Suicide, the 10th leading cause of death in the United States,1 has risen in incidence by 24% from 1999 to 2014, with the greater increase observed in the latter half of that period.2 At the opening session of the 169th Annual Meeting of the American Psychiatric Association (APA), President-Elect Maria Oquendo, MD, identified suicide prevention as an urgent and central goal for APA.3 Psychiatrists in outpatient and inpatient settings are faced with difficult, anxiety-provoking decisions about what to do when a patient reports suicidal ideation and may either overestimate or underestimate suicidality.4 For this reason, it is essential for clinicians to be “adept at conducting a thorough targeted assessment.”4
“There are no shortcuts,” Igor Weinberg, PhD, Assistant Professor of Psychology, Department of Psychiatry, Harvard Medical School, told Psychiatry Advisor.
Pioneer suicidologist Edwin Schneidman coined the term “psychache” to refer to the unbearable psychological pain that catalyzes suicidality.5 “People who are acutely suicidal feel pain akin to losing a limb,” according to Aruna Jha, PhD, LCSW, Research Assistant Professor, University of Illinois at Chicago. “The clinician’s role is to understand the nature, magnitude, intensity, and frequency of that pain.”
But many suicidal people experience difficulty describing these internal states, making assessment more challenging and demanding a high level of skill, Weinberg observed.
Establishing Trust and Safety
The starting point of suicide assessment is “creating a safe place where patients trust you enough to share their struggles,” Jha told Psychiatry Advisor. This is accomplished by “demonstrating that you are okay with whatever they share and you are not afraid to talk about suicide.” Reassurance is conveyed through verbal and nonverbal communication (eg, eye contact or tone of voice) and “acknowledges that, while the patient might find it hard to talk about suicidal thoughts, clinicians are accustomed to hearing them.”
Another important component of creating a trusting relationship is “the skill of talking to the person about painful emotional states without immediately trying to ‘fix’ them and without giving too many reassurances at first,” Weinberg added, acknowledging that this is “difficult” because many clinicians would like to “do something right away to allay their own anxiety.” But rushing in with premature solutions conveys that the clinician is impatient or unable to tolerate the patient’s pain.
Moreover, it is important to understand the patient’s state in the moment. “We do not have an x-ray of how people think and what is going on in their minds.” So before offering solutions, “it is important to get as close to an ‘x-ray’ as possible,” he emphasized.
Harnessing Your Curiosity
Once a trusting relationship has been established, the clinician can move to the specifics of understanding what the patient’s suicidal thoughts.
“Curiosity is your best tool, and it will guide your questions,” Jha said. “For example, ask, ‘how do you experience your suicidal thoughts? What time of day do you feel them the most?’ You can further narrow it down by asking, ‘do you feel suicidal in the evenings or mornings? When you are alone or with other people?’ Try to elicit specific events that might be triggers.”
These questions are also part of laying the groundwork for psychoeducation, she said. “I explain that suicidal thoughts are like other thoughts. They ebb and flow in their intensity. If you do not act on them or do anything to aggravate them further, they subside in time.” She encourages patients to note the pattern of their thoughts as related to suicidal impulses, and communicates that one can “make a choice to give in or not give in to the impulse.”
The Role of Assessment Tools
According to the American Psychiatric Association’s 2010 Practice Guideline for Assessment and Treatment of Patients with Suicidal Behaviors, self-report scales may be helpful framework in structuring the assessment process.6 However, the guideline warns against overreliance on these instruments and emphasizes that rating scales “cannot substitute for thoughtful and clinically appropriate evaluation and are not recommended for clinical estimations of suicide risk.”6
Jha recommended starting with an assessment tool and following up with a clinical interview. She warned clinicians “not to administer these tools in a mechanical manner” because “patients report not feeling comfortable or validated if the clinician’s agenda is to check off boxes.” Instead, she advised, sit next to the patient and complete the form together, using the patient’s language to describe the symptoms and making sure that trust has been established first.
Commonly used assessment tools are listed in Table 1.
Some Frequently Used Suicide Assessment Instruments
Linehan Reasons for Living Scale
Columbia Suicide Severity Rating Scale (C-SSRS)
Suicide Assessment Five-Step Evaluation and Triage (SAFE-T)
Suicide Behavior Questionnaire
Beck Scale for Suicidal Ideation
Beck Hopelessness Scale
Do Not Be Afraid to Ask
Many clinicians are concerned that asking targeted questions about suicidal intent might have iatrogenic effects.7 On the contrary, Jha stated, “in my experience, patients do not feel the questions are intrusive, nor do they elicit new suicidal thoughts. Instead, patients feel cared for and appreciate the concern and detail.”
She added, “Patients who are suicidal sometimes say that their thoughts are like a dark cloud over their heads. If clinicians do not ask about those thoughts, it is as if they do not see the dark cloud, which feels invalidating.”
Tips for asking questions can be found in Table 2.
How To Ask About Suicide
- Ask the most important question of all: “Are you thinking of killing yourself?”
- Ask after you have enough information to reasonably believe the person is suicidal
- Ask in a way that is natural and flows with the conversation
- Do not ask as though you are looking for a “no” answer (“You aren’t thinking of killing yourself, are you?”)
- Remain calm
- Listen more than you speak
- Maintain eye contact
- Ask and act with confidence
- Do not argue
- Use open body language
- Limit questions to gathering information casually
- Use supportive and encouraging comments
Jha A. Clinical Tech www.ctacny.com/…/ctac_suicide_prevention_training_-_aruna_jha-_7-17-13_1.pdf. Accessed: May 27, 2016.
The “Suicide Cone”
Jha explores with patients the frequency of their suicidal thoughts (eg, every week, every hour, every fifteen minutes). “If there is no interval between the thoughts, the patient is too vulnerable to leave the office,” she said.
The image of a cone is useful in shaping the discussion. “I explain that when the thoughts are few and far between, this is like the base of a triangle. As the state of mind intensifies or the triggering situation worsens, the thoughts tend to become more frequent and the cone becomes narrower, until suicide seems to be the only way to escape from the unbearable pain.”
Patients can identify their place on the cone, which helps the clinician determine the intensity of thought and lethality of intent and further expands the discussion.
Using Warning Signs and Stratifying Risk
The American Association of Suicidology8 has created a mnemonic, “IS PATH WARM,” to assist clinicians in being alert to warning signs either reported by family, self-reported, or emerging via an assessment tool. (Table 3) Additional warning signs are listed in Table 4. Based on these signs, and a broader evaluation of the patient’s psychosocial support system, risk level can be stratified. (Table 5) More detailed resources can be found in Table 6.
IS PATH WARM: A Mnemonic for Recognizing Warning Signs
- Ideation: Suicidal statements or other communications
- Substance use: Increased use of drugs or alcohol
- Purposelessness: Feeling of meaninglessness, no purpose in life
- Anxiety: Agitation
- Trapped: Feeling sense of entrapment, no way out
- Hopelessness: Feeling no sense of hope
- Withdrawal: Withdrawing from friends, family, employment, society
- Anger: Rage, uncontrollable anger, revenge-seeking
- Recklessness: Risk-taking, reckless behaviors, seemingly without thinking
- Mood changes: Dramatic changes in mood
American Association of Suicidology. Available at: http://www.suicidology.org/resources/warning-signs. Accessed: May 27, 2016.
Jha A. Clinical Tech www.ctacny.com/…/ctac_suicide_prevention_training_-_aruna_jha-_7-17-13_1.pdf. Accessed: May 27, 2016.
Additional Warnings Signs of Suicide
- Drastic change in patient (eg, banging head against the wall, barricading him/herself in a room)
- Giving away prized possessions
- Presence of firearm/other lethal means and poor judgment/suicidality/depression
- Suicide plan
- Exhibition of imminent danger to self or others
- Psychosis (eg, command hallucinations related to harming self or others)
- Intoxication or under influence of illegal drugs and behaving impulsively
Stratifying Suicidal Risk
|Level of Risk||Description|
Roberts AR et al. Brief Treat Crisis Interv. 2008;8(1):5-14.
- Substance Abuse and Mental Health Services Administration (SAMSHA). Suicide Assessment Five-Step Evaluation and Triage (SAFE-T): Pocket Card for Clinicians. Available at: http://store.samhsa.gov/product/Suicide-Assessment-Five-Step-Evaluation-and-Triage-SAFE-T-Pocket-Card-for-Clinicians/SMA09-4432. Accessed: April 14, 2016.
- Ontario Hospital Association. Suicide Risk Assessment Guide: A Resource for Healthcare Organizations. Available at: https://www.oha.com/KnowledgeCentre/Documents/Final%20-%20Suicide%20Risk%20Assessment%20Guidebook.pdf. Accessed: May 27, 2016.
Creating a Formulation for Suicide Risk
Beyond an initial interview to assess immediate suicidal intent, a second assessment includes a more detailed interview that arrives at a “formulation of suicide risk,” Weinberg said.
“A ‘formulation’ is a meaningful understanding of how a particular person operates in multiple domains—for example, dealing with stress or life events such as loss, failure, or legal difficulties.” It takes into account psychiatric or medical diagnoses, personal history, strengths and weaknesses, and relationships in “an attempt to understand how the various factors interact with each other and under what circumstances a given person might become suicidal.”
In ongoing treatment, it is important to conduct regular assessments, Weinberg said. “Once I have a formulation, I can keep track of where a patient stands in terms of risk. For example, if someone is particularly sensitive to loss, I am more likely to become alarmed and inquire about suicide if the person is experiencing a loss.”
Ambivalence and the Desire to Live
There are three typologies of suicidal individuals: those with a wish to live, those with a wish to die, and those who are ambivalent.9 “Understanding how the suicidal mind works involves understanding ambivalence,” said Weinberg. “The wish to die but also to stay alive creates the suicidal struggle.”
Ambivalence is one of the most important reasons that people acknowledge suicidality. “The part that wants to stay alive is what collaborates with the clinician, and what makes it more likely that the person will tell you about the wish to die,” he said.
Jha agreed. “Tap into the ambivalence and find out why the person wants to live,” she advised. “Ask straightforward questions. For example, ‘considering how difficult things have been for you, what has kept you alive so far? What is important to you now?’”
When patients acknowledge why they are alive—for example, the “sheer joy of a relationship, or worry about what would happen to loved ones after they die”—this is the “clinician’s instrument for working with the individual to increase the desire to live and diminish the desire to die,” Jha said.
She emphasized that this is a crucial component of the assessment. “Look for the attachment to someone or something positive and reinforce that.”
1. Centers for Disease Control and Prevention (CDC). Suicide Facts at a Glance (2015). Available at: http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf. Accessed: April 14, 2016.
2. Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, 1999–2014. NCHS data brief, no 241. 2016; Hyattsville, MD: National Center for Health Statistics.
3. Kranjac D. Discussing suicide with Maria Oquendo, MD, APA President-Elect. Psychiatry Advisor. May 20, 2016. Available at: http://www.psychiatryadvisor.com/discussing-suicide-with-maria-oquendo-md-apa-president-elect/printarticle/497959/. Accessed: May 27, 2016.
4. Bryan CJ, Rudd MD. Advances in the assessment of suicide risk. J Clin Psychol. 2006;62(2):185-200.
5. Shneidman ES. Suicide as psychache. J Nerv Ment Dis. 1993;181(3):145-147.
American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. (2010) Available at: http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed: May 22, 2016.
6. Gould MS, Marrocco FA, Kleinman M, et al. Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. JAMA. 2005 Apr 6;293(13):1635-43.
7. American Association of Suicidology. Available at: http://www.suicidology.org/resources/warning-signs. Accessed: May 27, 2016.
8. O’Connor SS, Jobes DA, Yeargin MK, et al. A cross-sectional investigation of the suicidal spectrum: typologies of suicidality based on ambivalence about living and dying. Compr Psychiatry. 2012 Jul;53(5):461-7.