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Is my patient
suicidal?
Rob Orman, MD
What to
say
What to
ask
Knowledge
Gap
Knowledge
Absence
Good
Bad
Rare
Complete
suicide
3% high
risk
60% low
risk
Lie
Lie
Self
Reported
The Suicide Thromboelastograph
Friends
and
Family
Friends
and
FamilyKnow
What is
suicidal
ideation?
Mindset
and
Intent
Suicide
attempt
Suicide
attempt
Stress relief
Suicide
attempt
Stress relief
attention
What
and
Why
Mindset
and
Intent
Injury is
secondary
Why did it
happen?
What
What
When
What
When
Why
What
Why
Mindset
and
Intent
Is this
suicidal
ideation?
What
Why
What
WhyStressed
Relieves Tension
Is this
suicidal
ideation?
What
Why
What
Why
Hopeless
Depressed
No way out
Is this
suicidal
ideation?
Behavior
Behavior
Motivation
Behavior
Motivation
What
Why
What
Why
Takes away
the pain
Do you
feel suicidal?
Do you
feel suicidal?
Always!
What
Chronic ideation
What
Why
Get the story
What
Why
Risk Assess
How to
assess
suicide
risk?
Gestalt
Gestalt
Decision
too
ls
Gestalt
Decision
too
ls
Spontaneous
questions
Organized
Organized
Systematic
Columbia Suicide
Severity Rating
Scale
What
questions
to ask
How to
ask
Structure
interview
6
questions
Doesn't
Have
to be the
patient
6
questions
Is there
ideation?
Have you ever wished
you were dead or
wished you could go
to sleep and not wake
up?
Have you ever had
thoughts of killing
yourself?
No?
Have you ever wished
you were dead or
wished you could go
to sleep and not wake
up?
Have you ever had
thoughts of killing
yourself?
No?
No
ideation
Have you ever done
anything, started to do
anything, or prepared
to do anything to end
your life?
Yes
ideation
Define
it
Vague thoughts
Vague thoughts
Specific Plan
Define
the
ideation
Is there
INTENT
Have you been thinking
about how you might
kill yourself?
Have you had these
thoughts and had some
intention of acting on
them?
Is there
INTENT
with a plan
Have you started to
work out the details
of how to kill
yourself? Do you
intend to carry out the
plan?
Have you ever done
anything, started to do
anything, or prepared
to do anything to end
your life?
Obvious
What did you think
would happen when
y0u did X?
How do you feel now
that you’re not dead?
Explore
the
ideation
Incessant
or
fleeting
Previous
attempts
What’s
stopping
you?
Protective
Factors
Did you want
to kill
yourself?
Did part of
you want to
kill yourself?
ideation
ideation
intent
ideation
intent
planning
inform
inform
suicide
risk
Organized
Systematic
What
Why
Mindset
and
Intent
Impulsive
Act
Short
Lived
hopelessness
hopelessness
trapped
hopelessness
trapped
previous
hopelessness
trapped
previous
ideation
Remove
the
Means
1-2%
1-2%
61%
1-2%
61%
82%
Remove
the
Means
Chance
of Dying
Lower
40%
Remove
the
Means
Chance
of Dying
Lower
ASK
What
Why
Get the story
What
Why
Mindset
and
Intent
Risk
Assessment
Is there
ideation?
Explore
the
ideation
Gestalt
Gestalt
Decision
too
ls
Gestalt
Decision
too
ls
Spontaneous
questions
The
what
Thinking
about OD
The
why
Breakup
Breakup
Lost Job
Breakup
Lost Job
Depressed
20yo
20yo
thinking
20yo
thinking
OD
20yo
thinking
OD
mult
triggers
What
Why
What
Why
Is there
ideation?
Have you ever wished
you were dead or
wished you could go
to sleep and not wake
up?
Yes
Have you ever had
thoughts of killing
yourself?
Tonight
Yes
ideation
Is there
INTENT
Have you been thinking
about how you might
kill yourself?
OD
Have you had these
thoughts and had some
intention of acting on
them?
Yes
Have you started to
work out the details
of how to kill
yourself? Do you
intend to carry out the
plan?
Lock self in
bathroom
Lock self in
bathroom
family asleep
Have you ever done
anything, started to do
anything, or prepared
to do anything to end
your life?
Not before
tonight
Explore
the
ideation
Incessant
or
fleeting
Previous
attempts
What did you think
would happen when
y0u did X?
How do you feel now
that you’re not dead?
What’s
stopping
you?
Fear
Trivial
Trivial
Life threat
Never Perfect
Never Perfect
Always Excellent

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Is Your Patient at Risk of Suicide? By Orman