Summary And Conclusions

There is a strong link between depression and suicidal behaviour, but there is also high divergence, as shown especially by the fact that the vast majority of depressed people do not commit or attempt suicide. The presence or absence of other factors might help explain this divergence. Factors such as other psychiatric diagnoses, especially personality disorder; protective factors; and other psychological factors, such as personality and affective traits, and problem-solving skills, have all been shown to distinguish suicidal from non-suicidal depressed individuals. The relationship between depression and suicidality is mainly dependent on one particular facet of depression—hopelessness about the future. Hopelessness appears to consist mainly of a lack of positive thoughts about the future rather than preoccupation with a negative future. Risk assessment and intervention in suicidal behaviour are difficult because of the relatively low base rate of suicidal behaviour and the heterogeneity of those who engage in it. Predictive models, whether using depressive hopelessness or a range of factors, are able to identify those at risk only through incorrectly classifing unac-ceptably high numbers of people as at risk. Because of predictive inaccuracy, the emphasis has shifted to assessment of relative risk rather than absolute risk. Treatments of depression are themselves never likely to be effective treatments for suicidal behaviour per se. The majority of studies testing specific interventions for suicidal behaviour have shown no benefit over treatment as usual, though a number of studies have shown positive results. There is no obvious pattern to the successful interventions in terms of their content, though they do seem either to target a specific subgroup of parasuicides or to involve a brief, flexible treatment delivered at home. Both these strategies potentially limit the problem of heterogeneity. A modular approach provides a framework for incorporating a range of treatment strategies derived from the interface between basic and applied research. Developing strategies to tackle depressive hopelessness, particularly lack of positivity about the future, is one of the most needed and promising lines for future research.

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