Risk Management With Suicidal Patients Bruce Bongar, Alan L. Berman, Ronald W. Maris, Morton M. Silverman, Eric A. Harris, Wendy L. Packman (Eds.). New York: Guilford Press (www.guilford.com). 1998, 197 pp., $30.00 (hardcover). Risk Management With Suicidal Patients addresses an increasingly important topic in the era of managed care, utilization review, limited resources, and mounting vigilance about liability in a litigious consumer climate. Divided in seven chapters, this edited volume is an amalgam of straightforward clinical advice combined with forensic and medicolegal issues. While the book poses important questions for both clinicians and administrators, it promises more than it delivers, at least clinically, as a guide for managing risk with suicidal patients. For me, the two major weaknesses of the book were its uneven integration of clinical and forensic/medicolegal areas, and the rather elementary, overly general review of how to manage a variety of psychiatric problems. Sections regarding treatment often bear on suicidality only peripherally, as one of many symptoms targeted in a treatment plan. A chapter on psychopharmacology, for example, cites standard repertoires of antidepressants, antipsychotics, anxiolytics, and mood stabilizers and the host of conditions for which they are prescribed, rather than specific antisuicide applications of these drugs. An important example of such an application, omitted from the text, would be the potential link between lithium and diminished suicidality in both bipolar and unipolar mood disorders. Similarly, agents such as clozapine also have received particular attention in the literature relative to suicidality in schizophrenia. Treatment, in general, is described throughout the book in global terms, relative to overall outcome, rather than relative to suicidality. It would seem that clinicians who are unfamiliar with current data on drug applications such as these are left at a disadvantage when they evaluate medication regimens for suicidal patients. In addition, pharmacologically, some of the material appears rather dated (e.g., fluoxetine is described as a new type of antidepressant, and trazodone is touted as an efficacious antidepressant). There is also little discussion of the risks of choosing higher- versus lower-lethality medications (such as MAO inhibitors) with suicidal patients, prescription-dispensing habits, and the thought process involved in weighing suicide risk against treatment options. More positively, there is a good general discussion of the adequacy of a medication trial, and lay misconceptions from the popular media that drugs such as Prozac can induce suicidality are appropriately laid to rest. Relatedly, no section deals systematically with the suicide risks of particular diagnoses, alerting clinicians to distinct symptoms or symptom constellations (other than Aaron Becks's construct of "hopelessness" in depression) that may be associated with elevated suicidality. There are many examples in the literature of discrete symptom profiles linked with suicidality, such as impulsivity in borderline personality disorder, mixed states or cycling within an episode among bipolar patients, alcohol comorbidity in mood disorders, and positive rather than negative symptoms in schizophrenia. The book would be far more cohesive and faithful to its title were the clinical material geared more directly toward suicide. A theme throughout the book involves defining (and contrasting) accepted "minimal standards" of clinical care and "ideal" care. As the authors note in their introduction and postscript, consensus opinions vary about optimal treatment approaches to many conditions involving suicidality; the book is meant to highlight these uncertainties and foster critical thinking and debate in such unresolved areas. However, because the editors and authors essentially treat suicide more as just one type of unfavorable outcome (resulting from suboptimal care), rather than as a unique event with a distinct psychopathology and treatment, little clarity or pragmatism comes from their lamentations about optimal treatment. …