Recommendation. Psychiatric evaluation in the absence of other psychiatric symptoms is unnecessary.
Follow-up. Reassess minimal risk patients following deterioration in their medical, functional, or social-environmental situations, or when starting them on an antidepressant.45
Passive suicide ideation
Presentation. Patients with passive suicide ideation have frequent thoughts that life is not worth living, or that they would be better off dead—for example, praying nightly that God will take them soon. Patients at this risk level deny thoughts about harming themselves. However, as many as 10% of medical patients report such passive suicide ideation,5 which is a moderate risk factor for suicide.
Recommendation. Patients endorsing passive suicide ideation require further psychiatric evaluation to determine the presence of a depressive or other psychiatric disorder. You may choose to conduct this evaluation personally and, if appropriate, pursue treatment by prescribing recommended antidepressant medications.46 Psychosocial interventions may seek to increase social contact, encourage hope, enhance ability to cope with stress and negative life events, and address meaning-of-life issues. Alternatively, you may refer such patients to psychiatrists, psychologists, social workers, or psychiatric nurses.
Follow-up. Schedule frequent visits with these patients, and assess their level of suicide risk at each office visit, particularly when the dosage of an antidepressant has been changed.45
Active suicide ideation
Presentation. Patients with active suicide ideation have thoughts about harming themselves, with differing levels of severity whose boundaries can be imprecise. At the severity level’s milder end, patients report active thoughts of self-harm but do not specify a particular method (“I feel like hurting myself, but I wouldn’t know how”).
Other patients may have specified a particular method for harming themselves, but lack a detailed plan or intention for doing so (“I’ve thought about taking all my pills, but I would never do that”). Ascertaining level of detail (for example, by asking “Which pills have you been thinking about? Have you thought about a particular time and place to take them? Have you made any preparations?”) will clarify a patient’s investment in harming him or herself. Insufficient detail or specificity suggests lack of an organized plan or intent.
Patients with active suicide ideation but no detailed plan must articulate convincing reasons for living such as having a purpose in life, not wanting to cause family or friends pain, or deeming suicide morally wrong or contrary to religious beliefs so as not to be classified at the highest risk level. They must also demonstrate good impulse control, or the ability to resist acting on these thoughts. Factors such as current alcohol or substance abuse, or a history of suicide attempts may indicate poor impulse control. While only about 1% of primary care patients endorse any level of active suicide ideation,5 those who do are at increased risk even when reporting reasons for living and demonstrating good impulse control.
Recommendation. Patients endorsing active suicide ideation even when lacking a specific plan or intention require immediate, same-day evaluation by a mental health specialist given the clinical complexities in precisely defining level of active suicide ideation. With the patient’s permission, a family member should be notified about his/her active suicide ideation. Medical ethics dictate that a family member be so informed without patient permission only when he or she is at a higher risk for suicide (see below). Primary care clinicians may directly treat patients with active suicide ideation,46 or refer them to specialty mental health practitioners.
Follow-up. Schedule visits with patients who have active suicide ideation more frequently than visits for those with passive ideation. Assess their level of suicide risk at each office visit.
Specific detailed suicide plan or intent
Presentation. Patients who report active suicide ideation with a specific detailed plan, intention to harm themselves, no convincing reasons for living, or a lack of impulse control are classified at the highest risk level. The term “suicide plan” means a patient reports an adequately detailed plan, as opposed to a more vaguely considered method. Given the association between suicide and firearms, especially in rural areas,47 also be sure to assess home or workplace firearms whenever active suicide ideation is present.3 An example of this highest risk level is a patient who states, “I’m planning to take all of my pain medication tomorrow morning,” or one who says, “I’ve been thinking about taking all of my pain medication, and I may not be able to stop myself from doing this.” Very few primary care patients endorse a specific plan or intention to harm themselves,5 but those who do so constitute a clinical emergency.