From the Editor
January, 2019. These days it’s hard to get through an issue of the New York Times or the Wall Street Journal or your own local newspaper without finding a report about suicide—a death by suicide of someone well-known; survey data citing alarmingly high suicide rates among young people; and among the elderly; and among those in mid-life; and in the military; and, especially, in Veterans. November 11, 2018, was Veterans Day, an important recognition of the debt of gratitude we owe to our Veterans. As a Vietnam-era air force veteran myself, I have some appreciation of the special needs of this population. Among my responsibilities as a hospital-based active duty psychiatrist was the psychiatric evaluation of a group of former pilots who had been liberated after about 7 years in solitary confinement. What struck me at the time was the amazing strength and resilience of these guys who pretty much held it together in ways hard to imagine. What I did not appreciate adequately at the time was how difficult it would be for them after they returned home. Some did remarkably well—like the 100-year-old veteran pilot whose photo was in the paper on Veterans Day and who served in World War II, the Korean War, and Vietnam, having flown 29 combat missions. But others who appeared at first to be equally resilient did not fare so well. Severe posttraumatic stress disorder, major depressive disorder, substance use disorders, and suicide have become increasingly recognized as some of the fallout from the prolonged stress of war. The most recent Veterans Affairs (VA) National Suicide Data Report, released by the U.S. Department of VA in September, 2018, recorded >6000 Veteran suicides each year from 2008 to 2016, and Veteran suicide rates increased 25.9% during this period. The Report states that the “VA has developed the National Strategy for Preventing Veteran Suicide, which provides a framework for identifying priorities, organizing efforts, and contributing to a national focus on Veteran suicide prevention,” a welcome strategy highly prioritized by the VA.
Strategies to accomplish these goals are badly needed as well for the general population. In the pages of this Journal, we have pretty regularly published informative and useful data, guidelines, and case studies addressing the problem of suicide. In this issue of the Journal, Kocabas and colleagues report that, in a sample of 200 patients with bipolar disorder, the co-occurring presence of lifetime social anxiety disorder was associated with lifetime suicide attempts independent of previous depressive episodes—a valuable signal alerting us to look for this comorbidity in our patients, since it might represent a heightened risk for suicide. Also in this issue, in the Psychotherapy column, Plakun presents the second column of his 2-part series on psychotherapy with suicidal patients—introducing an extremely practical and usable “Alliance based intervention for suicide.” And in the Law and Psychiatry column, Borges and colleagues focus on therapeutic risk management, describing the use of a “chain analysis of suicidal ideation and behavior”—another clinically valuable strategy to inoculate and equip us in our clinical work to reach a comfort zone that will enable us to face the reality of suicide in our risk-prone patients, and to partner with our patients to deal with it directly.
JOHN M. OLDHAM, MD