Stigma, Suicide, and Suicidal Ideation

With rates of suicide and suicidal ideation on the rise nationwide, it’s essential to reduce stigma around suicide and suicidal ideation, so that people in need can seek help without fear of judgment and discrimination.

The New DSM-5: Changes in Language to Reduce Stigma Around Suicide and Suicidal Ideation

In May 2022, a medical manual topped the bestseller list in the Psychiatry category on Amazon Books, and made the top selling list for e-books in the Wall Street Journal. The manual contains specific and detailed information on mental health diagnoses like depression, anxiety, post-traumatic stress disorder, and disorders related to suicide, suicidal ideation, and suicidal behavior.

Its popularity and subsequent surge in sales is an unprecedented phenomenon for books like this. The specific publication – the Diagnostic and Statistical Manual of Mental Disorders (DSM) – is not known as an easy read. That’s true for medical professionals as well as non-professional readers who drove up the sales. The complex and technical nature of the material – mental health disorders – means the language is often repetitive, dense, and challenging to understand.

In the big picture, the DSM, now in its 5^th edition, is the standard, go-to diagnostic reference for mental health treatment providers. It’s also valuable for any healthcare provider who observes any potential symptoms of a mental health diagnosis in any of their patients.

Here’s how the American Psychological Association (APA) describe the role of the DSM in mental health treatment. The DSM:

• Is the authoritative guide to the diagnosis of mental disorders
• Contains descriptions, symptoms, and diagnostic criteria
• Provides a common language for clinicians and treatment providers
• Allows providers to communicate accurately about patients
• Establishes consistent and reliable diagnoses for research purposes

That’s what makes the DSM an important tool: it’s how medical professionals diagnose and receive guidance for the treatment of mental health diagnoses. However, like most medical texts, it’s not an easy read.

Dr. Robert Smith, a professor at Michigan State University, interviewed in Axios, offers this analysis of the manual:

“The criteria in DSM, they are not easy to understand. In fact, primary care docs don’t use them because they’re difficult to understand.”

That begs the question: why is the DSM-5 suddenly a bestseller?

A New Text Revision Addresses Stigma and Suicide

Mental health experts think the spike in interest in the DSM-V is the direct result of an increase in awareness of and concern about mental health issues that appeared during the COVID-19 pandemic. Specifically, public health measures enacted to stop the spread of COVID-19 in the early days of the pandemic were associated with increased risk of developing mental health issues. Measures included:

• Shelter-in-place orders
• Social distance guidelines
• Facial coverings/mask mandates
• Remote/virtual work for non-essential businesses/services
• Remote/ virtual school
• Travel restrictions for all but essential trave

In addition to the stress caused by significant disruption of daily routines, for millions of people, the public health measures related to COVID-19 caused:

• Economic instability
• Housing instability
• Food instability
• Decreased access to mental health treatment
• Decreases access to substance use treatment
• Increased isolation
• Increased loneliness

The economic hardships related to COVID-19 are well-documented in the national news media. We’ll focus on those last two bullet points: the increases in isolation and loneliness during the pandemic. Research shows isolation has a negative impact on overall health and wellbeing. Actual physical isolation, i.e., living in a remote, rural area, and social isolation, including perceived social isolation, can lead to the following problems:

• Depressive symptoms
• Decreased sleep quality
• Insomnia
• Reduced executive function
• Cognitive decline
• Poor cardiovascular function
• Impaired immunity
• Increased risk of mental health disorders

Concern about mental health diagnoses that may have developed during the pandemic drive the interest, coupled with interest driven by the shocking increase in rates of suicide in the past two decades. Those conditions, and the fact that the APA released a new version with specific text revisions, called the DSM-V (TR). Many of those revisions revolved around language and stigma related to suicide, in hopes to decrease stigma and increase available support.

Prevalence of Suicide and Mental Health Diagnoses Increasing

Let’s take a look at the recent increase in rates of mental health disorders around the world, and the long-term increase in rates of suicide in the U.S.

According to the World Health Organization (WHO) and the Centers for Disease Control (CDC):

• Rates of anxiety and depression worldwide increased by 25%
• In the U.S., rates of depression tripled between 2020 and 2021, and rates of anxiety tripled between 2019 and 2021
• Total numbers of fatal suicide increased by 57% between 2000 and 2020
  • 2000: 10.4 per 100,000, or 29,350
  • 2020: 13.4 per 100,000, or 45,979
• In 2021, the rate of suicide in the U.S. increased by 4 %
  • 2021: 14.0 per 100,000, or 47,646
  • That’s a raw increase of 1,667:
    • 5 more per day than 2020
    • 50 more per day than 2000

Those figures explain the increased interest in mental health in general, and also explain why people bought a standard reference manual: they wanted to know if what they felt corresponded with clinical mental health pathology.

Or, as Saul Levin, the CEO of the American Psychological Association (APA) states:

“The public has been dying to know more about mental illness, and this book just happened to come out…I think what really caught the imagination was that we’re sitting at home now and looking to say, ‘Boy, I’m feeling [depressed, anxious, etc.] — let me now go and find out more about it.'”

The DSM-5-TR: What Changed to Reduce Stigma Around Suicide?

To be clear, the new version of the DSM-5 is called the DSM-5-TR. According to the authors at the APA, the new edition includes:

• Fully revised text
• New references
• Diagnostic clarifications
• A new disorder: prolonged grief disorder
• Changes to language related to suicide and suicidal behavior
• Changes to cultural, sex, and gender-related diagnostic criteria

Here’s how the APA went about making the changes:

• Recruited 200 subject matter experts in mental health and related areas
• Experts reviewed the current DSM and recommended any changes
• The APA editors and the DSM steering committee reviewed the changes
• Editors/committee members submitted changes to a collaborative review process
• After review, editors, committee members, and the APA board of trustees approved all proposed changes

Now let’s take a look at the specifics.

Stigma, Suicide and Suicide-Related Language: DSM-5-TR Changes

Two things changed with regards to suicide:

1. The language used to discuss suicide. In the diagnostic criteria for major depressive disorder (MDD) and bipolar and related disorders, the review team changed the bold section of the italicized wording below:

“Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.”

They replaced that wording with this:

“Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation, without a specific plan, a specific suicide plan, or a suicide attempt.”

2. The editors also added standalone diagnostic codes for suicidal ideation and nonsuicidal injury in the Chapter “Other Conditions That May Be a Focus Of Clinical Attention.” Here’s what the editors say about these changes:

“This addition will help improve documentation of these behaviors, which can serve to estimate risk factors for future suicide attempts or death. These codes can also help clinicians record suicidal behavior and nonsuicidal self-injury when occurring with other mental health conditions. Finally, adding these codes will encourage research targeting their treatment specifically rather than simply addressing these behaviors as symptoms of an associated condition such as major depressive disorder.”

We see this as a rection to the increase in suicide, suicidal ideation, suicidal behavior, and nonsuicidal self-injury reflected in the nationwide data we list above. These new designations and diagnostic codes – which help with insurance reimbursement, among other things – can help providers identify, record, and track suicidality and/or nonsuicidal self-injury in the absence of mental health and substance use disorders, as well as add them as symptoms to mental health disorders where the DSM-5 does not currently list them as symptoms.

The next thing the editors addressed was language related to culture, racism, and discrimination.

Culture, Racism, and Discrimination: DSM-5-TR Changes

In order to align with a patient-first, whole-person, approach to treatment characterized by a foundation of respect for diversity and cultural differences, the work group “…reviewed references to race, ethnicity, nationality, and related concepts throughout DSM-5-TR to avoid perpetuating stereotypes or including discriminatory clinical information.”

Here’s the language they changed:

• The term racialized replaces race/racial to highlight the socially constructed nature of race.
• The term ethnoracial replaces words like White, or African American that erroneously conflate race and ethnicity.
• Elimination of the terms minority and non-White because they perpetuate social hierarchies
• Latinx replaces Latino/Latina to promote gender-inclusion.
• Elimination of the phrase Caucasian is not used because it is based on “obsolete views about the geographic origin of a prototypical pan-European ethnicity.”

All the changes we list above can help improve diagnostic accuracy and also help reduce the role of stigma in mental health treatment. 

Download fact sheets on all the changes, whether minor or major, to the DSM-5 made in 2022: fact sheets on all the changes, whether minor or major, to the DSM-5 made in 2022 here: DSM-5-TR Fact Sheets.

• Attenuated Psychosis Syndrome
• Autism Spectrum Disorder
• Avoidant Restrictive Food Intake Disorder
• Bipolar and Related Disorders Due to Another Medical Condition
• Bipolar I and Bipolar II Disorders
• Delirium
• Depressive Disorder Due to Another Medical Condition
• Functional Neurological Symptom Disorder
• Gender Dysphoria
• Intellectual Disability
• Major Depressive Disorder
• Narcolepsy
• Olfactory Reference Disorder
• Other Specified Bipolar and Related Disorder
• Other Specified Delirium Disorder
• Other Specified Depressive Disorder
• Other Specified Feeding Disorder
• Other Specified Schizophrenia
• Persistent Depressive Disorder
• Prolonged Grief Disorder
• PTSD
• Social Anxiety Disorder
• Substance Medication Induced Bipolar Disorder
• Suicidal Behavior and Nonsuicidal Self-Injury
• Unspecified Mood Disorder

How We Can Reduce Stigma in Mental Health and Mental Health Treatment

Experts from the APA identify three types of stigma in mental health and mental health treatment:

1. Public Stigma

This refers to negative attitudes people with no mental health issues have about mental health that lead to discrimination.

2. Self-Stigma

This refers to self-directed negative attitudes about mental health that someone directs toward themselves, primarily related to shame and/or embarrassment about having a mental health diagnosis.

3. Institutional Stigma

This refers to public systems and/or policies and practices that reduce support or limit access to care for people with mental health issues. Institutional stigma occurs at the governmental level, as well as public or private institutions – including medical facilities and psychiatric facilities – that exist to help people with mental health issues.

Addressing and reducing these three types of stigma can help us improve the overall mental health and wellbeing of all our citizens. In 2017, the mental health advocates at the National Alliance on Mental Illness (NAMI) conducted a nationwide survey of people with mental health disorders to learn how they think we can all work together to reduce stigma. Here are the nine common themes survey respondents identified.

Nine Ways to Reduce the Stigma Around Suicide and Mental Health Issues

1. Talk About Mental Health

• • Don’t be afraid to talk about anxiety, depression, or other issues with friends or loved ones

2. Educate Yourself and Others

• • Don’t be afraid to share what you know. If you hear people saying things that are inaccurate, counter them with facts

3. Use Inclusive Language

• • Use respectful, person first, non-stigmatizing language. For instance, a person with a substance order is just that: they’re not a junkie or a druggie.

4. Recognize the Similarities Between Physical and Mental Illness

• • In 2021, we recognize the disease model of mental health. Like physical ailments, anyone can develop a mental health diagnosis. And when they do, they go to the doctor, get a treatment plan, and follow it, just like with a physical illness

5. Show Compassion for People with Mental Health Issues

• • Lead with kindness. Lead with empathy. Resist the urge to judge: people with mental health diagnoses need the support of their friends, loved ones, and society-at-large

6. Empower Yourself

• • If you have a mental health diagnosis and you’re receiving treatment, that’s a sign of wisdom and strength. Your recovery is something to be proud of. You don’t have to tell anyone if you don’t want to, but when you look in the mirror, learn to see yourself as brave and strong.

7. Be Honest About What You Know

• • Tell anyone who asks – based on your personal judgment of course – what you know about treatment. If someone needs help and they hear someone else talking about a successful treatment experience, it will increase the likelihood they seek help for themselves.

8. Call Out Stigmatizing Language

• • When people use stigmatizing language – including people in pop culture as well as your friends – don’t let it slide. Call them out and teach them how to use non-harmful language.

9. Avoid Self-Stigma

• • If you have a mental health diagnosis, work to accept and love yourself. The stigmatizing words and attitudes of others may find their way into your personal thoughts. Guard against this, and remember that you’re strong, brave, and just as valuable or important as people without mental health issues.

We agree with all nine of those points. If we all read, understand, and then put those suggestions into practice, we can reduce the harm stigma causes for people diagnosed with mental health disorders. It’s clear there’s widespread national interest in mental health and mental health issues. While it may be important to read the DSM-5-TR and understand issues in clinical mental health disorders and their diagnoses, it’s every bit as important to understand, address, and reduce stigma. When we do, we can improve quality of life and wellbeing for everyone who experiences mental health issues.