Thursday, May 23, 2019

Experts Argue for Addition of Suicide-Specific Diagnoses in DSM

A discrete, specific diagnosis of suicidal behavior disorder is included in DSM-5 Section III, which contains “conditions for further study.” Such a diagnosis could be enormously clinically useful, helping to identify at-risk patients for treatment and aiding in research on suicide, according to former APA President Maria A. Oquendo, M.D., Ph.D. (pictured at left), chair of the Department of Psychiatry at the University of Pennsylvania Perelman School of Medicine and a director on the National Board of the American Foundation for Suicide Prevention. She was the chair and a presenter at the Tuesday Annual Meeting session “The Argument for Suicide-Specific Diagnoses in the DSM.”

Inclusion of a diagnosis for suicidal behavior disorder would help solve a number of clinical and systemic problems associated with identifying patients at risk for suicide. Oquendo said that during an assessment, clinicians seek to make the primary diagnosis responsible for the chief complaint and use overview questions to identify comorbid conditions. If they do not find evidence for a major depressive episode or borderline personality disorder—two conditions for which DSM criteria specifically note a risk of suicide—questions about suicidal behavior may not be asked.

“While institutions today generally require suicide screening for psychiatric cases, many patients are seen in other settings that may not,” she said.

Moreover, since the Mental Status Examination targets the patients’ present condition, those denying suicidal ideation may not be asked about past suicidal acts, which results in underestimating the number of suicidality cases. In addition, current diagnostic algorithms may lead clinicians to overlook suicidal ideation or behavior in high-risk individuals, especially those with posttraumatic stress disorder or alcohol use disorder.

Most important, clinical studies demonstrate that suicide risk is often lost when patients are “handed off” in inpatient settings—that is, when a patient is passed from one treatment team or clinician to another. She also pointed out that electronic medical records encourage stilted, standardized patient descriptions, leading clinicians to rely more heavily on diagnostic codes in devising treatment plans.

Oquendo said the existence of a suicide-specific diagnosis would compel clinical and administrative structures to determine the suicide risk status of individuals assessed in psychiatric settings. “The presence of suicidal behavior can be documented in the medical record with the prominence that it deserves in written reports, allowing for treatment planning for vulnerable patients,” she said.

“For research purposes, a diagnosis would more reliably identify cases and controls or predictors of suicidal behavior in big-data analyses based on claims data or electronic medical records,” Oquendo added. “It would help to harness large cohorts with genomic and biologic data to study suicide and facilitate development of a registry to more accurately estimate the number of suicide attempters in specific cohorts to inform policy and prevention strategies.”

She was joined at the session by Igor Galynker, M.D., Ph.D., a professor of psychiatry at the Icahn School of Medicine at Mount Sinai, who described a proposal to include criteria for suicidal crisis syndrome in DSM. Thomas Joiner, Ph.D., a professor of psychology at Florida State University, outlined the case for creating the diagnosis of acute suicidal affective disorder. Both proposed diagnoses would be distinct from suicidal behavior disorder; they describe a discrete, highly acute and extremely high-risk pre-suicidal mental state marked by “frantic anxiety” and a feeling of entrapment, among other symptoms.

For related information, see the Psychiatric News article “Preventing Suicide Begins With Regular Assessments” and the book Clinical Manual for the Assessment and Treatment of Suicidal Patients, Second Edition, by APA Publishing.

(Image: David Hathcox)


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