nificant proportions (20–49 percent) of maltreated children do not display suicidal symptoms or why the majority of individuals affected with mental illness do not complete suicide. We also need to understand the large numbers of people who commit suicide in the absence of pathology, how suicide varies with social and cultural forces, and how it relates to individual, group, and contextual experiences.

Without a combination of a population-based approach and studies at the level of the individual patient within higher risk sub-groups, macrosocial trends cannot be related to biomedical measures. Most existing studies are retrospective or cross-sectional, involve few correlates, and do not address prediction of risk. Without specific data from well-defined and characterized populations whose community-level social descriptives are well known, normative behavior and abnormality cannot be estimated.

TREATMENT

Suicidality can be treated. There is evidence that lithium treatment of bipolar disorder significantly reduces suicide rates. In fact, lithium may have specific anti-suicidal effects for people with this disorder since these effects may be separate from its antidepressant and antimanic effects. Rates are reduced only while the patients take lithium; after discontinuation of lithium, the rates begin to rise to levels similar to those seen prior to lithium treatment. Despite the encouraging evidence, the protective effects of lithium are not consistent across studies. Other psychiatric medications, including anti-psychotic (especially clozapine) and antidepressants, also show promise for the reduction of suicide. A correlation has been observed between an increase in prescription rates for antidepressants, in particular the serotonin re-uptake inhibitors (SSRIs), and a decline in suicide rates in a number of countries. However, randomized clinical trials with antidepressants have failed to reveal significant differences versus placebo, perhaps due to methodological limitations.

Medications alone are not sufficient for treating mental disorders or suicidality, nor are treatments equally effective across individuals and diagnoses. Psychotherapy provides a necessary therapeutic relationship that reduces the risk of suicide. Cognitive-behavioral approaches that include problem-solving training seem to reduce suicidal ideation and attempts more effectively than treatment as usual or nondirective therapy.

Patients are at much greater risk of suicide in the weeks immediately following discharge from the hospital. Discharged patients who committed suicide were 3.7 times more likely to have had their outpatient care reduced at their last session. On the other hand, patients who continued



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