Does every allusion to possible suicide require the same response?
A structured method for assessing and managing risk
Using normalizing statements. Such statements can counteract the stigma experienced by patients with suicidal thoughts. For example, you may say “It is common for people who have medical problems or who experience pain to have problems adjusting. Some people have emotional reactions like feeling depressed or hopeless, or even in some cases feeling like life is not worth living.” Inquiring about suicidal thoughts generally won’t increase a patient’s distress, nor will it precipitate a suicide attempt. When performed by a concerned and sensitive clinician, this assessment usually makes the patient feel more understood and cared for.5
Background: Mrs. Lee is a 74 year old, married, Caucasian woman with the following medical conditions: 1. severe osteoporosis, 2. fracture of vertebrae, with lower back pain, and 3. history of breast cancer, on Tamoxifen prophylactically. She reports depressed mood associated with her back pain.
Clinician: “In the past couple of weeks, were things ever so bad that you had thoughts that life is not worth living or that you’d be better off dead?”
Mrs. Lee #1: “Oh, no. I don’t feel that way.”
Patient denies passive suicide ideation.
Stop questioning here.
Mrs. Lee #2: “Yes, sometimes I do think that I’d be better off dead. It would be much easier for my family. I’m such a burden.”
Patient endorses passive suicide ideation.
Continue questioning.
Clinician: “Have you had any thoughts about hurting yourself or suicide in the past couple of weeks?”
Mrs. Lee #2: “No. I would never hurt myself. But I sometimes wish I could just go to sleep and not wake up.”
Patient denies active suicide ideation.
Stop questioning here.
Mrs. Lee #3: “The thought has crossed my mind.”
Patient endorses active suicide ideation.
Continue with all remaining questions.
Clinician: “What have you been thinking of doing?”
Mrs. Lee #3: “I’ve thought of taking all my pills.”
Clinician: “How often do you have these thoughts? How long do they stay on your mind?”
Mrs. Lee #3: “Every day or so, especially when the pain gets bad.”
Clinician: “Besides dealing with the lower back pain, is there anything else going on in your life right now?”
Mrs. Lee #3: “Not really. I just can’t seem to get any relief from my pain.”
Clinician: “Do you have a plan to take all your pills?”
Mrs. Lee #3: “No.”
Mrs. Lee #4: “No. I haven’t worked up the courage yet.”
Clinician: “Do you intend to harm yourself?”
Mrs. Lee #3: “No. I would never do that.”
Mrs. Lee #4: “I might. I’m not sure.”
Clinician: “Is anything preventing you from harming yourself?”
Mrs. Lee #3: “I guess my faith. Plus, I’d never do that to my family. It would be devastating to them.”
Mrs. Lee #4: “Not really. I don’t really have anything to live for.”
Clinician: “Do you feel you can resist these thoughts?”
Mrs. Lee #3: “Yes. I told you I would never do that.”
Patient reports active suicide ideation, but denies plan and intention.
Mrs. Lee #4: “I’m not sure. I don’t know if I’ll be able to stop myself from taking the pills.” Patient reports active suicide ideation, and has uncertain intention, no reasons for living, and poor impulse control.
* From the educational videotape by Brown EL, Bruce ML, Raue PJ, et al. (2004): Depression Recognition and Assessment in Older Homecare Patients.
How the process works. As shown in FIGURE 1, the clinician asks a series of questions to determine the patient’s level of suicide risk. We suggest you ask about the prior 2 weeks, the same time frame covered in structured assessments like the PHQ-9.38 Use follow-up probe questions, as necessary, to formulate a clinical judgment.
Patients endorsing question 1 are considered at minimum to experience passive suicide ideation. In this instance, you should ask question 2, which deals with active suicide ideation. If a patient endorses question 2, pose questions 2a through 2g to identify a specific detailed suicide plan and to gauge a patient’s suicide intention, reasons for living, and impulse control. The CASE illustrates this process by presenting the same patient’s alternative responses to a clinician’s questions.
FIGURE 2 places the patient’s responses on a spectrum of risk and assists in conveying assessment findings to mental health professionals. The horizontal axis shows the continuum of suicide risk from very low (left) to imminent (right), and the correspondingly increased attention required by health care professionals. (Printable copies of these figures are available from the authors at www.geriu.org/suiciderisk)
The following descriptions assist in determining level of suicide risk and the associated intervention.
No suicide ideation
Presentation. Many primary care patients face end-of-life issues due to advanced age or severe illnesses. Indeed, older adults and the terminally ill are at the stage wherein occasional thoughts regarding death or mortality are normal and not pathological.44 Suicide ideation is considered present only when patients state that life is not worth living, or that they would be better off dead. Few primary care patients report such suicide ideation.5
