I read De Leo's (Reference De Leo2002) editorial on preventing suicide with interest. However, I would like to raise a few concerns. In spite of much development and understanding in both biological and psychological causes for suicide, the prevention of suicide remains an imperfect art. However, the comparison of suicide prevention with that of ischaemic heart disease seems inappropriate. The risk factors for ischaemic heart disease are well known, stable and quantifiable. Ideally, risk factors used for predictive purpose should be stable, whereas in suicide, clearly, most are not (Reference HawtonHawton, 1987). Therefore, when risk factors are not stable it will be difficult to apply the same analogy to suicide prevention.

The risk factors for suicide are different for community- and hospital-based populations. We have made progress in pharmacological interventions in hospital-based populations with lithium in bipolar disorders (Reference Kallner, Lindelius and PettersonKallner et al, 2000) and clozapine in schizophrenia (Reference Meltzer and OkayliMeltzer & Okayli, 1995), which have been shown to reduce suicide rates. However, the risk factors in community-based populations are different and a number of psychosocial risk factors have been reported to be significantly associated with the risk of suicide. We need to understand local perspectives and regional factors that influence suicide rates. There is a need for qualitative studies to examine these issues; the factors thus identified should then be explored in epidemiological studies.