Introduction
After over a century of serious attention to the public health problem of suicide and suicidal behaviors, there have been many significant advances in suicidology; yet challenges remain. We now know a great deal about the epidemiology of suicide and suicidal behaviors. We are beginning to develop a body of knowledge about the biological underpinnings to suicidal behavior through research on the neurobiology and genetics of risk for suicide. However, we still know little about protective factors and what places an individual at acute risk for suicidal behavior. We need to bridge the gap between our expanding knowledge base of the incidence and prevalence of suicidal behaviors in different populations, the etiology, progression, and transmission of suicidal behaviors, and the development of effective clinical and populationābased protocols, practices, procedures, and policies.
In order to achieve this goal, we need to translate what we have learned from epidemiological surveillance and research studies into practical clinical and populationābased applications. Similarly, what is learned in clinical settings needs to be communicated to researchers and theoreticians so they can better investigate and understand these behaviors. However, the suicide literature remains replete with confusing (and sometimes derogatory or pejorative) terms, definitions, descriptors, and classifications that make it difficult, if not impossible, to compare and contrast different research studies, clinical reports, or epidemiological surveys (Crosby, Ortega, & Melanson, 2011; Jenkins & Singh, 2000; Rudd & Joiner, 1998; Shneidman, 1985; Silverman, 2006), or to make comparisons, generalizations, or extrapolations (Linehan, 1997; Westefeld et al., 2000). Hence, advances in suicidology are hindered by a lack of a standardized nomenclature and classification system. This remains a challenge.
Most individuals who die by suicide are reported to have communicated their intent to others (usually next of kin or friends), and the majority have also visited or been treated by mental health professionals, primary care providers, or other physicians during the weeks or months preceding their death by suicide (Luoma, Martin, & Pearson, 2002). Why is this so? It may be that family members, significant others, or other supports do not recognize or respond to the conditions, contexts, or communications associated with escalating suicidal risk. A compelling answer is that suicidal behavior is often undiagnosed, undertreated, or mistreated in clinical settings because the signs and symptoms are misunderstood by the clinician, and, for the individual, truthfully answering questions about being suicidal can be influenced by stigma, denial, guilt, anger, and shame (Mann et al., 2005; Malone, Szanto, Corbitt, & Mann, 1995). Determining that a suicide risk assessment has been completed after receiving a negative response to asking a single question (e.g., are you thinking about suicide?) is insufficient, because, in part, the question provides no context, parameters, or time frame.
One of the major difficulties in communicating about suicidal phenomena with our patients and within our disciplines (as well as across disciplines) is that we do not share a precise set of terms or speak the same scientific language. We also do not share the same conceptualizations of what constitutes selfāharm and the suicidal process. The terminology we use is often based on our training (Silverman & Berman, 2014b); theoretical, political, social, psychological, biological, and religious perspectives; and the professional responsibilities to identify and count these behaviors in the first place (clinical, epidemiological, public health, research, etc.). Conceptual, methodological, and clinical challenges result from widely varying definitions and classification schemes for such terms as suicide attempt (Nock & Kessler, 2006). As a result, epidemiologists cannot consistently and accurately determine the incidence and prevalence of suicideārelated phenomena, researchers cannot easily compare their study populations or the effectiveness of their interventions, and clinicians have difficulty in translating research findings into practical applications when working with an individual at risk for suicidal behaviors.
It is a known fact that there is inaccuracy in the reporting of suicidal deaths (Jobes & Berman, 1985; Shneidman, 1980). Estimates of underreporting have ranged from 10% to 50% (Jobes, Berman, & Josselson, 1987; Litman, 1980). Some have noted substantial underreporting and misclassification of childhood and adolescent suicides (Wekstein, 1979). Jobes and Berman reported that the majority (58%) of medical examiners they surveyed in the United States either agreed or strongly agreed that āthe actual suicide rate is probably two times the reported rate.ā It appears that there may be variations in both the death certification process and the manner of death determination.
Jobes, Berman, and Josselson (1987) have identified over 20 possible sources of variability in the official reporting of suicide data. They suggest that perhaps the single most important source of variability and error in suicide statistics arises from the virtual absence of any standardized classification criteria that coroners and medical examiners might use more uniformly to evaluate cases of equivocal suicide. Although relatively small in number, the category of āundetermined manner of deathā may represent a significant number of true suicides (Elnour & Harrison, 2009; OāCarroll, 1989; Rockett, Kapusta, & Coben, 2014; Tollefsen, Hem, & Ekeberg, 2012).
If we cannot even agree upon what defines a suicide, how, then, are we to determine what is an attempt to die by suicide? There is considerable debate about the differential attributes of those who die by suicide, those who attempt suicide, and those who engage in deliberate selfāharm (DSH). The resolution of these controversies is hampered because studies have used dissimilar descriptive methods and definitions for what is a suicide attempt (Linehan, 1986; Maris, 1992). When the suicide attempts are medically serious (e.g., involving admission to an intensive care unit; requiring surgery under general anesthesia; needing extensive, specialized medical care), these two populations overlap considerably (Beautrais, 2001). However, because most epidemiological studies are based on selfāreport of prior suicidal behavior without defining these terms for the population being surveyed, the profile of those engaging in nonmedically serious suicide attempts remains inconsistent and unreliable.
Currently there is no international surveillance system for the primary purpose of estimating annual national rates of suicide attempts (Silverman, Berman, Sanddal, OāCarroll, & Joiner, 2007a). However, the International Association for Suicide Prevention and the International Association for Suicide Research have recently formed a task force to address this issue. Put simply, the absence of a universally accepted nomenclature and set of diagnostic criteria has limited our attempts to accurately quantify the extent of the problem (incidence and prevalence), identify effective interventions, both clinical and preventive, as well as useful markers of vulnerability.
The above problems, among others, make it difficult to
- accurately count the number of suicides and suicide attempts that occur annually;
- ac...
