- Although suicidal behaviors are common in depression, they can occur in the absence of depressive episodes.
- Some psychiatrists suggest that suicidal behavior should be a separate psychiatric diagnosis.
- Individuals with suicidal behavior should be carefully evaluated, monitored, and treated.
Research from over 50 years ago provided evidence that more than 70 percent of suicidal individuals suffer from major depression and or alcohol use disorder. Conversely, many persons who were evaluated following suicide attempts indicated that they did not intend to die, but were reaching out for help. These individuals often had symptoms of personality disorders, particularly borderline personality disorder. The majority of those who completed suicide were male. Of those who made suicide attempts, most were female. Nevertheless, those who attempted suicide were at higher risk for repeated suicide attempts and completed suicides.
There have been numerous studies of suicidal behavior during the last several decades. In a paper recently published in Molecular Psychiatry, Yingcheng Xu, Daniel Barron, Katherin Sudol, Sidney Zisook, and Maria Oquendo comprehensively review these studies. In their paper, they define suicidal behavior as suicide attempts as well as completed suicides.
Association with various psychiatric disorders
This review demonstrates that suicidal behavior occurs in 72 out of 145 psychiatric diagnoses. It is associated with autism spectrum disorders, attention-deficit-hyperactivity disorder, psychotic disorders, bipolar disorders, major depressive disorder, certain anxiety disorders, eating disorders, substance use disorders, personality disorders, and more. It is likely that many, but not all, persons with these disorders also suffer from co-morbid affective and or substance use disorders. Furthermore, the authors note that some individuals who exhibit suicidal behavior do not have a diagnosable psychiatric disorder. Thus, it is important that healthcare providers evaluate patients for current and past suicidal behavior regardless of diagnosis.
Suicidal behavior as a separate diagnosis
To reinforce the importance of such screening, the authors support the idea of considering suicidal behavior as a separate psychiatric diagnosis and not as a symptom of other disorders. In addition, they believe that having this designation would aid those conducting research on suicidal behavior and its response to treatment. The authors also point out that there are genes associated with the risk for suicidal behavior that may not be associated with other psychiatric diagnoses.
These investigators suggest that suicidal behavior should be a target for specific interventions even in the presence of a co-existing depression. By analogy, they note that separate treatment for insomnia is often provided concurrently with the treatment of depression. As a further example, they mention that an individual with a high fever due to bacterial infection is treated with medications to treat the fever at the same time antibiotics are prescribed to attack the bacterial source of symptoms. Others might argue that insomnia or suicidal behavior associated with depression should improve with successful treatment of depression and that monitoring insomnia and suicidal behavior is a way of evaluating the overall success of treatment.
Although the idea that suicidal behavior should be a separate diagnosis is controversial, these investigators demonstrate that a large range of psychiatric conditions is associated with increased risk for suicide attempts and, for some disorders, completed suicides. The authors encourage assessing suicidal behavior in all patients regardless of co-occurring symptoms, and when appropriate, implementing “specific suicide prevention interventions separate from treatments indicated for co-occurring diagnoses.”
The relationships among suicide, suicide attempts, and various psychiatric diagnoses are complex. Although treatment strategies are likely to be different depending on the circumstances of individual patients, all suicidal behavior warrants careful evaluation, monitoring, and treatment.
This post was written by Eugene Rubin M.D., Ph.D., and Charles Zorumski, M.D.
If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.
Xu, Y.E., Barron, D.A., Sudol, K., Zisook, S., & Oquendo, M.A. (2023 Jan 19). Suicidal behavior across a broad range of psychiatric disorders. Mol Psychiatry. doi: 10.1038/s41380-022-01935-7. [Online ahead of print.]