Rethinking Suicidal Behavior Disorder

DSM-5 suicidal behavior disorder: a systematic review of research on clinical utility, diagnostic boundaries, measures, pathophysiology and interventions

Background

It has been a decade since Suicidal Behavior Disorder (SBD) was introduced in Section III of the DSM-5 under "Conditions for Further Study". SBD is chiefly characterized by a self-initiated sequence of behaviors believed at the time of initiation to cause one's own death and occurring in the last 24 months.

Aims

To systematically review empirical studies on SBD to identify primary research themes and promising future research directions.

Method

A search of empirical articles on SBD published between May 2013 and March 2023 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

Screening of 73 records by two independent raters yielded 14 eligible articles. The primary research themes identified from these articles included clinical utility of SBD to predict future suicide risk, association of SBD with closely related disorders, psychometric properties of SBD measures, pathophysiology of SBD, and the effectiveness of interventions for people with SBD.

Conclusion

Understanding of SBD has slowly progressed since its introduction a decade ago and has mainly been applied in research to define study groups displaying suicidal behavior. The clinical utility of SBD for predicting future suicide risk is low and more research is needed to understand measurement of the diagnosis and its distinctiveness from related disorders and other self-harming behaviors.

Factors Related to Suicidal Ideation by Gender and Age Group in Korean Adults

BACKGROUND

According to the results of the age-standardized suicide rate (suicide deaths per 100,000 population) published by Organization for Economic Cooperation and Development countries from 2003 to 2019, the suicide rate in Korea is ranked first almost every year, so it should be managed at the national level. To reduce the suicide rate, many scholars are studying suicide. The suicidal process begins with suicidal ideation, progresses through suicide attempts, and ends with suicide. Among them, the frequency of suicidal thoughts was found to be highly correlated with suicide plans and attempts, and it is said that 60% of those who change from suicidal ideation to attempts appear within one year. Therefore, research related to suicidal ideation to lower the suicide rate will contribute to preventing suicide at an early stage.

METHODS

This study used data from the Korea National Health and Nutrition Examination Survey (KNHANES). Among them, data from 2013, 2015, 2017, and 2019 surveyed adults were compared for suicidal ideation among 18,339 adults. Considering the characteristics of the KNHANES data, complex sample analysis was performed considering the primary extraction unit (region), stratification variables, and weights. The Rao-Scott χ² test was stratified by age group to confirm the distribution of suicidal ideation according to general characteristics. Univariate and multiple logistic regression analyses were performed to understand the effect on suicidal ideation.

RESULTS

Among all subjects, the rate of suicidal ideation was 4.75%, and among the age groups, the rate of suicidal thoughts was the highest among those over 80 years old (10.39%). Compared to those who were 50s, those in their 30s had the lowest suicidal ideation (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.39-0.70), and those in their 80s had the highest rate of suicidal ideation (OR, 1.97; 95% CI, 1.38-2.82). Except for those in their 20s, the rate of suicidal ideation tends to increase with age. Overall, the lower 25% of the Euro Quality of Life-5 Dimensions (EQ-5D) index, depression lasting more than two weeks, and subjects with poor subjective health or high stress were more likely to have suicidal ideation. In particular, EQ-5D Index (OR, 5.86; 95% CI, 3.73-9.20), depressive symptoms (OR, 19.65; 95% CI, 9.94-38.83) in 20s, and stress in 80s (OR, 10.87; 95% CI, 5.63-20.96) was the highest, and those had the good subjective health perception in 30s (OR, 0.10; 95% CI, 0.05-0.20) was lowest. Participants in their 30s, 40s, and 60s who were divorced or widowed and those in their 50s and 60s who had never married or lived together were more likely to consider suicide ideation. Except for those in their 20s and 80s, the rate of suicidal ideation tends to increase with lower household income levels.

CONCLUSIONS

In the results of this study, it can be seen that a combination of factors such as a person's personality traits, stress or coping ability to various events, social support, and mental or physical limitations influence suicidal behavior. Suicidal ideation is not simply affected by a single factor but may be influenced by multiple factors.

Major depression with co-occurring suicidal thoughts, plans, and attempts: An increasing mental health crisis in US adolescents, 2011-2020

This study aimed to examine national trends and disparities in the prevalence and treatment of adolescent 12-month major depressive episode (MDE) with co-occurring suicidal thoughts, plans, and attempts. Publicly available data for adolescents aged 12-17 in the 2011-2020 National Survey on Drug Use and Health were analyzed. Bivariate and multivariable logistic regression analyses were conducted. In 2011, 4.6%, 2.1%, and 1.7% of adolescents had 12-month MDE with co-occurring suicidal thoughts, plans, and attempts, and the prevalence increased steadily to 9.8%, 5.3%, and 3.5% in 2019, respectively. In 2011, 45% of adolescents with MDE and suicidal thoughts received any mental health treatment, and the prevalence increased slightly to 46.6% in 2019. Meanwhile, the prevalence of treatment use among adolescents with MDE and suicidal plans remained stable at below 54%. Lastly, the prevalence of treatment use increased significantly from 53.6% in 2011 to 60.8% in 2019 among those with MDE and suicidal attempts. Continued high prevalence and low treatment use were observed in 2020. Disparities in treatment use were found in older adolescents, adolescents without insurance, Hispanics, and Asians. Concerted efforts are needed to prioritize evidence-based interventions, enhance outreach to high-risk groups, and expand service provisions to underserved adolescents.

Suicidal ideation and mental health care: Predisposing, enabling and need factors associated with general and specialist mental health service use in France

BACKGROUND

Population-based studies have shown that less than one in two individuals reporting suicidal ideation also report past-year mental health service use. Only a few studies have looked at different types of providers consulted. There is a need to better understand the factors associated with different provider combinations of mental health service use in representative samples of individuals with suicidal ideation.

AIMS

The aim of the current study is to assess, using Andersen's model of healthcare seeking behaviors, the predisposing, enabling and need factors associated with type of mental health service use in adults with past-year suicidal ideation.

METHODS

Data were drawn from the 2017 Health Barometer survey, a representative sample of the general population aged 18 to 75 years, among whom 1,128 respondents had reported suicidal ideation in the past year were analyzed. Past-year outpatient mental health service use (MHSU) was categorized into mutually exclusive groups as no use, general practitioner (GP) only; mental health professional (MHP) only; and both GP and MHP. Multinomial regression analyses were used to model mental health service use as a function of predisposing, enabling and need factors.

RESULTS

Overall, 44.3% reported past-year MHSU and this was higher in females than males (49.0% vs. 37.6%). Prevalence of GP only use in the overall sample was 8.7%, consulting with GP and MHP was 21.3%, consulting with MHP only was 14.3%. Higher education was associated with increased MHP use. Residing in a rural area was associated with increased GP only use. Presence of a suicide attempt within the year, a major depressive episode and role impairment were associated with consulting a GP and MHP, and MHP only, but not GP only.

CONCLUSIONS

When controlling for need and predisposing factors, socio-economic factors related to employment and income were associated with higher levels of consulting with mental health professionals.

Exploring the Safety of a General Digital Mental Health Intervention to Effect Symptom Reduction among Individuals with and without Suicidal Ideation: A Secondary Analysis

Trials of digital mental health interventions (DMHIs) often exclude individuals with suicide-related thoughts and behaviors precluding an understanding of whether DMHIs for affective disorders are safe for, and perform similarly within, this high-risk group. We explore the safety and performance of a DMHI for depression in participants with and without suicidal ideation (SI) at baseline. Three hundred and one participants were included in this secondary data analysis from a trial of an 8-week DMHI comprising 14 smartphone apps. We found that SI decreased across the study among participants with baseline SI and that baseline SI status did not attenuate depression treatment effects. Through a case study of the IntelliCare platform, we find that DMHIs for general affective disorders can be safe.

How to save a life: From neurobiological underpinnings to psychopharmacotherapies in the prevention of suicide

The impact of suicide on our societies, mental healthcare, and public health is beyond questionable. Every year approximately 700 000 lives are lost due to suicide around the world (WHO, 2021); more people die by suicide than by homicide and war. Although suicide is a key issue and reducing suicide mortality is a global imperative, suicide is a highly complex biopsychosocial phenomenon, and in spite of several suicidal models developed in recent years and a high number of suicide risk factors identified, we still have neither a sufficient understanding of underpinnings of suicide nor adequate management strategies to reduce its prevalence. The present paper first overviews the background of suicidal behavior including its epidemiology, prevalence, age and gender correlations and its association with neuropsychiatric disorders as well as its clinical assessment. Then we give an overview of the etiological background, including its biopsychosocial contexts, genetics and neurobiology. Based on the above, we then provide a critical overview of the currently available intervention options to manage and reduce risk of suicide, including psychotherapeutic modalities, traditional medication classes also providing an up-to-date overview on the antisuicidal effects of lithium, as well as novel molecules such as esketamine and emerging medications and further molecules in development. Finally we give a critical overview on our current knowledge on using neuromodulatory and biological therapies, such as ECT, rTMS, tDCS and other options.

Hazards of Using Constant Observation With Suicidal Patients

Constant observation is a necessary albeit controversial procedure. Although widely used in psychiatric hospitals to maintain the safety of patients experiencing acute suicidality, constant observation is associated with many medicolegal hazards. Some hazards threaten patients directly, others undermine the effectiveness of treatment, and still others challenge clinical decision-making and suicide risk assessment. Nevertheless, clinicians can take proactive steps to minimize potentially adverse effects of constant observation on patients, preserve the integrity of treatment, and limit legal exposure.

Childhood trauma increases vulnerability to attempt suicide in adulthood through avoidant attachment

BACKGROUND

Childhood trauma and affective disorders are known risk factors for adult suicidal behavior. Studies have shown a mediating effect of insecure attachment on the effect of childhood trauma and suicidal behavior but so far it is not clear whether this effect is related to an attachment dimension (anxiety, avoidance).

AIM

The present study sought to examine the mediating effect of attachment anxiety and avoidance on suicidal behavior.

METHODS

We analyzed data on childhood trauma, attachment style, depression severity, presence of prior suicide attempts and current suicide ideation from 96 patients diagnosed with an affective disorder. Two mediation analyses were conducted to assess the effect of childhood trauma on 1) prior suicide attempts and 2) current suicidal ideation through its effect on attachment.

RESULTS

We found that childhood trauma had a complete mediated effect on the presence of prior suicide attempts through its effect on avoidant attachment (a1b1 = 0.0120, 95%-CI [0.0031, 0.0276]). However, only emotional abuse had a direct influence on suicidal ideation (c' = 0.0273, p < 0.01) without any indirect effect of anxious or avoidant attachment.

LIMITATIONS

Variables were not assessed in a prospective way and sample size was small.

CONCLUSIONS

Our findings suggest that individuals with avoidant attachment and childhood trauma are likely to present a high suicide risk. Since avoidant attachment is associated with altered perceptions and eventual rejection of social support, we recommend to screen for attachment early and to engage patients in therapeutical approaches focusing on the client-therapist alliance.

The revised suicide crisis inventory (SCI-2): Validation and assessment of prospective suicidal outcomes at one month follow-up

BACKGROUND AND AIM

The Suicide Crisis Syndrome (SCS) is an evidence-based pre-suicidal cognitive and affective state predictive of short-term suicide risk. The most recent SCS formulation, proposed as a suicide-specific DSM diagnosis, features a feeling of Entrapment accompanied by four additional symptom clusters: Affective Disturbance; Loss of Cognitive Control; Hyperarousal; and Social Withdrawal. The aim of the present study was to revise the Suicide Crisis Inventory (SCI; Barzilay et al., 2020), a self-report measure assessing the presence of the SCS,in accordance with the current SCS formulation, as well as to assess the psychometric properties and clinical utility of its revised version, the Suicide Crisis Inventory-2 (SCI-2).

METHODS

The SCI-2, a 61-item self-report questionnaire, was administered to 421 psychiatric inpatients and outpatients at baseline. Prospective suicidal outcomes including suicidal ideation, preparatory acts, and suicidal attempts were assessed after one month. Internal structure and consistency were assessed with confirmatory factor analysis, convergent, discriminant, and current criterion validity. Receiver-operating characteristic (ROC) curves with Area under the Curve (AUC) were used to examine the predictive validity of the SCI-2 to prospective outcomes. Exploratory analyses assessed the predictive validity of the five SCI-2 dimensions.

RESULTS

The SCI-2 demonstrated excellent internal consistency (Cronbach's α = 0.971), good convergent, discriminant, and current criterion validity. The SCI-2 significantly predicted all three outcomes, and was the only significant predictor of suicidal attempts with AUC = 0.883.

DISCUSSION

The results of this study indicate that the SCI-2 is a valid and reliable tool to assess the presence and intensity of the Suicide Crisis Syndrome and to predict short-term prospective suicidal behaviors and attempts among psychiatric outpatients and inpatients regardless of patients' readiness to disclose suicidal ideation.

Psilocybin, a Naturally Occurring Indoleamine Compound, Could Be Useful to Prevent Suicidal Behaviors

The available interventions for people who are at risk of suicide have limited efficacy. Recently, research on new mental health treatments has started to consider psychedelic compounds, particularly psilocybin, a molecule with a few thousand years of history of use in human societies. The possible effects of psilocybin on suicidal ideation and behaviors have not been specifically studied yet; however, the current knowledge on the suicidal process and the available data on es/ketamine suggest that psylocibin could be used to modulate the thoughts and behavioral patterns in individuals who are at risk of suicidal behaviors. Here, we summarize the available evidence on the possible mechanisms underlying psilocybin positive effects on suicide risk. Major pathways related to suicidal behaviors that might be modulated by psylocibin include serotonin receptors. Specifically, psylocibin directly stimulates the serotonin 2A receptor (5HT_2A), targeting the inflammatory and oxidative stress pathways and leading to a rapid increase in brain plasticity and inflammation suppression and increases in cognitive flexibility, spirituality, and empathy. We also present preliminary epidemiological data and provide a rationale for studying psilocybin in individuals with suicidal ideation or who are at risk of suicidal behaviors. This review presents a framework to understand the basis for psilocybin use in individuals who are at risk of suicidal behaviors and calls for clinical studies.

The role of suicide ideation in assessing near-term suicide risk: A machine learning approach

BACKGROUND

The majority of suicide attempters do not disclose suicide ideation (SI) prior to making an attempt. When reported, SI is nevertheless associated with increased risk of suicide. This paper implemented machine learning (ML) approaches to assess the degree to which current and lifetime SI affect the predictive validity of the Suicide Crisis Syndrome (SCS), an acute condition indicative of imminent risk, for near-term suicidal behaviors (SB ).

METHODS

In a sample of 591 high-risk inpatient participants, SCS and SI were respectively assessed using the Suicide Crisis Inventory (SCI) and the Columbia Suicide Severity Rating Scale (C-SSRS). Two ML predictive algorithms, Random Forest and XGBoost, were implemented and framed using optimism adjusted bootstrapping. Metrics collected included AUPRC, AUROC, classification accuracy, balanced accuracy, precision, recall, and brier score. AUROC metrics were compared by computing a z-score.

RESULTS

The combination of current SI and SCI showed slightly higher predictive validity for near-term SB as evidenced by AUROC metrics than the SCI alone, but the difference was not significant (p<0.05). Current SI scored the highest amongst a chi square distribution in regards to predictors of near-term SB.

CONCLUSION

The addition of SI to the SCS does not materially improve the model's predictive validity for near-term SB, suggesting that patient self-reported SI should not be a requirement for the diagnosis of SCS.

Differentiating genuine from feigned suicidality in corrections: A necessary but perilous task

Feigning suicidality is common among patients in correctional settings, but there has been little discussion on the differences between genuine and feigned presentations of suicidality. Differentiating suicidality from feigned suicidality is among the riskiest diagnostic challenges. Still, some headway can be made if we compare features of genuine suicidality with those of feigned presentations. To this end, I first describe a typical profile of suicidality. Next, I contrast it with the features that correctional patients who feign suicidality display in California's prison health care system. I also outline the dangers involved in identifying feigned suicidality, and I offer some ways in which to understand feigned suicidality in corrections.

Suicide in DSM-5: Current Evidence for the Proposed Suicide Behavior Disorder and Other Possible Improvements

Suicide continues to be one of the greatest challenges faced by mental health clinicians and researchers, an issue made worse by increasing trends in the global suicide rate. Suicide behavior disorder (SBD) was introduced in DSM-5 as a disorder for further consideration and potential acceptance into the diagnostic system. There are numerous positive developments that would arise from the addition of a suicide-related diagnosis. Utilizing the 2009 guidelines established by Kendler and colleagues, the present review examines the evidence for SBD's validity and discusses the diagnosis' potential clinical benefits and limitations. Altogether, growing evidence indicates that SBD has preliminary validity and benefit. SBD presents with several significant limitations, however, and possible alternative additions to future DSMs are highlighted.

Impulsivity and Suicidal Behavior

Suicide is the leading cause of injury mortality in the United States and the second-leading cause of death in people aged 10-34 years. While many long-term risk factors are known, the short-term prediction of suicidal behavior remains elusive. Many characteristics of suicidal behavior cut across diagnoses, but suicide is increased in recurrent psychiatric disorders, addictive disorders, and trauma-related disorders. Suicide results from the interaction of short-term and long-term behavioral regulation. The shorter the time-course of the mechanism, the closer it is to actual suicidal behavior, and the harder it is to prevent. We will discuss the manner in which impulsivity, a major determinant of short-term suicide risk, interacts with longer-term risk factors, especially sensitization to addictive or traumatic stimuli. Impulsivity predisposes to sensitization; in turn, impulsivity is a prominent component of sensitized behavior. Impulsivity can be described as a general pattern of behavior ("trait" impulsivity), as responses that are not conformed to their context (action-impulsivity), or as inability to delay reward or to take future consequences into account (choice-impulsivity). Each of these contributes to suicidal behavior. The neural mechanisms of impulsivity and sensitization are analogous, and sensitization can produce rapidly fluctuating patterns of impulsive behavior, arousal, and anhedonia. In order to recognize and prevent suicidal behavior, it is necessary to identify factors associated with susceptibility to bouts of impulsive behavior in people at elevated long-term risk.

Is suicidality a mental disorder? Applying DSM-5 guidelines for new diagnoses

Suicidality-specific diagnoses have been proposed recently, but suicidologists are only just beginning to evaluate their merits. To advance this discussion, I introduce the term suicidal syndrome to describe the underlying entity, present a rationale for why a formal diagnosis is necessary, define the major features of the syndrome, and show how the syndrome could meet the requirements for new diagnostic candidates used in the development of the DSM-5. Against this backdrop, I examine common objections to a suicidality-specific diagnosis. Finally, I discuss several challenges with the creation of new diagnostic entities as they apply to suicidal syndrome.

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide-specific diagnosis

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self-reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence-based components-entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre-suicidal mental state, regardless of their self-reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.