speciallyforkiyoshitaro asked: can i request info on suicidal ideation ? can i ask for your personal thoughts on it too?

[Trigger Warning: Discussion of suicide]

‘Suicidal ideation’ is the term people in the mental health field use for thinking about suicide. They often have a difficult job in formulating assessments about a person’s risk to themselves in that they need to figure out whether a person’s thinking about suicide is likely to translate into serious attempts on their own life.

Here’s an answer to an ask I got in April about the relationship between antidepressants and suicidal ideation. If you’d like any more info, I’d be happy to provide it!

Anonymous asked: Since SSRIs increase the likelihood of suicidal ideation, what generally is done for people who are considering suicide before going on any sort of medication, besides just talk-therapy?

[Trigger Warning: Discussion of suicide, self harm]

The big distinguishing point here in psychiatry is between suicidal ideation and suicidal intent: If someone is judged to be an immediate and pertinent threat to the safety of themselves or others (i.e. high on suicidal or homicidal intent), the first step is often involuntary hospitalization. However, this is often gleaned from ideation and/or past behaviours. Someone like Szasz would argue that “thinking about suicide is simply thinking, a symptom of freedom of thought”, and to hospitalize someone against their will for this is wrong.

You’re right that SSRIs can sometimes as a side-effect increase the likelihood of suicidal ideation, and that’s why their use should be carefully monitored.  Though there is evidence that roughly 1 in 5 suicides discuss ideation in their last meeting with a mental health professional, the relationship between suicidal ideation and intent is not bidirectional or one of direct causation: i.e. thoughts about suicide are relatively common and don’t mean that the affected person will therefore inevitably go on to attempt or commit suicidal behaviours. Similarly, self harm is often mistaken for suicidal intent but actually often only very weakly related to it (though more strongly related to suicidal ideation).

I don’t know how things are done elsewhere, but in the UK the NICE guidelines run according to a stepped care model, according to which offering someone with suicidal thoughts / severe depression anything less than medication would be contravening this model. So there’s a Catch 22 situation…

To be honest, risk assessment is and forever will be a murky and imprecise task in all areas; especially psychiatry. There are no hard and fast definitions to go off because there are no neat behavioural rules that can tell us that if a person talks / thinks / behaves in X way, we will see Y consequence.

As Silverman (2004), said:

“There is little scientific debate or clinical disagreement that the following constitute key processes or expressions of the suicidal process: suicide ideation, suicide intent, suicide gestures, suicide attempts/deliberate self-harm, and suicide completions. Confusion remains about what is meant by saying that someone is “suicidal” or expressing “suicidality”. What constitutes “suicidal behaviors”? Does ideation fall within the domain of “behaviors”? The debates continue about defining “intent”, “motivation” and “lethality” (is it sufficient that it only be in the eye of the beholder?). As the Editor-in-Chief of Suicide and Life-Threatening Behavior, the official journal of the American Association of Suicidology, I can assure you thatthere are no standard research definitions being used for many terms that we associate with self-destructive or self-injurious behaviors. I do not believe that suicide prevention can achieve any meaningful successes until we clarify some key relationships, ascribe to thoughts (ideations), emotions (intent, wishes), and behaviors (deliberate self-harm, attempts, completions) the appropriate risk factors, protective factors, and warning signs, and construct valid profiles of populations at risk.”

I’ve rambled a bit, sorry. I hope this was of at least some use to you. The only thing I can say really is that, if this is something that is affecting you personally, you should check in with your doctor / mental health provider as much as possible - keep them informed of how you’re feeling. Sometimes it’s a matter of changing it up and finding a medication that works best for you. Good luck.