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March 18, 2020

Toward a Distinct Mental Disorder—Suicidal Behavior

Author Affiliations
  • 1Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2New York State Psychiatric Institute, Department of Psychiatry, Columbia University, New York
  • 3Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Psychiatry. 2020;77(7):661-662. doi:10.1001/jamapsychiatry.2020.0111

In 2017, there were 47 173 suicides in the US.1 The Surgeon General’s 2012 National Strategy for Suicide Prevention2 articulated strategies for addressing this epidemic, which included increased access to psychiatric services, restricting access to lethal means, and increasing resources for suicide prevention research, including proposed harmonized coding and methods to improve suicide-related data and their use. This last strategy could be addressed by recognizing suicidal behavior as an independent construct that would harmonize clinical and research data and permit the leveraging of large health-related databases to discover clinical and biological markers of imminent and longer-term suicide risk.

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    3 Comments for this article
    Suicide as a Distinct Disorder: More Than a Diagnostic Call for Change
    Jack Lennon, M.A | Adler University; Rush University Medical Center
    Sisti and colleagues should be commended for confronting psychiatric nosology in the context of suicidal behavior.[1] It is important that diagnostic criteria and the utilization of terminology evolve to conform to the evidence. This particular body of evidence strongly suggests that suicide is not simply a resultant cause of death due to depression or other psychiatric disorders known to increase risk. Instead, suicide may very well be a unique trajectory that not only contributes to the heterogeneity of Major Depressive Disorder (MDD)[2] amidst our current diagnostic classification but exhibits neuroscientific and -cognitive distinctions. As noted by the authors, these alterations would behoove research efforts aiming to develop interventions as well as secondary and tertiary prevention methods.

    Psychiatric nosology is a critical component of moving toward a universal acceptance of a stress-diathesis model of suicide. It is recognized that Sisti et al[1] have laid the foundation for a clinical paradigm shift. For example, it would no longer be necessary to minimize or undermine a presentation with a sole MDD diagnosis and briefly assess for active suicidality. Doing so, particularly in the absence of reported intent, may prolong situations without further interventions. Suicide would be accompanied by the known risk factors, as well as risk-taking, reduced global decision-making capacity,[3] and other known distinguishing features. These patients would be treated based on the comorbidity, whether this is MDD or Borderline Personality Disorder (BPD), but placing suicide at the forefront would revivify the utility of clinical judgment. This judgment would suggest that BPD is commonly associated with suicide attempts but less with suicide deaths,[4] while an MDD presentation may suggest that attempt risk may be lower unless NSSI or other major risk factors are present.[5]

    Ultimately, while coding suicidal behavior would be helpful, a strong diagnostic classification is warranted given the literature available at-present. Findings related to the serotonergic system, white matter integrity and hyperintensities, resting-state functional connectivity, and other molecular and neuroimaging findings suggest that we are on the brink of discovering reliable methods to distinguish between suicide ideators, attempters, and those who will die by suicide. This would be a remarkable achievement, but one that is feasible through incorporation of neurocognitive tools at our disposal as proxy measures for biomarkers. A simple paradigm shift could remove suicide from the top ten causes of death and, further, induce a decline in the rising death rates.

    [1] Sisti D, Mann JJ, Oquendo MA. Toward a distinct mental disorder – suicidal behavior [published online March 18, 2020]. JAMA Psychiatry.
    [2] Sanacora G. Is this where we stand after decades of research to develop more personalized treatments for depression? [published online February 19, 2020]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2019.4764
    [3] Jollant F, Bellivier F, Leboyer M, et al. Impaired decision making in suicide attempters. Am J Psychiatry 2005;162(2):304-310.
    [4] Soloff PH, Chiappetta L, Prospective predictors of suicidal behavior in borderline personality disorder at 6-year follow-up. Am J Psychiatry 2012;169(5):484-490.
    [5] Knorr AC, Tull MT, Anestis MD, Dixon-Gordon KL, Bennet MF, Gratz KL. The interactive effect of major depression and nonsuicidal self-injury on current suicide risk and lifetime suicide attempts. Arch Suicide Res 2016;20(4):539-552.
    An Invitation to Change
    bill Lang, PhD, Psych, Retired | none now
    I won’t go into a discussion of the somewhat convoluted and inaccurate foundations of the need for a change offered in this proposal. I will just start by agreeing that there is a nosology problem, more or less, of the type described and that time for change is long overdue.

    The solution, however, is not to define the problem away and go back to idea from the dark dark ages by making suicide even more of a mental health issue. I challenge the authors—and I suspect many readers—to think anew. To suggest a definition of suicide that
    is not stigmatizing and invites all kinds of approaches to help reduce suicide harm including that of current members of the psychiatric, medical and behavioural paradigm from which the article’s proposal originates.

    Try this perspective. Suicide is part of the human condition. It is an awareness of a choice or option that tends to arise in a person’s life when they question the value of living and/or their ability to meets its challenges. The issues related to the shift in focus to suicide are very idiosyncratic but it may be helpful to note that they could be about faith, social support, interpersonal support, the state of the environment, community optimism, existential crisis, economic concerns, cognitive functioning, bio-chemical imbalances and many more. It is always instructive to me to recall a person telling me, plain and simple, that they have no place to sleep safely tonight and they cannot take that anymore. If you treat people with respect, focus on encouraging their autonomy and decision making, you will soon discover the wisdom of the old adage, “there but for grace of god go I.” There is nothing disordered about this process. It is a highly individualized tale of pain, suffering and turmoil that requires our understanding and empowering help, not our judgement, labeling, and condemnation.

    The requirement of this proposal that genetic markers of a suicide-related diathesis can be found is at best wishful thinking. The idea that stress is any less idiosyncratic than suicide is similar but already known. This is proposal is a dead end and will serve no purpose but to further label the psychiatric, medical and behavioural paradigm as a suspect source of help for suicide. There are ways to help people keep safe from the harm of suicide for now. There are ways to help people work through their issues to find new competence and a re-vitalized life. There are ways to help people make meaning out of loss from suicide and find new directions. There are ways to help communities become suicide-safer and more life enhancing. And, there are ways to increase community willingness and readiness to embrace these challenges. Join in.
    CONFLICT OF INTEREST: Former designer for LivingWorks Education
    Genetic results support suicidal behaviours as a distinct diagnostic category
    Marcus Sokolowski, Ph.D., Ass. Prof | National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP), Karolinska Institute, Stockholm, Sweden
    We (M.S. and Prof. Danuta Wasserman) support the proposal by the author’s, as viewed from the experience of having studied the genetics of suicidal behaviours (SB). Also in Sweden, many suicides have occured in the absence of any coexisting psychiatric disorder and a previous lifetime suicide attempt (SA) is the greatest risk factor for a future suicide [1]. SB has a heritability of 30-55% and involves genetic components which are separate from other diagnoses [2]. But the required large scale genetic research is made difficult due to lack of more detailed and consistent descriptions of the SB or SA, e.g. the intent, which are of particular importance given the heterogeneity of suicidal phenomena [3,4]. The success of such research highly depends on that subjects can be correctly classified, as recognized in e.g. the research on major depression [5]. In our own studies, we utilize a sample wherein most subject do not have any coexisting psychiatric disorder, and more detailed information about the SB per se helped to resolve genetic associations [6-9]. In a recent review of the literature, we also find that there are forty specific genes which are uniquely implicated in SB, rather than psychiatric diagnoses, which also show distinct expression patterns during neurodevelopment [10]. To enable increased understanding about the stress-vulnerability in various forms of SB, a comprehensive diagnostic category of these tragic outcomes among the patients is needed, regardless if they have or lack coexisting psychiatric disorders.

    1. Tidemalm D, Langstrom N, Lichtenstein P, Runeson B. Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up. BMJ. 2008;337:a2205.
    2. Voracek M, Loibl LM. Genetics of suicide: a systematic review of twin studies. Wien Klin Wochenschr. 2007;119(15-16):463-475.
    3. Schild AH, Pietschnig J, Tran US, Voracek M. Genetic association studies between SNPs and suicidal behavior: a meta-analytical field synopsis. Prog Neuropsychopharmacol Biol Psychiatry. 2013;46:36-42.
    4. Sokolowski M, Wasserman J, Wasserman D. Genome-wide association studies of suicidal behaviors: a review. European Neuropsychopharmacology. 2014;24(10):1567-1577.
    5. Schwabe I, Milaneschi Y, Gerring Z, et al. Unraveling the genetic architecture of major depressive disorder: merits and pitfalls of the approaches used in genome-wide association studies. Psychol Med. 2019;49(16):2646-2656.
    6. Ben-Efraim YJ, Wasserman D, Wasserman J, Sokolowski M. Gene-environment interactions between CRHR1 variants and physical assault in suicide attempts. Genes Brain Behav. 2011;10(6):663-672.
    7. Ben-Efraim YJ, Wasserman D, Wasserman J, Sokolowski M. Family-based study of AVPR1B association and interaction with stressful life events on depression and anxiety in suicide attempts. Neuropsychopharm. 2013; 38(8):1504-1511.
    8. Sokolowski M, Wasserman J, Wasserman D. Polygenic associations of neurodevelopmental genes in suicide attempt. Mol Psychiatry. 2016; 21(10):1381-1390.
    9. Sokolowski M, Wasserman J, Wasserman D. Gene-level associations in suicide attempter families show overrepresentation of synaptic genes and genes differentially expressed in brain development. Am J Med Genet B Neuropsych Genet. 2018;177(8):774-784.
    10. Sokolowski M, Wasserman D. Genetic origins of suicidality? A synopsis of genes in suicidal behaviours, with regard to evidence diversity, disorder specificity and neurodevelopmental brain transcriptomics. Eur Neuropsychopharmacology. 2020:In press.