696354
research-article2017
ANP0010.1177/0004867417696354ANZJP CorrespondenceANZJP Correspondence
Commentaries
Commentaries
Commentary on: The
Journal’s concerns about
suicide
Robert D Goldney
Discipline of Psychiatry, School of Medicine,
The University of Adelaide, Adelaide, SA,
Australia
Corresponding author:
Robert D Goldney, Discipline of Psychiatry,
School of Medicine, The University of
Adelaide, Adelaide, SA 5005, Australia.
Email: robert.goldney@adelaide.edu.au
DOI: 10.1177/0004867417696354
‘The Journal’s concerns about suicide’
is a thoughtful essay by Snowdon
(2017) who has addressed the ongo-
ing concern and, one might add, fasci-
nation with suicide. The latter words
are included, as a recent book by
Beattie and Devitt (2015) explored
persuasively what they described as a
‘modern obsession’ with suicide.
Suicide lends itself to such specula-
tions, as so many papers commence
with statements such as ‘suicide is a
multifactorial issue’. While that is tech-
nically correct, the sometimes assumed
corollary is that all such issues are of
equal importance … every player wins
a prize and every opinion carries the
same weight, a populist approach in
keeping with a postmodern or even a
post-truth approach.
But psychiatry has a more solid
foundation. For example, the Population
Attributable Risk statistic has given us
the relative risks of suicide in different
populations, and there have been
advances in establishing the biological
substrate of suicide (Goldney, 2013).
Snowdon refers to longer term
changes in the patterns of suicide, which
he has explored elsewhere, but his
addition of a comparison between 2013
and 2015 is perhaps unwise because of
it’s short time-frame. He also notes the
increase in female suicide in China, and
he endorses the usual view that Chinese
decedents have less definable mental ill-
ness. However, probably still the most
rigorous exploration of the latter point,
utilising a standardised assessment
instrument, demonstrated no such dif-
ference between Chinese and Western
suicides or between three different
Chinese ethnic groups.Therefore, while
socio-cultural factors may be more
important in understanding the pre-
ponderance of female suicide in China,
mental illness issues should not be
ignored (Goldney, 2013).
The continued debate about the
importance of mental disorders in sui-
cide was also alluded to. Indeed, it has
persisted for over 200 years, with
Moore in 1790 noting that ‘there is a
sort of madness in “every” act of suicide,
even when all idea of lunacy is excluded....
such distinctions of sanity and insanity
are too fine spin to be just or equitable’
(Goldney, 2013).
Of course psycho-social stressors
are involved, more so in different
countries and between socio-eco-
nomic groups within a country. But
why do some persons succumb to
such stressors? After all, stress is ubiq-
uitous. The emerging field of epigenet-
ics is shedding some light on the
gene-environment interaction in this
regard. It is also germane to emphasise
that the previously referred to
Population Attributable Risk studies
have placed the role of such stressors
in perspective, with the primacy of
Australian & New Zealand Journal of Psychiatry, 51(8)
Australian & New Zealand Journal of Psychiatry
2017, Vol. 51(8) 841­–843
https://doi.org/10.1177/0004867417696354
© The Royal Australian and
New Zealand College of Psychiatrists 2017
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mental disorders in societies similar to
Australia being evident. Furthermore,
an innovative study from Canada, a
country similar to Australia and New
Zealand, reported in an examination of
those who had died by suicide that
those who did not have sufficient
symptoms to warrant a formal psychi-
atric diagnosis were more similar to
the diagnosed suicide group than to a
living group (Ernst et al., 2004).
Snowdon argues that we have
‘much to learn from others’, but, at
the risk of being considered xenopho-
bic, our society’s contributing factors
may be significantly different to those
of other countries. As suggested else-
where, suicide research can be broadly
categorised as ‘useful’ or ‘interesting’
(Goldney, 2014), and some informa-
tion from other countries, as well as
some from our own, may well fall in
the second category.
He also argues that ‘The Journal has
a responsibility to provoke such discus-
sions’, and that is certainly part of the
scientific process, particularly with the
inevitable differing interpretation of
data. However, the further suggestion
that it ‘can and should contribute to pro-
test and advocacy’ is potentially conten-
tious. Is the Journal primarily a vehicle
for scientific reporting? It would be
regrettable if we jeopardised our sci-
entific credibility by protesting and
advocating in advance of the science.
There is much food for thought in
Snowdon’s timely contribution.
Declaration of Conflicting
Interests
The author(s) declared no potential con-
flicts of interest with respect to the
research, authorship and/or publication of
this article.
842 ANZJP Correspondence
See Debate by Snowdon 51: 210–211.
Funding
The author(s) received no financial sup-
port for the research, authorship and/or
publication of this article.
Commentary on Snowdon:
‘The Journal’s concerns
about suicide’
Philip J Batterham
Centre for Mental Health Research (CMHR),
Research School of Population Health,
The Australian National University (ANU),
Canberra, ACT, Australia
Corresponding author:
Philip J Batterham, Centre for Mental Health
Research (CMHR), Research School of
Population Health, The Australian National
University (ANU), Building 63, Eggleston Road,
Canberra, ACT 2601, Australia.
Email: philip.batterham@anu.edu.au
DOI: 10.1177/0004867417694750
Suicide deaths, along with suicidal
thoughts and behaviours, place an
extensive burden on individuals, with
broader impact across the community.
Suicide deaths account for a dispro-
portionate number of deaths in young
adulthood, although suicide remains a
leading cause of death across the lifes-
pan. The article by Snowdon (2017)
draws together key threads of suicide
prevention research in Australia, not-
ing the particular role that Australian
and New Zealand Journal of Psychiatry
(ANZJP) has played as a flagship journal
for research in this field. In recent
years, ANZJP has published extensive
research on suicidal thoughts and
behaviours in Australia. Snowdon
notes the important role that mental
illness often plays in the development
of suicidal thoughts and behaviours.
However, he appropriately acknowl-
edges that suicide typically emerges
from a constellation of risk and pro-
tective factors including culture, avail-
ability of means, substance use,
Australian & New Zealand Journal of Psychiatry, 51(8)
References
Beattie D and Devitt P (2015) Suicide:
A Modern Obsession. Dublin: Liberties
Press.
Ernst C, Lalovic A, Lesage A, et al (2004) Suicide
and no axis I psychopathology. BMC Psychiatry
30: 4–7.
interpersonal processes, employment
and negative emotions or psychologi-
cal states. Although suicide prevention
research is often embedded in the
mental health domain, Snowdon
(2017) hints at a possible tension
regarding the fit of suicide prevention
research within the psychiatric litera-
ture, which sometimes has a focus lim-
ited to psychiatric states, rather than
on behaviours that arise from both
psychiatric states and biopsychosocial
context.
There are a number of areas where
suicide prevention research needs to
progress, including the need to inno-
vative in epidemiological research, to
better implement interventions for
suicidal individuals and to conduct
more research in high-risk popula-
tions. Most suicide prevention publi-
cations in ANZJP have focused on the
epidemiology of suicidal thoughts or
behaviours. Developing greater
understanding of why people die by
suicide is a crucial research endeav-
our. However, in the past 50 years,
the field has identified very few new
factors that robustly predict suicidal
ideation or attempts, and our ability
to predict suicide risk has not
improved (Franklin et  al., 2016).
Research has typically examined the
roles of a select few risk factors on
long-term suicide outcomes (Franklin
et  al., 2016). Suicide prevention
research may benefit from innova-
tions such as detecting complex inter-
actions between factors, developing
intra-individual prediction approaches
and improving short-term prediction
in high-risk populations.
Moreover, a stronger emphasis on
intervention and clinical research is also
needed. If we are to address the increas-
ing suicide rate in Australia, rigorous
Goldney RD (2013) Suicide Prevention, 5th Edition.
Oxford: Oxford University Press.
Goldney RD (2014) Suicide research: Interesting
and/or clinically useful? Australasian Psychiatry
22: 109–111.
Snowdon J (2017) The Journal’s concerns about
suicide. Australian and New Zealand Journal of
Psychiatry 51: 210–211.
evaluation of innovative approaches to
prevention and treatment is required.
Drawing on technology, big data, novel
methodologies and novel treatments to
prevent suicide are emerging areas
where we may see progress over the
next few years. However, we also need
to better implement strategies that are
supported by the existing evidence, but
which essentially are not put into place.
Without translational research that
identifies pathways for improving the
uptake of evidence-based strategies for
suicide prevention in the community,
we may have little impact on the suicide
rate. The Lifespan project is both a trial
and an implementation project, which
aims to introduce or reinforce nine
evidence-based strategies for suicide
prevention (Krysinska et al., 2016), and
if successful is likely to provide a model
for better implementation of evidence-
based suicide prevention programmes
across Australia.
There are also a number of popula-
tions and settings that may be under-
researched in the suicide prevention
field in Australia. In particular, there is
need for greater research with people
of diverse backgrounds on the basis of
culture, Aboriginality, sexual orienta-
tion or socioeconomic disadvantage,
all of whom have elevated risk of sui-
cidal behaviour. Such research needs
to be informed by the people who are
most at risk, incorporating their rich
understanding of their experience,
and draw on bottom-up solutions.
While there have been notable publi-
cations on suicidal behaviour within
these populations, there remain gaps
in our understanding of the sources of
disparity in the suicide rate and what
can be done about it. Suicidal behav-
iour often occurs outside the context
of the clinical setting, so an expansion