Not all suicidality is the same: Subtypes may lead to better diagnostic formulation

An exploration study of four hypothetical subtypes of suicidality in emergency mental health care shows promising results for usability. The quantitative and qualitative study, published in BMC Psychiatry in November 2023, looked at the subtypes as they pertain to entrapment leading to suicidality. The study had positive feasibility and usability results for the SUICIDI-2 instrument used to classify cases under subtypes.“The experience of entrapment plays a crucial role in suicidality as described in the integrated model of stress vulnerability and entrapment model, developed for the Dutch (Netherlands) multidisciplinary guideline on suicide and suicidal behavior,” the authors wrote. “Entrapment is described as the perception of being trapped: the stronger the feeling of entrapment, the higher the risk of suicidal acts.”The four hypothetical subtypes leading to entrapment are perceptual disintegration (PD), primary depressive cognition (PDC), psychosocial turmoil (PT) and inadequate communication/coping (IC), which the researchers consider a serious type of suicidality. “Inadequate coping should never be a reason to justify withholding care.” It is hoped that the differentiation of entrapment leading to suicidality will support improved clinical practice through better risk assessment and prognosis and allow for accurate scientific research. Subtypes of suicidality may also provide clarity as to what extent mental healthcare workers are responsible to prevent escalation of suicidal behaviours.“Suicidality is a heterogenous, seeming non-consistent phenomenon and it is not a clear-defined psychiatric symptom,” the authors wrote. It occurs as a symptom in two psychiatric classifications—major depressive disorder and borderline personality disorder—in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, suicidality is a frequently occurring symptom in other psychiatric diagnoses, such as PTSD, sleep disorders and adjustment disorders. Suicide is the leading cause of non-natural death worldwide, the study noted. In Canada suicide is the second leading cause of death among youth and young adults (15-to-34 years old), according to the Canadian Association of Suicide Prevention website. For the study, three psychiatrists and three nurses independently reviewed 25 anonymized discharge letters of suicidal emergency patients that were sent to general practitioners between January and March 2018. The cases were then classified into the proposed subtypes using the SUICIDI-2 instrument.“Intraclass Correlation Coefficients (ICC) for absolute/discrete and dimensional ratings were calculated to examine the model’s usability and the instrument’s feasibility,” the authors wrote. All raters were able to classify the cases into subtypes. There was an average measure of good reliability for absolute/discrete subtypes. For dimensional scores, excellent average measures were found for subtype PDC, and good average measures for the subtypes PD, PT and IC, the authors write. “The reliability of dimensional score for the SUICIDI-2 was relatively lower than an alternative dimensional rating but had good ICC values for all subtypes.” There were some inconsistent assessments between raters. For example, one rater rated perceptual disintegration (PD) relatively often. “According to this rater, alcohol and substance abuse distort perception and assessment of the situation a person finds himself in and may affect the suicidal process/suicidality,” the authors wrote. To improve consistency between raters, it is important to clearly explain the role of the underlying etiology of entrapment to raters, the authors said. The researchers give the example of a person with gambling debts leading to unemployment, of which their partner is not aware, who gets drunk. The rater because of the person’s intoxication may perceive this as perceptual disintegration. “However, in this case psychosocial turmoil (PT), induced by alcohol abuse is the actual underlying trigger for the onset of entrapment. As clinicians we encounter substance (such as psychedelics) use being probably responsible for suicidality at an individual level, however we cannot draw conclusions about the group in general.”The authors add that there is no clear and unambiguous evidence for substances to be linked to suicidality, but that this might be investigated in future research. A limitation of the study is the small sample size and the overlap of subtypes. To clarify differentiations of subtypes the SUICIDI-3 was developed.“Future research in larger and more varied samples of subjects (youth, elderly, substance abusers) and other raters than in the current study may reveal how overlap is distributed and whether subtypes are consistent over time, or whether further (sub)differentiation of types or adding subtypes are needed,” the authors wrote. “It is also important to investigate which clinical and demographic features are associated with subtypes to achieve more reliable identification of subtypes.”This study looked at suicidality in emergency care, however, the researchers note the majority of suicides happen without the intervention of mental health care services. Research in this group might be possible with follow-up studies. “The model might be useful for psychological autopsies of people who did not access specialised care and for looking at whether there is a difference between subdivisions/differentiations of suicides within services and suicides outside mental health services,” write the authors.

Not all suicidality is the same: Subtypes may lead to better diagnostic formulation

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