Suicidal Behavior: The Need for Its Documentation in Multiaxial DSM-V Diagnoses

To the Editor: The recent editorial by Maria A. Oquendo, M.D. et al. (1), published in the November 2008 issue of the Journal, calls attention to the fact that the current DSM formulations do not allow suicide risk to be documented as part of a multiaxial diagnosis. Thus, as a result of this absence, suicidal behavior fails to have the prominence that it requires in light of its association with increased risk for future completed suicides and suicide attempts. I am in full agreement with the need to address this important problem, since my previous attempt (2), approximately 25 years ago, to sensitize the scientific community to the same concern in conjunction with the then upcoming revision of DSM-III appears to have had no impact. However, in contrast to the recommendation by Dr. Oquendo et al. to consider suicidal behavior as a separate diagnosis with documentation in a distinct sixth axis, I proposed that “consideration be given to the possibility of including a sixth digit that would call attention to whether axis I or II diagnoses are associated with the presence of suicidal behavior” (2) . In retrospect, this approach should also be extended to suicidal behavior associated solely with general medical conditions or axis III diagnoses. I also emphasized the need “to denote single and multiple episodes and to indicate whether the behavior was life-threatening” (2) . Nevertheless, the differences between the respective recommendations should not detract from the main focus of efforts toward systematic documentation of suicidal behavior in the DSM-multiaxial system, and hopefully the discussion to determine the best solution will remain open.