Suicidal Ideation

Excerpt

Suicidal ideations (SI), often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide. There is no universally accepted consistent definition of SI, which leads to ongoing challenges for clinicians, researchers, and educators. For example, in research studies, SI is frequently given different operational definitions. This interferes with the ability to compare findings across studies and is frequently mentioned as a limitation in meta-analyses associated with suicidality. Some SI definitions include suicide planning deliberations, while others consider planning to be a discrete stage.

Beyond the lack of clear nomenclature, there are other concerns. A systematic review of the numerous interprofessional clinical guidelines for suicide yielded no consensus on a clinical gold standard for assessing and managing SI or people at risk of suicide. Although scales to measure depression, SI and risk for suicide exist, none produce a score that is sufficiently reliable or clinically useful in predicting the very small subgroup of suicide ideators whose death by suicide is imminent. (The American Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults, 3rd ed. 2016, p. 19).

It is evident that suicidal ideations present in a "waxing and waning manner" , so the magnitude and characteristics of SI fluctuate dramatically. It is critically important for healthcare professionals to recognize that SI is a heterogeneous phenomenon. It varies in intensity, duration, and character. As there is no "typical" suicide victim, there are no "typical" suicidal thoughts and ideations. Unfortunately, healthcare records often document SI in a binary yes/no fashion, although it encompasses everything from fleeting wishes of falling asleep and never awakening to intensely disturbing preoccupations with self-annihilation fueled by delusions. Therefore, thoroughly assessing and monitoring the pattern, intensity, nature, and impact of SI on the individual and documenting this accordingly is important for all healthcare professionals. It is also important to reassess SI frequently due to its fluctuating pattern.

The magnitude of SI fluctuations was studied using an ecological momentary assessment method. Individuals who attempted suicide in the past year plus a sample of suicidal in-patients recorded the intensity of their suicidal thoughts from hour to hour for four weeks. Analysis of these data showed dramatic fluctuations in the intensity of SI by all participants. All participants had SI, which varied in its intensity, either upwards or downwards, by one standard deviation on most days. Many had one standard deviation fluctuations several hours apart within the same day. This knowledge is important for all healthcare professionals to consider and highlights the need to monitor fluctuations and not dismiss the possibility of sudden increases in suicidal urges, even when the current level is mild, and the individual currently has control over them. Additionally, SI is considered a better predictor of lifetime risk for suicide than imminent risk, so assessments should include describing the characteristics and impact of prior SI as well as current.

The Center for Behavioral Health Statistics Quality publishes the results of the American nationwide household survey, the National Survey of Drug Use and Health (NSDUH). Piscopo's 2017 publication summarized the results from the 2009-2014 surveys, which show that 6% of 18-25-year-olds respond affirmatively to the survey question, "At any time in the past 12 months, did you seriously think about trying to kill yourself?" In contrast, the lowest rate of SI was 1.6% in those aged 65 years and above. There is no clear association between endorsing SI and attempting suicide. For every 31 Americans with SI, only one individual will attempt suicide. The rates of suicide deaths also vary by gender, age, race, and other demographic variables. Further evidence of the weak association between reported SI and fatal suicides is apparent when comparing the NSDUH results to CDC mortality records. Despite the low prevalence of SI in white males over age 75 years, they have the highest rate of fatality by suicide (approx. 40 per 100,000). Meanwhile, females over 75 years have much lower rates (4 per 100,000). The suicide ideators in the 18-25-year-old group had significantly fewer suicide deaths (approx. 17.5 per 100,000 for males and 4 per 100,000 for females).