Suicidal ideation and screening

Understanding Mental Health disorders

Suicidal ideation and screening are critical in an environment, be it professional or personal. Statistics show that at least 1 in 4 people (25%) is experiencing some mental health issue, with additional 50% of the population having some level of distress, overwhelm, rumination and struggling through life. Anxiety and depression are the most common types of mental health disorders and causes are multifactorial from genetical predispositions to neurobiological and social factors.

Suicidal ideation is a combination of long-lasting strain, depletion of resources and increasing despair. One can traverse from anxiety into eating disorders or depression (these are common co-morbidities and the most often disorders associated with suicide) and end in suicidal ideation and not only. Suicide is 4 times more likely to cause death than a traffic accident, it causes 2-3 deaths per day and is committed 3 times more often by male than females aged prevalently 40 to 59 years of age.

Spotting early signs

Mood:

• Feeling hopeless or trapped – discouraged/ displaying disinterest in activities or tasks that previously were of interest.
• Having mood swings: depressed, sad, or explosive/ irritable, occasionally euphoric
• Might include misuse of drugs or substances.
• Rumination, self-talk

Physical

• Change in eating and sleeping habits (digestion problems, stomach aches, nausea, weight gain or loss and insomnia or issues getting up)
• Limited mobility
• Exhaustion
• Pain in the chest
• Headache
• Neglectful appearance (clothes, personal hygiene)

Performance

• Reduced productivity and interest in performing daily tasks, loss of motivation
• Absenteeism or on the contrary too much presence and long hours
• Loss of focus / concentration
• Forgetfulness

Relationships

• Mistrust
• Causes conflicts.
• Disrespectful or overly cynical and negative
• Sensitive to difficult conversations or criticism
• Wanting to isolate and be alone (old or lonely), talking about being a burden

Suicide risk (professional) screening

In my efforts to document this topic, I identified 2 suicide risk assessment scales, considered the “gold standard”:

• BSS (Beck Scale for Suicidal Ideation)
• C-SSRS (Columbia-Suicide Severity Rating Scale / Columbia Protocol) https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/

C-SSRS is endorsed by the CDC, FDA and several US government agencies, it is also translated into several other languages and can be used for free.

Beyond the items in the above scales (which aim at the absence/presence of suicidal ideation, self-aggression and suicide plans), an assessment of the risk of suicide would also include (in a clinical interview) the motivation: (https://www.cdc.gov/suicide/factors/index.html )

• Bullying or other community violence, discrimination, lack of social integration, stigma
• Family history of suicide or existing trauma
• High conflict or violent relationships
• Perceived loss, grief, pain, suffering for not being seen, understood.
• financial or access to health care system concerns

https://medlineplus.gov/lab-tests/suicide-risk-screening/

Who else is at risk of suicide?

• People who have previously tried to take their lives
• People with depressions or use of substances (alcohol, drugs)
• People suffering from emotional distress (loss of loved ones, break-up, rejection)
• People suffering from illness and chronic pain
• People who have been experiencing violence, trauma, abuse, discrimination or exposed to war
• Socially isolated

It is important in this exploration to understand where the desire to die is coming from, what is the meaning of death

• To inflict suffering on someone else, to punish them, revenge, restitution
• To escape the pain, flight into sleep, a new life (as this one is too painful)
• Rescue, rebirthing, reunification

Supporting employees or close people

If you are worried about your close ones, be it in your team at work or in your close family / community relationships it is better to address it. Few questions can go a long way into helping the person reveal where they are in their thoughts and showing care and connection:

• I am here to understand and listen to you
• I am worried about you/ I have noticed some changes in your mood/ state of mind (choice of words based on your relationship). How are you feeling or What is going on for you? What are you worried about?
• Have you had any thoughts of harming yourself or others? Have you thought about taking your life (elicit on any suicidal ideation)
• If the answer is ‘’yes/ sometimes’’, you can continue the dialogue and ask ‘’What is your plan? How would you do it? Have you already made preparations?
• Often suicidal people are actually looking to be heard and to share their pain. If you find out that their life is at risk, please then co-create support
  • Have you talked to anyone about your intentions? Who knows about these thoughts? Who cares?
  • I am here for you, what would work to support you? engage the social environment and professional help (with your permission, I would like to recommend that you speak to a professional – EAP lines/ crisis hotline/ psychological support; ask them about anyone their network of support)

As you enter this dialogue, check first with yourself if you can sustain this conversation by:

• creating safety in the room – there is no place for blaming, judgements
• let them know you are there to listen with a white canvas mind
• take them seriously!
• create trust by hearing and understanding the emotion
• care for them!
• understand their cycle of thoughts by identifying key hints or sentences that indicate their beliefs
• show empathy!

Assessing the risk

1. no risk – there is no risk of suicide even when asked
2. small risk – occasional thoughts or in very rare moments (once per month); there is good social support and no suicide plan
3. medium risk – regular suicidal thoughts (weekly-monthly) with some vague suicidal plans but no direct access to the means that would allow the execution
4. high -very high risk – very common suicidal thoughts (daily) and clearly define plan; maybe previous attempts and very little social support

What to do

• If the risk is small or medium:
  • help them redefine and restructure their ways of thinking (what else have you thought about? How could you look at this differently?)
  • plan next steps to get support – encourage seeking professional help such as a doctor, mental health professional, counsellor or social worker
  • Stay in touch to check how they are doing
• If the risk is high
  • Do not leave them alone
  • If you are worried about their lives, makes sure they do not have access to means of self-harm
  • If they are dysregulated and you think they are in immediate danger address small grounding techniques: diaphragmatic breathing, 5 senses grounding (https://www.urmc.rochester.edu/behavioral-health-partners/bhp-blog/april-2018/5-4-3-2-1-coping-technique-for-anxiety.aspx)
  • immediately reach out for emergency services (crisis line, health care professional or turn to family members)
  • if you are not face to face
    • ask who is reachable (neighbours, family members),
    • keep them on the phone and ask for details (address / current location)
    • explain you will now get help and ask for agreement
    • ask them to cooperate and open the door when help arrives

Please know that, asking about suicide doesn’t not provoke the act of suicide and it is okay to talk about suicide. It often reduces the anxiety and helps people feel understood.