Suicidal ideation
Synonyms and keywords:

# Overview
Suicidal ideation is characterized by the thoughts of ending one's own life. Suicidal ideation may range in severity from fleeting thoughts to high intent with detailed planning. Patients with chronic medical conditions may develop secondary depression and suicidal ideation that require prompt management. A number of factors such as access to lethal weapons, and poor social support, when coupled with suicidal ideation, may result in a higher probability of completion of the act. In addition, suicidal ideation may coexist with a variety of medical or psychiatric conditions. Therefore, such patients should be assessed in detail for the presence of suicidal ideation and early intervention should be done to modify the underlying factors.

# Historical Perspective
- Meanings of suicide have varied through the centuries. For the Romans and the Greeks, suicide was widely accepted. On the contrary, in the periods of early Christianity suicidal behavior was an unacceptable self-murder.
- Sir Thomas Browne first coined the term suicide. It was derived from the Latin words Sui (of oneself), and caedes (murder).
- Suicide is a behavior that can be interpreted as communicative action, similar to a language. However, to understand it better one has to be familiar with the society's culture where the act is performed.
- Over centuries, females have had higher global rates of suicidal ideation and behavior but lower rates of completed suicide than males.
- The gender-pattern of suicidal ideation has differed across various cultures. In the United States, suicide is most common among older white men and is typically considered masculine behavior. In other societies, including China, suicide is viewed as an act of the powerless and is more common in young women.
- Therefore, there is significant variability in gender patterns and meanings of suicidal ideation and behavior across different cultures.

# Classification
- Suicidal Ideation can be broadly categorized into passive or active.
- Passive suicidal ideation means imagining or thinking about being dead whereas active ideation includes thinking of plans to die.
- Active ideators are found to be more likely to express self-disgust and self-hatred than passive ideators.
- The active and passive suicidal ideation should not be misinterpreted in elderly patients.It has been found that both groups are equally likely to have had a past history of suicide attempts.
- The clinicians should not have a lesser degree of vigilance by the presence of passive suicidal ideation. 

# Pathophysiology
- The three-step theory that explains the pathophysiology of suicidal ideation and behavior is: 
The combination of pain and hopelessness produces suicidal ideation.
Ideation increases if pain exceeds connectedness.
Acquired contributors to suicidal capacity promote the transition from ideation to attempts.
- The combination of pain and hopelessness produces suicidal ideation.
- Ideation increases if pain exceeds connectedness.
- Acquired contributors to suicidal capacity promote the transition from ideation to attempts.
- Individuals with suicidal ideation and behavior experience chronic activation of the Locus Ceruleus, resulting in synaptic norepinephrine depletion and compensatory changes in concentrations of noradrenergic proteins.
- Cytokine derangement is also observed in patients with suicidal ideation. Elevated interleukin (IL)-6 has been the most consistent finding in CSF, and blood. On postmortem, it was found elevated in the brains of individuals who died by suicide.
- Increased IL-6 level is also associated with more violent attempts and future suicide completion.
- Endogenous opioids have been found to be involved in the pathophysiology of suicidal ideation and behavior.
- Genetic and epigenetic studies show a major role of Brain-derived neurotrophic factors (BDNF) and BDNF receptor tropomyosin-related kinase B (TrkB) in the development of suicidal ideation and behavior. Dysregulation of BDNF gene expression resulting in decreased BDNF activity could alter the vulnerability to stress and increase the risk for suicide. 
- It has been noticed that BDNF derangement plays a more significant role in the development of suicidal ideation and behavior in adolescents than in adults. 

# Causes
Common causes of suicidal ideation include 
- Intensive cannabis use
- Substance use disorders (alcohol, cocaine, inhalants)
- Major depressive disorder
- Bipolar disorder
- Bereavement
- High stress
- Sexual assault
- Medical comorbidity
- Non-marital status

# Epidemiology and Demographics
- The prevalence of suicidal ideation is variable in different parts of the world.

## Age
- Patients of all age groups may develop suicidal ideation.
- It is more commonly observed among patients aged more than 75 years.
- In younger age groups suicide attempts are often impulsive acts, whereas suicide attempts in individuals aged 65 years and older are often long-planned. 
- It has been observed that depression and medical illness frequently coexist in the elderly and physical illness plays a major role in the development of suicidal behavior of these patients.

## Gender
- Both men and women may develop suicidal ideation.
- Females have been found to have suicidal ideation more commonly than men. However, men have a greater rate of completion of suicide. This may be explained by the fear of social disapproval, higher impulsivity, and lesser helpseeking behavior among males.

## Race
- There is no racial predilection for suicidal ideation.
- Differences in self-disclosure and mental health service utilization have been noticed among different races. 

# Risk Factors
The risk factors associated with completed suicide are:
- White males with age greater than 65 years
- Widowed
- Divorced
- Access to firearms
- Previous suicidal behavior
- Presence of stressful life events such as multiple debts
- Major depressive disorder
- Substance abuse
- Schizophrenia
- Borderline Personality Disorder
- Panic disorder
- High impulsivity
- Medical conditions such as cancer, epilepsy, head injury, peptic ulcer disease, psoriasis and AIDS.

# Screening
- The standardized protocol is used to identify individuals at risk for suicide.
- Various scales have been used to predict suicide risk in patients with suicidal ideation.
- Screening for suicide risk in primary care is very important. It can detect suicidal ideation and prompt a referral to a behavioral health care center before a fatal suicide attempt is made.
- Although screening assessment for suicide risk is only a part of the broader aspect of suicide risk assessment, a number of clinical rating scales are available:
Columbia Suicide Severity Rating Scale (C-SSRS)
Beck Scale for Suicidal Ideation (BSS)
Beck Hopelessness Scale
Hamilton Scale for Depression (HAM-D)
SAD PERSONS Scale
Adult Suicidal Ideation Questionnaire
Reasons for Living Inventory
Suicidal Behaviors Questionnaire
- Columbia Suicide Severity Rating Scale (C-SSRS)
- Beck Scale for Suicidal Ideation (BSS)
- Beck Hopelessness Scale
- Hamilton Scale for Depression (HAM-D)
- SAD PERSONS Scale
- Adult Suicidal Ideation Questionnaire
- Reasons for Living Inventory
- Suicidal Behaviors Questionnaire

# Natural History, Complications, and Prognosis
- There is a strong association between current suicidal ideation, history of suicide attempts, and depression. It has been observed that past suicide attempts occur in the context of psychosocial dysfunction.
- Elderly patients with severe depression, a history of suicide attempts with high intent, and poor social support are likely to have suicidal ideation and should be targeted for management. The severity of depression is the strongest predictor of the course of suicidal ideation.
- Hopelessness is an important clinical marker of suicidal ideation in terminally ill patients. Hopelessness has been more highly correlated with suicidal ideation than the severity of depression in these patients.
- It has been noticed that eating disorders are associated with high levels of comorbidity and suicidality. In these individuals, current suicidal ideation has also been linked with higher levels of Axes I and II comorbidity.

# Diagnosis

## History and Symptoms
Patients with suicidal ideation are more likely to complete suicide if they have the following symptoms:
- Anhedonia
- Insomnia
- Hopelessness
- Impaired concentration
- Psychomotor agitation
- Severe anxiety
The mental status examination is essential for any patient with suicidal ideation. However, a complete physical examination should be done first to rule out organic conditions that might be causing suicidal ideation.

## Mental status examination
- A detailed mental status examination is necessary for a patient with suicidal ideation. There may be slight variation in the mental status examination based on the underlying psychiatric condition.
- The mental status examination includes evaluation of appearance, behavior, ability to cooperate with the examiner, level of activity, speech, mood, affect, thought process and content, perception, cognition, insight, and judgment.
- While performing the mental status examination of patients with psychiatric conditions, it is always recommended to ask about any suicidal or homicidal ideation.
- Assessment should take special consideration about the length of most recent suicidal ideation, and frequency as well as the intensity of suicidal ideation.

# Treatment
- Treatment depends on whether it is an emergency situation that requires active intervention or just passive suicidal ideation that can be addressed by outpatient management.
- As compared to the younger patients, the management of suicidal ideation is multifaceted for the elderly. Effective interventions for this population are primary care-based depression screening and management programs; treatment interventions (pharmacotherapy and psychotherapy); telephone counseling; and community-based programs incorporating education, gatekeeper training, depression screening, and various group activities. 
- Primary care-based collaborative programs for depression is a strategy to reduce suicidal ideation in older primary care patients.
- Sustained collaborative care maintains high utilization of depression treatment, improves the outcomes of major depression and, reduces suicidal ideation.
- The management of suicidal ideation mainly consists of pharmacotherapy and psychotherapy.

## Pharmacotherapy
- Although Selective Serotonin Reuptake Inhibitors (SSRI) have been commonly used to treat depression, in 2004 the FDA labeled a black box warning stating there was an increased risk of suicide when these medications were used in children and adolescents.
- There had been a decrease in the use of antidepressant therapy in children and adolescents following this black box warning.
- In bipolar disorder, and also unipolar major depression, long-term treatment with lithium has preventive effects on suicidal behavior.
- Suicidal ideation associated with treatment-resistant major depressive disorder rapidly improves after infusion of an N-Methy-D-Asparatate (NMDA) receptor antagonist, ketamine.
- The short-term use of low dose sublingual buprenorphine is found to be associated with decreased suicidal ideation in severely suicidal patients without substance abuse.

## Psychotherapy
- In patients with schizophrenia, cognitive behavioral therapy (CBT) provides significant reduction in suicidal ideation at the end of therapy, and is sustained at the follow-up.
- Acceptance and Commitment Therapy (ACT) can be used as an adjunctive strategy in programs for suicide prevention. It is effective in reducing suicidal ideation and improving the clinical dimensions associated with suicidal risk. 
- Attachment-Based Family Therapy has been more effective than Enhanced Usual Care (EUC) in reducing suicidal ideation and depressive symptoms in adolescents.
- Intensive schoolbased interpersonal psychotherapy for depressed adolescents with suicidal risk (IPTAIN) is effective in reducing the severity of depression, and suicidal ideation in these individuals.
- Problem Solving Therapy (PST) is found to be more effective than Supportive Therapy (ST) in reducing suicidal ideation in elderly patients with major depression and executive dysfunction.

## Prevention
- Universal suicide risk screening programs can be used to identify youth in medical settings who may otherwise pass through the system with undetected suicide risk.
- Educating the primary care agencies to be vigilant for signs and symptoms of depression may reduce the probability of suicide. Secondary prevention of suicidal behavior warrants structured psychotherapy focused on problem-solving and emotion regulation.
- For secondary prevention, there are five major methods: pharmacological management, psychological interventions, follow-up care, reduced access to lethal means, and responsible media reporting of suicides.
- The Suicide Behavior Prevention Program (SBPP) is a secondary preventive intervention found to be effective in delaying and preventing suicide reattempts within the first year after the suicide.
Further research is needed to identify factors that increase suicide risk over years, months, weeks, days, hours, or minutes. A better understanding is also required in terms of different risk profiles and predictors for fatal and nonfatal suicide attempts.