What does suicidal ideation really mean? It comes down to mindset and intent. For example: wrist cutting. Is it a suicide attempt, a stress relief, a way to get attention? It could be any of those. The behavior, often called the WHAT, needs to be connected to the WHY.  There can be a bad injury, the 'what', but it's the 'why', the mindset and intent, that determine disposition when all the suturing is done.  The idea of connecting the WHAT and the WHY will recur throughout this discussion, not always in those words, but at least in concept. (credit to Kelly Posner for that 'what' and 'why' phrasing. I heard that in a lecture of hers and thought, "....couldn’t have said it better myself."

How do you assess suicide risk. You can use gestalt, decision tools, or whatever relevant questions come to mind. There’s no one best way, no one ring to rule them all. For those who have listened to the show for a while, you know that I use my own algorithm to organize the information in evaluating a mental health or potentially suicidal patient. It's more of a general overview, but getting to the specific question of

"Is my patient suicidal?" the Columbia Suicide Severity Rating Scale   gives a nice framework for asking questions. This isn’t a deep dive into this scale with its algorithm, decision trees,  etc. We're going to use it today as an example of what questions to ask and how to ask them, how to structure the interview - facilitate the assessment.

The Columbia Suicide Severity Rating Scale is a cascade of 6 questions

Step 1: Is there ideation, a wish to die

Questions

These are very general, the screening of the screening- spreading a wide net with maximal sensitivity but minimal specificity.

If the answer to both of these is no- no wish to be dead, no thoughts of killing themselves, then there’s no expressed suicidal ideation. If there’s no ideation, then there’s a final question, kind of a fail safe: Have you ever done anything, started to do anything, or prepared to do anything to end your life? If the answer to that is yes, then when did it happen? If it’s recent, within the past month or so, then the patient just went from potentially low risk, no stated thoughts of suicide, to high risk.

Step 2: If there is ideation, define it

We've established the patient has had thoughts of wanting to die or not wake up or kill themselves. Is there Suicidal Intent, not a specific plan, just intent?

Question:

Is there Suicide Intent with Specific Plan:

Question:

And the final question: 

Sometimes it's pretty clear what's going on, there has been an event and they've said that they were trying to kill themselves. They don't have to have actually hurt themselves. It’s the intent to die. 

Things that are not on the Columbia Scale that I ask in patient encounters

When we explore the ideation a little more deeply, there a few aspects that color the picture. 

Something I heard recently that isn’t something we’d normally ask, this was from  Kelly Posner, the developer of the Columbia tool. Ask...

As long as you’re organized, systematic, you learn the Why behind the What, the mindset and intent, if there even is intent, you’ll be off to a good start. But despite our best assessment, a great evaluation, an estimate that the patient is low risk, the reality is that is suicide is often an impulsive act, things change, the mind changes, an event can tip someone over the edge in a moment. For many, suicidal ideation is short lived, less than an hour, and the time between deciding on suicide and attempting is often less than 10 minutes.

While we want to assess the factors that are associated with suicide, hopelessness, previous attempts, feeling trapped like there’s no exit, the extent of suicidal ideation, we can't always outsmart the tides of the human psyche.  But there are other things that we can do to decrease someone's risk of killing themselves and one of those is completely unrelated to mental health.It is the means by which suicide happens. It is impossible to restrict all the means of suicide. People hang themselves,  are you going to take all the rope out of their house, or take away their car so they can't crash it or die from carbon monoxide, take away their shoes so they can’t run into traffic?

What is the likelihood of death from different means of suicide attempt?

No matter where you stand politically on firearms, there’s no denying that use of a firearm gives one of, if not the best, chances of dying from a suicide attempt.

If you remove the lethal means, the chance of dying is lower. Not zero, but lower. History gives us many examples of this. Prior to the 1960’s, in the UK, the most common method of death from suicide was gas asphyxiation, after a less toxic gas source was used, that rate dropped precipitously.  Other methods were used, but the overall rate of suicide death dropped. In Sri Lanka, suicide by pesticide was the most common method. When less toxic pesticides were introduced, the number of attempts didn’t drop but the number of suicide deaths plummeted. IN the Israeli army, a compulsory military force made up mostly of adolescents, 18 and 19 year olds, many soldiers were dying, not from missile attacks, but from suicide by firearm. The army instituted a policy that firearms couldn't be taken home on weekends (a time when an impulsive act of suicide attempt ma occur). The suicide rate dropped by 40%.

When the immediately lethal means are removed, does it make a difference? Yes. The evidence is there, the chance of dying is lower. But  we don’t always ask our depressed and suicidal patients about whether or not they own or have access to firearms, or plan on buying a firearm. Say you have a suicidal patient, even one who's low risk, and there is access to firearms. One way you can phrase it is this: "There’s no way to predict what’s going to happen when you go home. You feel better now, safe leaving the hospital, but that can change. When there’s access to a firearm, and someone feels suicidal  the chance of dying just went up, dramatically. I don’t want you to die, your family doesn’t want you to die, and you don’t want to die."  I have never had a situation where a discharged  patient and their family weren’t in agreement to get the guns out of the house or in some way made no access during the period of crisis.

Summary:

Links

Suicide Risk Assessment in the ED podcast