Does enquiry about suicidal thoughts increase a patient’s risk?
No. There is no evidence that patients are suggestible in this way. In reality many patients are relieved to be able to talk about suicidal thoughts.
Do antidepressants increase the risk of suicide?
The risk of increasing suicidal thoughts and gestures following commencement of an antidepressant has received considerable media coverage. The current consensus is that there may be a slightly increased risk among those under the age of 25, where closer monitoring is required. However, the active treatment of depression is associated with an overall decrease in risk. The most successful way of reducing suicide risk is to treat the underlying depressive illness, and to monitor patients carefully, especially during the early phase of treatment.
There is no evidence that enquiry about suicidal thoughts increases a person’s risk.
Are there any rating scales I can use to quantify risk?
There are many rating scales which attempt to quantify risk but none are particularly useful in an individual context. They tend not to take account of the circumstances in which a person may be experiencing suicidal ideation and are reliant upon self-report.
They should therefore be used with caution and only as an adjunct to a clinical assessment. Some measures of level of depression are useful (e.g. PHQ-9, Beck Depression Inventory), some of which include items on hopelessness and suicidality. Such a measure is best used at each patient visit in order to help monitor progress (the patient might be asked to complete this in advance or in the waiting room).
When should I ask about suicide?
All patients with depression should be asked about possible thoughts of self-harm or suicide. As already noted, there is no evidence to suggest that asking someone about their suicidal thoughts will give them “ideas”, or that it will provoke suicidal behaviour. When this is best asked will vary from patient to patient (see Asking about suicidal ideas).
Sharing your concerns with the patient in an empathic manner will allow them to feel listened to and allow you to both agree a plan to try and keep them safe.
The patient doesn’t want me to inform their family, friends or carers that they have had suicidal thoughts. What should I do?
This is a difficult situation as family, friends and carers play an important role in helping to support depressed individuals and in keeping them safe. It is always worth exploring why the patient is reluctant for others to be informed as you may be able to address some of their concerns. Offering to be present when they inform close ones can be helpful. Unless there is imminent risk you cannot breach patient confidentiality so ultimately you may have to respect their wishes.
The patient is always expressing suicidal ideation. When should I worry?
Chronic suicidal ideation most commonly occurs in people with long-term severe depression or personality disorders. This group of people is at higher risk of suicide in the long term. While it can be difficult to distinguish circumstances when ideation may transform into action it is important to try to identify any factors that may significantly destabilise the situation - for example, a relationship breakdown, loss of a key attachment figure, alcohol and/or drug misuse, or physical illness.
Should I tell the patient that I am concerned they are at risk?
In general a collaborative approach is advisable. Sharing your concerns with the patient in an empathic manner will allow them to feel listened to and allow you to both agree a plan to try and keep them safe. If psychosis is a prominent feature of the presentation this may be more difficult and may require urgent psychiatric care.