Clinical management of parasuicides: critical issues in the 1990s.

In view of recent rises in suicide rates of males aged 15-29 years, the literature on the specialised clinical management of parasuicides presenting at hospital is reviewed. Few studies demonstrate reduction in suicidal behaviour with such services, although substantial psychosocial benefits have been shown. These negative results with respect to suicidal behaviour partly relate to methodological problems such as small sample sizes, the exclusion of high risk subjects, short follow-up and confusing outcome measures. We cannot be confident that existing clinical practices have been effective in reducing suicide. Hence this paper focuses on selected issues of critical importance. Clinically, risk assessment is a problematic area worthy of clear understanding. There is a continuing confusion over the nature of affective disturbance associated with parasuicide and whether it might benefit from pharmacotherapy. Recent studies on the prevalence of psychological disorder in suicidal youth are discussed. Child abuse might usefully be screened for in parasuicidal patients, although this may be overlooked because of unfamiliarity with the association. New developments in cognitive and pharmacotherapies offer hope for suicidal rate reduction. There is a pressing need for further intervention studies. In particular, community and inpatient care of high risk patients require urgent evaluation. Further study of the role of depression and its appropriate management is needed. Although depression seems a significant factor, the recent rise in youth suicide remain largely unexplained.