Where did the patient express suicidal thoughts?

Assessment of Suicidal Expression Location

Information about where a patient expressed suicidal thoughts should be obtained from multiple sources, including the patient directly, parents or guardians, school reports, and any other individuals close to the patient. 1

Essential Information Sources for Assessment

The assessment of suicidal expression requires gathering information from several key locations and contexts:

Direct Patient Interview

• Ask patients directly about suicidal thoughts using a general question placed in the middle or toward the end of questions about depressive symptoms, such as "Have you ever thought about killing yourself or wished you were dead?" 1
• Follow up with "Have you ever done anything on purpose to hurt or kill yourself?" regardless of the initial answer. 1
• Adolescents may disclose information about suicidality on self-report screening scales that they deny in person, making written assessments a valuable complementary tool. 1

Collateral Sources

• Assessment information must always be drawn from parents or guardians, school reports, and any other individuals close to the child or adolescent. 1
• Regardless of the apparent mildness of the patient's suicidal behavior, the clinician must obtain information from a third party. 1
• Information should be sought from family members and others as appropriate to understand the full context of suicidal expression. 1

Clinical Settings Where Expression Occurs

• Emergency departments and crisis centers are common locations where suicidal patients present and express suicidal thoughts. 1
• Primary care offices may be where patients first disclose suicidal ideation, particularly during routine visits for other concerns. 1
• School settings may be where adolescents first express suicidal thoughts to counselors, teachers, or peers. 1

Important Contextual Considerations

Confidentiality vs. Safety

• For adolescents at risk to themselves or others, safety takes precedence over confidentiality, and the adolescent should have this explained at the onset so they understand. 1
• This means that suicidal expressions in confidential settings (therapy, school counseling) will need to be shared with parents and treatment teams. 1

Documentation Requirements

• Document the specific context in which suicidal thoughts were expressed, including who the patient told, when, and under what circumstances. 2
• Record whether suicidal ideation was spontaneously reported, disclosed on screening tools, or only revealed when directly questioned. 1

Common Pitfall to Avoid

• Never dismiss suicidal statements as unimportant regardless of where or how they were expressed. 1
• Do not rely solely on structured questionnaires, as they have limited predictive value and should complement but never replace thorough assessment from multiple sources. 1, 2