There is but one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy.—Albert Camus, The Myth of Sisyphus

But in the end one needs more courage to live than to kill himself.—Albert Camus, A Happy Death

Suicide is the ultimate negative outcome in psychiatry, and the ultimate goal, as with every bad outcome, is to prevent it. The lack of predictability makes prevention of suicide a complex and complicated matter. However, it does not mean that suicide(s) cannot be prevented. As the authors of the small book Suicide Prevention, Drs. Moutier, Pisani, and Stahl, point out: “Research shows that suicide can be prevented. From a public health perspective, suicide is considered a generally preventable cause of death. That does not mean all suicides can be prevented, nor that suicide is a predictable event” (p. 7). This public health perspective is a very important point all clinicians should remember when talking about prediction of individual cases of suicide. Drs. Moutier, Pisani, and Stahl note that we need to look at prevention of suicide as we look at other preventable situations in medicine. “In the same way that death due to myocardial infarction is not a predictable event on the individual patient level or with a pinpoint on the timing or severity of an event, but cardiologists and primary care understand that aggressively addressing risk factors of cardiovascular disease can save lives. The same principles are true for suicide” (p. 7). This and many other points about suicide prevention made in this volume to be incorporated into clinical practice and teaching.

Suicide prevention is divided into three sections: suicide prevention overview, clinical risk assessment and care, and special topics: medicolegal considerations and specific populations. This outline illustrates that the book is not simply a guide to suicide prevention but that it moves from the macro level to the interpretation of the risks and their incorporation to management of specific patient situations.

The first section reviews four important areas: translating science about suicide into action, dispelling myths surrounding suicide, the public health model of suicide prevention, and understanding drivers of suicide risk. Suicide has clearly been a growing public health crisis in the USA lately, as rates of suicide had been on rise for two decades (recently by 1.5 to 3.7%), with the first decrease in 2019. Thus, the rate of suicide in the USA “increased by 35% and is at its highest level in 30 years” (p. 14). The chapter on dispelling myths about suicide presents in detail 11 myth-busting truths about suicide myths, such as the notion that people who take their lives are weak or cowardly; that suicide is a one-cause-effect phenomenon; that suicide risk is set in stone; that a history of attempt suicide indicates that the person is destined to die by suicide; or that suicidal “gestures” suggest that people are just being manipulative. The text emphasizes that “While suicide can be precipitated by a triggering event, suicide is not thought to be caused by one factor or event. Psychological autopsy method research clearly demonstrates that there are multiple risk factors that converge or escalate at a moment of acute risk. While we do not always recognize all of the risk factors clearly at the time, suicide risk usually builds over time with changes in health—brain and body cognition, sense of hope, social connection” (p. 20).

The discussion of the public health model of suicide prevention presents a lot of information. First, it notes that national suicide prevention plans that utilize universal education about mental health, suicide risk factors, and warning signs and resources for support, crisis level support, and mental health care, actually work, for example, in Scandinavian countries or in Australia. Second, it emphasizes the role of primary care in suicide prevention, as primary care providers can and should routinely screen for worsening of mental health problems; twice as many patients who die by suicide visit their primary care physicians versus a mental health professional; and changes in physical health, the overt targets of primary care, can signal suicide risk. This chapter also includes important tables of definitions (e.g., suicide, suicidal behavior, suicidal ideation), terms to use with caution related to clarity (e.g., self-injurious behavior), and terms to avoid (e.g., commit suicide, suicide gestures, failed attempt). These definitions are important to remember and include into our language and to discuss their impact when teaching about suicide.

The following chapter contains a very good discussion of suicide risk factors (biological, psychological, and social environmental), warning signs, protective factors, the risks and protective factors interplay, and perspectives of a suicidal person. The authors use a case example discussing these issues throughout the chapter. The reader can wonder what one does after reviewing all risks in an individual patient. While this topic is addressed more in the second section of the book, the authors provide some guidance already here: (1) Identify possible risks; (2) Develop a more sensitive radar for patients who are struggling silently; (3) Suicidal ideation indicates risk but on its own is not sufficient to assess risk, as it is neither sensitive nor specific enough to be the only factor in determining a patient’s current risk; (4) Gain a sense of the patient’s trajectory including protective factors; and (5) Consider other historical factors.

Section 2 focuses on collaborative connections; prevention-oriented suicide risk assessment; responding to suicide risk, extending the impact of interventions, use of medications in suicide prevention, and suicide prevention in health care systems. The chapter on prevention-oriented risk assessment stresses that “Assessment of suicide risk must go beyond just questions about suicidal thoughts and plans. The goal of an assessment is to understand suicide risk in the context of the whole person and their situation” and that “The purpose is not prediction, but planning. The goal of risk formulation is to promote communication, collaboration, and action among professionals, patients, and families in order to reduce risk” (p. 88). The authors emphasize that in considering clinical factors, one needs to realize that mental health history is not only about depressions that if the clinician does not ask about family history of suicide, the patient may not tell the clinician that trauma-informed care is critical to suicide prevention, and that clinicians should avoid demographic stereotypes and try to understand the individual experience. Important also is the explanation of the fact that risk status is risk compared to whom, and risk state is risk compared to when.

The chapter on responding to suicide risk is clinically useful, outlining the basic principles of response, listing interventions (e.g., cognitive-behavioral therapy, dialectical-behavior therapy, collaborative assessment and management of suicidality, motivational interviewing) and medications (e.g., lithium, clozapine, ketamine, antidepressants). This chapter also includes a very good table of tactics, strategies, and phrases from evidence-based therapies one can use anytime (what you do, what you say). The next chapter discusses the impact of interventions beyond health care environments into the lives and networks of people and their families. It is followed by a solid, more detailed discussion of mentioned medications used in suicide prevention (lithium is clearly underutilized in this indication).

The final section includes chapters on medicolegal risk management, the role of culture and societal factors, youth and adolescents, military and veterans, older adults, LGBTQ populations, and suicide loss survivors. The reader, especially if in training, would probably appreciate most the chapter on medicolegal issues. It is important to realize that “In general, psychiatrists account for the lowest risk for malpractice suits of any medical specialists …though, depending on the practice setting, suicide and suicide behavior do not necessarily account for the majority of psychiatric malpractice claims” (p. 190) (actually, only about 15% of malpractice cases involve suicides or attempts). A useful part of this chapter is a table outlining steps to take following patient suicide. The remaining chapters of this section provide a solid coverage of specific topics. I liked, among others, the 4 Ds of suicide risk in older age: Depression, Disease/Disability, Disconnectedness, and Deadly means.

The book also includes an Appendix—Resource list (crisis support available 24/7, suicide prevention resources for patients and families, suicide loss support, mental health resources for patients and families, suicide screening, assessment, and clinical guidelines).

There is a lot to like about this small book. It is comprehensive, yet succinct. It is clinically very useful, putting almost all the clinician needs to know about suicide in a small, easy to read (except of small print) volume. There are many graphs and tables that one can convert to slides when teaching suicide prevention and management. The book could serve as a great template for a course on suicide in residency training programs. Is there anything to dislike? Well, the promotion of other books in the text is a feature that I did not particularly appreciate. However, that is a minor issue. I would definitely recommend the book to all training programs that teach on suicide (hopefully that means all programs) and all trainees.