Suicidal Behavior E-Book

Richard McKeon

• Herausgeber: Hogrefe Publishing
• Kategorie: Geisteswissenschaft
• Serie: Advances in Psychotherapy – Evidence-Based Practice
• Sprache: Englisch

Seitenzahl: 316

Veröffentlichungsjahr: 2022

Beschreibung

A new edition with the latest approaches to assessment and treatment of suicidal behavior With more than 800,000 deaths worldwide each year, suicide is one of the leading causes of death. The second edition of this volume incorporates the latest research, showing which empirically supported approaches to assessment, management, and treatment really help those at risk. Updates include comprehensively updated epidemiological data, the role opioid use problems, personality disorders, and trauma play in suicide, new models explaining the development of suicidal ideation, and the zero suicide model. This book aims to increase clinicians' access to empirically supported interventions for suicidal behavior, with the hope that these methods will become the standard in clinical practice. The book is invaluable as a compact how-to reference for clinicians in their daily work and as an educational resource for students and for practice-oriented continuing education. Its reader-friendly structure makes liberal use of tables, boxed clinical examples, and clinical vignettes. The book, which also addresses common obstacles in treating individuals at risk for suicide, is an essential resource for anyone working with this high-risk population.

Leseprobe

Advances in Psychotherapy – Evidence-Based Practice, Volume 14

Suicidal Behavior

2nd edition

Richard T. McKeon

Former Clinical Division Director, American Association of Suicidology

About the Author

Richard T. McKeon, PhD, MPH, received his doctorate in clinical psychology from the University of Arizona, and a master of public health degree in Health Administration from Columbia University. He has spent most of his career working in community mental health, including 11 years as director of a psychiatric emergency service and 4 years as associate administrator/clinical director of a hospital-based community mental health center in Newton, New Jersey. He established the first evidence-based treatment program for chronically suicidal borderline patients in the state of New Jersey utilizing Marsha Linehan’s Dialectical Behavior Therapy. In 2001, he was awarded an American Psychological Association Congressional Fellowship and worked for US Senator Paul Wellstone, covering health and mental health policy issues. He spent 5 years on the Board of the American Association of Suicidology as Clinical Division Director and has also served on the Board of the Division of Clinical Psychology of the American Psychological Association. He is currently Chief of the Suicide Prevention Branch for the Substance Abuse and Mental Health Services Administration in the US Department of Health and Human Services. In 2009, he was appointed by the Secretary of Defense to the Department of Defense Task Force on Suicide Prevention in the Military. He also serves as Co-Chair of the Federal Working Group on Suicide Prevention and participated in the development of the World Suicide Report for the World Health Organization

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, Saybrook University, Oakland, CA

Associate Editors

Jonathan S. Comer, PhD, Professor of Psychology and Psychiatry, Director of Mental Health Interventions and Technology (MINT) Program, Center for Children and Families, Florida International University, Miami, FL

J. Kim Penberthy, PhD, ABPP, Professor of Psychiatry & Neurobehavioral Sciences, University of Virginia, Charlottesville, VA

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a reader-friendly manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work and an ideal educational resource for students as well as for practice-oriented continuing education.

The most important feature of the books is that they are practical and easy to use: All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Continuing Education Credits

Psychologists and other healthcare providers may earn five continuing education credits for reading the books in the Advances in Psychotherapy series and taking a multiple-choice exam. This continuing education program is a partnership of Hogrefe Publishing and the National Register of Health Service Psychologists. Details are available at https://www.hogrefe.com/us/cenatreg

The National Register of Health Service Psychologists is approved by the American Psychological Association to sponsor continuing education for psychologists. The National Register maintains responsibility for this program and its content.

Library of Congress of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2021944412

Library and Archives Canada Cataloguing in Publication

Title: Suicidal behavior / Richard T. McKeon, former Clinical Division Director, American

Association of Suicidology.

Names: McKeon, Richard T., author.

Series: Advances in psychotherapy--evidence-based practice ; v. 14.

Description: 2nd edition. | Series statement: Advances in psychotherapy--evidence-based practice ;

volume 14 | Includes bibliographical references.

Identifiers: Canadiana (print) 20210314818 | Canadiana (ebook) 20210314974 | ISBN 9780889375062

(softcover) | ISBN 9781616765064 (PDF) | ISBN 9781613345061 (EPUB)

Subjects: LCSH: Suicidal behavior—Prevention. | LCSH: Suicidal behavior—Treatment.

Classification: LCC RC569 .M41 2021 | DDC 616.85/8445—dc23

© 2022 by Hogrefe Publishing

www.hogrefe.com

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

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ISBN 978-0-88937-506-2 (print) • ISBN 978-1-61676-506-4 (PDF) • ISBN 978-1-61334-506-1 (EPUB)

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|v|Acknowledgments

I would like to acknowledge all those who have made this book possible, including the publisher, Hogrefe Publishing, and all the staff who contributed to this effort. I would especially like to thank series editor Danny Wedding for supporting the 2nd edition of this book on suicidal behavior in the series Advances in Psychotherapy – Evidence-Based Practice. His guidance and assistance during the development of this manuscript was invaluable. I would also like to thank Robert Dimbleby at Hogrefe Publishing for his support and encouragement over the years.

It is of particular importance for me to express my gratitude to all those who have shared their stories, their pain, and their hopes with me over the years, including all those I have worked with in community mental health and all those who have shared their stories with me across the country. All that I know I learned from them. To all the colleagues I have worked with to prevent suicide, whether we have worked together in emergency rooms or on conference calls, in therapy groups or in symposiums, thank you for sustaining me in our shared vision of reducing the tragic loss of lives to suicide. I must also acknowledge all those I have met who have survived the loss of a loved one to suicide, but who have utilized their grief to insist we must do better, and in so doing have transformed the priorities of a nation.

Finally, this book would not have been possible without the support of my family. I would like to thank my wife, Liz, for her advice, love, editing, and encouragement, my daughters Britt and Shauna, my niece Katie and nephew Michael, and my grandchildren Samantha and Teddy, who are my sources of hope for the future.

Disclaimer

All opinions expressed in this book are those of the author alone and do not represent the views of the Substance Abuse and Mental Health Services Administration.

Dedication

This book is dedicated to the memory of my sister Kathy, who taught me how important it is to fight for every hour of life.

Contents

Acknowledgments

Disclaimer

Dedication

1 Description

1.1 Terminology

1.2 Definition

1.3 Differential Diagnosis

1.4 Epidemiology

1.5 Course and Prognosis

1.6 Comorbidities

1.7 Assessment Procedures

2 Theories and Models of Suicidal Behavior

2.1 Neuropsychiatric Theories

2.2 Psychological Theories

3 Risk Assessment and Treatment Planning

3.1 Assessing Suicide Risk and Protective Factors

3.2 Estimating Suicide Risk Level

3.3 Resolving Contradictory Risk Factors

3.4 Understanding the Time Dimension of Suicide Risk

3.5 Documenting Suicidal Risk

4 Treatment

4.1 Methods of Treatment

4.1.1 Multiphase Models

4.1.2 Orientation and Engagement

4.2 Crisis Intervention and the Management of Acute Risk

4.2.1 Assuring Telephone Accessibility After Hours

4.2.2 Suicide Prevention Hotlines

4.2.3 Emergency Appointment Capability

4.2.4 Use of the Emergency Department (ED)

4.2.5 Psychiatric Emergency Services

4.2.6 Involuntary Hospitalization and the Use of the Police

4.2.7 Use of Mobile Crisis Outreach Services

4.3 Safety Planning

4.3.1 Involving Family and Friends

4.3.2 Means Restriction

4.3.3 Safety Planning Versus No-Suicide Contracts

4.4 Treatment Techniques

4.4.1 Treatment Targets

4.4.2 Skills Training

4.4.3 Self-Monitoring/Homework Assignments

4.4.4 Cognitive Interventions

4.4.5 Exposure Treatment

4.4.6 Reducing Perceived Burdensomeness

4.4.7 Failed Belongingness

4.4.8 Bibliotherapy and Online Sources

4.4.9 Outreach and Follow-Up

4.4.10 Postvention

4.5 Mechanisms of Action

4.6 Efficacy and Prognosis

4.7 Variations and Combinations of Methods

4.7.1 The Zero Suicide Model

4.7.2 Medication and Psychotherapy

4.7.3 Working With Families

4.7.4 Treatment of Adolescents

4.7.5 Individual and Group Treatment

4.8 Problems in Carrying Out the Treatments

4.8.1 Problems in Communication and Information Gathering

4.8.2 Problems in Continuity of Care

4.8.3 Problems in Initial Risk Assessment

4.8.4 Problems in Collaboration

4.9 Multicultural Issues

5 Case Vignette

6 Case Example

7 Further Reading

8 References

9 Appendix: Tools and Resources

|1|1Description

Suicide is a tragic end to an individual’s life, a devastating loss to families and friends, a diminishment of our communities, and a public health crisis around the world. For clinicians, losing a patient to suicide is probably our worst fear. In 2018, over 48,000 Americans died by suicide (CDC, 2021) and suicide rates have increased in 49 of the 50 states (Stone et al., 2018). Worldwide, it is estimated 800,000 people die by suicide each year, more than are lost to homicide or to war (WHO, 2019b), leading the World Health Organization to issue the first world suicide report, Preventing Suicide: A Global Imperative (WHO, 2014), urging nations around the globe to adopt national suicide prevention strategies and programs. In addition, self-inflicted injury is estimated to account for 1.4% of the total burden of disease worldwide (World Federation for Mental Health, 2006). Yet, despite the magnitude of these losses, or perhaps because of the depth of our distress and uncertainty when confronted with acts of deliberate self-destruction, we have tended as a society to look away and not grapple with the issue of suicidal behavior, despite the tragic toll it exacts.

Kay Redfield Jamison has eloquently stated that in dealing with suicide, “The gap between what we know and what we do is lethal” (Jamison, 1999). In the two decades since Dr. Jamison wrote these words, we have learned much more, yet the lethal gap continues. In Night Falls Fast, her first-person account of her struggles with intense suicidal urges, she emphasizes the powerful link between mental illness and suicide, and the disturbing reality that the majority of those who die by suicide have never received mental health treatment (Jamison, 1999). Despite the fact that we know how to treat successfully many of the conditions that are risk factors for suicide, such as depression, substance abuse, and bipolar illness, so many of those who die by suicide never receive such treatment for these disorders (Luoma et al., 2002). When they do receive treatment, often this treatment does not focus on their suicidality, despite clear evidence that such a focus reduces suicidal behavior.

While the gap between what we know and what we do is undoubtedly lethal, there is still much more that we need to know. For, example, we do not have controlled trial research that confirms that inpatient treatment is effective in preventing suicide, let alone under what circumstances hospitalization might be effective. We lack this knowledge even though reliance on inpatient hospitalization is a cornerstone of how almost all mental health systems respond to suicidal individuals. The face of inpatient psychiatric care in the US has drastically changed overtime and in a Cochrane systematic review published in 2014 high income countries around the world the lengths of stay for people with serious mental illness were found to have been reduced drastically |2|(Babalola et al., 2014) This has amounted to a major, uncontrolled experiment in how we treat suicidal people, yet we know little about the impact such massive changes have had. In addition, despite the fact that involuntary hospitalization laws across the United States utilize the concept of imminent risk, the research on acute risk factors for suicide measures risk in months, not in hours or days (Simon, 2006). While the emerging literature on predictive analytics for suicide is encouraging, it also speaks to suicide risk in months (Kessler et al., 2015). Predictive analytics may be most helpful by identifying those who are at significantly lower risk of suicide, and those who may become suicidal months in the future, rather than identifying those who will die by suicide in the coming hours or days. Simon (2006) has characterized imminent risk prediction as an illusion. Because of this, Hogan (personal communication, February 2020) has argued that we should stop chasing the illusion of individual prediction and focus instead on improving care for groups identified as at elevated risk. Just as cardiology focuses less on predicting when an individual will die from a heart attack, and more on focusing on reducing risk in high-risk groups, so too should mental health focus on improving care and intervention using the accumulating evidence we now have for groups who have been identified as being at elevated risk.

We also need to know much more about how to successfully engage at risk people in treatment. The Utah Youth Suicide study showed that even though 44% of youth who died by suicide and had received psychiatric diagnoses had been prescribed psychotropic medication, upon autopsy none

of the youth were found to have either therapeutic or sub-therapeutic medication levels (Moskos et al., 2005), In the United States, the National Violent Death Reporting System has shown that while approximately half of women who die by suicide are receiving some type of mental health treatment, more than 70% of men are not (Niederkrotenthaler et al., 2014). Given the preponderance of suicides among males in the United States as well as in many other countries (Kapur & Goldney, 2019), this leads to the need to better understand what drives help seeking among men, particularly for mental healthcare and particularly when the depth of pain leads to suicidal thoughts or behaviors. This likely involves both men’s interpretation of their own experience of suicidality as well as their views about the kind of help is available and its potential for alleviating their pain. How people at risk for suicide respond not only to the interventions we have but the way they can be accessed, and how we can promote collaborations to stay safe are also critical issues.

The field of suicide prevention has begun to advance the state of knowledge by examining the full range of suicidal behavior as an outcome variable, rather than focusing exclusively on deaths by suicide. Demonstrating reductions in deaths by suicide in controlled trials is very challenging because the number of participants in the study needs to be extremely large. For example, a WHO study that demonstrated reduction in death by suicide by an emergency room intervention and follow-up with those who had attempted suicide had 1,867 participants from five different countries (Fleischmann et al., 2008). Because suicidal ideation and attempts are much more common than death by suicide, research demonstrating the effectiveness of interventions are much more feasible. Both treatment and prevention studies have demonstrated reductions in suicide attempts (Allmon et al., 1991; |3|Aseltine & DeMartino, 2004; Brown et al., 2005; May et al., 2005). While some would argue that those who die by suicide are a very different population from those who attempt suicide, and that therefore findings based on research on suicide attempters cannot be generalized to those who die by suicide, research that highlights both the subsequent mortality and morbidity associated with suicide attempts (Beautrais, 2004) supports the importance of research focused on this population. Further, even though suicidal ideation by itself is not considered to be a strong predictor of death by suicide given that the overwhelming majority of people who think about killing themselves do not go on to die by suicide, suicidal ideation is invariably associated with intense pain and despair and such suffering deserves effective treatment in its own right. Suicidal ideation, suicide attempts, and death by suicide are closely linked clinical phenomenon even if they are found in overlapping and not identical populations. Only by considering suicidal ideation, suicide attempts and death by suicide together do we see the true scope and impact of suicidality nationally and worldwide.

Advances in violence research focusing on imminent and near-term risk have taken place in part because of a willingness to look at violent behavior as a continuum, rather than focusing solely on homicide. As a result, findings with significant clinical implications, such as the ability to assess the risk of violent behavior on inpatient units at the time of hospital admission (McNiel et al., 2003), have occurred in violence research. Such findings in the violence risk literature suggest that while evidence identifying imminent risk for suicidal behavior may now be lacking, it may be possible to obtain this evidence, particularly if we include all suicidal behavior and not only fatal suicidal behavior.

Additional research has demonstrated reductions in suicidal thinking or in suicidal intent (Bruce et al., 2004; Gould et al., 2007). While reducing suicidal ideation or intent certainly does not assure a concomitant reduction in suicide attempts or in death by suicide, such cognitive phenomena are clearly very meaningful intermediate variables as they are very likely preconditions for suicide attempts or death by suicide.

The failure in the past, both nationally and internationally, to focus on suicide prevention has thankfully been changing. In a study of nations implementing national suicide prevention strategies, Lewitzka and colleagues (2019) showed a statistically significant decline in suicide in Norway, Sweden, Finland, and Australia compared to control countries. The decline was strongest in males, particularly ages 25–44 years and 45–64 years.

In 2001, the US Department of Health and Human Services, on behalf of a coalition of federal agencies and private nonprofit organizations, issued the National Strategy for Suicide Prevention (NSSP). In 2012, to capitalize on advances in suicide prevention over the past decade, a revised National Strategy for Suicide Prevention was released by the Office of the Surgeon General and the National Action Alliance for Suicide Prevention (US Department of Health and Human Services, 2012). WHO released its first suicide report, Preventing Suicide: A Global Imperative, in 2014, which called on nations to develop national programs or strategies for suicide prevention and highlighted efforts in nations as diverse as Japan, Scotland and Chile (WHO, 2014b). The Substance Abuse and Mental Health Services Administration |4|(SAMHSA) has released a report assessing implementation of the US national strategy (2018) and WHO has released a report assessing international efforts to implement national programs and strategies (WHO, 2018).

The revised US National Strategy for Suicide Prevention contains 13 goals and 60 objectives as part of a comprehensive public health strategy to reduce suicide and suicide attempts (US Department of Health and Human Services, 2012). The US national strategy has been adopted as a model for the majority of states which have developed state suicide prevention plans as well as a model for efforts focusing on specific high-risk groups such as the National Strategy for Preventing Veteran Suicide (US Department of Veterans Affairs, 2018) and the Department of Defense Strategy for Suicide Prevention (US Department of Defense, 2015). The national strategy also contains numerous objectives that challenge the mental health field to improve its readiness and capacity to prevent suicides. Implementation of these objectives holds promise for improving the treatment and management of suicidal people. The national strategy calls for the systematic implementation in clinical settings of all that we now know in clinical suicidology. One significant development called for by the US national strategy has been the incorporation of these advances as a clinical bundle or set of protocols under the rubric of the aspirational goal of zero suicide among the people under our care. The call in the US national strategy for zero suicide as a goal reflects the belief that aiming for zero is much more likely to lead to the kind of transformational change that is needed in healthcare systems to overcome the frequently pervasive sense of fatalism about preventing suicide. The possibility of making significant reductions in the rate of suicide among patients receiving mental healthcare has already been demonstrated in England which lowered the rate of suicide by more than 50% despite an increase in the number of mental health patients (Appleby et al., 2019). This was accomplished by systematically implementing recommendations from a series of annual reports called the National Confidential Inquiry Into Suicide and Homicide. The efforts in England to reduce suicide among those receiving mental healthcare are perhaps the most impressive of any nation in the world.

Additionally, the US national strategy objectives include the routine incorporation of training in suicide risk assessment, management, and treatment into graduate training programs and into continuing education programs. Bongar (2002) reviewed how frequently formal training in the study of suicide or the assessment or treatment of suicidal patients was offered in graduate school training in the mental health professions and found that the frequency of such training ranged from 29% to 41% in studies of psychology, social work, and marriage and family therapy training programs.

It is clear that many mental health professionals receive little or no formal training in suicide prevention. Yet, most Americans probably assume that when they go to see a mental health professional, they are seeing someone who has been trained to assess, manage, and treat suicide risk and behavior. The importance of continuing education has been demonstrated in England where training in suicide prevention every 3 years was shown to be one of the key variables associated with lowering rates of suicide among those receiving mental healthcare (While et al., 2012). In the United States, a growing number of states have recognized the critical importance of health and mental health |5|professionals being trained in suicide prevention and have instituted requirements for licensure or for continuing education. The state of Washington was the first such state and now requires all health professionals to be trained. California now also requires psychologists and other mental health professionals to demonstrate such training as a requirement for licensure, and New Hampshire, Kentucky, and other states have instituted similar requirements (American Foundation for Suicide Prevention, 2016).

Other crucial national strategy objectives emphasize the importance of developing guidelines for assessing and managing risk in mental health systems, for improving continuity of care of suicidal patients following discharge from emergency departments (EDs) and inpatient psychiatric units, and for more effectively involving and educating families of patients who are at risk of suicide.

While students in graduate training in the mental health professions may all too often receive little training in suicide risk assessment, treatment, or management, this does not mean that students are not treating patients at significant risk. In fact, one study found that one in nine graduate students in psychology had experienced a patient’s suicide at some point during their training, 40% of them prior to their internship (Kleespies et al. 1993). Findings such as these underscore the importance of training for graduate students in suicide prevention, not only to be a competent mental health professional, but also for trainees to be adequately prepared to treat those suicidal patients they will encounter during their training.

Treating suicidal patients requires numerous skills and competencies, including skills in assessment, treatment planning, managing crises, and knowledge of applicable laws and regulations. All these must occur within the context of clinicians having a clear understanding of their own feelings, attitudes, and judgments regarding suicidal behavior. We all react strongly to witnessing self-destruction and experience fear and anxiety about potentially losing someone we care about to suicide. These reactions are based on our own past personal and professional experiences, including our own or our family or friends’ experience of suicidal behavior. Understanding these reactions is essential to competently treating suicidal individuals.

I first experienced the loss of a patient to suicide when I was a psychology intern. I was providing outpatient psychotherapy to a patient that our entire treatment team believed to be at high, continuing risk for suicide. The reason for this perception of elevated risk was solidly grounded in what we now know about heightened suicide risk. He had a past history of suicide attempts, and these attempts were high in lethality, including one attempt during which he cut his own throat. A past history of suicide attempts, particularly attempts that are high in potential lethality, is the single, strongest predictor of ultimate death by suicide (Hawton, 2005). This was a man who had clearly demonstrated that he had the capacity for lethal self-destruction. Because of an increase in his level of depression, hopelessness, and suicidal ideation, he was hospitalized on an inpatient psychiatric unit. While he was hospitalized, I needed to return to my university to defend my doctoral dissertation. Upon my return to my internship, I learned that he had been discharged from the inpatient unit to a day hospital but had taken a fatal overdose within 48 hours of his discharge. This powerful personal experience made me appreciate something I would later |6|learn from the literature: The period immediately after an inpatient discharge, indeed after any episode of acute care for suicidality, contains significant, but frequently unrecognized risk for suicide.

In this book, I use the phrase “died by suicide” rather than the more common term “committed suicide.” I use this term out of respect to the countless family members who have lost a loved one to suicide. They have pointed out that we frequently use the word “commit” in contexts such as “commit a crime” or “commit a sin,” and that suicide, though in the past treated as both a crime and a sin, is neither.

1.1 Terminology

Suicidal thoughts or behavior are not limited to any single diagnostic group or condition. Death by suicide occurs with distressing frequency among many different illnesses, including mood disorders, substance abuse disorders, schizophrenia, and personality disorders. In 2002 the Institute of Medicine (IOM) summarized the state of research in suicide and suicide prevention and reported that in the US over 90% of suicides are associated with mental illness or substance abuse disorders (Institute of Medicine et al., 2002). While the recent CDC Vital Signs study (Stone et al., 2018) estimated that only about 50% of suicides were associated with a known mental health condition, this did not take into account substance abuse problems as well as mental health conditions that may have been undiagnosed.

Suicidal behavior is not a DSM-5 diagnosis, although suicidal behavior disorder is proposed as a disorder for further study. This diagnosis would be given to individuals who made a suicide attempt within the past 2 years. Additionally, suicide crisis syndrome (Shuck et al., 2019) and acute suicidal affective disturbance (Joiner et al., 2018) have both been proposed for consideration as new diagnoses based on the observation that a rapidly emerging acute suicidal state frequently occurs before a suicide attempt. Currently, two DSM-5 diagnoses reference suicidality (see Box 1). Of note, the DSM-5 also introduces the category of nonsuicidal self-injury where the absence of suicidal intent is a defining characteristic. However, the relationship between nonsuicidal self-injury and suicidal behavior is complex and nuanced (Klonsky et al., 2013). The 10th revision of the International Classification of Diseases (ICD-10-CM; WHO, 2019a) includes codes for classifying external causes of injury (E-codes). These codes are an important mechanism for surveillance of suicide attempts, particularly in hospital settings, and are used to distinguish between intentional and nonintentional injuries. The ICD also provides codes for overdose and poisoning in an appendix labeled overdose. These are used to code this frequent method for suicide attempts, as well as to code for accidental overdoses.

|7|Box 1: DSM-5 Diagnoses Referencing Suicidal Behavior (APA, 2013)

Diagnostic criteria for 296.xx major depressive episode

Criteria 9 – recurrent thoughts of suicide (not just fear of dying), recurrent suicidal ideation without specific plan, or a suicide attempt or a specific plan for committing suicide

Diagnostic criteria for 301.83 borderline personality disorder

Criteria 5 – recurrent suicidal behavior, gestures, threats, or self-mutilating behavior

Suicide behavior disorder (under study)

suicide attempt initiated within the past 2 years

does not include nonsuicidal self-injury

does not include suicidal ideation without an attempt

Nonsuicidal self-injury

5 or more days within the last year of intentional self-inflicted damage to the body without suicidal intent

expectation to relieve negative feelings or thoughts, to resolve a relationship problem or to induce a positive mood

1.2 Definition

As suicidal behaviors are not DSM-5 diagnoses, the diagnostic manual has not been the definitive source for definition and nomenclature that it has been in other areas of mental health. This has caused significant confusion. While many nations do have surveillance systems to monitor deaths by suicide, national surveillance systems for monitoring suicide attempts and estimating national rates of occurrence are far more rare (Silverman et al., 2007a) despite the significance of suicidal behavior as both a clinical and public health issue. In addition, many confusing terms and inconsistencies exist in both the research and clinical literature (Silverman et al., 2007a).

A pivotal event in the development of terminology occurred in 1970 when the Center for the Study of Suicide Prevention of the National Institute of Mental Health convened a committee on classification chaired by Aaron Beck (Brown et al., 2006). A classification system was developed that included the categories of completed suicide, suicide attempts, and suicidal ideation. Suicidal intent was identified as a critical variable in this classification scheme. For a self-injurious behavior to be considered a suicide attempt, suicidal intent was necessary (Beck et al., 1973). Self-injurious behavior was the recommended term when there was no suicidal intent associated with the behavior (Beck et al., 1973).

One challenge for this system has been that suicidal intent, which is essential for determining whether a death by suicide or suicide attempt has occurred, can be very difficult to determine. Self-report on intent after an attempt can be unreliable and heavily influenced by context and the potential consequences for patients of acknowledging suicidal intent. In addition, suicidal intent can |8|also fluctuate over time and be fraught with ambivalence. Despite these challenges, the nomenclature has met many clinical needs, and terms like suicidal ideation and suicidal intent have become familiar to virtually all clinicians. However, this terminology has proved inadequate for research purposes, leading nomenclature in this field to be described as a “Tower of Babel” (Silverman et al., 2007a) as studies have used varying definitions of terms such as suicide attempt. Such variability in definition has made comparability across studies extremely difficult. In the United Kingdom, the issue of determining intent has been avoided through the use of the term self-harm (formerly deliberate self-harm) (Kapur & Goldney, 2019). This term includes both a suicide attempt as well as nonsuicidal self-injury.

A revised nomenclature has been proposed with support from the Centers for Disease Control and Prevention in the United States (Silverman et al., 2007b). While a key goal of this revision was to help advance research, the revision was also “designed to serve as an instrument to assist clinicians in better identifying those most at risk for suicide related behaviors in order to keep them alive” (Silverman et al., 2007b, p. 274). The revision affirms the crucial role of suicidal intent, and, recognizing the inherently difficult nature of determining intent, utilizes three categories of no intent, uncertain intent, and intent. This replaces the prior dichotomy of suicide attempts vs. self-injury. A suicide attempt is defined as a self-inflicted, potentially injurious behavior with a nonfatal outcome for which there is evidence of intent to die (Silverman et al., 2007b). The term undetermined suicide-related behavior is used when suicide intent is uncertain. Self-harm is used rather than self-injury when it is clear there is no suicidal intent. This classification system thus explicitly deals with those problematic situations where intent is difficult or impossible to determine.

Suicide plan is another term frequently used in clinical practice but often not defined clearly. In fact, there is a tendency to equate having a suicide plan with considering a suicide method. While thinking about what method to use in a suicide attempt is clearly subsumed under the notion of planning, by equating them, much important assessment information is often missed. There may be other significant preparatory behaviors taking place (e.g., writing a suicide note, giving away possessions), and simply knowing whether a person has thought of a method tells us nothing about the degree of planning, forethought, and mental rehearsal the person has devoted to the possibility of killing themselves. In this proposed nomenclature, a suicide plan is described more broadly as “a systematic formulation of a program of action that has the potential to lead to self-injury” (Silverman et al., 2007b). An example of systematic planning is provided in Clinical Vignette 1.

Another common term in clinical usage is suicide gesture. Suicide gesture typically refers to a circumstance in which overt suicidal behavior takes place, but the person’s intent is judged by others to be an attempt to communicate distress rather than reflecting true intent to die. These gestures are frequently labeled as manipulative. Such terms are pejorative and can lead clinicians to assume the absence of potential lethality prior to a thorough assessment being completed. The proposed nomenclature recommends against the use of the term suicide gesture because of this pejorative implication (Silverman et al., 2007b). The term should be avoided.

|9|Clinical Vignette 1

Systematic Planning for Suicide

John told several high school friends he was planning on killing himself that night. Alarmed, one of his friends told a parent, who in turn contacted the mental health center. When evaluated, it was discovered that John had obtained a large stash of pills with which to overdose, had given away some of his prized records and other possessions, had decided where he wanted to kill himself, and had picked out the clothes he wanted to be found in when his body was discovered. He exhibited detailed, systematic planning for his suicide. He was assessed as being at high, imminent risk and was hospitalized.

The nomenclature proposed by Silverman and colleagues (2007b) is shown in Table 1. In addition to the important role of suicidal intent, the nomenclature also incorporates whether or not the outcome of a suicidal act is a fatal or nonfatal injury. There can be very serious suicide attempts that do not lead to injury. For example, a person who points a loaded gun at himself and deliberately pulls the trigger has clearly made a suicide attempt, even if the gun jams and there is no resulting injury.

An additional classification system for suicidal events has been proposed by Posner and colleagues (2007