The majority of suicides have denied having suicidal thoughts when asked by doctors in the weeks leading up to their death. An element of comfort for families who often feel guilty for not having seen it coming.
The widely held belief among psychiatrists and clinicians that it is possible to accurately predict suicide by assessing risk from a patient’s suicidal thoughts is false, according to an iconoclastic Australian study published in BJPsych Open.
Examination of data from 70 large studies on the prognostic value of suicidal ideation shows that only 1.7% of people who had had suicidal ideation actually committed suicide. Conversely, about 60% of people who died by suicide had previously denied having suicidal thoughts when specifically asked by a psychiatrist or general practitioner.
A bad marker
Physicians sometimes rely on what they call “suicidal ideation” (having suicidal thoughts, even planning one’s suicide) as a crucial test for short-term risk of suicide, and it has been proposed that this may part of a suicide screening test.
The meta-analysis shows that 80% of patients who were not undergoing psychiatric treatment and who had committed suicide declared that they had no suicidal thoughts when first asked for a general practitioner.
Some people will, in fact, try to hide their suicidal thoughts from their doctor, either out of shame or because they do not want to be prevented from committing suicide. In addition, suicidal feelings can fluctuate rapidly and people may commit suicide impulsively after only a short period of suicidal ideation (“acting out”).
A necessary change in practices
“We know that suicidal ideation is quite common and that suicide is in fact a rare event, even in people with severe mental illness,” said Professor Matthew Large, from the UNSW School of Psychiatry and who also works in the emergency department of a Sydney hospital. “This study shows that psychiatrists and general practitioners cannot base the detection of suicide risk on the sole search for suicidal ideation and they should not feel reassured in their absence”.
According to Professor Large, the main message is that clinicians should place less emphasis on suicidal ideation than previously and should “try to better understand the patient’s distress and not make them wait weeks before treat it or refuse treatment in the absence of suicidal thoughts”.
Another important message of this study according to Professor Large is for the relatives of a suicide: “Even if they were aware that their relative was suicidal, the risk of death was low. Conversely, it is not their fault if they did not realize that he was suicidal”.
.
