If the trend continues, every symptom will be separate disorder in DSM...

I actually appreciate this development both as a clinician and a researcher, but I think it can be dangerous if done incorrectly.

As a researcher, this could be valuable because while the world is moving slowly toward a dimensional model, we still are very categorical. Due to this, suicide researchers have often had to study suicide in the context of disorders such as depression, anxiety, etc. in order to get funded. Whether or not this changes is yet to be seen, but having suicidal behavior as a disorder would help those of us that want to study suicidal behavior first and foremost.

As a clinician, suicide is my greatest worry, and I appreciate having a flag to help identify that a client is at particular risk. However, I think this is where the potential dangers come in as well. We know from the Fluid Vulnerability model that suicide risk waxes and wanes. As such, you don't want a disorder that will be tied to a client forever. However, if it is time-limited, I think it could be useful.

According to my basic understandigs of psychiatry and psychiatric nursing (i'll begin a job as a psychiatric nurse in september, first experience), suicidal wishes and behaviour (as a non-psychotic state without influences of hallucinations ect.) accompaign a varity of other disorders and is often the result of an intention to change something or stop things/life how it is. so my conclusion is that it would be dangerous to simply treat and view suicidality as a disorder only, without any other promoting diseases or circumstances. one wouldn't only treat the pain in the leg with medicaments without caring about the injury from a bullet impact right?

I'm interested about other views and considerations

@Michael

Good thoughts, also about the fact that a disease may will cause a new and unwanted stigma.

Why wasn't suicidality formulated as a fluctuating syndrome, which can be present, absent or promoted by factors i.e. depression, crisis ect.? Would be a lot more understandable for me.

Thank you all for your comments. On further reflection I now see a possible distinct advantage to adding this disorder to the psychiatric tool kit. I will hazard a series of US-centric generalizations to make my point. Suicidal behavior accounts for the overwhelming majority of crisis center contacts, involuntary psychiatric evaluations, and psychiatric hospitalizations. Once a diagnosis is given, the primacy of suicidality as a focus of attention (other than precautions) largely shifts to the disorder(s) that insurors require for eligibility and payment. The discharge planning process moves further away from the presenting problem to the disorder. The aftercare plan may note suicide risk but offer little to deal with it because (i) outpatient providers are also diagnosis-driven and (ii) there are few community-based services or supports directed at suicide risk let alone suicide behavior. If "suicidal behavior disorder" gains status as a diagnosis it may lead to more inpatient/outpatient care directly targeting suicidality.

These are good thoughts. The ICD system allows for suicidal ideation, behavior diagnoses, unlike DSM up until now. Suicidal thoughts and behaviors have not stood on their own as a separate disorder or modifier, even though they are associated with a wide range of psychiatric disorders. We are hampered in prediction of suicide, and track the associated symptoms and behaviors in an appallingly haphazard way in our health systems, given the burden on public health. The vast majority of patients with suicidal ideation never worsen to result in suicidal behavior, and many "suicidal" behaviors would be more properly construed as non-suicidal self-injury. There are a variety of instruments and ranking schemes to clarify and quantify this complex area, some of which have been promoted for use in FDA medication registration trials. As it stands, the notation is binary in many systems, either suicidal ideas/acts are present or absent, with no standardized method for assessment of intent, preparation, severity of suicidal preoccupation etc.

Dear Tony,

Let me go through your arguments one by one having published evidence and clinical experience as the sole arguments: (1) medicalization is to transform a normal human or social event in one that is in need for medical care; (2) medical care is of organizational nature and displayed to answer to an health problem, it does not specify the nature of the care provider (doctor, nurse, psychologist, etc); (3) suicide attempts occur because people present psychopathology, such as hopelessness and despair, they are not common, not within the normal range, not universal occurrences; (4) actually, most suicide attempts occur in people that present mental health issues such as depressive states and in only a minority of people just went through a transient 'bad' moment; (5) a suicide attempt means clinically that there was intention to die; (6) the disease model is not synonymous to medical model which is a broader concept more akin to the biopsychosocial model whereas the disease model is a restricted concept; (7) suicidality means suicide plus attempted suicide and suicidal behavior includes these two and suicidal ideation; (8) it is well established that suicidal behavior is an important risk factor for suicide; (9) there are people with recurring suicidal behavior even if not self-aggression with no intent to die which is recurring by nature; (10) suicide is hardly a symptom of mental disorders and I agree it is not a mental disorder, but yes, it is a complication of mental disorders, and it complies with the definition of medical complication.

I am much more afraid of stigma around mental illness through the associated stigma towards 'medical disorders' : that makes people not finding for the right help they need.

I agree that this could be seen as categorising what is essentially a symptom or an indicator of distress as a disorder of its own, which may lead to enormous confusion, especially among the public.

And I'm not sure that it's particularly useful to shift the focus away from an underlying condition (although I expect in practice that an Axis I diagnosis will trump a "diagnosis" of suicidality).

It is rather disappointing that the DSM-V committee did not see fit to expand on the diagnosis of adjustment disorder, which captures into the classification system the distress of a person who has (among other presentations) attempted suicide due to various stressors. Aside from depression and psychosis, adjustment disorder is the most commonly diagnosed condition in people presenting with attempted suicide, particularly in certain populations (Consultation-Liaison psychiatry being one example). This is because context is important when considering suicidal attempts, and adjustment disorder is one of the few conditions which might be seen as having a multi-dimensional reach.

This context is particularly relevant when the fluctuating and even fleeting nature of distress and thoughts of suicide are considered. If suicidal thoughts and attempts require classification, Adjustment Disorder would seem to be a more appropriate category to use.

Medicalization of social behavior is not limited to suicide. Domestic violence, relation problems, social performance, children problems and so on, have been asigned as issues of health professionals.

It is evident that they are complex situations. As far as we know, behavior is the result of biological, psychological and social interaction. In my opinion means that we really do not know how the complex interaction works. We have information for all levels.

Medicalization has been the best political solution for these problems.

Health sciences are limited to solve these situations. Political, social, cultural issues are involved.

But it is not the first time that a problem is adressed to a scientific sector. It is a serious problem for medicine to deal with these situations.

Can u share Copy or p.801 DSM-V

There has been many historical attempts to say that symptom = disorder. This is an antequated way of looking at diagnoses. Suicidal behaviour may occur for a number of very different reasons. Predisposing factors may be linked to types of personality, mental disease, severe somatic disease, drug abuse etc. It is highly unlikely that all types of suicidal behaviour should fit into one common category.

I ran across a brief commentary pertinent to this discussion at http://www.psychologytoday.com/blog/promoting-hope-preventing-suicide/201205/dsm-5-s-proposed-suicidal-behavior-disorder. The author notes: "[Suicidal behavior disorder] creates a way to organize, and perhaps track, risk for suicide. Creating a code “calls out” suicidal risk in an individual’s clinical record, distinguishing it from being seen as 'just a symptom.'"

Some of you might see a valid connection between the subject being discussed here and this article from today's Guardian about anxiety.

http://www.guardian.co.uk/commentisfree/2013/jul/29/heed-age-of-anxiety-stress-exhaustion

Suicide attempts are common reasons for hospital admission and therapeutic concern. At present there is no code for a suicide attempt in DSM 4 and 5 other than as a symptom of depression, borderline personality disorder or bipolar disorder or as the individual who inflicted a physical injury or poisoning in part of ICD which is completed by non clinicians. There is now ample evidence that rates of suicide are increased in conditions other than depression most notably in schizophrenia, alcohol abuse , anxiety states , OCD and disorders characterized by aggressive behavior. A fine (but expensive) monograph has been published on this topic by W.H.O. edited by Matt Nock and colleagues that demonstrates that the disorders that predict suicide differ in different parts of the world which further strengthens the argument to disconnect this abnormal behavior from a small list of related diagnoses. An alternative that circumvents this problem is often used in the UK and Australasia and in certain parts of Europe is self harm or self injury but those are very broad entities and include behaviors that are undertaken without suicidal intent and the heterogeneity may obscure indicated treatment , prognosis and definitive research. The absence of any accurate and precise definition impacts on public health surveillance and on detecting the impact of preventive measures and of immediate importance undertaking large studies on the troubling phenomenon of elevated suicide risk after discharge from hospital, because there is no coding of whether or not the patients were admitted for a suicide attempt, owe cant access large national samples to determine whether this simply reflects the condition for which the patient was admitted or whether hospitalisation may induce suicidality de novo. . Proposals for a well defined set of criteria were deferred by DSM5 summit reviewers but no detailed rationale has been made available for examination so the precise reasons for rejecting the proposal that was widely requested by the field and by several of the other respondents to your question are not know. Some of the objections that were voiced before final consideration included the exclusion of suicidal ideation on the grounds that it has a very high base rate and its inclusion might meet the opposition of critics who were concerned that DSM avoid "psychiatrisation" of normal behaviors. The term medicalisation has been praised and criticised for several reasons including those mentioned by other respondents. Perhaps one of the most useful, because it avoids the contentious issue of who is best qualified to deliver helpful interventions or treatment and what impact does this have on the invaluable treatment offered by professionals without a medical degree was offered by Lee Robins who put forward the view that the essence of a medical diagnosis lies not only in understanding its pathology in the nervous or other systems but also in its ability to predict later course and outcome .

The consideration for inclusion in DSM-5 was controversial and the debate complicated and varied. It boils down to: a-more or less your point about medicalization and b-the pragmatic reality (captured in some publications) that even when suicidal behavior is THE reason for psychiatric care (e.g., hospitalization), the care tends to center on something else (e.g., the depression assumed to be the root cause of the suicidal behavior).

Anne, thank you for noting that suicidality indeed plays a big role in hospitalizations and is probably the dominant factor in involuntary admissions. Nonetheless starting with the psychiatric evaluation and the tentaive plan of care, except when precaustions are ordered, suicidality is quickly overshadowed by an Axis I diagnosis that becomes the object of inpatient treatment and basically shapes the D/C plan and focus of aftercare.

David, your comment about how "self harm or self injury...without suicide intent" are used in the UK and elsewhere is much appreciated. A British psychiatrist recently took issue with my assertion that maybe the reason she did not see "contingent suicide threats" is because she and her colleagues view parasuicidality differently. She doesn't see suicide threats being used to gain meds, shelter, hospitalization, or evade incareration to the same extent as seems to be the case in the US. I suggested that had more to do with the nature of their system and their concept of what constitutes suicidality and that her non-manipulative patients would be anything but if transplanted here.

I disagree strongly with Ricardo when he writes, "suicide attempts occur because people present psychopathology, such as hopelessness and despair, they are not common, not within the normal range, not universal occurrences. Hopelessness and despair are common, they are within the normal range and they are universal experiences. As are the lesser levels of distress including disappointment, shame and anger - all of which may play a role. Suicide is a response. It may be in response to illness or environmental circumstances - like coughing. Let's not make coughing a disorder.

I can't believe that the cause-effect relation listed by Ricardo is as clear than he designed that. Suicide attempts are very complex occurencies to simplify the relation to the psychopathology. Are there more things to influence these attempts ou the completed suicide. Are social variables that represent more impact than the psychological variables.

I agree with much of what has been said here. As the required criteria in most locations for hospitalization and involuntary commitments has at the core harm to self or others one would expect that to be predominant. While certainly there are those that are suicidal as an aspect of another disorder. In clinical practice there are also those who appear to be chronically suicidal. While there may be a disorder present, that is not the clear cause in some of these cases (in my experience).

I would guess that it really does depend on one's perspective in many ways. One of the key elements (whether stated or my interpretation I am not sure) was increasing access to health care and coverage. The DSM-V made changes in many cases that allowed this to become more easily possible, In doing so one increases the medicalization such processes.

I have to agree with Saxby as he disagrees with Ricardo. I also as I read Ricardo's post yelped at my computer screen much in the same way I think Saxby might have responded. Let me first begin with the fact that my education in Psychology coupled with personal experience both of from myself and acquaintances can assure any reader herein that this DSM suicide behaviour disorder is a disgrace to my field of research and work and long education. It doubly undermines the person that has attempted suicide. Behaviours can be changed; obviously suicide attempts cannot be changed or we would not be having this discussion. To believe that someone has a suicide behaviour disorder is like saying that I have a cancer behaviour disorder because I smoke. People that attempt suicide are NOT suicidal at all, in fact the opposite is more true; they are looking for a way to live... to feel alive... to get noticed... Cutters for example really screw up their skin and some attempts are yes, life threatening. However, the attempt at harm is the only way they can feel alive. People that follow through with suicide are not the ones that will ever be seen by a psychiatrist for suicidal behaviours. They are ept at disguising their motives and ultimate outcomes. Suicide by overdose is not suicide at all. the behaviour is the drug choices and addiction which comes well before the suicide of overdose. Suicide by death is intentional and planned and thought out.

I will try to express my best, but depending on my level of English for this, which is not very high, and I apologize for that.

I agree with many of the statements given in this line of comments, but mostly I think it is important to visualize the suicide and out of the anonymity associated with being a symptom or sign attached to the big "stars" of global mental health ( depression, personality disorders, psychosis, anxiety, etc. ..). I'm on the line which raises Professor Nadorff, the visibility of suicide helps us achieve several things: access to statistical and epidemiological data, in my country (Spain) there are no national statistics on suicide attempts and deaths completed suicide are not up to date, would also help if there was a greater amount of financiaciación for research projects related to suicide. It is not pathologizing suicide, but out of the darkness in which is found in many countries (some of them European). In addition, as posed by the teacher Páez are rarely taken into account the psychosocial and cultural aspects associated with this behavior, focusing exclusively on too often drug treatments for their disorders "actors" that result in serious consequences for the patient and family.

In short, while we continue to debate whether suicide is or is not a mental illness and whether it should be included or not as such in the Manual Diagnostics (DSM-5 and ICE 10), continue to grow suicide deaths worldwide, and especially in countries known as "welfare". Would be interesting to take this multidimensional aspect of the university and academia to educate our society about the importance of this great global plague, and also begin to influence factors that promote resilience to suicide, and its modulation by cultural and geographical aspects .

Million thanks to all for their contributions and interesting comments that advance us

David Sanchez offered some very profound and very well thought out possibilities to reduce the rates of suicides or at best suicide attempts. I agree that data is not readily available in any country to my knowledge, that provides fair statistics on this subject. For instance, many suicide attempts are never recorded as such. An example would be a person rushed to the hospital for a drug overdose and they survive. The medical records most normally would simply say, 'drug overdose' with no reference to attempted suicide behaviours. Therefore, as a professional in this field of study, I find it difficult to qualify anyone with this disorder unless the person delivers this information to me themselves... using my strict confidentiality standards. The only legal way I could share this information is if I thought the person was a risk to others or a harm to themselves. Most people living on this planet, if asked, would tell a therapist that yes they have at least once in their lives thought that they would be better off dead than alive. Let us now enter this new DSM disorder into that scenario. We would now have probably an estimate of over 3/4 of the world's population needing psych meds because they qualify for the suicide behaviour disorder. To try to simplify this example think of someone that goes off to college and leaves their home schooled life for the first time in their life... freedom! They get drunk 3 times per week and once in awhile in their four year college education, end up in the ER due to possible alcohol poisoning. They go on to Master level programs and leave the drinking behind except for some rare social gatherings where they have a cocktail or two. Does this qualify them as alcoholics or was their drinking span simply do to freedom and college and experimentation? It must be very clear to therapists, psychologists, psychiatrists and social workers that this issue of diagnosing someone must be used very carefully. Diagnosis puts an automatic stigma on the person diagnosed further supporting their reason to justify their actions or behaviours. It is also important to note that the professional doing the diagnosis or referrals for a diagnosis are human beings also. A patient could 'psychiatrist hop' for a year and literally receive all different diagnosis while all the while giving each doctor the exact same answers to the exact same questions.

I think both clinicians and researchers in APA will do some studies. This is to encourage people to think about this and see if there are going to be studies on patients who have predominantly suicidality as a clinical feature.

I see your point it is hard to just find patients who are suicidal and do not have any other psychiatric disease or problems.

I will agree with this if the patients analysis is considering all the variables in a multilevel and a multi methods are used to define the real situation. Not a single observation is sufficient to define the feature and the setting of patients life.

The 'experimental' diagnosis in DSM V is useful to differentiate patients with recurrent self harm who do not have the other symptoms of borderline personality disorder, from personality disorder. I had a patient with a history of self-harm as an adolescent due to disappointment in love, who went on to be well adjusted, successfully married, with children, etc. who became depressed due to a conjunction of life events and began repeated self cutting and overdoses over a 9 month period. she had none off the other stigmata of personality disorder, but found that self-cutting relieved overwhelming anxiety and stress. she recovered with treatment, but the referred to diagnosis seems appropriate to describe her syndrome.

STEVEN HIrsch

Unfortunately, I think the overall trend in the DSM has been to develop more diagnoses and to use your term, "medicalize" more and more variations of existing diagnoses. Although I believe the Big Pharm industry has much to do with this, insurance companies are also looking ahead to protect their high profits as they are forced to provide equivalent coverage for psychological issues and physical ones.

The DSM long ago lost its function as a diagnostic guide and is now simply a rule book for justifying medication. Suicidal Behaviour Disorder is an absurd categorisation of enormously complex behaviour and like many of the other value judgements in the DSM performs no useful function in the treatment of patients.

Categorising behaviour as a disorder, i.e. something the majority feel uncomfortable about has marginalised and stigmatised millions of people, in many cases exacerbating their distress and placing them outside of society. The DSM maintains the myth that any manifestation of mental distress is a chronic lifetime condition that can only be managed by psychopharmaceutical intervention. Very helpful for those who manufacture the drugs but a disaster for those so categorised.

There is little doubt that the use of drugs to treat acute psychiatric distress is not only medically efficacious for the patient but desirable in societal terms. What is not helpful is using labels or categories of patient and claiming that once in the category you are there for life. Treating mental illness as a chronic 'disease' is a self fulfilling prophecy locking people into a system that perpetuates itself. The DSM suits the interests of those who profit from this practice, it certainly does not suit the patient.

Who will research the topic? Pharmaceutical companies who will produce ghost written studies and pay KOLs to attach their names to them. The studies will all show suicidal behaviour disorder is pervasive and under diagnosed. They will show that treatment with psychotropics is safe and effective. Drugs will be produced or repackaged and marketed to prevent suiciality, doctors will be bribed to prescribe them...you know the drill. Why would this 'disorder' be approached any differently than the others which have travelled the path to inclusion in the DSM?

I think Foucault once stated that the increase in the number of disorders was given due to a myopic view of illness and health. And that's part of the idea that only those who have the capacity to produce (speak that much to live) should remain in society, and the others be aparted. Why these new disorders were separated other than for that reason? Can anyone give any clues?

We develope in future "antisuicidal drugs"...!? Or "prolife drugs"... New market!

If suicidal behaviour is to become a "genuine disorder" each element of this complex behavioural pattern must be fully examined and documented. This, I am sure will extract many more signs, symptoms and criteria that those listed in the disorder for further research. the highly complex psychopathology involved in both suicidal behaviour and non-suicidal self harm have a high influence environmentally and this is where our research must focus. Indeed, there are biogenetic influences. For example, in depression there are some genetic markers and we know that serotonin decreases but investigating the environmental triggers is key to formalizing a suicide behaviour disorder.

"We know that serotonin decreases." Really? Where is the evidence to support this statement?

Very good observation because several behavioral aspects is not only based in a genetic markers. If so, anyone who had the same score would have pre-determined action, which in practice does not occurs.

Thank you Maria for pointing out the "decrease". What I should have said is that current thinking sys the people who are prone to depression may have less sensitive dopamine receptors, so that they respond more dramatically to lower levels of serotonin. However, I believe that we should investigate the bio psycho social factors that lead to suicidal behaviour which may result in completed suicide.

William no biological basis for 'depression' (or as I prefer to call it, normal human reaction to stressful life events) has ever been established despite desperate attempts by psychiatry and the pharmaceutical industry. Neither has depression been proven to cause suicide. My child died because a doctor told us he had a chemical imbalance that would be corrected by SSRIs. No diagnosis of depression or any other mental disorder but a severe adverse reaction to the drugs that both the Regulator and Mylan pharmaceuticals have admitted was the probably cause of his suicide. You will understand that I am intolerant of claims made in the name of biological psychiatry which have no evidence base and cause such harm.

Maria I don't believe that we can dismiss the interaction between biology and socio-psychological factors that lead to suicide. I agree that there are medications with severe paradoxical effects that can and do lead to suicide. However, I think we must investigate the factors involved if we are really going to help people.

I agree William and there is good evidence that a range of physical health conditions can lead to suicidal thinking and behaviour but there is no evidence that those who die from suicide do so as a result of serotonin depletion or other chemical imbalances and so making statements around theories which despite exhaustive investigations have produced no sound empirical evidence is marketing not science and something that in my view requires vigorous challenge.

I agree with you Maria that the studies and results are inconsistent and as a psychologist I look at all factors and will not market chemicals but will investigate interactions between the bio psycho social factors not only what we choose to name "mental disorder" but physical health and how the suffer is or was thinking resulting in the particular behaviour.

That's great William. I apologise if I come across as aggressive on this issue. As well as losing my own child to an adverse reaction to psychiatric drugs I run a charity supporting other families with the same experience. Without exception they were told their child had a chemical imbalance that the drugs would fix. To see this myth being perpetrated and to be at the end of the process helping families bury their children and then fight for justice because clinicians refuse to take the time to do what you do, is heartbreaking. It is also an insult to the memory of my son when the lessons that can be learned from his death are ignored. Thank you for doing the right thing and for the discussion.

Maria I completely understand your feelings on this issue. I also lost a loved one by suicide. No you did not come across as aggressive. Disagreement should enable contemplation of an issue and then in the spirit of scientific inquiry we may reach agreement. I also wish to applaud your running a charity that certainly will always be a great comfort to people though their time of suffering.

It's really phenomenal to see heated discussions on the subject with various representations. This attitude creates opportunities for research needed to develop the theme and not the simple classification of the individual as a sick person. Thank you William and Maria

I don't think suicide attempts are necessarily due to mental illnesses and shouldn't be medicalized. They could be a rational response to a sudden economic disaster, which leads the person to see no hope of turning things around and so decides to end it all, rather than living on the street as a homeless person or leading his family down with him. I wrote a script about this issue described in an answer to another question, Dave's Suicide Party, which is being filmed in Las Vegas and LA in July. You can see more details about the party, including a short video, at www.gofundme.com/suicide-party.

A suicide attempt is a sign that something, whether medical, social, psychological or environmental, is happening to that person. Whether diagnosable or not the person sees no way out and hence may need help. Suicidal ideas come from somewhere. Not all ideators or attempters complete suicide. It is at the point of expressing the idea to someone, if they do, the attempt is noticed that some intervention must take place.

Selective Serotonin Re-uptake Inhibitors cause suicide ideation and in many cases lead to actual suicide. One theory is that the drugs act in a similar way to alcohol and remove the inhibitory control that prevents many people from actually killing themselves.

This dis-inhibitory effect occurs before the drugs desired effect and it can have disastrous results including homicide as well as suicide. It is self-explanatory that the last thing an anxious or distressed person should be given is a substance that removes the last obstacle to suicide.

One of the most disgraceful and criminal acts of the pharma industry was to cover this up in order to protect sales.

You are absolutely right Barry. Joiner's theory posits the desire to die is a product of lack of belonging and a sense of burdensomeness. Diagnostic labelling and psychiatric drugging can make a huge contribution to this given their contribution to joblessness, disability, and other adverse life circumstances. Joiner theorises that the ability to overcome the natural instinct for self preservation is an acquired capability which drugs can facilitate. In effect, psychiatrists hand those in emotional distress a drug which not only creates thoughts of suicide but allows those thoughts to translate to action to end life. A loaded gun in the name of medicine.

Update related to my original question: Oquendo and Baca-Garcia recently proposed that suicidal behavior be considered as a comorbid condition with mental illness (when present) in suicidal individuals. The rational being "...suicidal behavior does not appear to be an intrinsic dimension of any particular psychiatric disorder."

http://www.mentalhealth.org.nz/file/E-Bulletin/PDFs/suicidal-behavior-disorder-as-a-diagnostic-entity-2014.pdf

I can't believe that inclusion in DSM V makes more scientific researches appear or be developed.

It is risky to believe that such inclusion will do not increase the medicalization and, more than that, will not be a simple classification of "illness", causing stigmatization and more physical and mental suffering in individuals.

To update my previous comments, suicide can be a perfectly rational response to a situation that can't be reversed, such as a diagnosis of a terminal illness when one knows there is no hope and increasing pain and loss and functions.  There has also been a growth of suicide as a response to economic conditions where one has lost everything and in response to a looming prison sentence one can't face.  I don't think this should be medicalized, since these are not signs of a mental illness under such conditions.  However, suicidal thoughts could result from another mental illness, such as a deep depression and then that should be treated.  

Gini,

I agree! It is exceptional your viewpoint. There are many and complexes variables involved in such cases you cited. And many of them are not illness conditions, but social or instant situations that conducts one to suicidal behaviors.

Gini,

"suicide can be a perfectly rational response to a situation that can't be reversed, ...I don't think this should be medicalized, since these are not signs of a mental illness under such conditions. However, suicidal thoughts could result from another mental illness, such as a deep depression and then that should be treated. "

One of the examples that you have given such as someone facing a looming prison sentence one can't face suggest some ambiguity as to whether a suicidal person is mentally ill or because of adverse circumstances can no longer face life. Sometimes it can be both, sometimes it can be for a single reason.  I personally know a man who was potentially mentally ill (pedaphile) and because of that was facing a potential prison sentence.  Prior to that he seemed quite content with his situation.  Once revealed as a child molester he became deeply depressed and also suicidal.  Over time it became clear that he was also mentally ill.  It is difficult to pick apart the circumstances surrounding suicidal behavior, so I agree with your assessment.  I am also acquainted with a young woman whose perception was clouded by her mental illness. She is bipolar and during a psychotic break (mixed) became obsessively convinced that she and her husband should commit suicide together and that it was the only possible solution.  Suicidal behavior is a sticky wicket and is very complex at times.

There are many issues I see in the Suicidal Behaviors Disorder in DSM-5, but I will only focus on a few of them:

1) The focus is only on suicidal 'behaviors'.  If we took this approach to major depressive disorder, we would eliminate any ideation phenomena as being criteria for the disorder and only concern ourselves with instances where the depression resulted in specific behaviors [such as spending all day in bed] or resulted in the lack of specific behaviors [such as not eating or not bathing].  To limit the focus only on suicidal behaviors is limiting the scope of any research.  Particularly in suicidality, the hope is to prevent people from getting to the point of engaging in suicidal behaviors.  If the focus of the clinician in diagnosis is only on the behaviors, then the diagnosis of a patient that is experiencing suicidality can, by definition, only happen after the events that we hope to prevent!  This is like saying that we are going to try to avoid people being injured in car accidents by waiting until after they have been in an accident to require they wear a seat belt or have air bags installed in their car.  By that point, the person is already injured or dead.  [Due to the criteria for Suicidal Behaviors Disorder, then the patient may already be injured or dead by the time they meet criteria for the disorder.]

2) The criteria purposely ruled out suicide attempts that occurred while the patient was in an altered mental state.  This is ridiculous!  Alcohol can cause an altered mental state.  Is it important for a clinician to know that their patient with a substance abuse issue consistently makes suicide attempts while under the influence of alcohol?  Wouldn't that bit of information play a factor in any care the clinician gave this patient?  I believe it would and don't understand why these patients are purposely being excluded from the diagnosis.

3) Similarly, the criteria rules out anyone engaging in suicidal behaviors for religious or political purposes.  First, let's focus on the religious aspect.  If a patient with schizophrenia thinks they are having frequent conversations with god and god is telling them to try to kill themself, [and assuming there are no suicidal behaviors that are not connected to conversations with god, and that the patient does not engage in the suicide attempts while actively experiencing the hallucination, since that might count as an altered mental state] then this patient would not meet criteria for the disorder.  Again, is it important for a clinician to know that a patient they are seeing in an emergency room, who happens to be schizophrenic frequently makes suicide attempts?  Does the  fact that god told them to make the attempt somehow make this information less relevant to the treating clinician?  Second, now let's focus on the political purposes.  There is a growing body of evidence suggesting that some suicide terrorists are actually suicidal before becoming involved in any terrorism.  What if these people are actually being selected because they are suicidal?  A recent paper was published discussing the potential of this scenario.  [ https://www.researchgate.net/publication/269694025_Are_Suicide_Terrorists_Suicidal_A_Critical_Assessment_of_the_Evidence  ] Should this group of people that are suicidal not meet criteria for a disorder simply because they happen to have some level of political motivation tied to their suicide attempts?  For some people, having religious or political motivation for suicide attempts increases the likelihood of further behaviors.  Why are these groups being excluded?

4) I do not believe lumping everyone with suicidality that has made a suicide attempt within the past two years into one diagnostic category will yield any reasonable data.  I believe there are a number of suicidality disorders [just as there are a number of mood disorders].  If we lumped all mood disorders together and attempted to research a mixed sample of people with mood disorders, any results would be murky at best [the negatives would likely outweigh the signal of the positives, similar to how a mixed group of MDD and Bipolar patients would likely not show a statistically significant positive signal in response to an antidepressant].  Only by looking at each specific disorder can we gather information about how to best treat each disorder. 

Having said all of that, although I understand the issue about stigma related to the diagnosis of a disorder, I have heard from many patients that their suicidality is not understood by their clinicians and, in many cases, not taken seriously.  One patient told me their psychiatrist told them "we don't talk about that here" when they mentioned that  their suicidal ideation had returned [if patient's can't talk to their psychiatrist about this, what other people are they going to talk to about this?].  Many of these patients want treatment that will specifically treat their suicidality [not just antidepressants or CBT, or DBT, or other sometimes ineffective treatments] and are willing to take the risk of a medical label in order to get help with their struggle to keep themself alive.  At the very least, allow these patients the option of getting a label and possibly having treatment options instead of completely dismissing the potential of this being a disorder [or set of disorders] all together.  According to World Health Organization statistics, suicidality was the 15th leading cause of death worldwide in 2012 [ http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/ ].  We will not get anywhere in attempting to 'prevent' these deaths until we start to properly research the phenomenology of suicidality. 

On a slightly different note, I heard a rumor that part of the reason DSM-5 limited the criteria to only behaviors is because of the concern that also including ideations would open up any practitioner not properly assessing a patient's suicidality to further legal complications if a patient killed themself.  It was assumed to be an undue burden on clinicians that could cause them medico-legal risk.  It sounds like the higher-up powers that be at DSM decided to cover the rear-ends of clinicians instead of doing something meaningful to help patients.

Article Are Suicide Terrorists Suicidal? A Critical Assessment of the Evidence

RECURRENT DELIBERATE SELF HARM such as cutting can become a pattern in itself which individuals use to deal with stress, without meeting the full criteria for depression or another mental disorder.  It can lead to repeated medical attention, and in my view is a useful syndrome, worth recognition and study.  whether it should be an official diagnosis or only a syndrome requires epidemiological investigation.

Steven Hirsch wrote:

RECURRENT DELIBERATE SELF HARM such as cutting can become a pattern in itself which individuals use to deal with stress, without meeting the full criteria for depression or another mental disorder.

While it is possible for such an individual to not meet the criteria for another mental disorder due to similar loop-holes as the ones I described above in relation to the Suicidal Behaviors Disorder criteria, there is another disorder for a person that engages in "RECURRENT DELIBERATE SELF HARM such as cutting".  Assuming the self-harm is not tied to intent to die from that self-harm, that disorder is Non-Suicidal Self-Injury. 

On a slightly different note, although I understand many researchers, clinicians, and people in general may be resistant to the idea that suicidality is a disorder (or set of disorders), if you take a look at history you will see that suicidality has been going on for well over a thousand of years.  George Minois, in his book History of Suicide: Voluntary Death in Western Culture explores the history of suicidality and our understanding of suicidality over time ( http://books.google.com/books/about/History_of_Suicide.html?id=YoraAAAAMAAJ ).  Based upon the evolution of our understanding of suicidality, I can understand why people will be resistant to change about these concepts.  However, if we never at least take the opportunity to explore if suicidality is a disorder (or set of disorders) then we are not doing everything we can to reduce the rate of completed suicides.  If it is a disorder (or set of disorders) and we neglect to entertain the possibility that it is such, then a large number of people will die every year until we finally get over our resistance and allow for this possibility. 

Jennifer: Thank you for your responses. I concur and would like to comment on two of your points. The first is: “…if we never at least take the opportunity to explore if suicidality is a disorder (or set of disorders) then we are not doing everything we can to reduce the rate of completed suicides.” I reached a similar conclusion almost 20 years ago. I was struck that suicide as a phenomenon seemed to display most if not all of the attributes of the “disease model.” However, the literature then as now cautioned “suicide is not a disease.” Suicide was defined as a behavior. I remember being puzzled by how addiction, which I regard as a behavior, had been ordained a disease while suicide was not and, at least as far as the DSM-IV was concerned, amounted to no more than a symptom of “real” psychiatric disorders. At the very least, acute suicidality has “biopsychosocial” roots comparable to “addiction disorders” and discernible neurological aspects as well. For these reasons, I think we should reconsider suicidality as belonging primarily to the realm of psychiatry. Fifty years of psychological autopsies repeatedly finding that 90% of suicide victims of any age, race, or whatever had a diagnosable psychiatric disorder have blurred the relationship between suicide and mental illness from a risk factor to a virtual cause. In any case, dealing with suicidal people became the province of the mental health field, which brings me to your second very salient point: “I have heard from many patients that their suicidality is not understood by their clinicians and, in many cases, not taken seriously.***Many of these patients want treatment that will specifically treat their suicidality…”

Once suicide was decriminalized it fell into mental health partly by default and partly because of the theories and speculations of psychiatrists. Psychiatry accounts for a critical mass of the suicide research and conceptualization, but this, as your informants attest, has not trickled down to providers, particularly those in community mental health. With few exceptions, only crisis services and inpatient psychiatric facilities serve suicidal people in terms of their suicidality and only for as long as it takes to give them a psychiatric diagnosis. At the front door of the involuntary psychiatric hospitalization process 90% or more of the “patients” are in imminent danger of injury to self. However, by the time they are discharged a few days later suicide risk has faded in favor of some pathology covered by their insurer. Consequently, as you note, clinicians do not address suicidality and few services exist to help those recovering from a suicidal episode. Instead they must accept treatment that (i) may be marginally related to their real problem, (ii) at best alleviate only one or some of their risk factors for suicide, and (iii) if they are lucky enhance a protective factor or two. Okay so what do we do about it? If we created a silo dedicated to “addiction disorders” we should do the same for suicide. If we launched dedicated service systems for HIV/AIDS, we can do the same for suicide. Whatever it is called, suicide must be treated like a disorder, clinical and support resources will then emerge, reimbursement will follow, and eventually practitioners capable of serving suicidal people will appear to replace those who do not take their need and risk seriously.

Jennifer I agree particularly with "altered mental states". The DSM-5 uses delirium and confusion. Lets look at confusion. Any altered mental state will result in a confused state but what we actually see in many of our patients who attempt suicide are dissociative states typically depersonalization and/derealisation. Many in this state attempt suicide when they no longer recognize themselves or surroundings. It may be argued that anyone who attempts suicide  are confused,  dissociated or some other altered mental state. However, some people attempt suicide for a variety of reasons that may seem logical at the time while others attempt because they feel that they have lived, did what they wanted and now it is time to go. Are we going to medically diagnose suicide attempt before truly understanding why a suicidal attempt is made?

William

William Corulla wrote:

Are we going to medically diagnose suicide attempt before truly understanding why a suicidal attempt is made?

I believe we have to.  Until we label said actions as a suicide attempt, gathering the information about what proceeded it is relatively useless for research.  If we do not call it a 'suicide attempt' simply because the reasons for it don't fit the current assumption of why people make suicide attempts, then we will never fully understand the range of issues that contribute to suicidality.  Only once we acknowledge that a suicide attempt has happened can we then gather data about what lead to it.  Otherwise we have the mess that the FDA had when attempting to retrospectively determine the relationship between antidepressants and reported increases in suicidality.  No one was using the same language to describe what happened at the time, which meant that people had to later review the limited information collected about adverse events and make a guess as to if the situation would qualify as a suicide attempt. 

Let's call it what it is.  If it is a suicide attempt (here I'm using the 'a behavior engaged in with intent to die as the result of the behavior' definition of suicide attempt which varies from how others view suicide attempts) then call it a suicide attempt.  If it is the result of depersonalization or derealization then say it was a suicide attempt that occurred in a state of depersonalization or derealization.  By allowing for such groups to be excluded from research we are already limiting the scope of any research that can be conducted.  Researchers are supposed to be scientists.  How scientific is it to limit our research to not include all possibilities just because of (what I assume to be) political factors?

Jennifer when I wrote dissociation,  (depersonalization) I do not mean that these individuals be excluded from research. I also agree that assumptions can not be made as to why people attempt suicide - it is only the person who attempted that can tell us why. I completely agree that our research can not be limited and that all possibilities must be looked at taking care not to cloud any issue.  I think we have to able to diagnose. Thanks

William

William Corulla, I wasn't aiming my most recent post at you specifically.  I saw your question as an opportunity to further elaborate on my opinion of excluding particular groups from meeting the criteria for Suicidal Behaviors Disorder.  Similar exclusions were written into criteria for other DSM disorders and some of these exclusions were clearly the result of politics. 

Jennifer I understand and agree with your thinking in this area. We must keep all research options open without letting the politic distracting us or erecting barriers that block scientific enquiry in favour of politic ambition. So I do agree and I am glad for the further elaboration.

William

I have read all the previous post, and I think all of you. Bring something to teach me or something with which I agree. However, to date still the international diagnostic manual (DSM-V and ICE-10) too are influenced not only by the policy as Jennifer says but also for the economy. This makes many aspects of suicidal behavior that remain unanswered are invisibilicen. In particular, the urgent need for WHO to invite all countries to gather epidemiological data on suicide attempts, and not just about suicides. However, this seems, to date, impractical because it would set off alarms about the blindness of the public health systems in many countries that are designated as "welfare" for other so-called "underdeveloped". The growing importance of global macroeconomics in the prevention of suicide remains a handicap for researchers and scientists, and international diagnostic manuals are still dotted with these macroeconomic influences, which makes me cautious about the results provided by these operating diagnosis. (I apologize for my low English)

regards

David

My first reaction was positive in that this would provide a more specific diagnosis than a disorder such as MDD or BPD in which suicidality is often seen. On second thought it's probably unnecessarily pathologizing - seems it would be sufficient to create and use a suicide rating scale - of which at least one already exists: http://onlinelibrary.wiley.com/doi/10.1111/j.1943-278X.1984.tb00678.x/abstract;jsessionid=553D4E33BBBF24B41E0F442A265B2175.f02t03?deniedAccessCustomisedMessage=&userIsAuthenticated=false

The DSM V is total garbage and would medicalise everything if there was 10 bucks in it.

In recent weeks, a book, Suicidality: A Roadmap for Assessment and Treatment, that Dr. David Sheehan and I have been working on over the past 5 years was published.  Among other things it contains a phenotypic classification for 9 distinct suicidality disorders along with criteria and a structured diagnostic interview for these disorders, including one where people experience unexpected, unprovoked urges to immediately kill oneself.  I believe this piece of the puzzle is necessary for the field of research to move forward. 

In addition, the book contains various assessment tools, a new model to understand suicidality, a classification and definitions for suicidality nomenclature, a classification algorithm for events of suicidality, a hypothesis for a mechanism of action for candidate anti-suicidality medications, and a new candidate anti-suicidality medication. 

The book also contains case studies from data mining which support many of the ideas in the book.  One of these case studies explains how we happened upon the new candidate anti-suicidality medication while another case study describes what may be occurring in youth that report an increase in suicidality as a result of antidepressant use.

Book Suicidality: A Roadmap for Assessment and Treatment

Jennifer:

Thank you for bringing you text to my attention. It certainly sounds like you and Dr Sheehan are addressing a long unmet need in clinical suicidology.

Tony

I've just 'come across' Tony's question (3 July 2013) about psychiatry's latest attempt via DSM V (& VI & VII etc. et al.) to 'corner the market' in bogus cures for coping with 'the slings and arrows of outrageous fortune' that can and do appear, temporarily, to predominate, from time to time, in our human lives. Following their global success in 'inventing and treating PTSD' shrink-dom now seeks formally to medicalise suicide, as psychiatry's latest potential money-spinning behavioural disorder. You wonder it took them so long, eh!

As a consultant in psychotherapy and suicidology (MSc 2001; PhD 2010), I have been careful to steer well clear of psychiatry. My seminal experience in the 1980s long before any professional interest developed in helping self & others, was to visit my unfortunate young relative in hospital (viz. a psychiatric unit) just as s/he was reacting, face twisted and contorted, to an over / under dose of some unidentified chemicals (viz drugs / medications). Sadly and tragically, the poor guy never seems to have experienced compassionate, person-centred psychological support: merely ineffective, prescribed medication, that may have poisoned her/him during my visit, and on subsequent occasions afterwards, no doubt, in my absence.

From that day forward, I swore never to go within reaching distance of biological psychiatry lest I was tempted to employ more action than conversation (pace Elvis) to express my humble opinion regarding its one-eyed 'medicating' strategy. I have noticed during the post 'peace process' period (1998-2015) that, in N Ireland / Ireland, some biological psychiatry is gradually and slowly being replaced by a more person-centred, compassionate psychotherapy, backed up by standard, general medical training and experience. This is welcome though far too long overdue. And too late for my relative (RIP). However, the balefully, heavyweight influences of DSM dogma and their mirror image ICD-10 2016 (see Chapter 5), continue to sit like thunder clouds over and above the helping professions, waiting to lightning-strike down any psychotherapist who has the audacity to stray from 'treatment as usual'.

Roll on 'a new paradigm' for helping the lethally vulnerable that substitutes knee-jerk, risk-laden, 'this might or might not work' chemical medication with a psychotherapeutic heart and soul, in our helping work with suffering clients.  

Philip O'Keeffe wrote:

Roll on 'a new paradigm' for helping the lethally vulnerable that substitutes knee-jerk, risk-laden, 'this might or might not work' chemical medication with a psychotherapeutic heart and soul, in our helping work with suffering clients.

The problem with this approach is that some clients can spend 25+ years going through various psychotherapeutic treatments without any relief.  Some of my recent publications are case studies of one subject.  She was acutely suicidal for more than 25+ years.  During that time she tried various psychotherapeutic approaches and none of them were successful in treating her suicidality.  She also tried many medications, none of them were successful in treating her suicidality until very recently when we happened upon a treatment that was effective and reduced her suicidality.  Prior to this new treatment her suicidality ranged from an average of 30 minutes a day up to 800 minutes a day on her worst days.  The treatment brought this all the way down to no suicidality at all.  She has been free from suicidality now for over a year.  This is in contrast to her prior 25+ years of suicidality when she was only free from suicidality for between 3 to 5 days at most, which only occurred 8 times in those 25+ years.

The idea that either the psychiatric approach or the psychotherapeutic approach has all of the answers for every patient is ridiculous.  Each and every patient is unique and all tools available should be used to treat them.  By strictly limiting yourself to one approach or another, you are doing a disservice to your patients.  I sincerely hope that your patients are cautioned that you seriously restrict your suggestions to only one approach and that they are going to be limited in the treatment suggestions and response you offer based upon your personal bias.  You may consider taking the psychotherapeutic approach and looking at your own biases which may be hindering your ability to offer the best treatment suggestions to your patients.

Philip:

Thank you for your comments. I think the problem with suicide is that it has been PSYCHOPATHOLOGIZED. I'm not sure if that occurred before/after psychiatry was (seemingly) delegated ownership of a phenomenon that isn't a psychiatric disorder, does not necessarily respond to psychiatric treatment, and for which mental illness is only one risk factor albeit one that receives the most attention. Moreover if suicide belonged in the realm of psychiatry why is it that until recently most psychiatrists only learned about suicide "on the job" and not in the classroom? If suicidality is a "biopsychosocial" condition why do we force at-risk persons into the "psycho" part? Philp is correct in calling for "a new paradigm." This is evident from the new theoretical models of suicide that assign minor roles to mental illness. Come the new paradigm we should move suicidality and those it affects out from under mental health and into the tentatively emerging interdisciplinary field of clinical suicidology. 

Hi Tony,

Great, mental illnesses may result in someone taking their own life, such as is found in paranoia sometimes. . Suicidal ideation may be involved in depression. We have used interviews and  inventories to find if   someone ever felt like taking their own life. However, this ideation can only be a sign that someone is depressed. There are other people who just want to die and if you give them a Mental State Exam you won't find that all these people have a mental illness. When we study this I think we firstly must differentiate between symptom and just wanting  to die.

Tony - I noted - with due respect - Kou Haykawa's novel 'answer' to suicide, described by Kou as a 'serious disease'. I can't say that - so far - I have followed up by investing the several hours needed to work through his biochemical, documentary attachments. To sum it all up, apparently it's all in the brain and hence a re-launch of the embryo 'brain chemistry' industry. Big Pharma will be keenly interested. Meanwhile 46,000 fellow humans died by suicide in USA (2017) while the quantum of US prescribed anti-D medications ballooned. In N Ireland we lost over 300 fellow citizens in 2017 (our population is 1.8 million). I hold to the view that psychotherapy is more likely than mood altering biochemical medication to support clients in addressing their personal raisons d'etre in the context of humanity's inevitable natural mortality. Interesting isn't it that in recent times, many 'psychiatrists' now prefer to refer to themselves as 'psychotherapists'. Greetings to all working to preserve life by reducing human suicidal behaviours. Philip O'Keeffe PhD