Suicidal ideations (SI), often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide. There is no universally accepted consistent definition of SI, which leads to ongoing challenges for clinicians, researchers, and educators. For example, in research studies, SI is frequently given different operational definitions. This interferes with the ability to compare findings across studies and is frequently mentioned as a limitation in meta-analyses associated with suicidality. Some SI definitions include suicide planning deliberations, while others consider planning to be a discrete stage.
Beyond the lack of clear nomenclature, there are other concerns. A systematic review of the numerous interprofessional clinical guidelines for suicide yielded no consensus on a clinical gold standard for assessing and managing SI or people at risk of suicide. Although scales to measure depression, SI and risk for suicide exist, none produce a score that is sufficiently reliable or clinically useful in predicting the very small subgroup of suicide ideators whose death by suicide is imminent. (The American Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults, 3rd ed. 2016, p. 19).
It is evident that suicidal ideations present in a “waxing and waning manner” , so the magnitude and characteristics of SI fluctuate dramatically. It is critically important for healthcare professionals to recognize that SI is a heterogeneous phenomenon. It varies in intensity, duration, and character. As there is no “typical” suicide victim, there are no “typical” suicidal thoughts and ideations. Unfortunately, healthcare records often document SI in a binary yes/no fashion, although it encompasses everything from fleeting wishes of falling asleep and never awakening to intensely disturbing preoccupations with self-annihilation fueled by delusions. Therefore, thoroughly assessing and monitoring the pattern, intensity, nature, and impact of SI on the individual and documenting this accordingly is important for all healthcare professionals. It is also important to reassess SI frequently due to its fluctuating pattern.
The magnitude of SI fluctuations was studied using an ecological momentary assessment method. Individuals who attempted suicide in the past year plus a sample of suicidal in-patients recorded the intensity of their suicidal thoughts from hour to hour for four weeks. Analysis of these data showed dramatic fluctuations in the intensity of SI by all participants. All participants had SI, which varied in its intensity, either upwards or downwards, by one standard deviation on most days. Many had one standard deviation fluctuations several hours apart within the same day. This knowledge is important for all healthcare professionals to consider and highlights the need to monitor fluctuations and not dismiss the possibility of sudden increases in suicidal urges, even when the current level is mild, and the individual currently has control over them. Additionally, SI is considered a better predictor of lifetime risk for suicide than imminent risk, so assessments should include describing the characteristics and impact of prior SI as well as current.
The Center for Behavioral Health Statistics Quality publishes the results of the American nationwide household survey, the National Survey of Drug Use and Health (NSDUH). Piscopo’s 2017 publication summarized the results from the 2009-2014 surveys, which show that 6% of 18-25-year-olds respond affirmatively to the survey question, “At any time in the past 12 months, did you seriously think about trying to kill yourself?” In contrast, the lowest rate of SI was 1.6% in those aged 65 years and above. There is no clear association between endorsing SI and attempting suicide. For every 31 Americans with SI, only one individual will attempt suicide. The rates of suicide deaths also vary by gender, age, race, and other demographic variables. Further evidence of the weak association between reported SI and fatal suicides is apparent when comparing the NSDUH results to CDC mortality records. Despite the low prevalence of SI in white males over age 75 years, they have the highest rate of fatality by suicide (approx. 40 per 100,000). Meanwhile, females over 75 years have much lower rates (4 per 100,000). The suicide ideators in the 18-25-year-old group had significantly fewer suicide deaths (approx. 17.5 per 100,000 for males and 4 per 100,000 for females).
Most people have control over SI and do not attempt suicide, even when reporting SI. Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults (2016, p. 19) points out that SI is a symptom of another primary psychiatric diagnosis and suggests that 90% of people who end their lives by suicide meet the diagnostic criteria for one or more psychiatric diagnoses. However, data clearly show that numerous medical illnesses are associated with increased odds of suicide, and that suicidal death extends through all demographic groups and includes virtually all psychiatric and medical diagnoses. The CDC’s mortality records for 2017 reveal over 50% of deaths by suicide were by people with no known psychiatric illness. Some criticisms have been made that suicidality should be regarded as a distinct psychiatric diagnosis, with its symptoms and unpinning pathological processes. Although this is beyond the scope of this paper, this contention is becoming more widespread. After reviewing all of the existing clinical guidelines, Bernert et al. concluded there is an urgent need for “easily-accessible best practice guidelines, adaptable to diverse fields of medicine and clinical specialties, that may be the first point of contact for risk detection, intervention, and prevention.”
Although this paper aims to focus primarily on suicidal ideation, it is important to provide context. Therefore, while the intention is not to broaden the focus to suicide, it is impossible to address the significance of SI without also discussing suicidal behaviors and outcomes to some extent. It is estimated by the Center for Disease Control and Prevention (CDC) that in 2017 there were approximately 10 million people in the USA who experienced suicidal thoughts. Fortunately, the majority of ideators in the USA and globally will never attempt suicide, and fewer will use lethal means that result in death. Of the 10 million Americans with SI, it is estimated there were 1.4 million suicide attempts in 2017, but healthcare was only sought by approximately one-third of those who attempted. The degree of suicidal intent and the lethality of means used during attempts vary tremendously. One-half of the 47,000 suicides that occurred in America during 2017 were caused by firearms. (CDC).
Globally, the World Health Organization (WHO) collects mortality data, including the prevalence and means of suicides, for all member nations. Beginning in 2013, after declaring that the rising suicide rates constituted a “global public health crisis,” they advocated for evidence-based strategies to prevent suicides globally. In developing nations, where the ingestion of pesticides was the leading cause of fatal attempts, suicide prevention efforts promoted using less toxic pesticides. Evidence exists that reductions in suicides can be achieved by reducing access to lethal means, but this requires a comprehensive systemic approach that includes collaboration between policy-makers, healthcare professionals, and interventions to reduce modifiable risk factors.