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Abstract
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Suicide has been and continues to be a major concern, accounting for over 700,000 deaths worldwide in 2019 and being the fourth leading cause of death among people aged 15-29 (World Health Organization, 2021). In the United States, nearly 48,000 people died from suicide in 2019 (Centers for Disease Control and Prevention, 2019). Additionally, the US national suicide rate steadily increased from 1999 to 2019 (Hedegaard et al., 2021). To address this serious public health issue, an increasing number of experts in the field have argued for inclusion of a suicide-specific diagnosis in the Diagnostic and Statistical Manual (DSM) to improve suicide risk assessment and prevention (Fehling & Selby, 2021; Oquendo et al., 2008; Rogers et al., 2019; Sisti et al., 2020; Voros et al., 2021).
The DSM is an essential resource in the field of psychiatry, since it serves as a common nosographic system to group diagnostic criteria for mental disorders. Although most countries outside the United States rely on the World Health Organization's International Classification of Diseases (ICD) for psychiatric diagnosis, the ICD and DSM are mutually influential and changes in the DSM have significant impact beyond the United States. The DSM has undergone various iterations as knowledge expands. For example, the DSM-5 (American Psychiatric Association [APA], 2013) introduced the diagnosis of suicidal behavior disorder (SBD) as a "Condition for further study." The main diagnostic criterion of SBD was a suicide attempt within the previous 24 months. In the revised DSM-5 edition (DSM-5-TR; APA, 2022), suicidal behavior is also listed as a modifier of other diagnoses under "Other conditions that may be a focus of clinical attention." This welcome shift reflects the growing consensus that suicidal behaviors are not merely symptoms of depression and thus need to be assessed regardless of diagnosis. Indeed, as the National Violence Death Reporting System highlighted, 10%-54% of suicide deaths occur in individuals with no psychiatric diagnosis (Stone et al., 2018).
Although this change is welcome, we argue it will not provide clinicians with sufficient tools to assess imminent suicide risk or allow researchers to investigate the phenomenon. First and foremost, the code will only target patients who have already engaged in self-injurious behavior with intent to die and disclosed such behavior to their clinicians. Considering that a large percentage of suicide deaths, particularly those from firearms, occur on the first attempt (Anestis, 2016), flagging recent history of suicide attempts will not be sufficient. In the absence of recent suicidal behaviors, clinicians will inquire about patients' suicidal ideation (Ribeiro et al., 2016). As noted by many, this practice is very problematic; individuals at risk of suicide frequently conceal suicidal ideation (Høyen et al., 2021). In one study, more than 50% of patients who died by suicide explicitly denied suicidal ideation when questioned prior to their deaths (Berman, 2018). Additionally, the literature has described the fluctuating nature of suicidal ideation (Kleiman et al., 2017), such that some individuals may genuinely deny suicidal ideation and yet experience it soon after. In sum, while the inclusion of a suicidal behavior code in DSM-5-TR is a substantial advance, it will not provide a sufficient tool to guide clinicians' assessment of imminent suicidal risk.
In the absence of practical tools to identify individuals at imminent risk, assessing suicidal risk remains a highly stressful task for clinicians (Rothes et al., 2014). However, thanks to the growing body of research on short-term risk factors for suicidal behavior, new tools are now available. Over the past few years, two different research teams have described presuicidal states that are predictive of short-term suicidal thoughts and behaviors: the suicide crisis syndrome (SCS; Galynker, 2017) and acute suicidal affective disturbance (ASAD; Rogers et al., 2017). The SCS consists of five components grouped into two criteria: A and B. To be diagnosed with SCS, a patient must meet Criterion A, frantic hopelessness/entrapment, and have at least one symptom from all four subgroups within Criterion B: affective disturbances, loss of cognitive control, disturbance in arousal, and social withdrawal. Overall, at least five of 15 symptoms must be present...
Language: en |