Suicidal ideation

Suicidal ideation (or suicidal thoughts) is thinking about, considering, or planning suicide.[1] It is not a diagnosis, but is a symptom of some mental disorders and can also occur in response to adverse events without the presence of a mental disorder.[2]

Suicidal ideation
Other namesSuicidal thoughts, Suicidal ideas
Sappho (1897) by Ernst Stückelberg
SpecialtyPsychiatry, psychology

On suicide risk scales, the range of suicidal ideation varies from fleeting thoughts to detailed planning. Passive suicidal ideation is thinking about not wanting to live or imagining being dead.[3][4] Active suicidal ideation is thinking about different ways to die or forming a plan to die.[3][4]

Most people who have suicidal thoughts do not go on to make suicide attempts, but suicidal thoughts are considered a risk factor.[5] During 2008–09, an estimated 8.3 million adults aged 18 and over in the United States, or 3.7% of the adult U.S. population, reported having suicidal thoughts in the previous year. An estimated 2.2 million in the U.S. reported having made suicide plans in 2014.[6] Suicidal thoughts are also common among teenagers.[7]

Suicidal ideation is generally associated with depression and other mood disorders; however, it seems to have associations with many other mental disorders, life events, and family events, all of which may increase the risk of suicidal ideation. Mental health researchers indicate that healthcare systems should provide treatment for individuals with suicidal ideation, regardless of diagnosis, because of the risk for suicidal acts and repeated problems associated with suicidal thoughts.[8][9] There are a number of treatment options for people who experience suicidal ideation.

Terminology

Another term for suicidal ideation is suicidal thoughts.[5]

When someone who has not shown a history of suicidal ideation experiences a sudden and pronounced thought of performing an act which would necessarily lead to their own death, psychologists call this an intrusive thought. A commonly experienced example of this is the high place phenomenon,[10] also referred to as the call of the void.[11] The urge to jump is called "mountain fever" in Brian Biggs' book Dear Julia.[12]

Euphemisms related to mortal contemplation include internal struggle,[13] voluntary death,[14] and eating one's gun.[15]

Signs and symptoms

The US Centers for Disease Control and Prevention (CDC) defines suicidal ideation "as thinking about, considering, or planning suicide."[1] The DSM-5 defines it as "thoughts about self-harm, with deliberate consideration or planning of possible techniques of causing one's own death." The ICD-11 describes suicidal ideation as "thoughts, ideas, or ruminations about the possibility of ending one's life, ranging from thinking that one would be better off dead to formulation of elaborate plans."[16] Suicidal ideation is a symptom for many mental disorders and can occur in response to adverse life events without the presence of a mental disorder.[2]

Risk factors
See also: Suicide § Risk factors

The risk factors for suicidal ideation can be divided into three categories: psychiatric disorders, life events, and family history.

Psychiatric disorders

There are several psychiatric disorders that appear to be comorbid with suicidal ideation or considerably increase the risk of suicidal ideation.[17] For example, many individuals with borderline personality disorder exhibit recurrent suicidal behavior and suicidal thoughts. One study found that 73% of patients with borderline personality disorder have attempted suicide, with the average patient having 3.4 attempts.[18] The following list includes the disorders that have been shown to be the strongest predictors of suicidal ideation. These are not the only disorders that can increase risk of suicidal ideation. The disorders in which risk is increased the greatest include:[19]

Medication side effects

Some medications, such as selective serotonin re-uptake inhibitors (SSRIs), can have suicidal ideation as a side effect. Moreover, these drugs' intended effects, can themselves have unintended consequence of an increased individual risk and collective rate of suicidal behavior: Among the set of persons taking the medication, a subset feel bad enough to want to attempt suicide (or to desire the perceived results of suicide) but are inhibited by depression-induced symptoms, such as lack of energy and motivation, from following through with an attempt. Among this subset, a "sub-subset" may find that the medication alleviates their physiological symptoms (such as lack of energy) and secondary psychological symptoms (e.g., lack of motivation) before or at lower doses than it alleviates their primary psychological symptom of depressed mood. Among this group of persons, the desire for suicide or its effects persists even as major obstacles to suicidal action are removed, with the effect that the incidences of suicide attempt and of completed suicide increase.[23]

Life events

Life events are strong predictors of increased risk for suicidal ideation. Furthermore, life events can also lead to or be comorbid with the previous listed psychiatric disorders and predict suicidal ideation through those means. Life events that adults and children face can be dissimilar and for this reason, the list of events that increase risk can vary in adults and children. The life events that have been shown to increase risk most significantly are[24]

  • Alcohol abuse
    • Studies have shown that individuals who binge drink, rather than drink socially, tend to have higher rates of suicidal ideation[25]
    • Certain studies associate those who experience suicidal ideation with higher alcohol consumption[26]
    • Not only do some studies show that solitary binge drinking can increase suicidal ideation, but there is a positive feedback relationship causing those who have more suicidal ideation to have more drinks per day in a solitary environment[25]
  • Minoritized gender expression and/or sexuality[27]
  • Unemployment[26]
  • Chronic illness or pain
  • Death of family members or friends
  • End of a relationship or being rejected by a romantic interest
  • Major change in life standard (e.g. relocation abroad)
  • Other studies have found that tobacco use is correlated with depression and suicidal ideation[28]
  • Unplanned pregnancy
  • Bullying, including cyberbullying[29][30] and workplace bullying[31]
  • Previous suicide attempts
    • Having previously attempted suicide is one of the strongest indicators of future suicidal ideation or suicide attempts[25]
  • Military experience
    • Military personnel who show symptoms of PTSD, major depressive disorder, alcohol use disorder, and generalized anxiety disorder show higher levels of suicidal ideation[32]
  • Community violence[33]
  • Undesired changes in body weight[34]
    • Women: increased BMI increases chance of suicidal ideation
    • Men: severe decrease in BMI increases chance of suicidal ideation
      • In general, the obese population has increased odds of suicidal ideation in relation to individuals that are of average-weight
  • Exposure and attention to suicide related images or words[35]

Family history
  • Parents with a history of depression
    • Valenstein et al. studied 340 adult offspring whose parents had depression in the past. They found that 7% of the offspring had suicidal ideation in the previous month alone
  • Abuse[33]
    • Childhood: physical, emotional and sexual abuse[36]
    • Adolescence: physical, emotional and sexual abuse
  • Family violence
  • Childhood residential instability

Relationships with parents and friends

According to a study conducted by Ruth X. Liu of San Diego State University, a significant connection was found between the parent–child relationships of adolescents in early, middle and late adolescence and their likelihood of suicidal ideation. The study consisted of measuring relationships between mothers and daughters, fathers and sons, mothers and sons, and fathers and daughters. The relationships between fathers and sons during early and middle adolescence show an inverse relationship to suicidal ideation. Closeness with the father in late adolescence is "significantly related to suicidal ideation".[37] Liu goes on to explain the relationship found between closeness with the opposite sex parent and the child's risk of suicidal thoughts. It was found that boys are better protected from suicidal ideation if they are close to their mothers through early and late adolescence; whereas girls are better protected by having a close relationship with their father during middle adolescence.

An article published in 2010 by Zappulla and Pace found that suicidal ideation in adolescent boys is exacerbated by detachment from the parents when depression is already present in the child. Lifetime prevalence estimates of suicidal ideation among nonclinical populations of adolescents generally range from 60% and in many cases its severity increases the risk of completed suicide.[38]

Prevention
See also: Suicide prevention
Crisis hotlines, such as the National Suicide Prevention Lifeline, enable people to get immediate emergency telephone counselling
As a suicide prevention initiative, these signs on the Golden Gate Bridge promote a special telephone that connects to a crisis hotline, as well as a 24/7 crisis text line.

Early detection and treatment are the best ways to prevent suicidal ideation and suicide attempts. If signs, symptoms, or risk factors are detected early then the individual might seek treatment and help before attempting to take their own life. In a study of individuals who did commit suicide, 91% of them likely suffered from one or more mental illnesses. However, only 35% of those individuals were treated or being treated for a mental illness.[39] This emphasizes the importance of early detection; if a mental illness is detected, it can be treated and controlled to help prevent suicide attempts. Another study investigated strictly suicidal ideation in adolescents. This study found that depression symptoms in adolescents early as 9th grade is a predictor of suicidal ideation. Most people with long-term suicidal ideation do not seek professional help.

The previously mentioned studies point out the difficulty that mental health professionals have in motivating individuals to seek and continue treatment. Ways to increase the number of individuals who seek treatment may include:

  • Increasing the availability of therapy treatment in early stage
  • Increasing the public's knowledge on when psychiatric help may be beneficial to them
    • Those who have adverse life conditions seem to have just as much risk of suicide as those with mental illness[39]

A study conducted by researchers in Australia set out to determine a course of early detection for suicidal ideation in teens stating that "risks associated with suicidality require an immediate focus on diminishing self-harming cognitions so as to ensure safety before attending to the underlying etiology of the behavior". A Psychological Distress scale known as the K10 was administered monthly to a random sample of individuals. According to the results among the 9.9% of individuals who reported "psychological distress (all categories)" 5.1% of the same participants reported suicidal ideation. Participants who scored "very high" on the Psychological Distress scale "were 77 times more likely to report suicidal ideation than those in the low category".[40]

In a one-year study conducted in Finland, 41% of the patients who later committed suicide saw a health care professional, most seeing a psychiatrist. Of those, only 22% discussed suicidal intent on their last office visit. In most of the cases, the office visit took place within a week of the suicide, and most of the victims had a diagnosed depressive disorder.[41]

There are many centers where one can receive aid in the fight against suicidal ideation and suicide. Hemelrijk et al. (2012) found evidence that assisting people with suicidal ideation via the internet versus more direct forms such as phone conversations has a greater effect.

Assessment
See also: Evidence-based assessment

Assessment seeks to understand an individual by integrating information from multiple sources such as clinical interviews; medical exams and physiological measures; standardized psychometric tests and questionnaires; structured diagnostic interviews; review of records; and collateral interviews.[42]

Interviews

Psychologists, psychiatrists, and other mental health professionals conduct clinical interviews to ascertain the nature of a patient or client's difficulties, including any signs or symptoms of illness the person might exhibit. Clinical interviews are "unstructured" in the sense that each clinician develops a particular approach to asking questions, without necessarily following a predefined format. Structured (or semi-structured) interviews prescribe the questions, their order of presentation, "probes" (queries) if a patient's response is not clear or specific enough, and a method to rate the frequency and intensity of symptoms.[43]

Standardized psychometric measures
See also: Assessment of suicide risk § In practice

Treatment

Treatment of suicidal ideation can be problematic due to the fact that several medications have actually been linked to increasing or causing suicidal ideation in patients. Therefore, several alternative means of treating suicidal ideation are often used. The main treatments include: therapy, hospitalization, outpatient treatment, and medication or other modalities.[5]

Therapy

In psychotherapy a person explores the issues that make them feel suicidal and learns skills to help manage emotions more effectively.[5][45]

Hospitalization

Hospitalization allows the patient to be in a secure, supervised environment to prevent the suicidal ideation from turning into suicide attempts. In most cases, individuals have the freedom to choose which treatment they see fit for themselves. However, there are several circumstances in which individuals can be hospitalized involuntarily. These circumstances are:

  • If an individual poses danger to self or others
  • If an individual is unable to care for oneself


Hospitalization may also be a treatment option if an individual:

  • Has access to lethal means (e.g., a firearm or a stockpile of pills)
  • Does not have social support or people to supervise them
  • Has a suicide plan
  • Has symptoms of a psychiatric disorder (e.g., psychosis, mania, etc.)

Outpatient treatment

Outpatient treatment allows individuals to remain at their place of residence and receive treatment when needed or on a scheduled basis. Being at home may improve quality of life for some patients, because they will have access to their personal belongings, and be able to come and go freely. Before allowing patients the freedom that comes with outpatient treatment, physicians evaluate several factors of the patient. These factors include the patient's level of social support, impulse control and quality of judgment. After the patient passes the evaluation, they are often asked to consent to a "no-harm contract". This is a contract formulated by the physician and the family of the patient. Within the contract, the patient agrees not to harm themself, to continue their visits with the physician, and to contact the physician in times of need.[5] There is some debate as to whether "no-harm" contracts are effective. These patients are then checked on routinely to assure they are maintaining their contract and avoiding dangerous activities (drinking alcohol, driving fast, and not wearing a seat belt, etc.).

Medication

Prescribing medication to treat suicidal ideation can be difficult. One reason for this is that many medications lift patients' energy levels before lifting their mood. This puts them at greater risk of following through with attempting suicide. Additionally, if a person has a comorbid psychiatric disorder, it may be difficult to find a medication that addresses both the psychiatric disorder and suicidal ideation.

Antidepressants may be effective.[5] Often, SSRIs are used instead of TCAs as the latter typically have greater harm in overdose.[5]

Antidepressants have been shown to be a very effective means of treating suicidal ideation. One correlational study compared mortality rates due to suicide to the use of SSRI antidepressants within certain counties. The counties which had higher SSRI use had a significantly lower number of deaths caused by suicide.[46] Additionally, an experimental study followed depressed patients for one year. During the first six months of that year, the patients were examined for suicidal behavior including suicidal ideation. The patients were then prescribed antidepressants for the six months following the first six observatory months. During the six months of treatment, experimenters found suicide ideation reduced from 47% of patients down to 14% of patients.[47] Thus, it appears from current research that antidepressants have a helpful effect on the reduction of suicidal ideation.

Although research is largely in favor of the use of antidepressants for the treatment of suicidal ideation, in some cases antidepressants are claimed to be the cause of suicidal ideation. Upon the start of using antidepressants, many clinicians will note that sometimes the sudden onset of suicidal ideation may accompany treatment. This has caused the Food and Drug Administration (FDA) to issue a warning stating that sometimes the use of antidepressants may actually increase the thoughts of suicidal ideation.[46] Medical studies have found antidepressants help treat cases of suicidal ideation and work especially well with psychological therapy.[48] Lithium reduces the risk of suicide in people with mood disorders.[49] Tentative evidence finds clozapine in people with schizophrenia reduces the risk of suicide.[50]

See also

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