A Suicide-Specific Diagnosis – The Case Against

Abstract

Free AccessA Suicide-Specific Diagnosis – The Case AgainstAlan L. Berman and Morton M. SilvermanAlan L. BermanAlan L. Berman, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD, USA, drlannyberman@gmail.comDepartment of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USASearch for more papers by this author and Morton M. SilvermanDepartment of Psychiatry, Medical College of Wisconsin, Milwaukee, WI, USASearch for more papers by this authorPublished Online:June 02, 2023https://doi.org/10.1027/0227-5910/a000912PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreFirst and foremost, we applaud Dr. Cohen and her colleagues for developing the suicide crisis syndrome (SCS) and its attendant focus on high and acute suicide risk, in particular that of high and acute suicide risk that is not dependent upon the patient’s communicated suicide ideation (SI) as a gateway to its assessment. In several published papers (Berman & Silverman, 2014; Silverman & Berman, 2014a, 2014b) we have observed and commented upon the inadequacy of communicated or reported SI as a necessary condition to further establishing a patient’s acute risk of suicide and lamented that clinicians too often assume that the absence of SI indicates the relative absence of suicide risk. There are now more than a dozen published studies of individuals who died by suicide who denied that they were thinking about suicide when they were last asked by a clinical caregiver often within days of their deaths (see Berman, 2018). These studies highlight the importance of symptomatic and behavioral signs of high and acute risk, rather than a dependence on communicated SI as a beacon of such risk.Further, as we have written elsewhere (Silverman & Berman, 2020), we applaud Dr. Cohen and her colleagues for proposing the SCS with intent to make the features of a current crisis a central concern for the assessment and treatment of individuals at heightened risk. Suicide risk assessment is essential to make clinical care decisions and the SCS incorporates much of evidence-informed criteria to alert clinicians to patients needing intensive clinical care. However, proposing the SCS as a diagnosis is neither necessary nor sufficient for the purposes of improving the assessment and management of the person at such heightened risk (Wortzel et al., 2018).Traditional suicide risk factors have only limited clinical predictive value (Franklin et al., 2017; Ribeiro et al., 2016), because they provide little reliable information on the acute psychological processes leading to suicide and on “imminent suicide risk” assessment (Voros et al., 2021). The individual criteria in the proposed SCS significantly focus our attention to cognitive, emotional, and behavioral signs of high and acute risk of suicidal behavior. It is these individual symptoms and behaviors that demand clinical attention and care decisions in order to mitigate that risk. In this regard, there is simply no need to create a suicide-specific diagnosis to identify targets for intervention, such as establishing and implementing treatment plans to counteract feelings of entrapment and manage behaviors indicative of hyperarousal.While the independent criteria proposed in the SCS are all relevant and validated as near-term risk factors for suicide, insufficient evidence has been presented to date to validate that the criteria of the SCS, proposed as a diagnostic entity, are necessary and sufficient to establish that an individual is in a suicidal crisis. Two examples might illustrate this point. First, in addition to Criterion A, the SCS requires that all four categories in Criterion B must be met for the diagnosis of SCS to be made. This is an over-inclusive frame, as if it would be unreasonable to distinguish someone displaying only three of these four categories as not in a suicidal crisis. Published validation studies using the Suicide Crisis Inventory (SCI), the operationalized measure of the SCS, have already acknowledged this point in noting, as a limitation to the validation of the SCS, that “the SCI has not yet integrated the assessment of all proposed SCS components” (Barzilay et al., 2020, p. 189).The second example reflects an over-exclusive frame, as if other symptoms and behaviors associated with near-term suicide risk, but not identified as Criterion B categories, simply do not apply as indicators of near-term risk or criteria indicative of a suicidal crisis. Examples of these near-term risk factors are: (a) recent discharge from inpatient psychiatric hospitalization (Knesper et al., 2010); (b) sleep problems (Berman, 2018; Liu et al., 2020), more broadly defined than simply that of “global insomnia” that is listed in the SCS as a manifestation of hyperarousal; (c) negative emotions and self-evaluations such as shame, embarrassment, moral injury, or humiliation that arise in relation to the perception of having done something dishonorable, immoral, or improper (Szeto et al., 2023), but do not necessarily occur in “rapid spikes” or ruminations, as suggested by the SCS; and (d) a negative or mixed reaction to the patient by the clinician-interviewer, in the context of other criteria (Motto & Bostrom, 1990).With regard to negative emotions and self-evaluations, recent findings point specifically to shame/self-hatred as a singular predictor of 1-month postdischarge suicide attempt (Bentley et al., 2021). With regard to the clinician’s negative response to the patient, Dr. Cohen and colleagues, themselves, found that “clinician emotional responses” were significantly associated with 30-day occurrences of suicide attempts and plans (Foster et al., 2021; Rogers et al., 2021; Ying et al., 2020, 2021). Despite repeatedly finding this as an acute risk factor, this criterion has not been incorporated as a criterion into the SCS as a proposed diagnosis.Moreover, where does problematic or increased alcohol and/or drug use (Rudd et al., 2006; Suzuki et al., 2021), a behavioral manifestation of near-term risk, enter into the SCS? We recognize that the SCS is not meant to be a diagnosis that covers all manners of suicidal types or presentations, some of which are not associated with mental disorders (Logan et al., 2011), but as a diagnosis it is selective in its choice of criteria.The SCS has been characterized as “a condition associated with imminent suicidal behavior” (Bloch-Elkouby et al., 2020, p. 596) and “predictive of near-term suicidal behaviors” (Ying et al., 2020, p. 2). In fact, Dr. Galynker and colleagues use the terms “imminent suicide,” “short-term suicide risk,” “acute indirect risk,” and “suicidal thoughts and behaviors (STBs) at one-month follow-up” interchangeably and, in one case, in the very same article (Rogers et al., 2021). The most consistent time frame in which predicted outcomes of “suicidal thoughts and behaviors” are researched by Dr. Galynker and colleagues is that of “the next 30 days.” This is generally the time frame that is referred to as “imminent, “although in some studies this period of outcome measurement extends up to 60 days (Galynker et al., 2017; Yaseen et al., 2019). In our prior publications (Berman & Silverman, 2014; Silverman & Berman, 2020) we have affirmed that imminent suicide proposes an “illusion of short-term prediction” (Simon, 2006, p. 296) and that the term “imminent” has no agreed upon operational definition.In practice, the clinical imperative is to assess an individual as being in a suicidal crisis and, if so assessed, to maximize that individual’s safety from possible self-harm behavior in the immediate hours to days, for example, through psychiatric hospitalization. The time frame associated with a suicidal crisis is not that of the next month or two. A suicide-specific diagnosis has essentially no positive predictive value with regard to suicidal behaviors, notably death by suicide or suicide attempt (Berman & Carter, 2020; Carter et al., 2017). It has not yet been tested retrospectively on a sample of individuals who have died by suicide; and in prospective studies the number of suicide attempts in the follow-up 30-day period has been as few as 17 out of 670 psychiatric patients (2.5%) in one study (Rogers et al., 2021) and 11 out of 591 psychiatric patients (1.9%) in another (Barzilay et al., 2020); and in studies with an 8-week follow-up, as few as nine out of 106 patients (8.5%; Yaseen et al., 2019). Even categorizing and including self-reported “aborted” and interrupted attempts in these studies as “suicide attempts” fails to raise an overall proportion of followed-up psychiatric patients who engage in “suicidal behaviors” above 5%; hence 95% or more of the primary outcome variable tested to date is that of SI. Nonetheless, it is always important to remember that in behavioral science/medical research, effect sizes might be small.This means that the SCS, which primarily has been studied in individuals hospitalized for STBs, essentially has been shown to predict the presence of more SI among these individuals over the next 30–60 days. As it has been well-documented that the majority of SI has been found to be “episodic with quick onset and short duration” (Kleiman & Nock, 2018, p. 35), this is not to be unexpected.From our perspective, the jury is still out and not yet capable of asserting that the SCS predicts “suicidal behaviors.” Of course, the problem of predictive validity plagues all assessment tools (Berman & Carter, 2020), but were the SCS to be understood and proposed not as a diagnosis but as an assessment tool to define targets for intervention and management, as we have proposed it should be, the issue of predictive validity would be moot.In our prior editorial on this subject (Silverman & Berman, 2020), we outlined and discussed a number of other issues that disquieted us with regard to establishing a suicide-specific diagnosis. We can summarize these succinctly as follows:1.A suicide-specific diagnosis classifies individuals who have a disease or condition for which the etiology is well-established, its pathogenesis is understood, and its responses to evidence-based treatments can be described, none of which reasonably apply to suicide-related behaviors (Sartorius, 2015).Cohen and colleagues (2023) in this issue incorrectly state that we wrote (Silverman & Berman, 2020) that suicide-related behavior is not “a disease, a health problem or a disorder of structure or function.” Rather, we argued that these were criteria of a diagnosis. Cohen and colleagues (2023) further argue that Sartorius’s definition of a diagnosis is poorly applicable in psychiatry. To be fair, Sartorius, a psychiatrist, further wrote that “none of the illnesses with which psychiatrists deal satisfies these criteria” and that “it would be better to use syndromes instead of diagnoses” (p. 6). In this regard, we appreciate that the SCS is proposed as a syndrome. A syndrome is defined as a complex of symptoms describing a specific condition for which a direct cause is not necessarily understood (Calvo et al., 2003). Cohen and colleagues (2023) argue that the SCS, as a syndrome, should be a diagnosis, because the SCS is a syndrome “that responds to medical treatment.” Not only do Cohen and colleagues fail to state what is/are the medical treatment(s) to which this proposed diagnosis responds – and we would argue that there are no empirical data to support such an assertion – but suicidal behavior is not always associated with a mental disorder, nor does it necessarily indicate a psychobiological dysfunction (Stein et al., 2021).There is no single pathogenic pathway to suicide and some subtypes have been characterized by the absence of psychiatric conditions (cf., Logan et al., 2011). The SCS, as a diagnosis, would classify these nonpsychiatric subtypes as mental-health related. The SCS, as an assessment schema, would appropriately assess these subtypes as in a suicidal crisis.Cohen and colleagues note that “our effort is directed toward the evaluation specifically, of the SCS, an acute mental state. Therefore, our arguments may not be pertinent to the other associated phenomena (e.g., suicide, suicidal ideation, or suicidal behavior).” Hence their focus seems to be exclusively on the diagnosis of an acute mental state, without necessarily associating it with other suicide-related thoughts or behaviors (STBs).Further Cohen and colleagues liken the SCS to other “state-like” disorders, “such as panic attacks or depressive episodes.” What they fail to note is that a panic attack is not a codable disorder, but, rather, a symptom of a diagnosis, that is, a panic disorder. Further, a depressive episode diagnosis must meet a temporal criterion, that is, its symptoms must be present for a 2-week period. A temporal criterion is neither proposed for a suicidal “crisis,” nor likely to apply to a suicidal crisis as defined by the SCS.2.An SCS diagnosis appearing in DSM-5 or ICD-11 designates the presuicidal state as a medical disorder or disease, thus emphasizing the prescribing of medical treatments for a behavior with complex roots and manifestations.Cohen and colleagues (2023) in this issue misquote us as arguing that the SCS as a diagnosis would “overmedicalize” this condition. By contrast, and curiously, they agree with us that the SCS, as a diagnosis, “will medicalize the presuicidal mental state.” Once again, they argue that the SCS presents the “need for medical intervention,” a proposition we have already responded to above.3.A suicide-specific diagnosis has the potential for stereotyping or stigmatizing, offering a long-lasting label for individuals identified as in a short-term state of crisis and may affect long-term health insurance coverage, eligibility for jobs, etc. (Wortzel et al., 2018). Cohen and colleagues do not take issue with our position that, as a diagnosis, the SCS would be stigmatic, would potentially lead to rated, hence higher, costs for life insurance policies, etc. A suicide diagnosis objectifies the at-risk-for-suicide patient as a categorized entity.4.By definition, a crisis is a short-lived state and, as noted above, the SCS has only been proposed to help identify the heightened potential for suicidal behavior in the short term and has only been tested over a 30–60-day follow-up. Given the low base rate for suicidal attempts and the absence of deaths by suicide in the studied follow-up weeks, at best we can agree that the SCS helps to identify individuals at risk for further SI.Research has shown that interrater reliabilities for a large number of diagnoses are, at best, only fair to moderate, raising the possibility of misdiagnosis or improper diagnosis. Cohen and colleagues (2023) in this issue again raise Joiner et al.’s (2018) argument that “a suicide specific diagnosis will likely reduce litigation in the unfortunate event of a patient suicide by clarifying what is expected of clinicians and making it easier to follow clinical guidelines.” Just how a diagnosis does this is not stated. Other existing diagnoses, for example, depression or schizophrenia, have never served to lower risk of litigation; no less they have never served as guidelines for lowering a clinician’s risk of litigation. Our position is that clinicians who assess a patient’s near-term suicide risk using the SCS criteria as an evaluative model for that risk, indeed, are likely to limit their legal exposure. Doing so does not require a diagnosis. What significantly lessens the risk of a malpractice action is attention to making a suicide risk assessment, implementing an assessment-based treatment plan, collaborating with the patient’s support system, etc., and documenting clinical observations and rationales underlying these.5.Electronic health records (EHR), which include diagnostic codes for the myriad of disorders associated with suicidal behaviors, are already spurring a great deal of machine learning studies regarding suicidal patients. The SCS, as a diagnosis, is not needed to spur scientific research. This has recently been affirmed by the American Psychiatric Association, which determined that the retention of suicide behavior disorder in Section III of the DSM-5-TR, was “not necessary to stimulate further research on suicidality, an area that is an intense focus of research activity” (https://www.psychiatry.org/getmedia/34c43e15-2618-4d2b-9f67-6bef5c40f75a/APA-DSM5TR-Update-September-2022.pdf). What is needed in this regard is renewed attention to a large number of proposed research pathways outlined in the National Action Alliance for Suicide Prevention’s Research Prioritization Task Force Report (2014).6.The SCS is neither necessary nor sufficient to clarify discharge planning and improve safety planning. As an assessment tool, the SCS, again, outlines well the need for these clinical care activities.Lastly, Cohen and colleagues (2023) in this issue challenge our (Silverman & Berman, 2018) proposal that the SCS, as an evaluative tool, should be an extension of a mental status exam (MSE), rather than a DSM-5 diagnosis. Their position is that doing this would “increase the complexity and ambiguity of suicide risk assessment.” We are at a loss to understand their argument.Combining an MSE with the SCS criteria as an evaluative tool provides the clinician with a more thorough and in-depth assessment, which then will aid decision-making when encountering potentially suicidal patients, reduce misdiagnoses, and prevent unnecessary treatment.Our proposal would incorporate the SCS as it is presented, with all 15 symptoms with their criteria, as currently designed; that is, as an acute suicide risk evaluation tool to be administered along with a standard MSE. Given this, their argument, which appears to assume that we are suggesting a mere listing of symptoms, loses impact.ConclusionAs Cohen and colleagues (2023) in this issue have concluded, “Ultimately, our shared goal is to prevent suicide deaths.” We cannot agree more. However, as we concluded in 2020:What is needed is universal training and better supervision in the assessment of suicide risk, in the formulation of a suicide-specific treatment plan, and in evidence-based suicide-specific treatments and management. These actions lead to improved clinical care and patient safety… Establishing the goal of the clinical encounter as that of making a diagnosis does not alter the immediacy of a patient’s distress and the need for implementing short-term interventions to lessen it. The clinical emphasis needs to be first on learning how to ask about these “diagnostic criteria,” secondly how to listen for and interpret the patient’s answers, and thirdly how to organize the findings into a treatment plan that addresses the patient’s immediate needs. (p. 245)None of the published studies on the SCS that we have reviewed since our 2020 editorial have changed our opinions. In our prior editorial we acknowledged the strengths and promise of the SCS as a suicide assessment tool to characterize a patient’s suicidal state/crisis leading to an individualized plan to implement interventions to mitigate risk by targeting identified criteria. That should be our number one priority, that is, to better identify those in an acute state of despair and anguish and to identify the range and variability of factors to describe that patient’s suicide crisis state (e.g., the SCS criteria), such that clinicians can maximize the patient’s safety and actively collaborate to offer targeted clinical care designed to move the patient to a noncrisis state. Efforts to isolate idiosyncratic, acute risk factors pose a great opportunity to design and implement person-, context-, and criterion-specific interventions (Kleiman et al., 2022). There remain gaps and limitations in the evidence base related to the efficacy of interventions for patients exhibiting STBs (Menon & Vijayakumar, 2022). This should be where our efforts are maximally directed at, rather than adding one more poorly predictive diagnosis to the DSM-5-TR or ICD-10-CM.Author BiographiesAlan (Lanny) Berman, PhD, is an adjunct professor of psychiatry at the Johns Hopkins University School of Medicine in Baltimore, MD, USA. He is a past-president of the International Association for Suicide Prevention (IASP, 2009–2013) and the American Association of Suicidology (AAS, 1984–1985), and a fellow of the International Academy of Suicide Research.Morton M. Silverman, MD, is an assistant adjunct professor of psychiatry at the Medical College of Wisconsin, Milwaukee, WI, USA. From 1996 to 2009 he was Editor-in-Chief of Suicide and Life-Threatening Behavior. 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Cohen, Benedetta Imbastaro, Devon Peterkin, Sarah Bloch-Elkouby, Amber Wolfe, and Igor Galynker2 June 2023 | Crisis, Vol. 44, No. 3 Volume 44Issue 3May 2023ISSN: 0227-5910eISSN: 2151-2396 Published onlineJune 2, 2023 InformationCrisis (2023), 44, pp. 183-188 https://doi.org/10.1027/0227-5910/a000912.© 2023Hogrefe PublishingPDF download