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 BOOK REVIEWS

Suicide: Global Perspectives from the WHO World Mental Health Surveys

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Matthew K. Nock, Guilherme Borges, and Yutaka Ono. New York, NY: Cambridge University Press; 2012; ISBN 978-0-521-765008; pp 404; $120 (hardcover).

Understanding suicide is one of the Holy Grails of psychiatry. As the editors of this volume write, “suicide accounts for more deaths each year than all wars and other forms of interpersonal violence combined—meaning that we each are more likely to die by our own hand than by someone else’s. More alarming is the fact that suicide is projected to be an even greater contributor to the global burden of disease in the coming decades” (p 1). Yet we understand little about suicide and our efforts to prevent it are unsatisfactory. In efforts to understand and elucidate it, suicide has been studied, within the framework of what is possible and ethical, from many angles and views. One such approach is the epidemiological one. The epidemiological approach allows researchers to study some aspects of suicide in large population samples and hopefully find some common features of people who attempt and/or commit suicide.

In the past, most epidemiological studies of suicidal behavior have been done in smaller areas or individual countries. The World Health Organization (WHO) has expanded this approach to study suicidal behavior around the globe. This book provides “previously unavailable information about the occurrence of suicidal behavior around the globe—from a broad array of countries and cultures including those in the Americas, Europe, Africa, Asia and the Pacific; and the Middle East—in an effort to answer fundamental, and previously unaddressed questions about this devastating problem” (p 1). The information has been obtained from the WHO World Mental Health Surveys. The book’s 16 chapters, written by an international team of 50 authors, is divided into 4 sections and a large, 153-page Appendix.

Section 1, “Introduction,” includes 3 chapters. In the first chapter, the editors discuss the challenges to studying suicidal behavior—suicide and suicidal behavior occur at fairly low base-rates in the general population; suicidal behavior is the result of the combination of many factors and few studies of suicidal behavior are replicated (probably because of the difficulties with recruiting subjects). The rest of the chapter briefly describes the remaining chapters of the book. Chapter 2, “The epidemiology of suicide,” reviews the majority of what is already known about suicide and suicidal behavior—the data on the current rates and recent trends for suicide and suicidal behavior in the United States and cross-nationally, the data on the onset, course, and risk and protective factors for suicide and suicidal behavior, and the data on recent suicide prevention efforts (p 6). Suicide is the 11th leading cause of death in the United States (10.8/100,000) and accounts for 1.4% of all deaths in the United States (p 7). The earliest onset ever reported for suicidal behaviors is in children age 4 to 5 (p 17)! These are staggering pieces of information. Fortunately, it seems that restricting access to lethal means and training physicians to recognize and treat depression and suicidal behavior reduces suicide rates (p 20). Interestingly, the suicide rate in the United States has decreased approximately 11% since 1990. However, it seems that the rates have fluctuated over the past century between 10.0 and 19.0/100,000 (the current rate is the same as it was in the 1950s).

The rest of the book focuses on the WHO study and its results in the area of suicide. The third chapter describes the methodology of the WHO study. The data in this study were obtained by using the same standardized procedure as for sampling interviews. The WHO Composite International Diagnostic Interview (CIDI) was used to interview patients in 28 countries (the book’s data comes from 21 countries). Presenting the data from only some countries and the use of the CIDI are, in my mind, the main limiting factors of this study and of the data presented in this volume.

Section 2, “Prevalence and course of suicidal behavior,” includes 2 chapters. Chapter 4, “Prevalence, onset, and transitions among suicidal behaviors,” notes the wide ranges of prevalence of suicidal ideation (2.6% in Romania, 15.9% in New Zealand), suicidal plans (0.7% in Bulgaria, Romania, and Italy, and 6.2% in India), and suicide attempts (0.5% in Bulgaria and Italy, 5% in the United States). The authors also confirm that suicidal ideation rarely is reported before the early teen years and that in all countries, history of suicidal ideation is a key risk factor for future suicide plan. The results presented in chapter 5, “Persistence of suicidal behaviors over time,” show that persistence of suicidal behavior is complex. “A substantial proportion of suicidal behavior is short-lived, resolving within the year of onset and never recurring. But the remainder is often highly persistent” (p 85).

Seven chapters of the third section, “Lifetime risk factors for suicidal behavior,” present data on various risk factors for suicide, such as sociodemographic risk factors (chapter 6), parental psychopathology (chapter 7), childhood adversities (chapter 8), traumatic life events (chapter 9), mental disorders (chapter 10), and chronic physical conditions (chapter 11). The final chapter of this part, “Integrative models of suicidal behavior,” attempts to integrate all these risk factors into one model of suicidal behavior. The reader will find a lot of interesting information in this section. Some of it is well-known (eg, women are at a significantly increased risk for suicide ideation and attempts; those never married are at increased risk for suicide ideation and attempts), some information is less well-known (fewer years of education are associated with higher risk of suicide ideation and attempts). Interestingly, only parental generalized anxiety disorder (GAD) increases the chance of offspring developing a suicide plan, and only panic disorder, antisocial personality disorder, and GAD predict unplanned suicide attempt (p 110). It seems that the presence of mood disorders in parents is more likely to predict the onset of suicidal thoughts while anxiety and poor impulse-control behaviors, such as panic disorder, intermittent explosive disorder, and substance abuse disorders are stronger predictors of suicide attempts (p 110). The results of this large study also noted that a broad range of childhood adversities (bodily injury-related adversities, eg, sexual and physical abuse) are strong predictors of subsequent onset of suicide ideation and attempts. There also is a strong association between sexual and interpersonal violence and suicide ideation and attempt, with sexual violence also predicting the persistence of suicide ideation (p 143). What I found most interesting and clinically relevant with regard to a person’s psychiatric disorder was that “although depression is among the strongest risk factors for suicide ideation, it does not predict which people with suicide ideation go on to make a suicide plan and/or attempt. Instead, disorders characterized by anxiety and poor impulse-control (eg, bipolar disorder, alcohol use disorder, PTSD [posttraumatic stress disorder], panic disorder) predict this transition” (p 160). Another important finding is the fact that epilepsy was the physical condition most strongly associated with suicidal behavior (p 175).

Section 4, “Twelve-month risk factors and treatment,” includes 2 chapters: chapter 13, “Prevalence and identification of groups at risk for twelve-month suicidal behavior in the WHO World Mental Health Surveys” and chapter 14, “Treatment of suicidal behaviors around the world.” The results on treating suicide around the world are quite disappointing: only 39% of suicidal respondents received treatment in the past year, with consistently lower proportions having received treatment in low- (17%) and middle-income (28%) countries than in high-income (56%) countries. Low perceived need for care was the most common reason for not seeking help, followed by attitudinal and structural barriers; stigma or financial concerns were not major barriers (p 208). On another interesting note, up to 17% of respondents received treatment from complementary or alternative medicine (p 209)!

The final section, “Conclusion and future directions,” consists of chapters focused on “Research, clinical, and policy implications of the World Mental Health Survey findings on suicidal behavior,” and on “Conclusion and future directions.” These are chapters that are included in almost every volume of this kind and could be omitted in almost any volume. The Appendices include numerous tables summarizing the findings of this study.

This study and the book summarizing its results were supposed to bring us better understanding of suicidal behaviors and suicide. I am not sure they really do. The book definitely presents a vast amount of information. How much of it really is new and elucidating is the question. Maybe the fact that many of the issues apply across many countries is fairly new. Unfortunately, the book (and maybe the study) really does not pay much attention to cultural factors—an unfortunate fact in a study of this scope and nature. The 2 most important pieces of clinical information are the mentioned impacts of parental and patient psychopathology (depression vs poor impulse-control conditions) and the fact that persons with suicidal ideation or behaviors rarely get treated, especially in low- and middle-income countries. The book probably will be appreciated by policy makers and suicide researchers. The rest of us will wonder whether the book and the study were worth the money spent.