Working with the suicidal patient
1. Assess current suicidal ideation
- Is suicidal ideation present now?
- Have you gotten to the point where you did not want to go on?
- Have you had thoughts of not wanting to be alive?
- What about right now?
Passive Ideation:
- The patient would rather not be alive, but does not indicate a plan that involves an act of initiation = LOWER RISK (e.g., I’d rather not wake up in the morning; I wouldn’t mind if a car hit me when I was crossing the road)
Active Ideation:
- The patient has acute thoughts of completing suicide = HIGHER RISK (e.g., I do think about killing myself; I feel like throwing myself into traffic)
Intense, continuous ideation = HIGHER RISK - Is there a plan? Do you have a plan as to how you would end your life?
- Detailed, carefully thought-out plan = HIGHER RISK
- Is there intent? You talk about wanting to die, and have even considered
[taking pills] but are you intending to do this? - Low Intent:
- Suicidal thoughts and fantasies about plans, with absolutely no intent to put these plans into action. Fantasizing about suicide can provide some comfort to those in distress to know there is always a way out = LOWER RISK (e.g., Oh no, I could never do that, I have children)
- High Intent:
- Expression of specific intent to end life = HIGHER RISK (e.g., I intend to do this as soon as my daughter’s graduation is over)
- Ambivalent or Unclear Intent:
- Ask about what has helped in past.
- What has stopped you from ending your life to this point?
- What has helped in the past when/if you’ve had these thoughts?
2. Obtain details if there is a suicide plan
- How lethal is the plan?
- How lethal does the patient believe the method(s) to be?
- Is there access to means? (Obtain specific details - what pills do you have or would you take to overdose?)
- Has patient chosen a time and/or place? (How isolated is the patient? What preparations were made?)
- Has patient made final arrangements? (prepared a suicide note, settled their affairs or communicated to others?)
- Higher lethality, access to means, preparations and arrangements = HIGHER RISK
3. Gather details on current and previous attempts
- Previous attempts, especially in past year = HIGHER RISK
- Triggers of Present Attempt (Tell me about last 24 hours. When did you consider suicide?)
- Triggers of Past Attempts
- Lethality
- Impulsivity (or planned). Was the direction of hostility (goal to hurt self or others)?
- Intoxication
- Expectations of Dying
- Outcome (Was medical intervention required?)
- Feelings about Survival
- Guilt, remorse, embarrassment = LOWER RISK
- Disappointment, self-blame = HIGHER RISK (e.g., I couldn’t even kill myself properly)
SAD PERSONS provides a useful screening acronym to identify the high risk patient:
Sex (male)
Age (adolescent or elderly)
Depression
Previous attempt
Ethanol abuse
Rational thinking loss (psychosis)
Social supports lacking
Organized plan
No spouse/partner
Sickness – especially chronic/uncontrolled pain
Other factors suggesting high risk are: multiple risk factors; profound hopelessness; lack of protective factors; high lethality; premeditation of present attempt; and/or family history of suicide, depression or substance abuse.
4. Obtain info on psychiatric and other history.
5. Conduct mental status examination
- Emotional State ( Extremes in emotional state/mood = HIGHER RISK)
- Behaviour & Appearance
- Thought processes
- Problem solving capacity
- Reasons for Living & Level of Hope
- Hopelessness, helplessness, and view of future as empty or meaningless = HIGHER RIS
6. Communicate with families/ significant other(s)
Note: In an emergency, consent is not required to release information to family/significant other(s), although it is a courtesy to inform the patient of disclosure of information.
7. Communicate with primary care provider(s)
- Provide meaning and support
- Develop a safety plan
- Provide information. Provide a written copy of a treatment plan, including details of medications (if applicable) and dates of follow-up appointments to patient, primary care provider and family/significant other(s).
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Links & references
- Content based on Working with the Suicidal Patient
