The aim of this book is to present a comprehensive explanation of suicidality. This is postulated as a process that is based on personality vulnerability, related to traits of impulsivity and aggressiveness. These in turn are linked to hyposerotonergic functioning. The stress—diathesis model suggests that in such vulnerable individuals, stress events such as adverse life episodes, depression or other mental illness may lead to suicidal behaviour in which the related neurochemical parameter is the hypothalamic—pituitary—adrenal axis.

The first section presents supportive evidence from the fields of psychopharmacology, epidemiology, ethology, neuropsychology and clinical psychiatry. The text is on the whole clearly focused on relevant and well-researched data, although at times the clinical heterogeneity of problems subsumed under the category ‘attempted suicide’ introduces a degree of ambiguity. Nevertheless, the hypothesis is set out in a systematic and detailed way, which should facilitate further research towards eventual replication or refutation of its various components.

The second section sets out the potential practical value of such a hypothesis. First, a penetrating analysis of risk factors spells out starkly their gross limitations as they are currently used in clinical practice. Nevertheless, the relatively new discipline of risk-factor research appears to have made an impressive start in clarifying the nature of risk factors and in paving the way to improving their clinical usefulness. There follow several chapters on social causation, the relevance of action theory, which focuses on the goal-directed nature of the suicidal process, and the role of pharmacological and psychotherapeutic approaches to treatment. Deliberate self-harm is evaluated in detail on the basis of a recent meta-analysis of the literature.

The hypothesis set out here should surely encourage us to review our approach to the assessment and management of suicide risk, and to widen our perspective on what is a tremendous clinical challenge. Personality traits of impulsivity and aggression, and biased memory, which may encourage a sense of entrapment and hopelessness, all have a claim to be considered carefully, along with routine clinical method. It is surprising, though, to discover that the stress—diathesis hypothesis accords depression and other mental illnesses a peripheral stressor role in the process of suicidality. This seems to run counter to clinical experience of severe and acute suicide risk. However, there will be little dissent from the view expressed here that the bedrock of any effective clinical approach to suicide prevention must depend upon skills in face-to-face assessment, particularly with regard to the individual significance of symptoms and behaviour. On reflection, did not Adolf Meyer say this some time ago?