From the Editor The Problem of Suicide, Continued September, 2014. In my editorial in the July, 2013 issue of the Journal, I wrote about “The Complex Problem of Suicide,” describing a decision by the National Quality Forum to endorse a Performance Measure developed by the American Medical Association to establish as a standard the evaluation of a patient with first onset major depressive disorder for suicide risk. In that issue of the Journal, in the Law and Psychiatry column, Wortzel and colleagues introduced a model for therapeutic risk management of the suicidal patient, the first of a series of columns on this critical topic. Quite recently, on September 5, 2014, the World Health Organization issued a first-ever global report on suicide (http://www.who.int/mental_health/suicide-prevention/exe_summary_english.pdf?ua=1). In its introduction, the report states: “Social, psychological, cultural and other factors can interact to lead a person to suicidal behavior, but the stigma attached to mental disorders and suicide means that many people feel unable to seek help. Despite the evidence that many deaths are preventable, suicide is too often a low priority for governments and policy-makers. The objective of this report is to prioritize suicide prevention on the global public health and public policy agendas and to raise awareness of suicide as a public health issue.” Bravo! The need is indisputable, and the magnitude of the problem is staggering. The WHO report estimates that over 800,000 people die from suicide annually, and that it is the second leading cause of death for 15–29 year olds. And that for every person who dies by suicide, there may have been more than 20 others who attempted suicide. The report estimates that, worldwide, a suicide occurs once every 40 seconds. The world wakes up with alarm when someone who is well known dies by suicide, such as the recent tragic suicide of Robin Williams. In a blog that I wrote for the “Say No To Stigma” page of the Menninger Clinic website, I pointed out that “however much we know about the prevalence of depression and of suicide itself, we are still shocked when someone who feels so familiar chooses this way to disappear.” Media coverage usually focuses on the public, celebrity persona, but the internal landscape of thoughts and feelings is often tucked away in the shadows until it erupts with the intensity of a crisis. In my blog, I added: “I would go so far as to say that no one is 100% immune to the powerful, magnetic idea of suicide. When misfortune and stress become overwhelming and we feel like we’re boxed into a corner of hopelessness, it may seem to be the only way out.” The WHO report is entitled “Preventing suicide: A global imperative.” And prevention must be our crusade—an imperative for all of us. Every 40 seconds, somewhere, prevention must prevail, but that can only happen if we are on the alert, reaching out, and not reluctant to ask the right questions. In this issue of the Journal, Yen and colleagues report on adolescents who had been psychiatrically hospitalized for suicide risk, to evaluate their patterns of treatment utilization after discharge. Although treatment engagement was high, suicide risk remained substantial, suggesting that intensification or modification of outpatient treatment might be indicated. Also in this issue, Jayaram chronicles a 30-year process of establishing a culture of safety within inpatient care at Johns Hopkins, by utilization of a set of prevention strategies. Finally, in this issue’s Law and Psychiatry column, Silverman describes the essentials of suicide risk assessment and suicide risk formulation, a wrap-up overview of the model of therapeutic risk management of the suicidal patient developed at the Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education and Clinical Center and described by Wortzel and colleagues in Law and Psychiatry columns in four previous issues of the Journal.

John Oldham, MD Editor DOI: 10.1097/01.pra.0000454776.44680.52

Journal of Psychiatric Practice Vol. 20, No. 5

September 2014

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