There’s no good data on how to determine who will attempt / commit suicide. Lots of risk factors have been identified, but no decent way to predict. Things to consider:Plan — Have they decided how they’d commit suicide? If so:
- Are means available (does patient have / know how to buy a gun?
- Is patient able to implement (e.g. know how to use a gun)?
- Does it seem lethal? A benign plan that’s perceived as lethal to patient is nonetheless concerning. I had one patient attempt overdose on 8 amoxicillin capules, but she was real serious about it.
- Is rescue likely?
Preparation — If there’s a plan, has patient decided on time & place? Have they practiced? Written suicide note / recent will?
Prior Attempt — This greatly increases risk.
Psychosis — Ask if the patient hears voices. If so, what do they say? Command hallucinations, i.e. voices telling patient to kill themselves, are the worst.
Determination — How determined are they to kill themselves? How often do they think about it?
Substance Use / Impulsivity — Binging is the most dangerous type of substance use. Persons who endorse acting impulsively in general are at high risk (especially adolescents)
Hopelessness — Of all the characteristics of depression, a sense of hopelessness is the one most associated with suicidality. Makes sense. Interestingly, it’s not included per se in DSM-4 diagnostic criteria of major depression.
WHAT TO DO ??? If a patient has suicidal ideation plus a realistic plan with imminent intent, call the police. Not an ambulance, since EMTs don’t restrain people.