Assessment of Suicidal Ideation
The appropriate method to assess suicidal ideation involves a systematic psychiatric evaluation that directly asks about suicidal thoughts, intent, plans, and access to lethal means, while documenting multiple risk factors across psychiatric, historical, and social domains. 1, 2
Direct Questioning Approach
Ask direct, specific questions in a sequential manner to establish the presence and severity of suicidal ideation 2:
- "Have you ever felt so upset that you wished you were not alive or wanted to die?" 2
- "Have you ever thought about killing yourself or wished you were dead?" 2
- "If you were to kill yourself, how would you do it?" (to assess for specific plans) 2
- "Have you ever done anything on purpose to hurt or kill yourself?" (to assess for prior attempts) 2
These questions do not increase suicide risk or cause suicidal thoughts in patients, contrary to common clinician fears 2, 3. Asking high-risk patients about suicidal intent leads to better outcomes 4.
Comprehensive Risk Factor Assessment
The evaluation must systematically document multiple domains 1, 2:
Current Suicidal Ideation and Intent
- Active versus passive thoughts of suicide or death 1, 2
- Specific plans and intended course of action if symptoms worsen 1, 2
- Access to lethal means, particularly firearms, medications, and knives 1, 2
- Balance between wish to die versus wish to live 2
- Steps taken to conceal behavior and avoid discovery 2
Psychiatric Symptoms and Mental Status
- Hopelessness (a critical risk factor for suicide) 2
- Severity of depression 1
- Presence of psychosis, command hallucinations, or delusional guilt 1
- Level of agitation and impulsivity 1
- Mood, anxiety level, thought content and process, perception, and cognition 2
Historical Factors
- Lifetime history of suicide attempts (the strongest predictor of future attempts) 1, 2
- Recent self-directed violence 1
- Comorbid substance abuse (often co-occurs with mood disorders and increases risk) 1, 2
- Previous high-lethality suicide attempts 2
Protective Factors
- Reasons for living 1
- Quality of therapeutic alliance 1
- Adequate support system and responsible adult supervision 1, 2
Social Determinants
Demographic Characteristics
- Male sex and older age (particularly males ages 16-19 or older adults) 2
- Gender considerations (males have higher completion rates) 1
Critical Pitfalls to Avoid
Do not rely solely on structured suicide scale questionnaires, as they have limited predictive value and sensitivity/specificity, especially in low-risk populations 2. Clinical assessments are only weakly associated with subsequent suicides, and structured tools do not predict better than comprehensive clinical evaluation 5.
Do not place confidence in "no-suicide contracts", as their value is unproven and they have no proven efficacy in preventing suicide 2. These may impair therapeutic engagement 2.
Do not use coercive communications such as "you can't leave until you say you're not suicidal," as this encourages deceit and defiance, undermining therapeutic alliance 2.
Do not discharge patients with irritability, agitation, threatening violence, delusions, or hallucinations without psychiatric evaluation 2.
Collateral Information Sources
Obtain information from multiple sources beyond the patient interview 2:
Documentation Requirements
Document an estimate of the patient's suicide risk, including specific factors influencing risk and rationale for treatment selection 2. This should include discussion of specific factors that influenced the treatment choice 2.
High-Risk Indicators Requiring Immediate Action
Certain signs indicate high risk and warrant immediate psychiatric evaluation or hospitalization 1, 2: