Assessing and Treating Suicidal Thoughts and Behaviors

Webinar Introduction

Good afternoon, everyone. Welcome to today's webinar hosted by Patagonia Health. Today's webinar topic is assessing and treating suicidal thoughts and behaviors. If you're not familiar with the Zoom webinar platform, take a look at the control panel at the bottom of your screen. Here you can configure your audio settings, send chat messages, and ask questions.

Dr. Ross said she would be open to questions at the end of the webinar. Also, just so you know, this session is being recorded and a copy of the recording will be sent to your email after the webinar.

As a quick background to our speaker, Dr. Jaclyn Ross is a clinical psychologist who specializes in mood, anxiety, and trauma disorders, as well as PMDD and borderline personality disorder. Dr. Ross has expertise in assessing and treating suicidal thoughts and behaviors. She received her PhD from UCLA and completed her clinical internship at Northwestern University.

She is the founder of a Chicago-based private practice specializing in evidence-based treatments for mood, anxiety, and trauma disorders, as well as premenstrual disorders.

Without further ado, I am going to pass it over to you, Dr. Ross.

Alright, once again, thank you so much for that introduction and thank you for having me.

As was already said, I am Jackie Ross, and I am really looking forward to speaking with you all today about assessing and treating suicidal thoughts and behaviors.

I have several goals for today's presentation. First, I plan to present current data on suicide prevalence and common challenges to suicide prediction and prevention.

Second, I hope to highlight new directions in suicide risk assessment and intervention.

Next, I am going to present an evidence-based assessment of suicidal thoughts and behaviors.

Finally, I am going to introduce dialectical behavioral therapy, or DBT, as an effective behavioral treatment to address suicidality. At the very end, I will also provide some practical guidance for integrating high-quality, evidence-based suicide risk assessment and management within therapeutic sessions.

Suicide Prevalence and Significance

According to the latest CDC data, 49,000 people died by suicide in the United States in 2023. That is one death every 11 minutes, and suicide rates increased by 37% between 2000 and 2018.

In 2020:

• 12.8 million adults seriously thought about suicide
• 3.7 million adults made a suicide plan
• 1.5 million adults attempted suicide

These numbers are alarmingly high.

Demographic Differences

To take a closer look at what is driving some of this:

Race and Ethnicity

As of CDC data from 2022, suicide rates are highest among American Indian and Alaska Native populations, followed by white populations.

Age

Suicide rates are highest among older adults. As of 2022, the next highest group was adults ages 25 to 34.

Sex Differences

We also see profound sex differences in suicide death rates. Rates of suicide death are much higher among males, at approximately 22.8 per 100,000, compared to 5.7 per 100,000 for females.

Although suicide death rates are much higher among men, this is likely due to social factors like increased access to lethal means such as firearms. It is worth noting that women make far more suicide attempts than men, even though death rates are higher among men.

Methods of Suicide-Related Deaths

As of 2023:

• 24.3% of suicide-related deaths involved suffocation
• 12.1% involved poisoning
• There is a smaller “other” category
• Over half, 55.3%, involved firearms

What is striking is that more than half of suicide-related deaths are completed via firearm.

We are also seeing that current suicide rates in the United States are at a 30-year high, with over 40,000 annual suicides and 117 deaths daily.

In the 1970s, the risk of being killed by someone else or in a car accident exceeded the risk of suicide. Today, suicide is more prevalent.

Challenges in Suicide Prediction

What is especially challenging is that while suicidality nationwide continues to increase, research historically has not had a strong track record of predicting suicide.

Traditional factors such as:

• Depression
• Substance abuse
• Stress
• History of suicide attempt

have actually proven to be poor suicide predictors. Research shows that none of these predictors performed better than chance when placed into statistical models.

A meta-analysis of 365 suicide studies by Franklin and colleagues revealed flaws in past research methods that led to inaccurate risk prediction.

Historically, research focused heavily on stable, trait-level risk factors, such as:

• A diagnosis of major depressive disorder
• Low serotonin levels

Researchers would then follow patients over a decade. This long-term approach created an incomplete understanding of risk factors and failed to accurately identify who needed mental health intervention in real time.

The problem is that too much attention was placed on stable factors and not enough on time-varying factors.

New Approaches and Time-Varying Predictors

New approaches are leveraging AI and machine learning to identify more accurate risk factors. Much of this work is still in early stages.

What we really need is greater emphasis on state-like, time-varying factors in addition to trait-like, stable factors.

Examples of time-varying factors include:

• Loss of employment
• Emotional symptoms on a particular day
• Biological factors that fluctuate over time

These state-like factors help us understand not just who is at risk, but when they are at risk.

Challenges in Working With Suicidal Patients

There are several common challenges that may lead providers to hesitate when working with suicidal patients.

Risk and Liability Concerns

Legal and ethical concerns can arise. Providers may worry about liability if a patient harms themselves despite treatment.

Emotional Toll

Caring for suicidal patients can be emotionally overwhelming and may contribute to burnout.

Limited Resources

Overcrowded emergency rooms and understaffed psychiatric units can make effective crisis intervention difficult.

Complexity of Care

Suicidal patients often have complex needs, including co-occurring mental health and substance use disorders. Treatment frequently requires a multidisciplinary approach.

Lack of Training

Some mental health professionals do not receive adequate training in suicide risk assessment and intervention, which can lead to discomfort and uncertainty.

Addressing these challenges is crucial for improving suicide prevention efforts and ensuring providers feel supported and prepared.

Time-Varying Correlates of Suicide Risk

Research now shows that emotional experiences can increase suicidal ideation at the daily, and sometimes momentary, level.

These experiences include:

• Depression
• Stress
• Feelings of worthlessness
• Overwhelm
• Anger
• Anxiety
• Perceived rejection

Importantly, this does not simply mean that a person who generally experiences these emotions is more suicidal overall. Rather, on days when those emotions intensify, suicidal ideation is also more likely to intensify.

We also know that:

• Job loss
• Severe interpersonal conflict

are associated with suicide attempts.

One notable biological correlate of suicide risk is the premenstrual phase of the menstrual cycle. Research shows that this phase is associated with:

• Increased suicidal ideation
• Increased suicidal planning
• Increased likelihood of suicide attempts

Individual Differences in Risk

Research published with my team in 2024 in the American Journal of Psychiatry highlights the importance of individual differences.

Nearly all emotional symptoms studied were associated with suicidal ideation at the daily level, with anxiety and loss of interest being weaker predictors.

However, there was enormous variability between individuals.

For one person, perceived burdensomeness may strongly predict suicidality. For another, worthlessness may be the strongest factor.

This highlights the need for individualized assessment and intervention.

Just-in-Time Adaptive Interventions

New technology is introducing “just-in-time adaptive interventions” for suicide prevention.

These interventions provide support based on an individual’s needs and current context.

Key components include:

Decision Points

Moments when interventions are delivered based on elevated risk.

Intervention Options

Tailored support options based on the person’s current situation.

For example:
“We see that you are experiencing more hopelessness today and the weather is nice. Could you go for a walk?”

Tailoring Variables

Contextual information such as:

• Weather
• Mood reports
• Behavioral data

Decision Rules

Rules that determine when and how interventions are delivered.

For example, someone reporting increased suicidal ideation might automatically receive an offer for urgent clinician contact.

Challenges With Digital Suicide Prevention

These models also present challenges.

Real-Time Measurement

We need more reliable ways to assess suicidal thoughts in the moment.

Balancing Risk and Receptivity

As suicidal thoughts intensify, individuals may become less receptive to interventions.

Ethical Concerns

Questions arise around:

• Privacy
• Confidentiality
• Informed consent
• Timing of intervention

We must also avoid creating systems that discourage honesty. If people fear automatic hospitalization after endorsing suicidal thoughts, they may underreport symptoms.

The Importance of Assessment

The most important step in developing competence in suicide management is building strong assessment skills.

The Columbia Suicide Severity Rating Scale (C-SSRS)

The C-SSRS is considered the gold standard for suicide risk assessment.

It:

• Creates a common language for assessment
• Helps assess suicidal intent
• Tracks change over time
• Can be used in inpatient or outpatient settings
• Has both screening and full versions

The assessment evaluates:

• Suicidal ideation
• Intensity of ideation
• Suicidal behavior
• Lethality of attempts
• Interrupted attempts
• Aborted attempts
• Preparatory behaviors

Levels of Suicidal Ideation

There are varying levels of concern when assessing suicidal ideation.

Active Suicidal Ideation Without Plan or Intent

Example question:
“Have you thought about how you would kill yourself?”

At this stage, clinicians would typically:

• Develop a safety plan
• Discuss coping strategies
• Reduce access to lethal means
• Identify support people

Active Suicidal Ideation With Intent but No Specific Plan

Example question:
“When you thought about killing yourself, did you think this was something you might actually do?”

At this level:

• Monitoring increases
• More frequent contact may be necessary
• Commitment-to-safety discussions become important

Active Suicidal Ideation With Specific Plan and Intent

Example questions:

• “Have you decided how or when you would kill yourself?”
• “What is your plan?”

At this point:

• Urgent intervention is needed
• Confidentiality may need to be broken
• Hospitalization may be considered

Introduction to DBT

Dialectical Behavioral Therapy, or DBT, is an evidence-based treatment for suicidality.

DBT was originally developed for individuals with borderline personality disorder and chronic suicidality.

DBT is:

• Behavioral
• Cognitive
• Skills-oriented
• Collaborative
• Focused on balancing acceptance and change

A fully adherent DBT program includes four components:

1. Individual therapy
2. Skills group
3. Phone coaching
4. Consultation team

Functional Chain Analysis

A core component of DBT is functional chain analysis.

If a patient reports suicidal ideation or self-harm, clinicians examine:

• Vulnerability factors
• Prompting events
• Thoughts and emotions
• Behaviors
• Consequences

Example: Hannah

Imagine Hannah, a 25-year-old with borderline personality disorder and PMDD who has made several suicide attempts.

Vulnerability Factors

• Premenstrual phase
• Skipping meals
• Missing psychiatric medications

Prompting Event

Criticism from her father.

Chain of Events

• Shame
• “I can’t handle feeling this way”
• Desire to escape
• Suicidal planning

Short-Term Consequence

Relief.

Long-Term Consequence

Avoidance of real problem solving and emotional growth.

Building a Life Worth Living

DBT treats suicidality by helping patients build a “life worth living.”

Many suicidal patients genuinely do not feel their lives are worth living. That reality must be validated.

Early in treatment, therapists help patients identify meaningful goals and values.

Questions might include:

• “What life do you long for?”
• “What would your relationships look like?”
• “What would your career look like?”

Treatment then focuses on changing behaviors that interfere with those goals.

DBT Skills Modules

Mindfulness

Developing present-moment awareness without judgment.

Distress Tolerance

Learning crisis survival strategies.

Emotion Regulation

Managing emotions effectively without self-destructive behavior.

Interpersonal Effectiveness

Improving communication and relationships.

Walking the Middle Path

Balancing acceptance and change.

Mindfulness serves as the foundation across all DBT modules.

DBT Strategies for Managing Suicidal Behavior

Key therapeutic tasks include:

• Preventing suicide and self-harm
• Reducing future suicidal behavior
• Avoiding accidental reinforcement of suicidal communication

Three DBT Rules

1. Suicidal behavior is always discussed in depth.
2. No therapist contact for 24 hours after self-harm behavior.
3. Potentially lethal patients are not prescribed lethal quantities of medications.

Crisis and Safety Planning

A DBT safety plan may include:

Warning Signs

• Physical sensations
• Emotions
• Situational triggers

Life Worth Living Goals

Reminders of meaningful goals and values.

Distress Tolerance Skills

TIP Skill

• Temperature: cold water or ice
• Intense exercise
• Paced breathing

Distraction Strategies

Activities across different areas of life.

Self-Soothing

Using the senses to calm the nervous system.

Environmental Safety

• Restricting access to firearms
• Locking medications
• Avoiding high-risk situations

Support Contacts

People and crisis resources to contact.

Managing Imminent Suicide Risk

If a patient reports immediate intent and plan:

• Assess short- and long-term risk
• Review the safety plan
• Restrict access to lethal means
• Encourage problem-solving
• Maintain contact
• Involve support if necessary
• Consider hospitalization only when safety cannot otherwise be maintained

Collaborative Hospitalization

Whenever possible, hospitalization should be collaborative rather than involuntary.

This:

• Preserves trust
• Reduces stigma
• Reduces trauma
• Empowers the patient

Q&A Segment

Question About the 2019-2020 Dip in Suicide Rates

Dr. Ross:
“I have no idea. I really don’t. I don’t think there’s a good explanation either. I wouldn’t make too much of it given that it was just one year and the numbers rose right back up afterward.”

Question About Discussing Suicide Repeatedly

Dr. Ross:
“One thing I would highlight is that if someone repeatedly talks about suicide outside of genuinely needing immediate help, it can really burn out relationships. Loved ones often feel helpless and overwhelmed because they don’t know how to respond or help.

I also think the key point is the problem-solving approach. If suicide is the only option on the table, the person cannot see other possible solutions. If we can temporarily take suicide off the table, we can begin exploring other ways to solve the underlying problem.”

Question About LGBTQ+ Resources

Dr. Ross:
“Offhand, I do not have LGBTQ-specific suicide prevention resources, but when I share my slides, I would be happy to look into that and add some resources.”

Thank you so much, Dr. Jaclyn Ross, for your expertise. This was incredibly informative and enlightening.

If you would like to learn more about Patagonia Health, please visit www.patagoniahealth.com. We are an integrated EHR, practice management, and billing solution.

Have a great day, everyone.

Great. Thank you so much.