What does suicidal ideation really mean? It comes down to mindset and intent. For example: wrist cutting. Is it a suicide attempt, a stress relief, a way to get attention? It could be any of those. The behavior, often called the WHAT, needs to be connected to the WHY. There can be a bad injury, the ‘what’, but it’s the ‘why’, the mindset and intent, that determine disposition when all the suturing is done. The idea of connecting the WHAT and the WHY will recur throughout this discussion, not always in those words, but at least in concept. (credit to Kelly Posner for that ‘what’ and ‘why’ phrasing. I heard that in a lecture of hers and thought, “….couldn’t have said it better myself.”
How do you assess suicide risk. You can use gestalt, decision tools, or whatever relevant questions come to mind. There’s no one best way, no one ring to rule them all. For those who have listened to the show for a while, you know that I use my own algorithm to organize the information in evaluating a mental health or potentially suicidal patient. It’s more of a general overview, but getting to the specific question of
“Is my patient suicidal?” the Columbia Suicide Severity Rating Scale gives a nice framework for asking questions. This isn’t a deep dive into this scale with its algorithm, decision trees, etc. We’re going to use it today as an example of what questions to ask and how to ask them, how to structure the interview – facilitate the assessment.
The Columbia Suicide Severity Rating Scale is a cascade of 6 questions
Step 1: Is there ideation, a wish to die
- Have you wished you were dead or wished you could go to sleep and not wake up?
- Have you actually had any thoughts of killing yourself?
- Have you wished you were dead and have you had thoughts of killing yourself?
These are very general, the screening of the screening- spreading a wide net with maximal sensitivity but minimal specificity.
If the answer to both of these is no- no wish to be dead, no thoughts of killing themselves, then there’s no expressed suicidal ideation. If there’s no ideation, then there’s a final question, kind of a fail safe: Have you ever done anything, started to do anything, or prepared to do anything to end your life? If the answer to that is yes, then when did it happen? If it’s recent, within the past month or so, then the patient just went from potentially low risk, no stated thoughts of suicide, to high risk.
Step 2: If there is ideation, define it
We’ve established the patient has had thoughts of wanting to die or not wake up or kill themselves. Is there Suicidal Intent, not a specific plan, just intent?
- Have you had these thoughts and had some intention of acting on them?
Is there Suicide Intent with Specific Plan:
- Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
And the final question:
- Have you ever done anything, started to do anything, or prepared to do anything to end your life? More insight and an idea of history because previous attempts are a risk factor for future attempts.
Sometimes it’s pretty clear what’s going on, there has been an event and they’ve said that they were trying to kill themselves. They don’t have to have actually hurt themselves. It’s the intent to die.
Things that are not on the Columbia Scale that I ask in patient encounters
- If a patient comes in after an attempt or has been thinking about it, “What did you think would happen when you did X?”
- A follow up question to that is, “How do you feel now that you’re not dead, that you’re here talking to me?”
When we explore the ideation a little more deeply, there a few aspects that color the picture.
- Is this incessant or fleeting ideation?
- Have you attempted suicide before?
- In a patient with ideation but hasn’t attempted, one of the most important question is: Why haven’t you killed yourself? What’s stopping you from doing it?
- This gives insight into protective factors and makes a huge difference. Protective factors decrease the chance of completing suicide. Things like family, like religious beliefs. If someone says they haven’t jumped off a bridge yet because they just haven’t gotten up the nerve. Is that a protective factor? Not much of one. If they haven’t attempted because they don’t want to leave their family and it’s against their religious beliefs, are those protective? Yes, not like a force field, or being superman, but more than nothing.
Something I heard recently that isn’t something we’d normally ask, this was from Kelly Posner, the developer of the Columbia tool. Ask…
- Did you want to kill yourself? No? Did any part of you want to kill yourself?
As long as you’re organized, systematic, you learn the Why behind the What, the mindset and intent, if there even is intent, you’ll be off to a good start. But despite our best assessment, a great evaluation, an estimate that the patient is low risk, the reality is that is suicide is often an impulsive act, things change, the mind changes, an event can tip someone over the edge in a moment. For many, suicidal ideation is short lived, less than an hour, and the time between deciding on suicide and attempting is often less than 10 minutes.
While we want to assess the factors that are associated with suicide, hopelessness, previous attempts, feeling trapped like there’s no exit, the extent of suicidal ideation, we can’t always outsmart the tides of the human psyche. But there are other things that we can do to decrease someone’s risk of killing themselves and one of those is completely unrelated to mental health.It is the means by which suicide happens. It is impossible to restrict all the means of suicide. People hang themselves, are you going to take all the rope out of their house, or take away their car so they can’t crash it or die from carbon monoxide, take away their shoes so they can’t run into traffic?
What is the likelihood of death from different means of suicide attempt?
- Overdose and sharp instruments 1-2%
- Gas 45%
- Hanging 61%
- Firearms 82%
No matter where you stand politically on firearms, there’s no denying that use of a firearm gives one of, if not the best, chances of dying from a suicide attempt.
If you remove the lethal means, the chance of dying is lower. Not zero, but lower. History gives us many examples of this. Prior to the 1960’s, in the UK, the most common method of death from suicide was gas asphyxiation, after a less toxic gas source was used, that rate dropped precipitously. Other methods were used, but the overall rate of suicide death dropped. In Sri Lanka, suicide by pesticide was the most common method. When less toxic pesticides were introduced, the number of attempts didn’t drop but the number of suicide deaths plummeted. IN the Israeli army, a compulsory military force made up mostly of adolescents, 18 and 19 year olds, many soldiers were dying, not from missile attacks, but from suicide by firearm. The army instituted a policy that firearms couldn’t be taken home on weekends (a time when an impulsive act of suicide attempt ma occur). The suicide rate dropped by 40%.
When the immediately lethal means are removed, does it make a difference? Yes. The evidence is there, the chance of dying is lower. But we don’t always ask our depressed and suicidal patients about whether or not they own or have access to firearms, or plan on buying a firearm. Say you have a suicidal patient, even one who’s low risk, and there is access to firearms. One way you can phrase it is this: “There’s no way to predict what’s going to happen when you go home. You feel better now, safe leaving the hospital, but that can change. When there’s access to a firearm, and someone feels suicidal the chance of dying just went up, dramatically. I don’t want you to die, your family doesn’t want you to die, and you don’t want to die.” I have never had a situation where a discharged patient and their family weren’t in agreement to get the guns out of the house or in some way made no access during the period of crisis.
- When your suicidal patient comes in, or someone potentially suicidal, get the story, the what and the why. How are those connected. What was the link between what they did and and why they did it. Their mindset and intent.
- And then, a risk assessment. Is there ideation? If there is ideation, explore it. You can use the my method, Columbia Scale, combinations of the two (which is what I do). There are other tools out there as well. No matter what the tool, think of it as a way to organize questions and collect information, to can inform your risk assessment. It does not trump your clinical judgment and gestalt, it facilitates.
TRAAPPED SILO SAFE method of interviewing potentially suicidal patients
Suicide risk chart documentation
Suicide Risk Assessment in the ED podcast from 2011 (audio quality suboptimal)
- Large, Matthew, et al. “Risk factors for suicide within a year of discharge from psychiatric hospital: a systematic meta-analysis.” Australian and New Zealand Journal of Psychiatry 45.8 (2011): 619-628.
- Shah, Seema, et al. “Adolescent suicide and household access to firearms in Colorado: results of a case-control study.” Journal of Adolescent Health 26.3 (2000): 157-163.
- Simon, Robert I. “Gun safety management with patients at risk for suicide.”Suicide and Life-Threatening Behavior 37.5 (2007): 518-526.
- Levin, Aaron. “Several Signs Should Alert Clinicians to Suicide Risk.” (2014).
- Pinholt, Ellen M., et al. ““Is There a Gun in the Home?” Assessing the Risks of Gun Ownership in Older Adults.” Journal of the American Geriatrics Society 62.6 (2014): 1142-1146.
- Wintemute, Garen J., et al. “Mortality among recent purchasers of handguns.”New England Journal of Medicine 341.21 (1999): 1583-1589.
- Fisher, Lauren B., James C. Overholser, and Lesa Dieter. “Methods of committing suicide among 2,347 people in Ohio.” Death studies ahead-of-print (2014): 1-5.
- Barber, Catherine W., and Matthew J. Miller. “Reducing a suicidal person’s access to lethal means of suicide: a research agenda.” American journal of preventive medicine 47.3 (2014): S264-S272.
- Spicer, Rebecca S., and Ted R. Miller. “Suicide acts in 8 states: incidence and case fatality rates by demographics and method.” American Journal of Public Health 90.12 (2000): 1885.