DSM-5 guides doctors on suicide risks and prevention

As physicians become acclimated with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, they should pay close attention to the sections on suicide risk, said David J. Kupfer, MD, chair of the DSM-5 task force.

The manual, which was released by the American Psychiatric Assn. on May 17 and is available online, aims to reduce suicide by helping physicians identify and treat suicidal ideation and behaviors in patients with an assortment of mental health conditions.

Suicides have surpassed deaths from motor vehicle crashes during recent years in the United States, according to the Centers for Disease Control and Prevention. In 2010, there were 38,364 deaths from suicide compared with 33,687 from motor vehicle crashes, the CDC said.

Yet, there has been little, if any, discussion among medical professionals and the public about the new focus in DSM-5 on suicidal ideations and behaviors, Dr. Kupfer said.

“It’s one of the area’s [of the new manual] I’m most proud of,” he said. But he hasn’t seen it get much attention.

Part of the problem could be that sections labeled “suicide risk” are spread throughout the manual in various disorders rather than being put together in one area, Dr. Kupfer said. Among the approximately 20 mental health conditions that include suicide risk information are anorexia nervosa, anxiety, bulimia-nervosa, opioid use and schizophrenia.

In DSM-IV, which was published in 1994, suicide risk was addressed in diagnostic criteria only for borderline personality, dissociative amnesia and mood disorders, Dr. Kupfer said.

“Singling out suicide risk [in DSM-5] helps elevate the [importance] of this issue for clinicians,” he said.

For instance, the suicide risk section for schizophrenia alerts health professionals that 20% of patients with the mental health condition try to take their own lives.

“Highlighting this for clinicians — it raises a flag for them,” he said. It reminds “them that suicide risk should be assessed in these patients.”

Rate rises for middle-age adults

The manual’s spotlight on suicide comes as suicide rates among adults age 35 to 64 have substantially increased between 1999 and 2010, the CDC said. Annual rates in that age group climbed from 13.7 suicides per 100,000 people in 1999 to 17.6 per 100,000 in 2010. The findings were published in the May 3 issue of the CDC’s Morbidity and Mortality Weekly Report.

“Suicide is a tragedy that is far too common,” CDC Director Tom Frieden, MD, MPH, said when the report was issued. The data highlight “the need to expand our knowledge of risk factors so we can build on prevention programs that prevent suicide.”

DSM-5 offers assessment tools to help doctors identify patients who are at risk of taking their own lives, Dr. Kupfer said. Those tools, which are largely clinical assessment and patient self-assessment measures, can be found in a new component of the manual called Section III. That section introduces conditions, such as suicidal behavior disorder, that warrant more research before they might be considered formal disorders.

Both the patient self-assessment measures and the clinical assessments include checklists to track change in a patient’s mental health symptoms over time. The checklists include questions about self-harm and suicidal ideation.

“Tools like this help clinicians provide comprehensive evaluation of patients,” Dr. Kupfer said.

The APA is determining whether a version of DSM-5 tailored to primary care physicians is needed.