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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.
Most suicides occur in the context of psychiatric illnesses and approximately 60% are mood disorders; the rest include substance use and personality, eating, or psychotic disorders. Yet, most psychiatric patients never attempt suicide. Thus, suicide risk is best explained by a stress-diathesis model in which the diathesis encompasses clinical and biological characteristics that make the individual vulnerable.3 Greater subjective distress and impulsive/aggressive traits are diathesis elements. The former magnifies suicidal ideas triggered by internal stressors, such as depression, or external stressors, such as problems with relationships or employment. The latter increases the probability of acting on suicidal thoughts. Psychological autopsies also identify suicides with no detected psychiatric disorder. Such cases are uncommon in Western countries (12.7%) but more prevalent in countries like China, where up to 50% of suicides are reported to have no evidence of psychiatric diagnoses.4,5 A pronounced diathesis may result in suicide triggered by a stressor despite the absence of a psychiatric diagnosis.
Psychiatric Nosology and Suicidal Behavior
The existence of a diathesis for suicide answers the most fundamental objection to codifying suicidal behavior: suicide is merely a symptom of psychiatric diagnoses. However, there is a psychopathological domain associated with the diathesis for suicidal behavior apart from the psychopathology of the associated psychiatric illness. It is problematic that the current diagnostic system lists suicidal ideation or behavior as diagnostic criteria for only major depressive disorder and borderline personality disorder, implying that suicidal risk is relevant in very few psychiatric illnesses. Yet, psychological autopsy studies show suicide is associated with many different psychiatric diagnoses.4
A second objection to recognizing suicidal behavior as a diagnosis is that some suicides have no detectable psychiatric illness. The argument is that such suicides are culturally determined (eg, seppuku suicide in Japan) or carried out by individuals seeking relief from adverse experiences caused by a terminal illness through physician-assisted death. However, the DSM offers a cultural formulation interview for mental disorders to assist clinicians in assessing whether suicidal behavior is culturally determined. Seekers of physician-assisted death in the context of terminal illness and with the capacity to decide about their death would not be considered suicidal in a psychopathological sense. Those with a strong diathesis and a stressor would wrongly fall into these categories. Because approximately 12% of suicides in Western nations have no psychiatric disorder detected, it is critical not to assume cultural causes and thereby ignore the role of the diathesis, a potentially modifiable risk factor.
Finally, some argue that clinicians cannot distinguish between suicidal behavior and nonsuicidal self-injury. Self-injury can have many motivations. A person may self-harm to relieve severe anxiety or dysphoria (nonsuicidal self-injury), reverse a partner’s decision to end a relationship (instrumental self-injury), or end their life (suicidal behavior). Critically, intent to die is distinct from intent to self-injure. Thus, suicidal behavior cannot occur absent a specific mental experience: that of both suicidal ideation and suicidal intent. Certainly intentionality is sometimes difficult to assess, and patients are sometimes ambivalent about their intentions or deliberately seek to mislead the clinician and loved ones about their intentions.
The DSM-5 recognizes that pathophysiological mechanisms remain unclear for many disorders and many disorders share overlapping diagnostic criteria. Sometimes, pragmatic considerations associated with clinical, public health, and research use justify designating a set of symptoms as a distinct disorder. Such considerations bolstered the creation and inclusion of social (pragmatic) communication disorder in DSM-5.6 Given the burden of suicide, recognizing suicidal behavior as an independent, codable construct offers the benefits of harmonizing clinical and research reporting and improving the detection and documentation of risk factors in large data sets. Such valuable data may aid clinicians caring for individuals at the highest risk for suicide: those with past suicidal behavior. The solution should involve a new DSM category for suicidal behavior in the main section (Section II) of the DSM-5.
Were a separate DSM category to be developed for suicidal behavior, a similar process for the International Classification of Diseases, 11th Revision (ICD-11) would be essential. In ICD-11, suicidal behavior is listed outside the chapter on mental, behavioral, or neurodevelopmental disorders. Intentional injury and self-harm, including suicide and self-mutilation, are listed in chapter 23 entitled “External Causes of Morbidity or Mortality.” As well, nonsuicidal self-injury, suicide attempt, and suicide behavior are listed in chapter 21 entitled “Symptoms, Signs, and Clinical Findings not Elsewhere Classified.” Alignment of DSM and ICD would be imminently attainable.
Nosological change is necessary as new scientific evidence emerges. For example, when a discrete genetic marker is identified for a particular condition, such as Rett syndrome, that condition is removed from the DSM. Likewise, new categories, such as autism spectrum disorder, may subsume old ones as evidence reveals the dimensional, interconnected characteristics of existing, independent constructs. A new category for suicidal behavior would capture the ontology of what has been historically considered a complication of psychiatric illness and acknowledge that suicidal behavior is an entity independent from the associated psychiatric disorders. An instructive parallel is the evolution of the association between sleep disturbances and major depressive disorder in DSM-5. Evidence that sleep disturbances would resolve with the treatment of depression did not materialize. Consequently, hypersomnia and insomnia are now recognized not simply as symptoms of depression but also as distinct disorders requiring focused treatment and research. Risk for suicidal behavior is analogous. It may not remit with depression treatment. It deserves explicit attention.
We therefore recommend, at a minimum, the creation of a specific code for suicidal behavior similar to the ICD codes for suicide attempt. Although the DSM-5 includes codes for economic, lifestyle, and relationship problems, it includes no such codes for suicidal behavior. This code would aid in clarifying diagnoses that co-occur with suicidal behavior and identifying suicidal behavior involving no obvious psychiatric comorbidity. Optimally, suicidal behavior should be officially recognized in psychiatric nosology as an independent, codable entity and as a distinct diagnostic category in the DSM-5 and ICD-11. As a distinct diagnosis, the rationale for research to develop interventions for individuals who have suicidal thoughts, including targeting its diathesis, would be bolstered. Such action may help to reverse the 18-year steady increase in US suicide rates.
Corresponding Author: Maria A. Oquendo, MD, PhD, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market St, Ste 200, Philadelphia, PA 19104 (email@example.com).
Published Online: March 18, 2020. doi:10.1001/jamapsychiatry.2020.0111
Conflict of Interest Disclosures: Dr Oquendo reported support from the Research Foundation for Mental Hygiene with royalties paid, family-owned stock in Bristol Myers Squibb, and shares in Mantra Inc. No other disclosures were reported. Dr Sisti acknowledges the support of the Thomas Scattergood Behavioral Health Foundation.
Additional Contributions: We thank the reviewers and Darrel Regier, MD, MPH, Center for the Study of Traumatic Stress, for their invaluable feedback. They were not compensated for their contributions.
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Sisti D, Mann JJ, Oquendo MA. Toward a Distinct Mental Disorder—Suicidal Behavior. JAMA Psychiatry. Published online March 18, 2020. doi:10.1001/jamapsychiatry.2020.0111
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