Can Psychiatry Prevent Suicide? Not Yet!

Let me begin by saying that I believe psychiatrists can and should play a significant role in the prevention of suicide in Canada. Whether this is currently the case is another question. Dr Lesage has advanced the “pro” opinion on this matter. It is my aim to examine these arguments in terms of scope, accuracy, and future planning. The “pro” part of this debate suggests that psychiatrists can prevent suicide in 3 ways: first, by adopting a shared care model that allows greater collaboration and thus better support for treatment of mental disorders (particularly depression) by general practitioners (GPs); second, by optimizing treatment of depression via the application of clinical management procedures as outlined by the Canadian Psychiatric Association; and third, by collaborating with addiction services, because alcohol and drugs are heavily involved in cases of completed suicide. Scope The merits of these points notwithstanding, they encompass an approach that falls far short of what might be considered comprehensive in regard to suicide prevention. In the first place, all the focus is on treatment of individuals who are actively suicidal and (or) suffer from mental illness. This approach has no room for early detection and intervention, no focus on healthy child development, and no emphasis on community development or ecologic interventions. To be fair, perhaps this is outside the purview of the In Debate section, since the topic refers to what psychiatrists can do, rather than to a comprehensive suicide prevention plan. Second, the focus seems to be on depression, but the evidence shows that virtually all mental disorders are associated with suicidal behaviour (for example, 1). In fact, schizophrenia and bipolar disorder show an equal or higher level of association with suicidal behaviour than does major depression (2,3). Third, it is important to consider suicide–substance abuse comorbidity, but suicide is related to any number of other social problems and conditions, including interpersonal violence, relationship difficulties, unintentional injuries, and being left out of the mainstream (4,5). This suggests that something causal underlies all these conditions, perhaps something social in nature. Finally, although it is reasonable, from the point of view of this journal’s readers, to conceive of a scheme with the medical profession at its centre, not everyone else sees it that way. Other professionals compete with psychiatry and general practice medicine to deliver treatment services—not as team members, but as primary care clinicians. It does not seem sensible either to ignore this or to compete. It should be noted, however, that the primacy of any mental health treatment specialist declines when we consider interventions at the societal level and when we engage in primary prevention with presuicidal children and youth.

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