The interview setting
Assessment should take place in a quiet room where the chances of being disturbed are minimised. Ideally you should meet with the patient alone but also see their family/carers/ friends, together or alone, as appropriate. In general, open questioning is advisable although it may become necessary to use more closed questions as the consultation progresses and for purposes of clarification. There is no definitive way to approach enquiring about suicide but it is essential that this is assessed in anyone who is depressed.
There is no definitive way to approach enquiring about suicide but it is essential that this is assessed in anyone who is depressed.
There may be circumstances under which assessment is conducted by telephone. This will clearly place limitations on the assessment procedure (e.g. access to non-verbal communication). However the principles of assessment are the same. Where feasible, a face-to-face assessment is recommended.
Asking about suicidal ideas
Some patients will introduce the topic without prompting, while others may be too embarrassed or ashamed to admit they may have been having thoughts of suicide. However the topic is raised, careful and sensitive questioning is essential. It should be possible to broach suicidal thoughts in the context of other questions about mood symptoms or link this into exploration of negative thoughts (e.g. “It must be difficult to feel that way – is there ever a time when it feels so difficult that you’ve thought about death or even that you might be better off dead?”). Another approach is to reflect back to the patient your observations of their non-verbal communication (e.g. “You seem very down to me”. “Sometimes when people are very low in mood they have thoughts that life is not worth living: have you been troubled by thoughts like this?”).
It is important to pay heed to non-verbal cues and intuitive feelings about a person’s level of risk.
You may want to ask about a number of topics, starting with more general questions and gradually focusing on more direct ones, depending on the patient’s answers. This must be done with respect, sympathy and sensitivity. It may be possible to raise the topic when the patient talks about negative feelings or depressive symptoms. It is important not to overreact even if there is reason for concern. Areas that you may want to explore include:
- Are they feeling hopeless, or that life is not worth living?
- Have they made plans to end their life?
- Have they told anyone about it?
- Have they carried out any acts in anticipation of death (e.g. putting their affairs in order)?
- Do they have the means for a suicidal act (do they have access to pills, insecticide, firearms...)?
- Is there any available support (family, friends, carers...)?
There is increasing evidence that visual imagery can strongly influence behaviour. Therefore it is worth asking whether a person has any images about suicide (e.g. “If you think about suicide, do you have a particular mental picture of what this might involve?”). While assessment of risk factors for suicide in people with depression and more generally can inform evaluation of risk, it is also important for the clinicians to pay heed to non-verbal clues and their intuitive feelings about a person’s level of risk.
Sometimes patients with few risk factors may nevertheless make the clinician feel uneasy about their safety. The clinician should not ignore these feelings when assessing risk, even though they may not be quantifiable.