Suicidal ideation means thinking about, considering or planning one's own death, from passive wishes to be dead to a detailed plan. Asking about it directly does not put the idea in someone's head, and a careful assessment can save a life.
Key symptoms
- Talking about wanting to die or being a burden
- Hopelessness, deep sadness or feeling trapped
- Withdrawing from others or giving away belongings
- Increased alcohol or drug use, reckless behavior
- Sudden calm after a period of depression
What you find on exam
- Ask directly about thoughts, intent, plan and timing
- Ask about access to firearms, stored medicines and other means
- Mental status exam: mood, psychosis, intoxication, insight
- Look for self-harm injuries or signs of an overdose
- Use a structured tool such as the Columbia scale (C-SSRS)
Tests
- Screening with the ASQ or PHQ-9 item 9 in medical settings
- Acetaminophen and salicylate levels and toxicology if overdose is possible
- Blood alcohol and urine drug screen
- ECG after an ingestion
Treatment basics
- Keep the patient safe: one-to-one observation and remove dangerous items when risk is high
- Emergency psychiatric evaluation; admission for high risk
- Safety plan and lethal means counseling, such as storing firearms away from home
- Treat the underlying depression, psychosis or substance use
- Crisis line 988 and close follow-up within days
Red flags
- A specific plan with intent or a recent attempt
- Access to a firearm or a large supply of pills
- Psychosis, intoxication or command hallucinations
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Related guides
Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.