Suicide is a complex behaviour in which mental disorder usually plays a central role

Australian & New Zealand Journal of Psychiatry, 49(1) Pridmore, in his Viewpoint in this issue, asserts that experts in the field of suicidology and public health place undue emphasis on the role of mental disorder in the causation of suicide and that this leads to the majority of suicide prevention funding being spent on measures to improve the detection and treatment of mental disorder (Pridmore, 2015). But is this really so? Insel states that ‘the presence of mental illness is a risk factor, but it is not universally present or identified in those who attempt suicide’ (Insel, 2014), a view with which others concur. Regarding funding for suicide prevention, consider the example of the UK where, although some suicide prevention funds have been directed towards reducing risk of suicide in certain high-risk groups, including patients with psychiatric disorders, and improving the detection and treatment of mental disorder in primary care, there has also been investment in other key areas; for example, in reducing access to lethal means, reducing inequalities in certain disadvantaged groups and increasing the availability of psychological therapies. Systematic reviews have indeed demonstrated that the majority of people who die by suicide or engage in non-fatal self-harm have a mental disorder. The findings of studies examining the prevalence of psychiatric disorders in people dying by suicide in the non-Western world have varied widely, sometimes being lower than those conducted in the West and sometimes being comparable. Interestingly, in a meta-analysis of studies from around the world of self-harm patients presenting to general hospitals, the reported prevalence of psychiatric disorders in nonWestern countries was slightly lower than in the West but still high (71% vs 90%; Hawton et al., 2013b). Regarding the risk of suicide in specific psychiatric disorders, in a recent meta-review of meta-analyses of suicide risk in mental disorders, particularly high rates of suicide were found in borderline personality disorder, where the risk was estimated at 45 times that of the general population, depression (20-fold risk), bipolar disorder (17-fold risk), opioid use (14-fold risk) and schizophrenia (13-fold risk), as well as in anorexia nervosa (31-fold risk) and alcohol misuse or dependence in females (16-fold risk) (Chesney et al., 2014). It is therefore undeniable that there is a strong association between suicide and psychiatric disorders. So is it important to identify whether or not patients potentially at suicide risk, including those who have self-harmed, have an underlying psychiatric disorder? A primary aim of all mental health services is to alleviate suffering and enhance recovery. The UK government has adopted the slogan ‘No health without mental health’ for its strategy to improve well-being and services for people with mental health problems. Identification of specific psychiatric disorders in patients at risk should then lead to targeted evidence-based therapies aimed at preventing suicide and self-harm, as well as improving mental well-being. For example, there is evidence that a specific form of talking therapy, dialectical behavioural therapy, for people with borderline personality disorder may reduce the frequency of self-harm and the amount of hospitalisation for suicidal ideation when compared with non-behavioural psychotherapy delivered by expert therapists. Regarding the effectiveness of pharmacotherapy in suicide prevention, it was initially thought that clozapine exerted a specific anti-suicidal for people with schizophrenia but in a more recent and large-scale study several other second-generation antipsychotics were found to exert a similar effect in reducing suicides compared to controls (odds ratio (OR), 0.29; 95% confidence intervals (CIs), 0.09, 0.97) (Reutfors et al., 2013). The use of lithium to reduce suicide in bipolar disorder now has a reasonably strong evidence-base. However, the potential role of antidepressants in diminishing the risk of suicide and of self-harm in patients with depression is not established. There is evidence, especially in young people, that initiating these drugs may in a few cases precipitate suicidal ideation, although current thinking is that the reaction of regulatory agencies to this finding may have caused more harm than good. It is obvious that the majority of people with a psychiatric disorder do not engage in suicidal behaviour, so Suicide is a complex behaviour in which mental disorder usually plays a central role