Suicidal Ideation

Excerpt

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.

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. 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. 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. 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. 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. 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.

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. 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. Primary care clinicians are uniquely positioned to manage patients with suicidal ideation, assess suicide risk, and implement appropriate interventions.