Suicidal ideation

Did You Know?

• The ICD-11 describes suicidal ideation as thoughts, ideas, or ruminations about the possibility of ending one's life, ranging from thinking one would be better off dead to formulation of elaborate plans.
• Among LGBTQ youth, suicidal ideation rates are significantly higher than in the general population, with transgender youths facing the highest rate: an estimated 82% consider suicide and 40% attempt it.

Risk factors

Risk factors for suicidal ideation fall into three categories: psychiatric disorders, life events, and family history. Suicidal ideation is a symptom of many mental disorders but can also occur in response to adverse life events without a mental disorder. Several psychiatric disorders are strongly linked to suicidal ideation, including mood disorders such as major depressive disorder, persistent depressive disorder, bipolar disorder, and premenstrual dysphoric disorder; anxiety disorders; neurodevelopmental disorders like autism spectrum disorder and attention deficit hyperactivity disorder; post-traumatic stress disorder and complex post-traumatic stress disorder; personality disorders, particularly borderline personality disorder; psychosis, paranoia, and schizophrenia; substance use disorders; nightmare disorder; gender dysphoria; conduct disorder; learning disorders; obsessive compulsive disorder; and eating disorders such as anorexia, binge eating disorder, and bulimia. Life events also increase risk, and these can differ between adults and children. Alcohol use disorder and binge drinking are associated with higher rates of suicidal ideation. Recent sociological work has emphasized meaning, culture, and meso-level mechanisms in explanations of suicide.

Prevention

Catching suicidal thoughts early and getting treatment is the most effective way to prevent suicide attempts. Research on people who died by suicide shows that 91% likely had a mental illness, but only 35% were receiving treatment for it. In teenagers, depression symptoms appearing as early as ninth grade can signal future suicidal ideation. Most individuals who struggle with long-term suicidal thoughts never seek professional help. To encourage more people to get help, therapy should be made available earlier, and the public needs better awareness of when psychiatric care is useful. People facing difficult life circumstances are just as vulnerable to suicide as those with a diagnosed mental illness. A study using the K10 Psychological Distress scale found that individuals with very high scores were 77 times more likely to report suicidal ideation than those with low scores. Out of the 9.9% of participants who reported any psychological distress, 5.1% also reported suicidal ideation.

Assessment

Assessment integrates information from clinical interviews, medical exams, standardized psychometric tests, structured diagnostic interviews, record reviews, and collateral interviews. Clinical interviews are often unstructured, while structured or semi-structured interviews prescribe questions, order, probes, and rating methods. Instruments used include the Beck Scale for Suicide Ideation, the Nurses' Global Assessment of Suicide Risk, the Suicidal Affect–Behavior–Cognition Scale (SABCS), and the Columbia Suicide Severity Rating Scale.

Management

Treatment of suicidal ideation can be complicated because some medications may increase or cause suicidal ideation. Main treatments include psychotherapy, hospitalization, outpatient treatment, and medication or other modalities. Psychotherapy helps a person explore issues that make them feel suicidal and learn skills to manage emotions. Hospitalization provides a secure, supervised environment to prevent suicide attempts. Involuntary hospitalization may occur if an individual poses a danger to self or others or is unable to care for themselves. Hospitalization may also be chosen if an individual lacks social support, has a suicide plan, or has symptoms of a psychiatric disorder such as psychosis or mania. Outpatient treatment allows individuals to remain at home and receive treatment on a scheduled basis. Before outpatient treatment, physicians evaluate social support, impulse control, and judgment. Patients may be asked to consent to a no-harm contract, agreeing not to harm themselves and to continue visits; there is debate about the effectiveness of such contracts. Patients are checked routinely to ensure they avoid dangerous activities.