_____________________________________________________________ Suicide Assessment and Prevention
• Do you feel life is not worth living? • Have you had thoughts of ending your own life? It is important to ask these questions after rapport has been established, when the patient feels comfortable expressing his or her feelings, and when the patient is in the process of expressing negative feelings [59; 60]. After the patient confirms an initial suspicion of suicidal ide- ation, the next step is to assess the frequency and severity of the ideation and the possibility of suicide. It is important to ask the patient about whether a method has been developed and planned, the accessibility to the means to attempt suicide, and the magnitude of lethal intent in a manner that is not demanding or coercive, but is asked in a warm and caring way that demonstrates empathy with the patient. Such general questions might include [59; 60]: • Have you made any plans for ending your life? • How are you planning to do it? • Do you have in your possession [pills/guns/other means]? • Have you considered when to do it? In general, the more an individual has thought about suicide, made specific plans, and intends to act on those plans, the greater the suicide risk. Thus, as part of the assessment of suicide risk it is essential to inquire specifically about the patient’s suicidal thoughts, plans, behaviors, and intent. Such questions may often flow naturally from discussion of the patient’s current situation, but in other cases they should be explicitly asked [62]. Other questions may help further elucidate suicidal thoughts, plans, or behaviors, including [62]: Patient’s Feelings about Living • Have you ever felt that life was not worth living? • Did you ever wish you could go to sleep and just not wake up? Thoughts of Death, Self-Harm, or Suicide • Is death something you’ve thought about recently? • Have things ever reached the point that you’ve thought of harming yourself?
• How likely do you think it is that you will act on them in the future? • Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to edge of bridge but not jumping)? • What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)? • Have you made a specific plan to harm or kill yourself? If so, what does the plan include? • Do you have guns or other weapons available to you? • Have you made any particular preparations (e.g., pur- chasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)? • Have you spoken to anyone about your plans? • How does the future look to you? • What things would lead you to feel more (or less) hope- ful about the future (e.g., treatment, reconciliation of relationship, resolution of stressors)? • What things would make it more (or less) likely that you would try to kill yourself? • What things in your life would lead you to want to escape from life or be dead? • What things in your life make you want to go on living? • If you began to have thoughts of harming or killing yourself again, what would you do? For persons with previous suicidal or self-harm behavior, the following questions address the antecedents, methods, and aftermath [62]: • Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)? • What thoughts were you having beforehand that led up to the attempt? • What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)? • Were other people present at the time? • Did you seek help afterward yourself, or did someone get help for you? • Had you planned to be discovered, or were you found accidentally? • How did you feel afterward (e.g., relief versus regret at being alive)? • Did you receive treatment afterward (e.g., medical ver- sus psychiatric, emergency department, inpatient versus outpatient)?
Follow-Up Questions • When did you first notice such thoughts?
• What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhe- donia, hopelessness, anxiety, agitation, psychosis)? • How often have those thoughts occurred (including frequency, obsessional quality, controllability)? • How close have you come to acting on those thoughts?
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