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.