Recognizing Suicidal Ideation


Ideation is “the capacity for or the act of forming or entertaining ideas”.

Suicidal ideation (SI) is “Thoughts, ideas, or ruminations about the possibility of ending one’s life, ranging from thinking that one would be better off dead to formulation of elaborate plans”.

  • This definition allows for a wide range of emotion and intent (i.e., passive SI vs active SI)
  • SI may portend a suicide attempt as it gives insight into’s suicidality or “risk of suicide”


In a 2008 study of over 84,000 adults, the cross-national lifetime prevalence of SI, plans, and attempts was 9.2%. 

In the US, prevalence of SI is about 4% with approximately 50% not subsequently receiving mental health services.

Suicide rates differ by age

  • Middle-aged adults (aged 35-64yo) account for 47.2% of all suicides in the US. 
  • Adults aged 75yo and older account for fewer than 10% of all suicides, but have the highest suicide rate (19.1 per 100,000). Men aged 75 and older have the highest rate (40.5 per 100,000) compared to other age groups. 
  • Youth and young adults ages 10-24yo account for 14% of all suicides in the US. Suicide is the 3rd leading cause of death for young people; for youth ages 10-14, suicide is the 2nd leading cause of death.
    • Suicides/suicide attempts are comparatively rare in prepubertal-aged children
  • Youth and young adults aged 10-24yo have lower suicide rates, but have higher rates of ED visits for self-harm (342.5 per 100,000) compared to people ages 25yo and older (121.9 per 100,000).
  • In 2019, 9% of high school students reported attempting suicide during the previous 12 months, up from 6.3% in 2009. Additionally, approximately 1 in 5 youth seriously considered attempting suicide, and 1 in 6 made a suicide plan.

Populations at highest risk for suicide: 

  • Veterans
  • People who live in rural areas
  • Sexual and gender minorities
  • Middle-aged adults
  • Tribal populations

Risk factors for suicide


  • Previous suicide attempt (single strongest risk factor for suicide mortality)
  • Mental illness, such as depression
  • Feelings of hopelessness
  • Social isolation
  • Criminal problems
  • Financial problems
  • Impulsive or aggressive tendencies
  • Job problems or loss
  • Legal problems
  • Serious illness, including chronic pain and TBI
  • Substance use disorder


  • Adverse childhood experiences such as child abuse, neglect, or trauma
  • Bullying
  • Family history of suicide
  • Relationship problems such as a break-up, violence, or loss
  • Sexual violence


  • Barriers to health care
  • Cultural and religious beliefs such as a belief that suicide is noble resolution of a personal problem
  • Suicide cluster in the community


  • Stigma associated with mental illness or help-seeking
  • Easy access to lethal means among people at risk (e.g., firearms, medications)
  • Unsafe media portrayals of suicide

*Protective Factors:

  • Coping and problem-solving skills
  • Cultural and religious beliefs that discourage suicide
  • Connections to friends, family, and community support
  • Supportive relationships with care providers
  • Availability of physical and mental health care
  • Limited access to lethal means among people at risk


No evidence that routine screening reduces suicide attempts in adolescents in the general population (but does increase rate of identifying SI)

Conversely, no data to support asking about suicide increases level of suicidality

AAP recommends directly asking patients about suicide (often part of a HEADS exam in practice): 

  • “Do you ever think about dying? How often?”
  • “Do you ever think the world would be better off without you?”
  • “Do you ever think life isn’t worth living?”
  • “Have you had thoughts about hurting yourself? Killing yourself?”

Some warning signs are more obvious than others: 

  • Talking about feeling hopeless or having no reason to live
  • Talking about feeling trapped or in unbearable pain
  • Talking about being a burden to others
  • Increasing substance use 
  • Acting anxious or agitated; behaving recklessly
  • Sleeping too little or too much
  • Withdrawing or isolating themselves
  • Showing rage or talking about seeking revenge
  • Extreme mood swings

What to do for a positive screen: 

  • Risk Stratify
    • Content and chronicity of the suicidal thoughts
    • Existence and level of detail of a plan
    • Access to means described in the plan
    • Level of intent
    • Presence of risk factors
  • Need for urgent/emergent intervention?
    • Existence of plan with access to means -> emergent psychiatric eval
    • Intent without plan -> shared decision making with parents, safety planning, counseling psych referral, medication if indicated
  • Safety plan, follow-up, referral, consider pharmacologic therapy (if appropriate)

Crisis resources



Blog post based on Med-Peds Forum talk by Fritz Siegert, PGY3

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