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.
A Clinician’s Guide to Talking about Suicidal Thoughts and Behaviors
The goal of this conversation is to understand the patient’s experience of suicidal thoughts and behaviors to deepen the therapeutic alliance and allow you to co-create an appropriate personalized safety plan. Some of the sections offer multiple ways of asking similar questions.
Screening
Many people who feel [depressed / anxious / etc.] have thoughts about not wanting to wake-up anymore. Have you had those thoughts?
If your clinic uses the PHQ9: I noticed that you checked the box indicating that you have thoughts of hurting yourself or being better off dead more than half the days. Can you tell me more about that?
Exploring Suicidal Ideation
-Have you had thoughts about killing yourself? Can you tell me more about those thoughts?
Context
-When did you begin thinking about suicide?
-Was there something that happened that led to these thoughts of suicide?
-What is it that you feel you can’t live with?
Duration and Frequency
-How often do you have these thoughts? How long do they stick around?
-How many hours a day do you spend thinking about suicide?
Emotional Impact & Coping
-When you have these thoughts, how do you feel?
-When you have these thoughts, what do you do?
Protective factors
-What has kept you from acting on these thoughts so far?
-When people think about suicide, they are often split. There is one part that wants to die because something in life is too painful. There is also a part that wants to live. Can you tell me about the part of you that wants to live?
Exploring Suicidal Plans, Preparations, and Intent
Plan
-If you decided that you were going to kill yourself, do you have a plan for how you would do it?
-Have you spent time researching methods of suicide online?
Preparations
-Have you made any preparations for suicide?
–Ask specifically about acquiring means for the plan discussed in the previous questions (firearm, poison, rope, stockpiling pills, etc.). Do you have a stockpile of pills at home?
–Ask about suicide rehearsal of the plan discussed in the previous question (going to a bridge or tall building or subway station). Have you ever gone to the [XX] building?
–Ask of Everyone, regardless of their plan: Do you have access to a firearm?*
-Have you taken any steps to prepare for death, like writing a note or giving things away?
Intent
-How likely are you to carry out your plan in the next month?
History of Suicidality
-Have you ever tried to kill yourself before? What happened?
-Have you had thoughts about suicide in the past? What happened?
-Have you lost someone to suicide?
-Some people intentionally hurt themselves, for example by cutting or burning themselves, but they are not trying to die. Have you ever intentionally hurt yourself in this way?
These questions may sound blunt or intrusive, just like the questions discussing sexual history sounded when we first asked them. Patients are more comfortable talking about suicidality if clinicians are comfortable, so practice saying the word suicide without flinching. People are having these thoughts whether or not we are talking about them. We also know that talking about suicidality does not lead to more suicide attempts.
*As discussed in the previous PsychSnap, our ability to predict suicidal behavior is poor. However, the assessment and removal of lethal means of suicide can save lives. Suicide attempts are often impulsive acts and firearms are the most lethal means of suicide. I ask everyone with suicidal thoughts if they have access to a firearm. I also ask this question of patients with family members who are depressed, impulsive, or ambivalent about living.
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
- 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.
- 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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