Continuing Education Activity

Suicidal ideation, marked by thoughts of self-harm or ending one's life, is a significant mental health issue with the potential for grave outcomes if not appropriately addressed. This phenomenon affects a broad spectrum of individuals and is frequently linked to mental health disorders, although ideation can also emerge due to situational stressors. Recognizing suicidal ideation early and identifying the underlying causes are crucial steps in enhancing a patient's quality of life and reducing the likelihood of suicide. Given the global rise in suicide rates, a thorough understanding and effective management of suicidal ideation are imperative.

This activity reviews the essential knowledge and tools for practical evaluation and management of patients with suicidal ideation. Understanding the intricacies of suicidal ideation, including etiology, risk factors, potential complications, and the critical role of early intervention, leads to reduced morbidity and mortality. Participating clinicians will acquire knowledge and skills to understand various manifestations of suicidal thoughts, their impact on daily lives and relationships, and vital techniques for risk assessment and management.

Objectives:

• Differentiate the current theories associated with suicidal ideation, considering prior risk factors.

• Implement the appropriate screening considerations when caring for patients with suicidal ideation.

• Select the evidence-based treatment recommendations for patients endorsing suicidal ideation.

• Apply effective strategies among interprofessional team members to facilitate positive outcomes for patients presenting with suicidal ideation.

Introduction

Suicide remains a significant public health issue in the United States, with the age-adjusted suicide rate reaching 14.1 per 100,000 population in 2021. Increasing concern exists regarding deaths categorized as unintentional falls or poisonings, both of which have risen, as they may be misclassified suicides. The age-adjusted suicide rate saw a 36.7% increase between 2000 and 2018. Notably, in the 10 to 24-year-old age group, suicide is the second leading cause of death. While the suicide rate in this demographic was stable from 2001 to 2007, an upward trend was observed through 2021.[1]

The suicide rate in the United States exhibits significant variations across different demographics. According to the Centers for Disease Control and Prevention (CDC), in 2021, the rate of suicide among men was 4 times higher than that among women. Additionally, individuals aged older than 85 experienced the highest rates of suicide. In the population aged 55 and older, the suicide rate increased with age among men, whereas the rate decreased with age among women.[2] Substantial racial disparities are apparent in suicide rates, with the highest rate observed among American Indian and Alaska Native populations; in contrast, the lowest rate is found in Asians, with the rate among the former being approximately 4 times higher than the latter.[3] According to the CDC, in 2021,12.3 million adults reported experiencing suicidal thoughts, 3.5 million adults made suicide plans, 1.7 million adults attempted suicide, and 48,183 individuals died by suicide.

Suicidal ideation refers to thinking about or formulating plans for suicide. The ideation exists on a spectrum of intensity, beginning with a general desire to die that lacks any concrete method, plan, intention, or action and progressing to active suicidal ideation, which involves a detailed plan and a determined intent to act on the ideas. Suicidal ideation is closely associated with both suicidal attempts and deaths, serving as a significant risk factor for future suicide attempts.[4] Suicidal thoughts and actions are often viewed as a single concept, whereas passive thinking, active planning, and actual behavior are seen as a continuous spectrum.[5] Research indicates that some individuals attempt suicide without prior suicidal ideation, though this is debated due to potential underreporting post-attempt due to stigma. A helpful analogy is to view suicidal ideation as the more significant, unseen portion of an iceberg, with the act of suicide as the visible tip.[6] This perspective emphasizes the need for early identification and targeted intervention of those with suicidal ideation to prevent progression to suicide.

Assessing suicidal ideation is an early warning for subsequent suicidal acts and also offers valuable insights into the patient's level of suffering and their specific needs. This dual purpose underscores the importance of evaluating suicidal ideation comprehensively. Only a subset of patients with suicidal ideation will carry out the act. Nevertheless, suicidal ideation accompanied by intention and a specific plan is a psychiatric emergency and needs to be aggressively managed.[7][8]

Given that 90% of individuals who die by suicide have a psychiatric illness, with the most common being mood disorder, recognizing suicidal ideation in patients presents a crucial opportunity for a thorough evaluation to understand their challenges, needs, and risk levels.[9] Research shows that 80% of suicide victims had seen primary care clinicians within 1 year of their death, compared to just 25% to 30% who had consulted with psychiatric clinicians in that timeframe.[10][11] Primary care clinicians are uniquely positioned to manage patients with suicidal ideation, assess suicide risk, and implement appropriate interventions.

Etiology

Suicide arises from a variety of risk factors that build up throughout life, with individual psychiatric disorders exerting the most significant impact on suicide rates. Conditions such as depression, bipolar disorder, schizophrenia-spectrum disorders, substance use disorders, epilepsy, and traumatic brain injury significantly increase the risk of suicide, elevating the odds by over 3-fold. While risk factors for suicide are well-established, the same level of certainty does not apply to suicidal ideation. However, the results of a 2017 meta-analysis found that suicidal ideation was the third most robust predictor of future suicide deaths, following prior psychiatric hospitalizations and suicide attempts. Additionally, the most prominent risk factor for future suicidal ideation episodes was past suicidal ideation, underscoring the persistent nature. 

According to the CDC, in the United States, in 2021, about 35 suicide attempts were completed for each adult suicide. Additionally, for every 1 suicide attempt, 2 adults contemplated suicidal ideation and had plans, and 7 adults were ideating about suicide. However, these figures may not fully capture the full extent of the issue, as suicides are often misclassified as accidental deaths, and suicidal ideations frequently go underreported by patients due to the stigma associated with mental health.[12][13] These data underscore the critical need to identify individuals with suicidal ideation and comprehend their progression toward suicide attempts.

Suicidal ideation results from intricate psychological, biological, environmental, and cultural interactions. The progression of suicidal ideation to suicidal behavior can be conceptualized within the framework of the following theories. 

Psychological Theories

Stress-diathesis models

Diathesis represents a person's tendency for suicidal behavior, influenced by factors like genetics, biology, or psychology, including mental illness history, personality traits, or past trauma. This model posits that when such a person encounters stressful life events that overwhelm their ability to cope, the feelings are expressed as suicidal ideation. Traits of impulsivity and aggression increase the likelihood of acting on suicidal ideation.[14]  

Ideation-to-action framework

This framework focuses on understanding how individuals progress from contemplating suicide to attempting, recognizing that suicidal thoughts and attempts are related but separate behaviors. The critical factor in this transition from ideation to action is an individual's capability for suicide, encompassing various elements that enable a person to make a suicide attempt. The following 4 theories use this framework.

1. Interpersonal theory of suicide: As per the interpersonal theory of suicide, 'acquired capability' is a critical factor in the progression from suicidal ideation to suicide attempts. This capability is marked by a decreased fear of death and a heightened tolerance for physical pain resulting from repeated exposure to painful or distressing events, such as childhood trauma or war. An individual with an elevated level of acquired capability is more prone to transition from suicide ideation to suicide attempts.                                      
2. The integrated motivational-volitional model: This model provides a comprehensive framework for understanding suicidal behavior. This model delineates 3 distinct phases: the 'pre-motivational phase,' which focuses on background factors and life events that may trigger suicidal thoughts; the 'motivational phase,' due to feelings of defeat, entrapment, and lack of support suicidal ideations develop; and the 'volitional phase,' which is concerned with the transition from suicidal ideation to actual attempts. Key to this phase are 'volitional moderators' such as access to means for suicide, exposure to suicidal behavior, reduced fear of death and increased pain tolerance, impulsivity, planning, mental imagery, and history of past suicidal behavior. This model integrates psychological, biological, and social factors, offering a detailed perspective on the complex pathways leading to suicidal actions.                                                                           
3. Three-step theory: The 3-step theory of suicide elucidates the progression from suicidal ideation to suicidal behavior. The theory posits that individuals first experience intense psychological pain and hopelessness, leading them to contemplate suicide as an escape (first step). The second step involves feelings of disconnection and perceiving oneself as a burden to others, exacerbating the initial distress. Finally, the third step is the development of a capability for suicide, characterized by overcoming the fear of death and acquiring the means to commit suicide.                                                                                          
4. The fluid vulnerability theory: This theory proposes that an individual's risk fluctuates over time, with baseline factors (chronic or stable risk and protective elements) and acute factors (reaction to external forces) interacting dynamically. The concept of the "suicidal mode" includes chronic factors like sex, trauma, psychiatric history, and past suicide attempts interacting with acute factors such as emotional distress and adverse life events. These interactions affect cognition, behavior, physiology, and emotion. This theory further suggests that mitigating acute triggers can shift an individual from a high-risk state back to baseline. Empirical research supports the theory, showing that suicidal ideation and related feelings can vary significantly within short periods.[15][16][17][18][19][20]

Biological Theories

Hypothalamic-pituitary-adrenal axis dysfunction 

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, integral to stress response, is increasingly linked to mental health issues, particularly suicidal ideation.[21] This axis, involving a hormonal sequence from the hypothalamus, pituitary, and adrenal glands, controls cortisol release. Disruptions in this system, possibly due to epigenetic factors like early life trauma and gene variations (eg, FKBP5 gene affecting glucocorticoid receptor sensitivity), can lead to an imbalance in cortisol release.[22] Research on HPA axis dysregulation and suicidal ideation shows diverse results, indicating different cortisol responses in suicidal ideation subgroups. For instance, acute suicidal ideation cases may have higher cortisol increases than chronic ones, and a family history of suicide or suicide attempts is linked to reduced cortisol levels under stress, underscoring the HPA axis's complex role in suicidal ideation.[23]

Neuroinflammation and immune system dysfunction

Increased microglial density and activation have been linked to suicidal ideation, as evidenced by post-mortem studies and in vivo positron emission tomography (PET) scans.[24] This activation impacts the tryptophan-kynurenine pathway, increasing neurotoxic compounds like quinolinic acid, which affects glutamate neurotransmission. Dysregulation of the tryptophan-kynurenine pathway has been associated with neuropsychiatric conditions and suicidality.[25] Targeting tryptophan-kynurenine pathway enzymes is suggested for treating depression and suicidal ideation.[26] Translocator protein levels, indicative of neuroinflammation, are elevated in patients with depression, especially those with suicidal ideation.[27] Research on brain-derived neurotrophic factor has demonstrated its potential as a biomarker for suicidality, with lower levels correlated with suicidal ideation, particularly in military personnel.[28][29]

Genetic factors

Research in this area has focused on the FKBP5 gene variants implicated in depression and suicidal ideation. The results of systematic reviews and meta-analyses have found associations between these gene variants and increased risk of depressive disorders and suicidality, suggesting a genetic predisposition.[30]

Epidemiology

Suicide is a significant public health issue around the world. According to the World Health Organization (WHO), over 800,000 people globally die by suicide annually. Suicide is the 18th leading cause of death worldwide and the second leading cause among individuals aged 15 to 29 years. The frequency of suicide deaths is alarmingly high, with 1 occurring every 40 seconds. Many countries experience substantial rates of suicide deaths. From 1950 to 1995, suicide rates increased by approximately 35% in men and 10% in women globally, affecting all age groups.[31] Actual suicide rates might be underreported. Often, deaths by suicide are misclassified as “unnatural” or “undetermined,” leading to possible underestimations.[32][33] The actual rates could be 10% to 50% higher than reported, and the number of nonfatal suicide attempts is estimated at 10 to 20 times the number of suicide deaths with a higher suicide attempt-to-death ratio in adolescents.[34][35] Suicidal ideation without subsequent action is more prevalent than actual suicidal behavior.

In the United States, a report by the CDC revealed that from 1999 to 2017, the age-adjusted suicide rate increased by 33%, rising from 10.5 to 14.0 per 100,000 individuals.[36] However, a slight decrease occurred in the rate in 2019, dropping from 14.2 per 100,000 individuals in 2018 to 13.9 per 100,000 individuals but rose again to 14.1 per 100,000 individuals in 2021.[2] The underestimation of suicide rates is a concern in the United States, with many deaths potentially misclassified, suggesting that the actual rates may be higher.[37]

History and Physical

The history and physical examination of patients with suicidal ideation are essential components of comprehensive psychiatric assessment, aiming to elucidate contributing factors, assess immediate risk, and guide therapeutic interventions.

Screening for Suicidal Ideation

Assessing suicidal ideation and suicide risk is essential in mental health and primary care settings. However, no definitive tool or method for accurately determining risk levels exists. Clinicians should use a combination of evaluation methods, including clinical interviews and self-report measures. The United States Preventive Services Task Force (USPSTF) highlights the inadequacy of routine screening for suicide risk in significantly reducing suicide attempts or related mortality among adolescents, adults, and older adults. These findings underscore the limitations of existing tools and emphasize the need for comprehensive, multifaceted patient evaluations. No evidence is available since asking about suicide increases suicidal ideation or behavior in patients.[38]

Risk Factors for Suicide

Elevated suicide rates are observed in specific demographics, such as older populations, men, and LGBTQ community members.[39] Risk factors are categorized into predisposing (neuropsychiatric disorders, family history of suicide, past suicide attempts, adverse childhood experiences, socioeconomic challenges) and precipitating factors (substance use disorders, access to lethal means, stressful life events, recent diagnoses of terminal or chronic illness). These factors can contribute to feelings of isolation, hopelessness, and perceived burdensomeness. Media influence on suicide is also noted, although the direct correlation with suicide deaths is relatively weak.[14] When taking a clinical history of the patient with suicidal ideation, the risk factors for suicide should be comprehensively explored.

Psychiatric Evaluation in Suicide Risk Assessment

In assessing suicide risk, conducting a thorough psychiatric evaluation encompasses a range of factors. This includes current suicidal ideation, history of suicide attempts, existing psychiatric conditions (such as depression, schizophrenia, substance use disorders, anxiety, borderline personality disorders, and adjustment disorders), psychiatric symptoms, previous psychiatric hospitalizations, and recent biopsychosocial stressors. Additionally, evaluating access to firearms and protective factors, especially those related to reasons for living, is crucial despite limited evidence supporting their impact.

Substance use, particularly involving alcohol, significantly heightens suicide risk, and this risk increases further when comorbid with conditions like bipolar or depressive disorder, often due to associated impulsivity and aggression. A comprehensive suicide risk evaluation should also consider the patient's psychiatric history, past and current treatments, family history of psychiatric disorders, coping mechanisms, and additional information gathered from external sources such as friends, family, and treatment records.

Risk stratification is an important element of suicide risk assessment. However, current evidence is insufficient to firmly recommend for or against its use, mainly due to inconsistencies in findings and limitations in study methodologies. Employing a comprehensive approach that includes multiple evaluation methods and collateral information is critical for an accurate and effective risk assessment.[40][41]

Assessment of Suicidal Ideations

When conducting a clinical evaluation of a patient presenting with suicidal ideation, a thorough assessment encompasses the following key areas:

1. Characteristics of suicidal ideation: A detailed assessment of suicidal ideation is essential, including onset, frequency, duration, intensity, triggers, associated factors, the individual's ability to control these thoughts, attribution, and whether the ideation is passive or active. This comprehensive understanding helps in evaluating the severity and immediacy of the risk.                                                                                       
2. Nature of suicidal ideation: Differentiating between passive and active suicidal ideation helps identify immediate short-term risks. However, suicide attempts can occur without prior expression of suicidal ideation, and the long-term risk is similar for both passive and active suicidal ideation.                                           
3. Suicide plan: Inquiring about a suicide plan is critical as the presence and detail of a plan are strongly associated with suicide risk. More detailed plans often indicate a higher likelihood of serious attempts.                               
4. Access to means: Evaluating access to lethal means is essential, as increased access raises the risk of a deadly suicide attempt.                                                                                                                                      
5. Suicidal intent: Determining the extent of the patient's intent to die is vital. Any level of intent above zero is considered an affirmation of suicidal intent.                                                                                            
6. Lethality of the method: While the clinician's objective appraisal of the lethality of a suicide plan or attempt is significant, understanding the patient's perception of lethality is equally essential.                                    
7. Protective factors: Identifying people or circumstances that motivate the patient to continue living is a crucial aspect of the assessment, offering insights into potential areas of intervention.                                               
8. History of suicide attempts: Inquiring about previous suicide attempts or aborted or interrupted attempts is crucial, as a history of such attempts is associated with an increased risk of future attempts.

Evaluation

Suicide risk assessment scales provide structured tools for clinicians to systematically evaluate the severity of suicidal ideation and guide decision-making regarding intervention strategies, ultimately enhancing the precision and efficacy of suicide prevention efforts.

Suicide Risk Assessment Scales

While several scales evaluate the severity of suicidal ideation and assess the risk of suicide, the most commonly used include the following:

1. Columbia-Suicide Severity Rating Scale (C-SSRS): The Columbia-Suicide Severity Rating Scale is used extensively for assessing suicidal ideation and behavior. C-SSRS evaluates the severity and immediacy of self-destructive thoughts, suicide attempt behaviors, and the lethality of attempts. The C-SSRS effectively identifies individuals needing immediate intervention and is commonly used in clinical and research settings.                                                                                                                                            
2. Beck Scale for Suicide Ideation (BSI): Developed by Dr. Aaron T. Beck, the BSI measures the intensity of suicidal ideation through 21 items focusing on various aspects of suicidal thoughts. The scale is valuable in clinical settings for identifying at-risk individuals and tracking changes in ideation, with higher scores indicating greater severity.                                                                                                                                 
3. Suicidal Ideation Attributes Scale (SIDAS): The SIDAS assesses the presence and intensity of suicidal thoughts, particularly in community populations. The scale includes 5 items that evaluate aspects like the frequency, control, distress level, and impact of suicidal thoughts. Higher scores on the 10-point scale indicate greater severity.                                                                                                                                    
4. Patient Health Questionnaire-9 (PHQ-9): The PHQ-9 is a quick reporting scale used in medical records, with the ninth item focusing on thoughts of death or self-harm. This item's responses are crucial for identifying patients at increased suicide risk, making the PHQ-9 an essential tool in various settings.[39][42][43][44]

Treatment / Management

Nonpharmacological Treatment

Cognitive behavioral therapy: Cognitive behavioral therapy (CBT)-based interventions are strongly recommended for patients with a recent history of self-directed violence to reduce future incidents. Studies utilizing CBT have directly addressed suicide risk, and systematic reviews/meta-analyses have examined CBT's effect on suicide-related outcomes. Patient satisfaction with CBT focused on suicide prevention is generally high. The quality of evidence supporting these benefits is moderate.

Dialectical behavior therapy: Dialectical behavior therapy (DBT) is suggested for individuals with borderline personality disorder (BPD) who have recently engaged in self-directed violence. DBT, which incorporates CBT elements, skills training, and mindfulness techniques, aims to develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance. Research supports the efficacy in reducing nonsuicidal and suicidal self-directed violence among patients with BPD. The quality of evidence is low.

Crisis response plans: Crisis response plans are recommended for individuals with suicidal ideation or a history of suicide attempts. Studies have shown that these plans decrease suicide attempts among military personnel with acute suicidal ideation or a history of attempts. The quality of the evidence is low, with some study limitations.

Problem-solving-based therapies: Problem-solving-based therapies (PST) are suggested for patients with a history of self-directed violence or hopelessness, especially those with moderate to severe traumatic brain injury. PST improves coping with stressful life experiences. Research supports the effectiveness in reducing repeat self-directed violence and suicidal ideation. The evidence quality is low due to small sample sizes and other limitations.[45][46][47][48][49][50]

Pharmacologic Treatments

Antidepressants: In a recent systematic review, antidepressants led to a reduction in suicidal ideation in 9 out of 12 studies that specifically examined their effects on such thoughts. Additionally, a meta-analysis conducted by the FDA revealed that antidepressants decrease the risk of suicidal behavior in older adults. Beyond these findings, further pharmacoepidemiological studies have shown that selective serotonin reuptake inhibitors (SSRIs) are effective in reducing suicidal behavior more broadly, encompassing not only older individuals but also young adults. Antidepressants have an FDA black box warning for increased suicidal risks in children and adolescents, necessitating close monitoring for medication-induced suicidality.

Ketamine: Ketamine rapidly reduces suicidal ideation, with effectiveness observed after a single dose of 0.5 mg/kg, typically administered via intravenous (IV) infusion. Although the Veterans Affairs/Department of Defense (VA/DoD) clinical practice guidelines endorse the use, the primary concern with ketamine is that trials have involved small patient groups, leading to off-label use in treating suicidal behavior. Ketamine in the dose of 0.5 mg/kg is generally well tolerated, with common adverse effects being sedation, depersonalization/derealization, nausea, dizziness, and agitation. In August 2020, the FDA approved the intranasal preparation of esketamine to treat depressive symptoms in adults with major depressive disorder exhibiting acute suicidal ideation and behavior.

Lithium: Lithium is suggested for patients with mood disorders, especially bipolar disorder, to decrease the risk of death by suicide. Lithium maintenance has been associated with fewer suicidal behaviors and deaths in patients with unipolar depression or bipolar disorder. Patients' preferences and adherence challenges due to adverse effects should be considered when prescribing lithium. Long-term lithium use can lead to greater glomerular filtration rate (GFR) reduction than aging, with a 30% higher decline observed over an average 18-year treatment period. Significant kidney function impairment typically occurs after 6 to 10 years, with about 18.1% of users developing stage 3 chronic kidney disease after 30 years. Risk factors include extended treatment duration, elevated serum lithium levels, older age, and comorbidities. No specific treatments are available for lithium-induced kidney dysfunction, but maintaining lower serum levels (0.4 to 0.6 mEq/L) is advised to reduce the risk, with lower doses still effective in relapse prevention.

Clozapine: Clozapine is suggested for patients with schizophrenia or schizoaffective disorder who have suicidal ideation or a history of suicide attempts. Studies have found clozapine to reduce suicidal behaviors in this patient group. However, the quality of evidence is low for a reduction in suicide attempts and suicide, with challenges in clozapine use due to side effects and required monitoring. The FDA requires weekly monitoring during the first 6 months of treatment; if the absolute neutrophil count remains ≥1500/µL (≥1000/µL for benign ethnic neutropenia), then monitoring may be reduced to every 2 weeks for the next 6 months and monthly following.[41][51][52][53][54][55][56][57]

Brain Stimulation Methods

Brain stimulation methods, such as repetitive transcranial magnetic stimulation and electroconvulsive therapy (ECT), are promising in reducing suicidal ideation. However, the sample sizes in these studies are too small to assess their impact on actual suicide attempts effectively. Similarly, deep brain stimulation has not yet demonstrated efficacy in preventing suicide attempts.

Lethal Means Safety Measures

Lethal means safety measures, including firearm restrictions, reduced access to poisons and medications, and barriers at lethal heights, reduce suicides effectively. Firearm access is a key risk factor, with firearms involved in half of suicides in the US and most firearm suicide attempts being fatal. State laws and firearm ownership rates are correlated with suicide rates. The military and veterans frequently use firearms for suicide, with mechanisms in place for sequestering weapons from at-risk service members. Safety counseling is aimed at reducing firearm-related deaths, with many gun owners and veterans not storing firearms safely. Recommendations include secure storage and transferring firearms to authorized individuals. Restricting access to opioid medications and reducing paracetamol pack sizes have been associated with lower rates of suicide and accidental poisoning. Studies in Sri Lanka and India demonstrate that restricted access to pesticides reduces suicide rates. Installing barriers at lethal heights has been effective in decreasing jumping suicides, although this may increase such suicides at nearby sites without barriers.

Public Health and Suicide Prevention

Public health strategies have long focused on community-based suicide prevention interventions. However, evidence for the effectiveness of these interventions is inconclusive, leading to no specific recommendations. The evidence is limited by inadequate assessment of confounders and uncertainty about the balance of benefits and harms.[9][40]

Differential Diagnosis

The differential diagnosis for suicidal ideations encompasses a range of psychiatric, psychological, and medical conditions that can contribute to or be associated with these thoughts. Considering these differential diagnoses is important to ensure a comprehensive assessment and appropriate treatment. Key conditions to consider include the following:

• Mood disorders: This includes major depressive disorder, bipolar disorder (both manic and depressive phases), and dysthymia. Mood disorders are strongly associated with suicidal ideations.                                      
• Anxiety disorders: Conditions such as generalized anxiety disorder, panic disorder, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD) can be associated with suicidal thoughts.                     
• Personality disorders: Particularly borderline personality disorder and antisocial personality disorder are linked with impulsivity and self-harm behaviors.                                                                                                  
• Psychotic disorders: Such as schizophrenia or schizoaffective disorder, where delusions and hallucinations can influence suicidal ideations.                                                                                                    
• Substance use disorders: Alcohol and drug abuse can exacerbate underlying psychiatric conditions or directly contribute to suicidal ideations through their effects on mood, cognition, and impulse control.                                
• Adjustment disorders: Where individuals struggle to cope with major life changes or stressful events, leading to suicidal thoughts.                                                                                                                                     
• Neurocognitive disorders: Dementias and other cognitive impairments can sometimes manifest with depressive symptoms and suicidal ideations.                                                                                                     
• Chronic medical conditions: Long-term physical health conditions, especially those associated with chronic pain, disability, or terminal illness, can contribute to the development of suicidal thoughts.                                                                   
• Eating disorders: Anorexia nervosa and bulimia nervosa, which are often accompanied by severe psychological distress, may include suicidal ideations.                                                                                           
• Childhood trauma and abuse: A history of trauma, abuse, or neglect can lead to long-term psychological consequences, including suicidal ideations.                                                                                       
• Situational factors: Acute stressors such as relationship problems, financial difficulties, or legal issues can precipitate suicidal thoughts, especially in the absence of adequate coping mechanisms or support.

Pertinent Studies and Ongoing Trials

The 2019 FDA approval of esketamine for adults with treatment-resistant major depressive disorder means some people with coexisting suicidal intent may qualify for this treatment. Meanwhile, investigators are turning their focus toward determining whether ketamine will provide a measurable and clinically significant reduction in suicidal intent. Alternative doses and routes of administration are also being examined. Most completed studies included a ketamine IV dose of 0.5 mg/kg administered over 40 minutes. Samples were drawn from individuals with treatment-resistant MDD who had varying severities of suicidal intent. Fewer studies have examined the efficacy of ketamine administered by oral, intramuscular, or intranasal inhalation.[58] Currently, researchers are recruiting participants with suicidal thoughts for randomized clinical trials that utilize intranasal and oral administration of ketamine. 

Prognosis

The prognosis of patients with suicidal ideation varies widely and depends on several factors, including the underlying causes of the ideation, the presence and severity of any mental health disorders, the effectiveness of treatment, and the individual's support system.

• Underlying causes and severity: The prognosis is generally more favorable if the suicidal ideation is linked to situational factors that can be resolved, such as acute stress or a specific problem that has a solution. In cases where suicidal ideation is a symptom of a chronic mental health disorder, such as MDD or bipolar disorder, the prognosis depends on the severity of the disorder and the patient's response to treatment.                                                                                                                                                      
• Treatment effectiveness: Patients who receive timely and appropriate psychiatric care, including psychotherapy, medication, or a combination of both, generally have a better prognosis.                                                 
• Support system: A strong support system, including family, friends, healthcare professionals, and community resources, can significantly improve the prognosis.                                                                            
• Risk factors: The presence of certain risk factors can worsen the prognosis. These include a history of previous suicide attempts, substance abuse, a lack of a support system, chronic physical illness, and concurrent psychiatric conditions.                                                                                                                        
• Suicide risk management: Continuous risk assessment and management, including monitoring for warning signs of suicidal behavior and making necessary adjustments in treatment, can improve the prognosis.                                                                                                                                                         
• Individual resilience and coping skills: The patient's resilience and coping skills can influence the prognosis. Those who develop effective coping strategies and have a higher level of resilience may have a more favorable prognosis.

Suicidal ideation is a serious and potentially life-threatening condition that requires immediate attention from healthcare professionals. With appropriate care and support, many patients with suicidal ideation can achieve significant improvement in their symptoms and quality of life.

Complications

Suicidal ideations, if not appropriately addressed, can lead to several complications, both for the individual experiencing them and for their wider social network. These complications can be psychological, physical, social, or a combination of these factors and include the following:

• Increased risk of suicide attempts and completion: The most severe complication of suicidal ideations is the progression to suicide attempts or completed suicide.                                                                    
• Mental health deterioration: Persistent suicidal thoughts can exacerbate existing mental health disorders such as depression, anxiety, or PTSD, leading to a further decline in mental well-being.                                     
• Impaired daily functioning: Individuals with suicidal ideations may experience difficulties in performing daily tasks, maintaining employment, or attending educational activities due to the overwhelming nature of these thoughts.                                                                                                                                           
• Social withdrawal and isolation: Suicidal ideations can lead to withdrawal from social interactions and isolation, which can further exacerbate feelings of loneliness and despair.                                                                           
• Substance abuse: To cope with their distressing thoughts and feelings, some individuals may turn to substance abuse, which can lead to addiction and worsen mental health conditions.                                                                
• Physical health problems: Chronic stress associated with suicidal ideation can contribute to various physical health issues, such as cardiovascular problems, weakened immune response, and gastrointestinal issues.                                                                                                                                                             
• Relationship strain: Suicidal ideations can strain relationships with family, friends, and partners, leading to interpersonal conflicts, breakdowns in communication, and, in some cases, the loss of important support networks.                                                                                                                                                                  
• Stigma and discrimination: Individuals with suicidal ideation may face stigma and discrimination, which can prevent them from seeking help and exacerbate their feelings of isolation and despair.                                                                                                                        
• Legal and financial issues: In some cases, suicidal behaviors can lead to legal issues or financial difficulties, especially if they result in injury or require prolonged medical treatment.                                                     
• Emotional trauma to loved ones: The emotional impact on family and friends of individuals with suicidal ideations is profound, leading to their mental health challenges.

Consultations

Psychiatric consultation is often indicated to complete the suicide risk assessment and establish a treatment regime. Psychological testing may be warranted. Social work, occupational therapy, and other disciplines may be included in planning care to address modifiable risk factors.

Deterrence and Patient Education

Counseling patients and families to restrict access to lethal means (locking medications, removing or locking firearms, etc) during episodes of suicidal ideation is encouraged in the literature. However, chart reviews show this is frequently not implemented. A training intervention for healthcare professionals in the emergency department (ED) improved the frequency of the initiated counseling against lethal means.[59] When ED nurses do not have a designated person available to provide counseling, patients may not receive counseling because many nurses do not want to appear confrontational.[60] Further research and guidelines are needed to identify how best to provide patient education and counseling.

School-based educational programs may reduce suicidal ideation, but a recent systematic review determined the quality of evidence is low. At present, insufficient evidence is available to support gatekeeper training programs.[61] A project in rural India trained laypersons to work within their communities to improve the detection and treatment of mental health issues. Additionally, community education successfully reduced the stigma of mental illness in these rural communities.[62] Similar approaches may be beneficial to target high-risk groups. For example, a systematic review showed people who are bereaved by the death of a loved one by suicide have very high rates of suicidal intent (15% to 49%).[63] Education to reduce the stigma and fear of appearing weak or unfit for duty may improve the reporting of suicidal intent by groups known to have high rates of suicidality but who generally avoid disclosing it.[64][65] A best practice intervention is helping the patient formulate a safety plan that includes appropriate support, resources, distractions, and safeguards to prevent access to lethal means. 

Enhancing Healthcare Team Outcomes

In the management of patients with suicidal ideations and at risk of self-harm, clinicians, including physicians, advanced care practitioners, nurses, pharmacists, and other healthcare professionals, should employ a blend of specialized skills, strategic planning, ethical considerations, defined responsibilities, effective communication, and coordinated care to enhance the overall patient care experience, improve outcomes, ensure patient safety, and strengthen team performance.

Physicians and advanced care practitioners require skills in conducting detailed psychiatric evaluations and risk assessments, which are crucial for identifying the severity and immediacy of suicide risk. Nurses play a vital role in continuous patient monitoring, observing behavior changes, and ensuring treatment plan adherence. Pharmacists manage the patient's medication regimen, advise on appropriate dosages, and monitor potential adverse effects or interactions. Strategically, the approach to managing suicidality should involve a comprehensive treatment plan that addresses patients' biological, psychological, social, cultural, and spiritual aspects. This requires a multidisciplinary effort where each professional's expertise is utilized to develop a holistic care plan. Regarding responsibilities, delineating roles within the multidisciplinary team is essential to avoid overlaps and gaps in care. Each professional should understand their duties and how they contribute to managing the patient's suicidality.

Ethically, respecting patient autonomy and ensuring informed consent are fundamental. Patients should be involved in their care decisions and understand the risks and benefits of different treatment options. This patient-centered approach respects their dignity and enhances their engagement and cooperation in treatment. 

Interprofessional communication is vital in ensuring that all team members know the patient's status, treatment plan, and any changes in their condition. Regular team meetings, shared electronic health records, and open lines of communication can facilitate this process. Finally, care coordination is critical, especially when patients transition between different levels of care or healthcare settings. Ensuring that all relevant information is communicated effectively among team members and to the patient can help maintain continuity of care, prevent relapses, and manage crises effectively. Collaborative attention to patient-centered care enhances outcomes and safety while improving the performance and cohesion of the interprofessional care team managing at-risk patients.