Understanding Suicidal Behaviour: The Suicidal Process Approach to Research, Treatment, and Prevention

Alan Apter and Hadas Ofek

There has been considerable progress in the identification of psychiatric risk factors for suicidal behaviour. Up to 90 per cent of suicides and suicide attempts are associated with an Axis-I disorder, which is most commonly a depression, but often complicated by co-morbid conditions (Brent et al, 1987; Brent et al, 1990; Apter et al, 1991; Brent et al, 1993a; Brent et al, 1993b; Brent et al, 1993c). However, these diagnostic categories have low specificity in the prediction of suicidal behaviour, and do not shed light on its aetiology.

Since the majority of patients with a psychiatric disorder do not commit or even attempt suicide (Brent et al, 1993d), psychiatric disorder may well be a necessary but not a sufficient condition for suicide. Therefore, one of the most pressing clinical research questions in the area of suicide is to determine which factors beyond psychiatric disorder predispose to suicide.

There are many different ways to conceptualize such factors. For instance, as discussed in Chapter 11, there is substantial evidence showing that the course of the suicidal process is influenced by sociological factors, and that many of the risk factors are social in nature. Thus unemployment, poverty, availability of guns and even “national character” are important risk factors for suicidal behaviour. In addition,

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