Is my patient suicidal?

Rob Orman, MD

What to say

What to ask

Knowledge Gap

Knowledge Absence

Good

Bad

Rare

Complete suicide

3% high risk

60% low risk

Lie

LieSelf

Reported

The Suicide Thromboelastograph

Friends and

Family

Friends and

FamilyKnow

What is suicidal ideation?

Mindset and

Intent

Suicide attempt

Suicide attempt

Stress relief

Suicide attempt

Stress reliefattention

What and Why

Mindset and

Intent

Injury is secondary

Why did it happen?

What

WhatWhen

WhatWhen

Why

What

Why

Mindset and

Intent

Is this suicidal ideation?

What

Why

What

WhyStressedRelieves Tension

Is this suicidal ideation?

What

Why

What

WhyHopelessDepressedNo way out

Is this suicidal ideation?

Behavior

Behavior

Motivation

Behavior

Motivation

What

Why

What

Why

Takes away the pain

Do you feel suicidal?

Do you feel suicidal?

Always!

What

Chronic ideation

What

WhyGet the story

What

WhyRisk Assess

How to assess suicide risk?

Gestalt

Gestalt

Decis

ion tools

Gestalt

Decis

ion tools

Spontaneous questions

Organized

Organized

Systematic

Columbia Suicide Severity Rating

Scale

What questions to ask

How to ask

Structure interview

6 questions

Doesn't Have

to be the patient

6 questions

Is there ideation?

Have you ever wished you were dead or

wished you could go to sleep and not wake

up?

Have you ever had thoughts of killing

yourself?

No?

Have you ever wished you were dead or

wished you could go to sleep and not wake

up?

Have you ever had thoughts of killing

yourself?

No?

No ideation

Have you ever done anything, started to do anything, or prepared to do anything to end

your life?

Yes ideation

Define it

Vague thoughts

Vague thoughts

Specific Plan

Define the

ideation

Is there INTENT

Have you been thinking about how you might

kill yourself?

Have you had these thoughts and had some intention of acting on

them?

Is there INTENT

with a plan

Have you started to work out the details

of how to kill yourself? Do you

intend to carry out the plan?

Have you ever done anything, started to do anything, or prepared to do anything to end

your life?

Obvious

What did you think would happen when

y0u did X?

How do you feel now that you’re not dead?

Explore the

ideation

Incessant or

fleeting

Previous attempts

What’s stopping

you?

Protective Factors

Did you want to kill

yourself?

Did part of you want to kill yourself?

ideation

ideationintent

ideationintentplanning

inform

inform

suicide risk

Organized Systematic

What

Why

Mindset and

Intent

Impulsive Act

Short Lived

hopelessness

hopelessnesstrapped

hopelessnesstrapped

previous

hopelessnesstrapped

previousideation

Remove the

Means

1-2%

1-2%

61%

1-2%

61%

82%

Remove the

Means

Chance of Dying

Lower

40%

Remove the

Means

Chance of Dying

Lower

ASK

What

WhyGet the story

What

Why

Mindset and

Intent

Risk Assessment

Is there ideation?

Explore the

ideation

Gestalt

Gestalt

Decis

ion tools

Gestalt

Decis

ion tools

Spontaneous questions

The what

Thinking about OD

The why

Breakup

BreakupLost Job

BreakupLost JobDepressed

20yo

20yothinking

20yothinking

OD

20yothinking

OD

mult triggers

What

Why

What

Why

Is there ideation?

Have you ever wished you were dead or

wished you could go to sleep and not wake

up?

Yes

Have you ever had thoughts of killing

yourself?

Tonight

Yes ideation

Is there INTENT

Have you been thinking about how you might

kill yourself?

OD

Have you had these thoughts and had some intention of acting on

them?

Yes

Have you started to work out the details

of how to kill yourself? Do you

intend to carry out the plan?

Lock self in bathroom

Lock self in bathroom

family asleep

Have you ever done anything, started to do anything, or prepared to do anything to end

your life?

Not before tonight

Explore the

ideation

Incessant or

fleeting

Previous attempts

What did you think would happen when

y0u did X?

How do you feel now that you’re not dead?

What’s stopping

you?

Fear

Trivial

TrivialLife threat

Never Perfect

Never PerfectAlways Excellent