cost, and fragmentation of services. Additional patient barriers to care are fear of being hospitalized and thinking that they can handle their problems without formal treatment (Kessler, 2000; Sussman et al., 1987). If patients succeed in overcoming these general barriers to treatment, there are additional barriers confronting them within treatment itself.

Medication adherence is one key barrier. The term “adherence” is defined as the extent to which an individual’s use of medication adheres to medical advice. About 24–28 percent of suicide victims are non-adherent with medication treatment in the month before death (Appleby et al., 1999). More generally, about one-third of patients with mood disorders or psychosis (regardless of whether they are suicidal) are non-adherent (Cramer and Rosenheck, 1998), thereby placing them at risk for suicide. The reasons for non-adherence are complex. Certainly the barriers operating against reaching care—cost, fragmentation of services, and stigma— also apply for patients who are receiving care. Patients may be non-adherent to avoid the stigma attached to having a mental disorder, considering that most psychiatric medications need to be taken on a chronic basis (Kihlstrom, 1998). Medication side effects represent another major reason for less than optimal adherence (Fenton et al., 1997). Other reasons for patient non-adherence include: impaired cognition from the underlying disorder or co-occurring substance use; lack of social support; attitudes against medication or treatment; and dissatisfaction with treatment or poor therapeutic alliance, including lack of information from clinicians about dose and side effects (Fawcett, 1995; Fenton et al., 1997; Schou, 1997).

Another major barrier operating in the treatment setting is that the vast majority of patients who are suicidal often do not spontaneously report their suicidal intent to their clinician. A study, cited earlier, found that only 22 percent of suicide victims communicate their intent to their clinicians (Isometsa et al., 1995). The reasons for patient underreporting of suicidal intent are complex and difficult to discern upon psychological autopsy. The most commonly asserted reasons are the hopelessness of suicidality or the underlying symptoms of mental illness. Patients perceive their condition as hopeless and their clinician as unhelpful or unable to meet their needs for counseling, medication, and information (Hintikka et al., 1998; Michel, 2000; Pirkis et al., 2001). Fifty percent of adults who previously attempted suicide retrospectively reported that they could not have accepted help at the time of their attempt (Michel et al., 1994). Their cognition, judgment, or memory may be impaired, thus undermining their ability to appreciate the therapeutic value of treatment (Fawcett, 1995)



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