Having been trained in a lab that specializes in the systematic investigation of suicide, I have been frequently exposed to the perspective that evaluating suicide risk is imperative and should be done routinely, even with patients for whom there is no reason to suspect high levels of risk. I was taught to think of psychologists assessing suicidality as akin to physicians assessing resting heart rate: this might not be the primary reason for presenting and there might be small meaningless fluctuations from time to time, but we want to keep an eye on the situation so as to ensure that we can intervene when necessary.
All of that being said, I realize this is not the universal approach to things. Many people fear that, if we ask somebody about suicide, it might increase the likelihood that they will think about and potentially even attempt to kill themselves. After all, might we be putting such thoughts into people's heads? As it turns out, the answer is no, but rather than asking you to take my word for it, I would like to describe a study published in the Journal of the American Medical Association (JAMA) in 2005 by Madelyn Gould of Columbia University and several of her colleagues (thanks to Ted Bender for calling my attention to this article). In this study, the authors sought to investigate this question empirically, collecting data capable of informing us as to whether or not assessing for suicide risk can be legitimately considered iatrogenic.
To do this, the authors recruited a total of 2,342 students from six high schools in the northeastern United States. Students ranged in age from 13 to 19, with an average age of 14.8. Participants were randomized into two groups - the experiment group and the control group. In both groups, students were assessed on two occasions separated by two days. In the experiment group, both the first and second assessments consisted of measures of distress as well as measures of suicidal ideation and behavior. In the control group, only the second assessment included the questions regarding suicidal ideation and behavior. In other words, the experiment group was assessed for suicide risk at both time points to see if the first assessment caused an increase at the second time point and the control group was only assessed for suicide risk at Time 2 in order to compare their scores at the second assessment with those of the experiment group. This design allowed the authors to determine if asking about suicide increased suicidal ideation or behavior or distress levels (e.g., depression). Additionally, it allowed for a comparison across groups to see if the group that was screened for suicide risk at Time 1 as well as Time 2 would be more distressed and/or suicidal than the control group.
The results, quite fortunately, indicated that the suicide risk screening procedure was not at all harmful. First of all, the experiment group and control group did not differ on distress levels immediately after the first survey. In other words, even though the experiment group was asked about suicide, they did not experience more distress than did the control group. Additionally, rates of depressive feelings in the two days between the assessments did not differ between the groups, meaning that asking about suicide did not cause an increase in depressive symptoms in the days following the assessment.
Taking this result a step further, the experiment group reported no more suicidality than did the control group after the initial survey and the same result held true for the two-day interim period between assessments. So, in a direct test of the central research question, the results indicated that asking about suicide had no negative impact on levels of suicide risk.
An astute reader might look at these results and say "well, this was conducted in a high school, so maybe none of these kids were suicidal anyway and the results would not generalize to a clinic when people are actually struggling with a mental illness." Fortunately - as might be expected of an article published in JAMA - the authors were careful to consider and investigate this question as well. Step 1 in this process was to investigate individuals with high levels of depressive symptoms (higher than 15 on the Beck Depression Inventory). Results indicated that being exposed to suicide questions did not increase distress or suicidal ideation amongst depressed students. In fact, depressed students in the experiment group had slightly lower depression scores after suicide risk was assessed than the control group exhibited after their first assessment (which lacked any assessment of suicidality). As such, it appears that, for depressed students, being asked about suicidality may have had significant beneficial effects.
That last finding was impressive, but the authors did not stop there. The greatest predictor of future suicidal behavior is a past history of suicide attempts, so the authors examined the impact of suicide screening on students with a history of past attempts. Much like with the depression analyses, the authors found that students with a past history of suicide attempts who were screened for suicide risk at Time 1 reported less suicidal ideation than did students with a past history of suicide attempts who were not assessed for suicide risk at Time 1. So, for high risk students, assessing suicide risk appeared to have significant beneficial effects on suicidal ideation.
So, why is it that assessing for suicide risk is beneficial? For one thing, it might simply be that, for individuals suffering from suicidal ideation, having somebody normalize the experience and express concern by asking about it actually feels good. In other words, rather than carrying around a secret that makes them feel isolated and different, perhaps such individuals feel more understood and connected when a clinician systematically assesses whether or not he or she is at risk. Regardless of the answer to the question, however, these results are highly meaningful. They not only failed to support the belief that assessing for suicide risk is harmful - they actually supported the opposite conclusion, that suicide risk has beneficial effects, particularly for those at the greatest level of risk. For those of you who read Dr.Jill Holm-Denoma's featured article on diagnostic feedback, these results might not be all that surprising. Remember, Dr.Holm-Denoma reported that, by providing careful accurate diagnostic feedback (information regarding a client's diagnosis/diagnoses), clinicians can actually help their clients feel better.
It appears that, at times, our concern regarding labeling people or making them feel judged might actually get in the way of us providing effective care. Of course, shouting labels or callously asking about personal topics without empathy would not be a good approach. Just like in everything else we do, it is useful to maintain a reasonable level of social skills. Assuming that the clinician is not boorish, however, and that he or she can follow the proper protocol, it appears that assessing for suicide risk is, in fact, an incredibly useful and beneficial option that should be performed and documented routinely.
If you would like to learn more about suicide and suicide risk assessment procedures, we recommend the following resources, all of which are available through our online store:
- Why People Die by Suicide
by Thomas Joiner
- Treating Suicidal Behavior: An Effective, Time-Limited Approach
by David Rudd, Thomas Joiner, and Hasan Rajab
- The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients
by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
