Psychiatric Evaluations: Questions on Suicide Need to Be Rephrased

Suicidal ideation in patients is often missed by psychiatrists who use questions biased toward confirming patients are not suicidal.

When screening for suicidal intentions, psychiatrists are most likely to use questions biased toward confirming patients are not suicidal, rather than identifying patients who may be considering suicide, according to results of a new study by Rose McCabe, PhD, from the University of Exeter Medical School in the United Kingdom, and colleagues, published in BioMed Central Psychiatry.1

Using both quantitative and qualitative analyses, the team of investigators from the United Kingdom assessed video recordings of 319 outpatient visits to secondary mental healthcare facilities between June 2001 and October 2012. Suicidal ideations were specifically addressed by 35 psychiatrists on 83 occasions during 77 visits with 77 patients (the patient was assessed twice during 6 visits). A separate convenience sample of 6 occasions of suicidal evaluations conducted over the course of 5 primary care visits (from as total of 46) was also included in the study for comparison.

One of the main findings was that the psychiatrists framed the discussion in a way that predisposed patients to confirm they were not suicidal. The investigators identified a frequent use of “gateway” questions by psychiatrists to enquire about suicide risk, the answers to which determined whether any further evaluation was done. In all cases, these were closed, yes/no questions. Phrasing of the questions was often leading in nature, suggesting a particular favored response.

The majority (24 of 35) of the psychiatrists studied always employed negatively framed questions compared with 7 (20%) who always asked positively framed questions. Of 83 questions recorded in the study, 62 (75%) conveyed an expectation of negative response, whereas 21 (25%) indicated expectation of a positive response. Negatively phrased questions were highly likely to elicit a negative response that confirmed nonsuicidal thinking; 41 of 62 negative questions received “no” responses, 6 received “yeses,” and 15 had narrative answers (66%, 9.7%, and 24.2%, respectively). Positively framed questions, however, were not more likely to elicit a positive response confirming suicidal thoughts.

Narrative responses were of the most concern to the investigators, who viewed them as missed opportunities. In 19 of 83 exchanges, patients offered a multiword complex response to a question that expected a 1-word “yes” or “no” response. In these cases, the psychiatrists did not appear to recognize the patient’s ambivalence or distress over the content of the question, and instead returned to questioning that elicited the anticipated single-word response.

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A previous study by Haynal[1] -Reymond et al2 reported that facial expressions such as frowning or concentrated gazing by psychiatrists accurately predicted 90[2] % of suicidal intentions, when their written notes only corresponded to 22% of suicide attempts. McCabe and colleagues suggested psychiatrists were instinctively aware of a potential risk that was diminished by the act of reporting.

Questioning regarding suicidal thinking was likely to evoke conflicted responses in patients as well, whom the authors felt may be inclined to avoid further questioning by confirming such thoughts, while also needing help and support. They concluded that closed questions normally employed by psychiatrists in screening for suicidal ideations automatically lead to preferred responses confirming no suicidal intentions, and should therefore be avoided. In addition, questions should be positively framed to reduce influencing responses.


  1. McCabe R, Sterno I, Priebe S, Barnes R, Byng R.  BMC Psychiatry doi: 10.1186/s12888-017-1212-7
  2. Fiedorowicz JG, Weldon K, Bergus G. Determining suicide risk (hint: a screen is not enough): it takes more than an algorithm to accurately assess suicide risk. These tips will help you individualize your approach. J Fam Pract 2010;59:256-261.