How do you talk with patients about suicidal thoughts and behaviors?

David is a 60 yo man with chronic pain on opioids, PTSD, alcohol use disorder, and major depression, who was introduced in our last PsychSnap. He calls his primary care clinic every few weeks saying that he is going to kill himself if his pain isn’t better controlled. He now presents to a routine follow-up appointment with you, his PCP. How do you address the suicidality that he previously expressed on the phone?

This PsychSnap will focus on how to talk with patients with suicidal thoughts and behaviors. How can our conversation gather the information needed to create an individualized safety plan AND be therapeutic in and of itself? Some patients are comfortable talking about suicidal thoughts and behaviors. Others experience suicidal thoughts and behaviors as shameful secrets that need to be concealed, which further deepens their sense of shame. Talking with these patients about their suicidal thoughts and behaviors can pop the bubble of isolation created by these “unacceptable” experiences, often bringing some relief.



We return now to David. You mention that when he calls the clinic in a lot of pain, he often tells clinic staff that he might need to overdose on pills if his pain isn’t controlled. “I wonder if we could take some time today to talk about your experiences with suicidal thoughts and behaviors?”

Over the next 15 minutes, you learn that David has had suicidal thoughts ever since his husband died 30 years ago. These are usually visual images of him hanging and his spirit escaping to join his late husband. At baseline, he has fleeting thoughts of suicide twice a week. In times of stress the thoughts happen daily and are associated with 10-20 minutes of rumination about whether life is worth living. He has had these thoughts for so long that he is “used to them.” David has no plan for suicide. He wants to live for his friends and his cat, and generally likes his life. He does not have access to a firearm. He does not have a stockpile of pills or a rope at home.

You circle back to the clinic phone calls. “Can we talk about what’s going on when you call the clinic in pain?” 

David says that when he is in severe pain, he gets desperate and finds himself saying to himself, “I can’t live like this, I can’t live like this.” When a staff member asks, based on a standard suicide script, if he has a plan for suicide, David answers that he might take a whole bottle of pills if his pain doesn’t improve. “When I do that, someone calls me back,” he says sheepishly. He is very clear that the desperation from pain is different from the other suicidal thoughts that he experiences. 

In terms of David’s history, he has never cut or burned himself intentionally. He tried to hang himself twice 30 years ago when his husband died. He tied the noose in his home and wanted to die. “But I couldn’t do it,” he says. He called 911 and was psychiatrically hospitalized. He took medications for depression for a few years. At that time, he didn’t think he could live without his husband. 

“It’s hard to go back to those memories,” you say. 

David nods.

You thank David for sharing his experiences with you. You agree to spend the next visit creating a written safety plan.  

Look for the final PsychSnap in this series on suicidality on May 21 focused on clinical interventions for patients with suicidal thoughts and behaviors.


Key Points

  1. Talking with patients about suicidal thoughts and behaviors is a crucial clinical skill. It can also be a therapeutic intervention, popping the bubble of isolation so often associated with suicidal thoughts.
  2. Ask every patient with suicidal ideation or a significant psychiatric illness if they have access to a firearm.

Related PsychSnaps:
Can suicide risk assessments prevent your patients from dying by suicide?” Emma Samelson-Jones, March 2024.
“How do you talk with patients about their substance use?” Era Kryzhanovskaya, September 2023.


References:

Melvin, Glenn A., et al. “Assessment and management of suicidal risk.” Tasman’s Psychiatry. Cham: Springer International Publishing, 2023. 1-32.

Zortea, Tiago C., et al. “Understanding and managing suicide risk.” British Medical Bulletin 134.1 (2020): 73-84.


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