Suicidal Ideation

Excerpt

Suicide comprises a significant public health issue in the U.S., 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 and may represent misclassified suicides. Between 2000 and 2018, the age-adjusted suicide rate increased by 36.7%. Among individuals aged 10 to 24 years, suicide stands as the 2nd leading cause of death. While the suicide rate in this demographic remained stable from 2001 to 2007, an upward trend persisted through 2021.

Suicide rates in the U.S. demonstrate substantial demographic variation. In 2021, men had a suicide rate 4 times higher than women, according to the Centers for Disease Control and Prevention (CDC). Individuals older than 85 years experienced the highest rates overall. Among adults aged 55 and older, the rate increased with age in men but decreased with age in women. Pronounced racial disparities are evident, with the highest rate observed in American Indian and Alaska Native populations and the lowest among Asians. The rate in the former group is approximately 4 times higher than in the latter. In 2021, the CDC reported that 12.3 million adults developed suicidal thoughts, 3.5 million made suicide plans, 1.7 million attempted suicide, and 48,183 died by suicide.

Suicidal ideation is characterized by preoccupation with thoughts of self-harm or formulating plans for suicide. The intensity of ideation exists on a spectrum, beginning with a general desire to die without a concrete method, plan, or intent, and progressing to active suicidal ideation, which involves a detailed plan and determined intent to act. Suicidal ideation comprises a significant risk factor for both suicide attempts and deaths. Although suicidal thoughts and behaviors are often considered a single concept, passive thinking, active planning, and actual behavior form a continuous spectrum.

Some individuals attempt suicide without prior ideation, though underreporting due to stigma complicates accurate assessment. An illustrative analogy conceptualizes suicidal ideation as the substantial, unseen portion of an iceberg, with the act of suicide representing the visible tip. This framework underscores the need for early identification and targeted intervention to prevent progression to suicide.

Assessing suicidal ideation provides an early warning for potential suicidal acts and offers insights into the patient’s level of distress and specific needs. Only a subset of patients with suicidal ideation will attempt suicide. However, ideation accompanied by intention and a specific plan constitutes a psychiatric emergency requiring immediate and aggressive management.

An estimated 90% of individuals who complete suicide have a psychiatric disorder, most commonly a mood disorder. Recognizing suicidal ideation in these patients provides a critical opportunity for comprehensive evaluation of their challenges, needs, and risk levels. Research indicates that 80% of suicide victims had consulted primary care clinicians within 1 year of death, but only 25% to 30% had seen psychiatric clinicians during the same period. Therefore, primary care clinicians are uniquely positioned to identify patients with suicidal ideation, assess suicide risk, and implement timely, appropriate interventions.