Reply to the Multifaceted Aspects of Suicide Behavior by Tondo
Authors: Jose de Leon, Enrique Baca-Garcia, Hilario Blasco-Fontecilla
Journal: Psychotherapy and Psychosomatics (2016)

We have always admired Dr. Tondo's bipolar research and particularly his article on the antisuicidal properties of lithium [1]. Now we are grateful for this opportunity to further clarify the extremely complex statistical and philosophical ideas about psychiatric nosology packed into an editorial with a limited word count. Dr. Tondo may have misunderstood the goal of the editorial, which did not try to deny the relevance of biological factors to suicide in bipolar disorder or severe major depression. The editorial only raises doubts about the relevance of biological factors in many cases of completed suicide which do not appear to have been associated with severe mental illness.The lack of space prevents addressing all 8 issues. Regarding [a], we do not think the serotonin hypothesis can apply to all suicidal behaviors and may be a particularly poor predictor in those behaviors not associated with severe mental illness (personality disorders and/or addiction). Next, [b], we disagree that the clinical hierarchy and continuity of three steps in suicide is always true. It is very clear that in the case of a substantial number of completed suicides, the individuals had never before attempted suicide [2]. Furthermore, the editorial questioned their continuity as mathematical objects for statistical prevention models. Scientific models are supposed to predict. Unfortunately, most sophisticated statisticians [3,4] have realized that some things can be predicted but others cannot, either because they are too complex (e.g. weather more than one week in advance) or too rare, so-called 'black swans' (e.g. strong earthquakes). The editorial questioned the ability of suicidal ideation to predict suicide attempt and the ability of suicide attempt to predict completed suicide. There are too many false positives; most individuals with suicidal ideation do not attempt suicide [5] and those who do attempt it are statistical outliers, presenting a problem for predictive models. With more room available, we would try to explain, hopefully intelligibly for clinicians, that completed suicides may be 'black swans' [4]. Regarding [c], Dr. Tondo quoted a study about the importance of depression in suicide committed by sufferers of bipolar disorder [6]. We agree 100%, but that particular study does not deny the meta-analyses of psychological autopsies that suggest that many patients do not have depression as a clinical entity [7]. Dr. Tondo commented [d]: 'Psychosocial factors are major contributors to the risk of suicide and are considered precipitants rather than causal'. However, we did not describe life events as causal; we explained that they were more strongly associated with suicide attempts and were better predictors than biological measures in the large cohort of suicide attempters with all kinds of psychiatric diagnoses that we have collected in the last 20 years [8]. Regarding his comment on non-Western countries [e], the editorial stated that the limited epidemiological studies suggest that nonpsychiatric issues may be more important in less developed countries [9]. Regarding [g], Dr. Tondo immediately associates Jaspers with 'descriptive psychopathology', which the editorial did not mention; rather, it stated that Jaspers encouraged psychiatrists to think. A quoted reference [10] provided a more extensive elaboration of the importance of reading about Jaspers's psychiatric nosological groups.The authors thank Lorraine Maw, MA, for her editorial assistance.This letter to the editor received no support from any funding agency, commercial business or not-for-profit institution. In the past 3 years, Dr. Hilario Blasco-Fontecilla has received lecture fees from Eli Lilly, AB-Biotics, Janssen and Shire. The remaining authors declare no commercial conflicts of interest in the past 3 years.