Joel Paris

8 The Association Between Physical Illness/Medical Conditions and Suicide Risk 133Maurizio Pompili, Alberto Forte, Alan L. Berman, and Dorian A. Lamis

9 Relationships of Genes and Early‐Life Experience to the Neurobiology of Suicidal Behavior 149J. John Mann and Dianne Currier

10 Understanding the Suicidal Brain: A Review of Neuropsychological Studies of Suicidal Ideation and Behavior 170Kees van Heeringen and Stijn Bijttebier

Contents

viii Contents

11 Visualizing the Suicidal Brain: Neuroimaging and Suicide Prevention 188Katherin Sudol and Maria A. Oquendo

12 Present Status and Future Prospects of the Interpersonal–Psychological Theory of Suicidal Behavior 206Christopher R. Hagan, Jessica D. Ribeiro, and Thomas E. Joiner

13 The Integrated Motivational‐Volitional Model of Suicidal Behavior: An Update 220Rory C. O’Connor, Seonaid Cleare, Sarah Eschle, Karen Wetherall, and Olivia J. Kirtley

14 Sociological Perspectives on Suicide: A Review and Analysis of Marital and Religious Integration 241Steven Stack and Augustine J. Kposowa

15 Inequalities and Suicidal Behavior 258Stephen Platt

16 Economic Recession, Unemployment, and Suicide 284David Gunnell and Shu‐Sen Chang

Part II Intervention, Treatment, and Care 301

17 Evidence‐Based Prevention and Treatment of Suicidal Behavior in Children and Adolescents 303Yari Gvion and Alan Apter

18 Prevention and Treatment of Suicidality in Older Adults 323Diego De Leo and Urška Arnautovska

19 Therapeutic Alliance and the Therapist 346Konrad Michel

20 Clinical Care of Self‐Harm Patients: An Evidence‐Based Approach 362Keith Hawton and Kate E. A. Saunders

21 After the Suicide Attempt—The Need for Continuity and Quality of Care 387Lars Mehlum and Erlend Mork

22 Management of Suicidal Risk in Emergency Departments: A Clinical Perspective 403Simon Hatcher

23 Treating the Suicidal Patient: Cognitive Therapy and Dialectical Behavior Therapy 416Nadine A. Chang, Shari Jager‐Hyman, Gregory K. Brown, Amy Cunningham, and Barbara Stanley

24 Lessons Learned from Clinical Trials of the Collaborative Assessment and Management of Suicidality (CAMS) 431David A. Jobes, Katherine Anne Comtois, Lisa A. Brenner, Peter M. Gutierrez, and Stephen S. O’Connor

Contents ix

25 Modes of Mind and Suicidal Processes 450J. Mark G. Williams, Danielle S. Duggan, Catherine Crane, Silvia R. Hepburn, Emily Hargus, and Bergljot Gjelsvik

26 Brief Contact Interventions: Current Evidence and Future Research Directions 466Allison J. Milner and Gregory L. Carter

27 Delivering Online Cognitive Behavioral Therapy Interventions to Reduce Suicide Risk 480Ad Kerkhof and Bregje van Spijker

28 Helplines, Tele‐Web Support Services, and Suicide Prevention 490Alan Woodward and Clare Wyllie

Part III Suicide Prevention: Bringing Together Evidence, Policy, and Practice 505

29 Suicide Prevention in Low‐ and Middle‐Income Countries 507Lakshmi Vijayakumar and Michael Phillips

30 Suicide in Asia: Epidemiology, Risk Factors, and Prevention 524Murad M. Khan, Nargis Asad, and Ehsanullah Syed 

31 Cultural Factors in Suicide Prevention 541Lai Fong Chan and Maniam Thambu

32 Suicide Prevention Strategies: Case Studies from Across the Globe 556Gergö Hadlaczky, Danuta Wasserman, Christina W. Hoven, Donald J. Mandell, and Camilla Wasserman

33 Rurality and Suicide 569Cameron R. Stark, Vincent Riordan, and Nadine Dougall

34 Why Mental Illness is a Risk Factor for Suicide: Implications for Suicide Prevention 594Brian L. Mishara and François Chagnon

35 Suicide Prevention Through Restricting Access to Suicide Means and Hotspots 609Ying‐Yeh Chen, Kevin Chien‐Chang Wu,Yun Wang, and Paul S. F. Yip

36 Reducing Suicide Without Affecting Underlying Mental Health: Theoretical Underpinnings and a Review of the Evidence Base Linking the Availability of Lethal Means and Suicide 637Deborah Azrael and Matthew J. Miller

37 Surviving the Legacy of Suicide 663Onja T. Grad and Karl Andriessen

38 Suicide Prevention Through Personal Experience 681DeQuincy A. Lezine

x Contents

39 Time to Change Direction in Suicide Research 696Heidi Hjelmeland and Birthe Loa Knizek

40 Suicide Research Methods and Designs 710Catherine R. Glenn, Joseph C. Franklin, Jaclyn C. Kearns, Elizabeth C. Lanzillo, and Matthew K. Nock

41 School‐Based Suicide Prevention Programs 725Lynda Kong, Jitender Sareen, and Laurence Y. Katz

42 Media Influences on Suicidal Thoughts and Behaviors 743Jane Pirkis, Katherine Mok, Jo Robinson, and Merete Nordentoft

43 Suicide Clusters 758Jo Robinson, Jane Pirkis, and Rory C. O’Connor

44 Making an Economic Case for Investing in Suicide Prevention: Quo Vadis? 775David McDaid

Index 791

Notes on Contributors

Karl AndriessenSchool of PsychiatryUniversity of New South WalesRandwick NSWAustralia

Alan ApterFeinberg Child Study CenterSchneider’s Children’s Medical Center of Israel

Petach Tikvah and Sackler Faculty of Medicine

Tel Aviv UniversityTel AvivIsrael

Ella ArensmanNational Suicide Research FoundationDepartment of Epidemiology and Public Health

WHO Collaborating Centre for Surveillance and Research in Suicide Prevention

University College CorkCorkIreland

Urška ArnautovskaAustralian Institute for Suicide Research and Prevention

WHO Collaborating Centre on Research and Training in Suicide Prevention

Griffith UniversityAustralia

Nargis AsadDepartment of PsychiatryAga Khan UniversityKarachiPakistan

Deborah AzraelHarvard Injury Control Research Center

Harvard T.H. Chan School of Public Health

Boston, MassachusettsUSA

Alan L. BermanDepartment of PsychiatryJohns Hopkins School of MedicineBaltimore, MarylandUSA

Stijn BijttebierUnit for Suicide ResearchGhent UniversityGhentBelgium

Lisa A. BrennerVA Veteran Integrated Service Network 19 – Mental Illness Research Education, & Clinical Center

DenverColoradoUSA

Gregory K. BrownDepartment of PsychiatryUniversity of PennsylvaniaPennsylvaniaUSA

Gregory L. CarterCentre for Translational Neuroscience and Mental Health

Faculty of Health and MedicineUniversity of Newcastle, CallaghanAustralia

François ChagnonCentre for Research and Intervention on Suicide and Euthanasia and

Psychology DepartmentUniversité du Québec à MontréalMontréal, QuébecCanada

Lai Fong ChanDepartment of PsychiatryUniversiti Kebangsaan Malaysia [National University of Malaysia]

Kuala LumpurMalaysia

Nadine A. ChangDepartment of Psychiatry Mount Sinai St. Luke’s HospitalNew YorkUSA

Shu‐Sen ChangInstitute of Health Behaviors and Community Sciences and Department of Public Health

College of Public HealthNational Taiwan UniversityTaiwan

Ying‐Yeh ChenTaipei City Psychiatric Center Taipei City Hospital & National Yang‐Ming University

TaipeiTaiwan

Seonaid CleareSuicidal Behaviour Research Laboratory

Institute of Health & WellbeingUniversity of GlasgowGlasgowScotlandUK

Katherine Anne ComtoisDepartment of Psychiatry and Behavioral Sciences and Department of Psychology Harborview Medical Center

University of WashingtonSeattleWashingtonUSA

Kenneth R. ConnerUniversity of Rochester Medical CenterRochesterNew YorkUSAVA VISN 2 Center of ExcellenceCanandaiguaNew YorkUSA

Paul CorcoranNational Suicide Research FoundationDepartment of Epidemiology and Public Health

National Perinatal Epidemiology CentreWHO Collaborating Centre for Surveillance and Research in Suicide Prevention

University College CorkCorkIreland

Catherine CraneOxford Mindfulness CentreDepartment of PsychiatryUniversity of OxfordEnglandUK

xii Notes on Contributors

Notes on Contributors xiii

Amy CunninghamCentre for Acceptance and ChangePennsylvaniaUSA

Dianne CurrierCentre for Epidemiology and Biostatistics

Melbourne School of Population and Global Health

University of MelbourneMelbourneAustralia

Diego De LeoAustralian Institute for Suicide Research and Prevention

WHO Collaborating Centre on Research and Training in Suicide Prevention and Life Promotion Clinic

Griffith UniversityAustralia

Antoine DesîletsMcGill Group for Suicide StudiesDouglas Mental Health University Institute

McGill UniversityMontrealCanada

Peter DömeLaboratory for Suicide Research and Prevention

National Institute of Psychiatry and Addictions

BudapestHungary

Nadine DougallNMAHP Research UnitSchool of Health SciencesUniversity of StirlingStirlingScotlandUK

Danielle S. DugganOxford Mindfulness CentreDepartment of PsychiatryUniversity of OxfordEnglandUK

Sarah EschleSuicidal Behaviour Research Laboratory

Institute of Health & WellbeingUniversity of GlasgowGlasgowScotlandUK

Alberto ForteDepartment of Neurosciences, Mental Health and Sensory Organs Suicide Prevention Center

Sant’Andrea HospitalSapienza University of RomeItaly

Joseph C. FranklinDepartment of PsychologyVanderbilt UniversityNashvilleTennesseeUSA

Bergljot GjelsvikOxford Mindfulness CentreDepartment of PsychiatryUniversity of OxfordOxfordEnglandUK

Catherine R. GlennDepartment of Clinical and Social Sciences in Psychology

University of RochesterRochesterNew YorkUSA

Onja T. GradCentre for Mental HealthUniversity Psychiatric HospitalLjubljanaSlovenia

Eve GriffinNational Suicide Research FoundationWHO Collaborating Centre for Surveillance and Research in Suicide Prevention

University College CorkCorkIreland

David GunnellSchool of Social and Community Medicine

University of BristolEnglandUK

Peter M. GutierrezVA Veteran Integrated Service Network 19 – Mental Illness Research, Education and Clinical Center

DenverColoradoUSA

Yari GvionDepartment of PsychologyBar Ilan UniversityRamat GanIsrael

Gergö HadlaczkyNational Centre for Suicide Research and Prevention of Mental lll‐Health (NASP)

Karolinska InstitutetStockholmSweden

Christopher R. HaganLaboratory for the Study and Prevention of Suicide‐Related Conditions and Behaviors

Department of PsychologyFlorida State UniversityUSA

Emily HargusOxford Mindfulness CentreDepartment of PsychiatryUniversity of OxfordOxfordEnglandUK

Simon HatcherDepartment of PsychiatryUniversity of OttawaOttawaCanada

Keith HawtonCentre for Suicide ResearchDepartment of PsychiatryUniversity of OxfordEnglandUK

Silvia R. HepburnDepartment of Clinical Health Psychology

St Mary’s HospitalEnglandUK

Heidi HjelmelandDepartment of Social Work and Health Science

Norwegian University of Science and Technology

TrondheimNorway

Christina W. HovenDepartment of Epidemiology and Division of Child Psychiatry

Child Psychiatric Epidemiology Group, College of Physicians and Surgeons and Mailman School of Public Health, Columbia University

New York State Psychiatric Institute

New YorkUSA

xiv Notes on Contributors

Isabelle M. HuntCentre for Suicide PreventionCentre for Mental Health and SafetyUniversity of ManchesterManchesterEnglandUK

Shari Jager‐HymanAaron T. Beck Psychopathology Research Center

University of PennsylvaniaPennsylvaniaUSA

Mark A. IlgenVA Serious Mental Illness Treatment Research and Evaluation Center & University of Michigan Department of Psychiatry

Ann ArborMichiganUSA

David A. JobesSuicide Prevention LabDepartment of PsychologyThe Catholic University of AmericaDepartment of PsychologyWashington, DCUSA

Thomas E. JoinerLaboratory for the Study and Prevention of Suicide‐Related Conditions and Behaviors

Department of PsychologyFlorida State UniversityUSA

Navneet KapurCentre for Suicide PreventionCentre for Mental Health and SafetyUniversity of ManchesterManchesterEnglandUK

Laurence Y. KatzDepartment of PsychiatryUniversity of ManitobaWinnipegCanada

Jaclyn C. KearnsNational Center for PTSDVA Boston Healthcare SystemBostonMassachusettsUSA

Ad KerkhofDepartment of Clinical, Neuro, and Developmental Psychology and the EMGO Institute for Health and Care Research

Faculty of Behavioural and Movement Sciences

VU UniversityAmsterdamThe Netherlands

Murad M. KhanDepartment of PsychiatryAga Khan UniversityKarachiPakistan

Olivia J. KirtleySuicidal Behaviour Research LaboratoryInstitute of Health & WellbeingUniversity of GlasgowGlasgowScotlandUK

Birthe Loa KnizekDepartment of Applied Social SciencesDepartment of Social Work and Health Science

Norwegian University of Science and Technology

TrondheimNorway

Lynda KongDepartment of PsychiatryUniversity of ManitobaWinnipegCanada

Notes on Contributors xv

Augustine J. KposowaDepartment of SociologyUniversity of CaliforniaRiversideUSA

Myriam LabossièreMcGill Group for Suicide StudiesDouglas Mental Health University Institute

McGill UniversityMontrealCanada

Dorian A. LamisDepartment of Psychiatry and Behavioral Sciences Emory University School of Medicine

AtlantaGeorgiaUSA

Elizabeth C. LanzilloDepartment of PsychologyBrown UniversityRhode IslandUSA

DeQuincy A. LezinePrevention CommunitiesFresnoCaliforniaUSA

Donald J. MandellInternational Center for Child Mental Health

National Center for Disaster Preparedness

Mailman School of Public HealthColumbia UniversityNew York State Psychiatric InstituteNew YorkUSA

Maniam ThambuDepartment of PsychiatryUniversiti Kebangsaan Malaysia [National University of Malaysia]

Kuala LumpurMalaysia

J. John MannDivision of Molecular Imaging & Neuropathology

Department of PsychiatryCollege of Physicians and SurgeonsColumbia UniversityNew York State Psychiatric InstituteUSA

David McDaidPersonal Social Services Research UnitLSE Health and Social CareLondon School of Economics and Political Science

LondonUK

Alexander McGirrDepartment of PsychiatryUniversity of British ColumbiaVancouverCanada

Lars MehlumNational Centre for Suicide Research and Prevention

Institute of Clinical MedicineUniversity of OsloOsloNorway

Konrad MichelUniversity Hospital of PsychiatryUniversity of BernBernSwitzerland

Matthew J. MillerDepartment of Health SciencesNortheastern UniversityBostonMassachusettsUSA

Allison J. MilnerMelbourne School of Population and Global Health

University of MelbourneMelbourneAustralia

xvi Notes on Contributors

Centre for Mental Health ResearchSchool of Population and Global HealthThe University of MelbourneMelbourneAustralia

Brian L. MisharaCentre for Research and Intervention on Suicide and Euthanasia and Psychology Department

Université du Québec à MontréalMontréalQuébecCanada

Erlend MorkNational Centre for Suicide Research and Prevention

Institute of Clinical MedicineUniversity of OsloOsloNorway

Katherine MokCentre for Mental HealthMelbourne School of Population and Global Health

University of MelbourneMelbourneAustralia

Matthew K. NockDepartment of PsychologyHarvard UniversityCambridgeMassachusettsUSA

Merete NordentoftPsychiatric Center CopenhagenUniversity of CopenhagenCopenhagenDenmark

Rory C. O’ConnorSuicidal Behaviour Research LaboratoryInstitute of Health & WellbeingUniversity of GlasgowGlasgowScotlandUK

Stephen S. O’ConnorDepartment of Psychiatry and Behavioral Sciences

University of LouisvilleLouisvilleKentuckyUSA

Maria A. OquendoMolecular Imaging & Neuropathology Division (MIND)

Department of Psychiatry College of Physicians and Surgeons

Columbia UniversityNew York State Psychiatric InstituteUSA

Joel ParisInstitute of Community and Family Psychiatry

McGill UniversityMontrealQuebecCanada

Michael PhillipsSuicide Research and Prevention Centre

Shanghai Jiaotong University School of Medicine and Emory University School of Medicine

ShanghaiChina

Jane PirkisCentre for Mental HealthMelbourne School of Population and Global Health

University of MelbourneMelbourneAustralia

Stephen PlattUsher Institute of Population Health Sciences & Informatics

University of EdinburghScotlandUK

Notes on Contributors xvii

Maurizio PompiliDepartment of Neurosciences, Mental Health and Sensory Organs

Suicide Prevention CenterSant’Andrea HospitalSapienza University of RomeItaly

Zoltán RihmerLaboratory for Suicide Research and Prevention

National Institute of Psychiatry and Addictions

BudapestHungary

Jessica D. RibeiroVanderbilt UniversityNashvilleTennesseeUSA

Vincent RiordanWest Cork Mental Health Services, Cork, Ireland and

Centre for Rural Health Research and Policy

InvernessScotlandUK

Jo RobinsonOrygen, The National Centre of Excellence in Youth Mental Health

MelbourneVictoriaAustralia

Jitender SareenDepartment of PsychiatryUniversity of ManitobaWinnipegCanada

Kate E. A. SaundersDepartment of PsychiatryUniversity of OxfordWarneford HospitalEnglandUK

Morton M. SilvermanDepartment of PsychiatrySchool of MedicineUniversity of ColoradoDenverUSA

Steven StackDepartments of Criminology, and Psychiatry & Behavioral Neuroscience

Wayne State UniversityDetroitUSA

Barbara StanleyDivision of Molecular Imaging & Neuropathology

Department of Psychiatry College of Physicians and Surgeons

Columbia UniversityNew York State Psychiatric InstituteUSA

Cameron R. StarkDepartment of Public HealthNHS Highland, InvernessCentre for Rural HealthUniversity of AberdeenAberdeenScotlandUK

Sarah SteegCentre for Suicide PreventionCentre for Mental Health and Safety

University of ManchesterManchesterEnglandUK

Katherin SudolFrank H. Netter, M.D. School of Medicine

Quinnipiac UniversityNorth Haven, ConnecticutUSA

xviii Notes on Contributors

Ehsanullah SyedDepartment of PsychiatryPenn State Milton S Hershey Medical Center

Penn State College Of MedicineHersheyPennsylvaniaUSA

Gustavo TureckiMcGill Group for Suicide StudiesDouglas Mental Health University Institute

McGill UniversityMontrealCanada

Kees van HeeringenUnit of Suicide Research and Flemish Suicide Prevention Centre

Ghent UniversityGhentBelgium

Bregje van SpijkerNational Institute for Mental Health Research

Research School of Population HealthThe Australian National UniversityAustralia Capital TerritoryAustralia

Lakshmi VijayakumarVoluntary Health ServicesSNEHA Suicide Prevention CentreIndia & University of MelbourneChennaiIndia

Yun WangHong Kong Jockey Club Centre for Suicide Research and Prevention

University of Hong KongHong Kong

Camilla WassermanChild Psychiatric EpidemiologyDepartment of Child and Adolescent Psychiatry

Columbia UniversityNew York State Psychiatric InstituteNew YorkUSA

Danuta WassermanNational Centre for Suicide Research and Prevention of Mental lll‐Health (NASP)

Karolinska InstitutetStockholmSweden

Karen WetherallSuicidal Behaviour ResearchLaboratoryInstitute of Health & WellbeingUniversity of GlasgowGlasgowScotlandUK

J. Mark G. WilliamsOxford Mindfulness CentreDepartment of PsychiatryUniversity of OxfordOxfordEnglandUK

Kirsten WindfuhrCentre for Suicide PreventionCentre for Mental Health and Safety

University of ManchesterManchesterEnglandUK

Alan WoodwardLifeline Research FoundationLifeline AustraliaCanberraAustralian Capital TerritoryAustralia

Notes on Contributors xix

Kevin Chien‐Chang WuDepartment and Graduate Institute of Medical Education and Bioethics

National Taiwan University College of Medicine

Department of PsychiatryNational TaiwanUniversity HospitalTaiwan

Clare WyllieResearch & EvaluationSamaritansUK

Paul S. F. YipCentre for Suicide Research and Prevention & Department of Social Work and Social Administration

University of Hong KongHong Kong

xx Notes on Contributors

The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.

IntroductionRory C. O’Connor and Jane Pirkis

Since the publication of the first edition of the International Handbook of Suicide Prevention in 2011 (O’Connor, Platt, & Gordon, 2011), Preventing Suicide: A Global Imperative has been published by the World Health Organization (World Health Organization [WHO], 2014). This landmark publication, the first ever world suicide prevention report, highlighted the scale of the task of suicide prevention. At least 804,000 people take their own lives each year across the globe, which translates into a death every 40 seconds. The report also touches on many of the issues that we examine in detail herein, including the epidemiology of suicide and how best to inter­vene to prevent it. We are delighted that many of those who contributed to the WHO report have authored chapters for the second edition of this Handbook.

There are a number of changes in this edition of the Handbook. First, there is a change in editorship. Rory C. O’Connor has been joined by Jane Pirkis from University of Melbourne as coeditor, and Jane takes the place of Stephen Platt and Jacki Gordon, who were coeditors of the first edition. Second, we have expanded the Handbook; in terms of chapters, it is now 20% longer, which has allowed us to include more hot topics in suicide research and prevention. Third, given that the majority of the world’s suicides occur in Asia and low‐ and middle‐income countries, additional chapters have been dedicated to better understand suicide across different countries and cultures. Fourth, the majority of chapters end with a section describing up to 10 key resources. These resources include a selection of journal articles, books, reports, or online resources that the authors believe the reader would benefit from reading.

As in the first edition of the Handbook, we have tried to understand why people attempt suicide and what can be done to reduce suicide by harnessing the expertise of more than 110 suicidologists from across the world. The Handbook offers kaleido­scopic views on the complex multitude of factors that may explain suicidal behavior and the array of approaches to suicide prevention. It should appeal to anyone with an interest in trying to comprehend suicide and, ultimately, prevent it. To this end, one of the guiding principles of this volume is to improve our understanding of the r elationship between attempted suicide and deaths by suicide. A more comprehensive understanding of this relationship is important not only for theoretical and conceptual reasons but also because secondary prevention interventions are frequently directed at  those who attempt suicide. Any national or international suicide prevention strategy, to be effective, must be able to engage those who have attempted suicide.

2 Rory C. O’Connor and Jane Pirkis

Although this may seem self‐evident, it is crucial, given the universal recognition that maintaining patients who have attempted suicide in treatment is fraught with diffi­culties. Further, it is sobering to note that the best predictor of future suicidal behavior (and suicide) is past suicidal behavior. Therefore, if we can intervene with those who have previously tried to take their own lives, we should be able to prevent at least some of the future deaths by suicide. Consequently, nonfatal suicidal behavior and suicide receive equal attention in this Handbook. As suicide attempt and self‐harm are often used interchangeably in the research literature (also see the following text), where we use the term suicide attempt/suicidal behavior in this Introduction, we are referring to self‐injurious behavior with evidence of suicidal intent. Self‐harm is used to describe all self‐harming behaviors where suicidal intent is not explicitly ascertained.

The overarching aim of this Handbook is to bring together the different exponents of suicide research and prevention irrespective of country of origin or professional background, because only through learning and working together internationally and across disciplines will we rise to the challenge of reducing suicidal behavior in every country. Suicidology, defined as the science of suicide and suicide prevention (Maris, 1993), is little over 55 years old, and embraces researchers, practitioners, and policy planners whose disciplinary backgrounds include psychology, psychiatry, epidemi­ology, sociology, social work, health economics, nursing, emergency medicine, ethics, law, and public health. This heterogeneity is a major strength, as the whole (i.e., the discipline of suicidology) is much greater than the sum of its constituent disciplines. We continue to learn from each other’s difficulties and successes, and to exchange a broad range of theoretical and methodological perspectives. However, one of the challenges of working in an interdisciplinary manner is that there are inevitable differ­ences in emphasis, which can lead to difficulties in how we communicate about self‐injurious behavior across countries and professions. Although there have been several efforts to reach consensus on definitions and nomenclature (see Chapter  1 by Silverman), as a discipline we have yet to agree on a common definition of suicidal behavior. This renders the comparison of studies difficult. One study may include a heterogeneous sample of patients, some of whom are reporting suicidal intent and some of whom are not, whereas another may include only individuals who have engaged in potentially lethal suicide attempts, with explicit and high suicidal intent. Despite our best efforts, we are unlikely to achieve an agreed definition of suicidal behavior for some considerable time. Indeed, an inspection of the international liter­ature still yields a myriad of different terms to describe the broad spectrum of self‐injurious thoughts and behaviors (e.g., self‐harm, attempted suicide, suicidal behavior, nonsuicidal self‐injury; see Chapter 1 by Silverman). Consequently, we asked each contributing author to make explicit early in their chapter how they operationalized and defined suicidal behavior therein.

Additional aims of the book are to showcase the state of the science in terms of research, policy, and practice, to share insights and expertise, and to enhance mutual learning. In this Handbook, we present the latest research on determinants of suicidal behaviors and the most promising interventions, treatments, and ways of caring for those at risk. We also describe the challenges of translating research, policy, and prac­tice into saving lives. The extent to which suicidologists meet this latter challenge will determine, in large part, whether or not the universal goal of reducing suicide rates across the globe is attained. In short, this Handbook addresses the key questions of

Introduction 3

why people attempt suicide, what the best interventions are for those at risk, and what the key international challenges are in our pursuit of suicide prevention. In addressing these questions, it is important to recognize that the evidence base is, by and large, limited and that it must be understood in terms of the specific characteristics of a study population or the particular context of an intervention. Encouragingly, though, there have been major advances in our understanding of how best to treat and prevent suicidal behavior since the publication of the first edition.

As before, this edition of the Handbook is organized into three parts. Part I is concerned with the determinants and frameworks that inform our understanding of suicide and attempted suicide. Part II focuses on treatment, intervention, and care, and Part III reviews a range of suicide prevention issues that span research, policy, and practice. Chapters 1 to 3 provide the foundations for many of the subsequent chapters. In Chapter 1, for example, Silverman provides an overview of how the international community defines, classifies, and communicates about self‐injury with and without suicidal intent. As noted earlier, these remain contested issues within the field with much of the recent debate stimulated by the inclusion of nonsuicidal self‐injury and suicidal behavior disorder in DSM 5 as areas requiring further research (e.g., Kapur, Cooper, O’Connor, & Hawton, 2013; Oquendo & Baca‐Garcia, 2014). In Chapter 2, Windfuhr, Steeg, Hunt, and Kapur endeavor to bring together the research literature on the factors associated with suicidal behavior from different disciplines, and in Chapter 3, Arensman, Griffin, and Corcoran consider the specific challenge of pre­dicting repetition of self‐harm. These are followed by four chapters (Chapters 4–7) that summarize the research and clinical literature on the relationship between sui­cidal behavior and psychiatric illness (depression [Chapter 4 by Rihmer and Dome], schizophrenia and other psychotic disorders [Chapter  5 by Desîlets, Labossière, McGirr, & Turecki), substance user disorders [Chapter 6 by Conner and Ilgen], and personality disorders [Chapter 7 by Paris]). The Handbook also considers the extent to which the treatment of these disorders can reduce suicide and attempted suicide. The risk of suicide in medical conditions is described in Chapter 8 (by Pompili, Forte, Berman, and Lamis).

The neurobiological and neuropsychological substrates that underpin suicidal behavior are considered in Chapters 9 and 10. In Chapter 9, Mann and Currier review the role of the serotonergic and noradrenergic neurotransmitter systems and the hypothalamic–pituitary–adrenal axis. They highlight the importance of study­ing the interaction between genetic vulnerability and environmental adversity in early life as a means of understanding how the effects of developmental changes in neurobiological systems can persist into adulthood and affect suicide risk. Chapter  10 by van Heeringen and Bijttebier investigates how changes in brain function are mediated by neuropsychological factors to increase the risk of suicide in response to stressors. In a new addition to this edition, the research findings and clinical implications of magnetic resonance imaging (MRI), diffusion tensor imaging, functional MRI (fMRI), positron emission tomography, and single photon emission computed tomography studies in suicide attempters are reviewed in Chapter 11 by Sudol and Oquendo.

The central role of psychology in understanding suicide risk is highlighted in Chapters 12 and 13. For example, the interpersonal‐psychological theory of suicidal behavior is described by Hagan, Ribeiro, and Joiner in Chapter 12, together with its history, its current status, as well as suggestions for further directions. The integrated

4 Rory C. O’Connor and Jane Pirkis

motivational‐volitional model of suicidal behavior, a tripartite model that maps the relationship between background factors and trigger events and the development of suicidal ideation/intent into suicidal behavior is outlined by O’Connor, Cleare, Eschle, Wetherall, and Kirtley in Chapter 13. In the final three chapters (Chapters 14–16) of Part I, the focus shifts to the social context of suicide. In Chapter 14, Stack and Kposowa consider sociological perspectives, including the role of marital and religious integration. The powerful effects of inequalities, economic recession, and unemploy­ment on suicide rates across the globe receive detailed analyses in Chapters 15 and 16. Lower socioeconomic status (at an individual level) and socioeconomic deprivation (at an area level) are both risk factors, although the evidence presented by Platt in Chapter 15 suggests that the “area effect” is compositional (rather than c ontextual). The complicated relationship between an economic recession and suicide risk is emphasized by Gunnell and Chang in Chapter 16: levels of debt, house repossession, relationship difficulties, alcohol misuse, pressures on those remaining in work and job insecurity, and cuts in mental health services ought to be considered in addition to unemployment.

Part II begins with two chapters that review the evidence‐based treatment and care of suicidal children and adolescents (Chapter 17 by Gvion and Apter) and older adults (Chapter  18 by De Leo and Arnautovska). In the former, the interplay b etween biological, genetic, environmental, social, and psychological factors in the etiology and course of suicidal behavior is considered alongside the effectiveness of  prevention and treatment among children and adolescents. Chapter  18 high­lights the age‐specific and gender‐specific risk and protective factors in old age as well as  reviewing the efficacy of existing treatment and preventative strategies. The fundamental role of the therapist and the importance of the therapeutic alliance are considered in Chapter 19 by Michel. The subsequent six chapters (Chapter 20–25) also address clinical issues concerning treatment of patients who have attempted suicide, are actively suicidal, or who have presented to hospital following self‐harm. Recent systematic reviews of studies of attitudes of self‐harm patients toward clinical services and staff attitudes toward self‐harm patients are included in Chapter 20 (by Hawton and Saunders), as is a study of service provision with recommendations for the clinical management of self‐harm patients. Results of a systematic review of aftercare interventions are also summarized in Chapter 20. The authors conclude that there is now robust evidence that short‐term psychological therapy should be routinely offered to patients following self‐harm. After reviewing the l iterature, with a particular focus on clinical practice, Mehlum and Mork’s Chapter 21 suggests a set of requirements to ensure the continuity of care of suicide attempters, and makes recommendations for policy and clinical practice. In another new chapter, Hatcher presents a systems approach (adopted elsewhere in medicine and in other industries) applied to the management of suicide risk in emergency departments (Chapter 22).

Chapters 23–25 focus on key psychological processes in suicidality and emphasize how a better understanding of such processes is integral to a range of psychotherapeutic treatments. Cognitive Therapy, Dialectical Behavior Therapy, and the Collaborative Assessment and Management of Suicidality are reviewed in Chapters 23 (by Chang, Jager‐Hyman, Brown, Cunningham, and Stanley) and 24 (by Jobes, Comtois, Brenner, Gutierrez, and O’Connor). Chapter  25 (by Williams, Duggan, Crane, Hepburn, Hargus, and Gjelsvik) explores the conditions under which suicidal ideas may persist

Introduction 5

and escalate. It also describes mindfulness training and presents preliminary evidence that such training may be beneficial to those at risk of suicidal ideation and behavior. In the final three chapters of Part II (Chapters 26–28), different types of interven­tions adopting alternative modes of delivery are examined. Because it is often difficult to engage suicidal patients in treatment, interest in brief contact interventions has grown in recent years, with studies yielding promising findings in some subgroups (Chapter 26 by Milner and Carter). The role of online interventions to reduce suicide risk is considered by Kerkhof and van Spijker in Chapter 27. The authors ask whether the high expectations around online interventions have been met and highlight a number of challenges for future research. The significance of helplines in suicide p revention is explored by Woodward and Wyllie in Chapter  28. Although crisis helplines have been a mainstay of many national suicide prevention activities for decades, the authors review the evidence for their efficacy, noting the difficulties of evaluating their benefits.

Part III of the Handbook comprises 16 chapters directed at a selection of hot topics in suicide prevention. These topics bring together the different domains of research evidence, policy, and practice and highlight many of the challenges and successes in suicide prevention internationally. Part III begins with a chapter on suicide preven­tion in low‐ and middle‐income countries by Vijayakumar and Phillips (Chapter 29). This chapter stresses the importance of understanding suicide within the global context, recognizing that three­quarters of the world’s suicides occur in low‐ and m iddle‐income countries. The international theme continues in Chapters 30 and 31. In  Chapter  30, Khan, Asad, and Syed discuss suicide in Asia (the world’s largest continent, where approximately 60% of the globe’s total deaths by suicide occur). In Chapter 31, Chan and Maniam discuss the cultural factors in suicide prevention. In both chapters, research gaps are identified, and consideration is given to the establishment of culturally relevant suicide prevention programs. In Chapter 31, the authors call for stronger collaborations between the disciplines of mental health, sociology, and anthropology to facilitate better translational research. In Chapter 32, Hadlaczky, Wasserman, Hoven, Mandell, and Wasserman use case studies to compare the widely used primary, secondary, and tertiary model of suicide prevention with the U.S. Institute of Medicine model oriented toward universal, selective, and indicated approaches. In  Chapter  33, drawing on evidence from across the globe, Stark, Riordan, and Dougall disentangle the relationship between the nature of rurality and suicide, following a critical dissection of the potential influence of other recognized suicide risk factors in the rural context. In Chapter  34, Mishara and Chagnon tackle the difficult issue of why a minority of people with mental health problems die by suicide. The authors argue that a better understanding of the mechanisms that may explain why mental disorder is so closely associated with suicide will improve our knowledge of why only a minority of people with mental health problems die by suicide.

The next two chapters (Chapter 35 by Chen, Wu, Wang, and Yip and Chapter 36 by Azrael and Miller) shift the focus away from factors that contribute to the development of suicidal distress to understanding how restricting access to the means of suicide can reduce suicide deaths. Although there is some overlap between the two chapters, they have a different focus, and each contributes a unique pers­pective to understanding the relationship between means restriction and suicide prevention.

6 Rory C. O’Connor and Jane Pirkis

One of the most important developments in the field of suicidology in the past 10 years has been the greater inclusion of those with lived experience (those who have lost loved ones to suicide as well as those who have been suicidal themselves) in suicide research and prevention activities. To reflect this, in Chapters 37 and 38 (by Grad and Andriessen, and Lezine, respectively), the authors describe the complexity of the bereavement process and how it impacts upon family, friends, and professionals, as well as noting the insights that those with lived experience can provide. The whole field of suicidology can benefit from these insights. The barriers to speaking out and being a lived experience advocate are also described.

In Chapter  39, Hjelmeland and Knizek critique mainstream suicidological research, and give consideration to the extent to which suicidology has dispropor­tionately focused on explaining suicidality to the detriment of understanding it. This chapter also reviews the posited (im)balance between quantitative and qualitative methods used in international suicide research and calls for a change in direction in suicide research. Staying with the research methods focus, Chapter 40 (by Glenn, Franklin, Kearns, Lanzillo, and Nock) reviews the commonly used methods and designs for psychological studies of suicidal behavior. This chapter ends by high­lighting major gaps in our knowledge that require future research. In the next three chapters (Chapters 41–43), the effect of social influences or social context on s uicidal behavior is evaluated, albeit in very different contexts. In Chapter 41, Kong, Sareen, and Katz evaluate school‐based suicide prevention programs and present recommen­dations for future policymaking. Chapter  42, by Pirkis, Mok, Robinson, and Nordentoft, reviews the evidence for and against the “Werther effect,” the p resumed impact of media reporting on suicide, derived from the suicide of the p rotagonist in Goethe’s (1774) novel The Sorrows of Young Werther following an ill‐fated love affair and subsequent so‐called “copycat” suicides following its publication. The emerging evidence for the positive effects of media reporting (“Papageno effect”) and the role of new media in suicide prevention are also evaluated. In the penultimate chapter (Chapter 43), Robinson, Pirkis, and O’Connor describe suicide clusters, posit var­ious mechanisms to explain their effects, and explore approaches to prevent or reduce their impact on affected communities. In the final chapter of the Handbook (Chapter 44), McDaid makes the economic case for investing in suicide prevention. He acknowledges that every single death by suicide is a personal and social tragedy, and that placing a cost on a person’s life may seem unpalatable, but argues that if the economic case helps to shore up resources for suicide prevention (and it does help), then it is vital that this case be made. Indeed, McDaid ends Chapter 44 with the call to embed economic analyses into all evaluations of suicide prevention strategies.

We are extremely grateful to the contributors to this Handbook, all of whom responded extremely positively to our requests and queries. We hope that the material contained herein from many of the world’s leading experts in suicide research and prevention will inform suicide prevention efforts across the globe. We are also extremely passionate about enthusing and training the next generation of suicidolo­gists, so we very much hope that the exciting and innovative research, policy, and practice detailed within this volume will act as a catalyst for others to get involved in the fight against suicide.

Introduction 7

References

Kapur, N., Cooper, J., O’Connor, R. C., & Hawton, K. (2013). Attempted suicide versus non‐suicidal self injury: New diagnosis, or false dichotomy? British Journal of Psychiatry, 202, 326–238.

Maris, R. W. (1993). The evolution of suicidology. In A. A. Leenaars (Ed.), Suicidology: Essays in honor of Edwin Shneidman. Northvale, NJ: Jason Aronson.

O’Connor, R. C., Platt, S., & Gordon, J. (Eds.). (2011). The International handbook of suicide prevention: Research, evidence and practice. Chichester, England: Wiley‐Blackwell.

Oquendo, M. A., & Baca‐Garcia, E. (2014). Suicidal behavior disorder as a diagnostic entity in the DSM‐5 classification system: Advantages outweigh limitations. World Psychiatry, 13, 128–130.

World Health Organization (WHO). (2014). Preventing suicide: A global imperative. Geneva,  Switzerland: WHO. http://apps.who.int/iris/bitstream/10665/131056/1/ 9789241564779_eng.pdf