Social and familial risk factors in suicidal behavior.

The focus of this article is on the presence or absence of external and constraining social facts, as reflected in indicators like divorce rate, marital status, the number of close friends, loss of crucial significant others, or sometimes having no one who cares if the person lives or dies, feelings of shame or intolerable guilt, the belief of sacrificing one's life for a higher cause or another person, and military suicide. This article reviews the history of the sociology of suicide, social isolation, contagion, imitation, suicide clusters, stress, and negative life events.

Social suicide.

At first blush suicide seems like the ultimate private action. However, it is argued that social forces and social pathologies figure prominently in the dynamics of suicide interacting with more individual characteristics. Several examples of "social suicide" (intentional cotemporaneous self-murder of two or more persons) are considered, including mass suicide, organizational self-destruction, social analogues to individual suicide, and military suicide. Suicide prevention requires social, economic, and cultural transformations at the primary prevention level, not just individual psychotherapy and dispensing of the latest antidepressants.

Beyond the Tower of Babel: a nomenclature for suicidology.

Suicidology finds itself confused and stagnated for lack of a standard nomenclature. This paper proposes a nomenclature for suicide-related behavior in the hope of improving the clarity and precision of communications, advancing suicidological research and knowledge, and improving the efficacy of clinical interventions.

The prevention of suicidal behaviors: an overview.

The authors discuss the development of the concept of prevention as it has evolved from the public health and mental health fields. Concepts of epidemiology, treatment, and community mental health are defined in terms of their contributions to the evolution of prevention thinking. Four models of prevention are presented and critiqued: the public health model, the operational model, the antecedent conditions model, and the injury control model. Essential ingredients for implementing effective preventive interventions are presented, as well as examples of practical preventive interventions.

Suicide prevention in adults (age 30-65).

Relatively little is known about midlife suicides, compared to adolescent and elderly suicides. A life-span model of suicidal behaviors is suggested as a heuristic conceptual tool. General midlife tasks and crises, as outlined by Levinson and Erikson, are reviewed. However, more than routine midlife developmental problems occur in most suicides. Some of the possible distinctive traits of midlife suicides (versus younger and older suicides) include: loss of spouse, years of heavy drinking, reaching the age of high depression risk, and occupational problems (including unemployment, inability to work, and retirement). Midlife suicide rates tend to be highest among white males, although female suicide rates peak in midlife. The paper concludes with a review of assessment and treatment issues related to a half-dozen high-risk midlife suicide types.

Inpatient standards of care and the suicidal patient. Part II: An integration with clinical risk management.

The authors elaborate on the standards of care for the assessment, management, and treatment of hospitalized suicidal patients. The authors attempt to synthesize the concepts of the minimal standard of care with clinical risk management and clinical judgment. They point out the areas of overlap and where optimum care diverges from legal standards of care. Case examples are provided to illustrate major areas of concern. Alleged failures of omission and commission are discussed. Tables are provided that differentiate duties and responsibilities between and among clinicians, hospital staff, and hospital administration.

Inpatient standards of care and the suicidal patient. Part I: General clinical formulations and legal considerations.

The most common legal action involving psychiatric care is the failure to reasonably protect patients from harming themselves. In this regard it is critical to understand that courts have tended to impose much stricter standards on inpatient than on outpatient care; that at the present time, most malpractice actions involve clinical activities related to inpatient care (negligent admission, treatment, supervision, discharge, etc.). This article reviews the current climate in the legal and clinical formulation of standards of care for hospitalized adult suicidal patients. It suggests general guidelines for effective assessment, management, and treatment procedures that balance the need for high-quality care by a reasonable and prudent practitioner with the requirements of court-determined and statutory standards. The authors specifically discuss court cases that show common failure situations in inpatient care, discharge planning, and follow-up (e.g., problems in pharmacotherapy, the decision to hospitalize, the assessment of imminence and lethality, etc.). The paper also emphasizes the crucial element of clinical judgment in developing any inpatient standard of care.

Outpatient standards of care and the suicidal patient.

This article is a review of the legal and clinical literature on standards of care for nonhospitalized adult suicidal patients. The authors discuss effective assessment, management and treatment procedures that balance the need for high-quality care by a reasonable and prudent practitioner with the requirements of court-determined and statutory standards. Through a review of malpractice claims data and through an examination of the clinical literature we detail the essential guidelines for sound assessment, intervention, and management procedures. The authors specifically discuss common failure situations in outpatient care (e.g., problems in pharmacotherapy, the decision to hospitalize, inappropriate and dual relationships, the assessment of imminence and lethality, and so on). Details regarding practical considerations in developing an outpatient standard of care are provided, as are suggestions that such a standard of care must include an ongoing assessment of the therapeutic alliance.

Exchange, balance, and formal organization in psychotherapeutic interactions.

Psychotherapeutic interactions in crisis situations are analyzed in terms of the "sociodynamic" concepts of exchange, balance, and formal organization. It is argued that psychodynamic interpretations of crisis intervention therapy tend to be incomplete and nonsystematic and, thus, fail to produce adequate predictions, explanations, and control of psychotherapeutic outcomes. Small-group principles and methods are applied to selected crisis cases to illustrate gains in prediction and control over psychiatric approaches.

Medicine and the behavioral sciences: the Johns Hopkins M. D. - Ph. D. program.

The behavioral sciences have much to offer medical research and practice, and they are likely to play an increasingly important role in medical education. The need for researchers and teachers trained in both medicine and behavioral sciences has been addressed at Johns Hopkins by the establishment of a joint degree program. Concurrent, as opposed to consecutive, training in both fields shortens the duration of study and fosters interdisciplinary research early in the trainee's career.