the literature between what is known about general risk factors versus knowledge of specific etiological pathways to suicide.

Several points should be noted that might explain the differing results in the efficacy literature. Linehan (1997) evaluated trials in her review based on the inclusion or exclusion of “high risk” patients (operationalized as needing immediate psychiatric treatment, at high risk of suicide or having characteristics known to increase suicide risk). Forty-five percent of the efficacy trials for treatment of suicidal behavior excluded high-risk individuals. (For comparison, this is fewer than the 88 percent exclusion for high-risk individuals in pharmacotherapy trials for depression [Beasley et al., 1991] but greater than one might think in studies on suicidal behavior.) Linehan then examined the 13 outpatient studies, of which six excluded high-risk individuals. None of the 6 studies excluding high-risk individuals showed beneficial effects, but six of the seven including high-risk did show significant effects. This effect may be one of power (i.e., the frequency of suicide attempts during follow-up is likely to be greater in high-risk individuals, thus creating a larger possible effect size), which suggests the need for larger trials. This also highlights, however, that high-risk individuals are able to benefit from outpatient interventions and, therefore, exclusion from such treatments is unwarranted (see Chapter 10 for further discussion of research issues).

INPATIENT AND FOLLOW-UP CARE FOR SUICIDALITY

Inpatient Care

Although suicidality is the most common precipitant for psychiatric inpatient admission (Friedman, 1989), no randomized clinical trials have been done to determine whether hospitalizing high-risk suicide attempters saves lives (AACAP, 2001). Between 60 and 75 percent of child, adolescent, and adult patients and 40 to 55 percent of geriatric patients are admitted to inpatient units with concerns of self-harm (Jacobson, 1999). Hospitalization may be voluntary or involuntary. Involuntary hospitalization is legally permitted when an individual meets criteria for mental illness and dangerousness to self or others, per each jurisdictions’ laws.

Involuntary hospitalization is correlated with many of the common risk factors for suicide, including serious suicide attempts and completed suicide on the unit, a diagnosis of schizophrenia; history of prior attempts of high lethality; and history of living alone or living in a household without younger children (Roy and Draper, 1995).

The immediate priority upon hospitalization is to reduce the suicidal thoughts, anxiety, and other symptoms associated with the suicide attempt. Various pharmacological approaches are generally used. Patients



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