When evaluating any person who presents with symptoms of depression, it is very important to not skip asking directly and specifically about suicidal ideation.
But, to abruptly ask, “Have you been having any thoughts about killing yourself?” can be awkward and make the person uncomfortable. Some persons consider suicidal ideation to mean that the person is “crazy.” Others may take the question to mean that we think that they are doing quite poorly.
Instead, I suggest using a simple, gentler approach that I call “The Three-Step Ladder” to start to ask about suicidal ideation.
Step 1: We start by asking not about suicidal ideation itself but about discouragement. We ask something like the following: “It seems that you have been feeling quite depressed for the last 6 months or so. During this time, did you feel discouraged to the point where you thought: ‘Life’s no good. What’s the point of living?’”
Note that there is no mention yet about dying. We are just asking about discouragement. Not discouragement about some aspect of the illness or treatment, but discouragement about life itself. The person may respond by saying something like, “Yes, sometimes I think—what is the point of it all?”
Step 2: If the person says Yes to the question in step 1, we take the next step on the ladder: “At any point, did you feel so bad that you thought: ‘Maybe I’m better off dead?’”
The person might respond to this question with something like, “Sometimes I wish I would go to sleep and never wake up.” Or, “Sometimes I wish God would take me.” Or, “If a truck hit me, I wouldn’t care.” Such thoughts are quite common in persons who are sad or depressed. Mental health clinicians refer to such thinking as “passive suicidal ideation.”
Step 3: If the person says Yes to the question in step 2, we take the third step in the ladder of questioning: “Did you have thoughts that ‘Maybe I should do something to end my life?’” Here, we put the emphasis on the word “I” to make it clear that we are talking about the person himself doing something to end his life. With this question, we are looking for what mental health clinicians call “active suicidal ideation.”
We must ask about suicidal ideation in all persons presenting with depressive symptoms rather than skipping the questioning in persons who are depressed but don’t “look like” they have been thinking about suicide. It is very hard to judge the presence or absence of suicidal ideation simply by the person’s appearance or even by the severity of the depression.
Even though we ease into asking about suicide, we should not avoid getting to asking explicitly about whether the person has thoughts about killing himself or ending his life, making it clear that we are talking about suicide. Asking whether the person has thoughts about harming himself can be ambiguous and unclear.
If there is any suicidal ideation at all, a careful assessment of suicide risk must be done by a mental health professional. That is discussed on other pages on this website.
But it all starts with the Three Step Ladder. Using this skillfull and gentler approach will make asking about suicidal ideation fit smoothly into the assessment process, making the person being interviewed more comfortable in sharing with us these very personal thoughts.
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Suicide: A New Conceptualization, A Neglected Question, and Specific Medications (Interview with David Sheehan, MD)
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