August 1, 2011

Suicide Behavior to Be Included as a DSM-5 Diagnosis

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Paul King, MD

Parkwood Behavioral Health System, Olive Branch, Mississippi


The DSM-5 Mood Disorders Work Group is looking into including suicide behavioral disorder (SBD) in the forthcoming DSM-5.1 The goal of including this diagnosis is to increase awareness of the need to improve clinicians’ ability to recognize risk factors for suicide. Certainly, clinicians who routinely deal with suicidal patients understand that statements such as “patient denies suicide” are worthless. Furthermore, a “contract” to disclose becoming suicidal has little to no value. However, clinicians still unfortunately use such terms in the evaluation of patients in danger of suicide, and this important issue certainly still needs to be addressed.

The FDA became involved in examining suicide when its Psychopharmacologic Drug Advisory Committee, in 2006, conducted its own meta-analysis and reviewed controlled clinical trials of antidepressants.2 The FDA used the term “suicidality” and issued a revised black box warning for all antidepressants in 2007 with special attention given to children, adolescents, and young adults. We are all aware of the confusion this created about the use of antidepressant medications. The warning applies to patients of all ages.

A recent longitudinal study2 was done using 757 affective disorder patients spanning 27 years across 5 academic medical centers. The patients were initially enrolled during an episode of mania, depression, or schizoaffective disorder. Patients were 17 years of age or older. This study concluded that antidepressants reduced the risk of suicidal behavior.

We currently have an excellent tool for evaluating suicide risk. The Columbia-Suicide Severity Rating Scale (C-SSRS)3 examines elements of ideation, as well as self-injurious behavior. This scale is currently being used in all clinical trials that test new psychopharmacological agents. Phase III investigators are trained or have to demonstrate recent training in the use of the C-SSRS.

As a profession, we need to take control of assessing patients for suicide risk and develop criteria that we can use in our work with patients. Assessment of suicide across the diagnostic spectrum can be done and the tools are already in existence. The government (FDA) will assess suicide for us unless we demonstrate greater competence in keeping our patients safe. Does psychiatry or the government address this issue?

Financial Disclosure:Dr King had no relevant personal financial relationships to report.


1. Otto MA. Suicidal behavior disorder diagnosis gaining favor: DSM-5 work group thinks stand-alone diagnosis might help increase emphasis on suicide prevention. Clinical Psychiatry News Digital Network. May 1, 2011. Accessed July 20, 2011.

2. Leon AC, Solomon DA, Li C, et al. Antidepressants and risks of suicide and suicide attempts: a 27-year observational study. J Clin Psychiatry. 2011;72(5):580–586.

3. Columbia University Medical Center. Columbia-Suicide Severity Rating Scale (C-SSRS): Scales for clinical practice. Accessed July 19, 2011. ​

Category: Depression , Mental Illness , Schizophrenia
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