Responding to Suicidal Ideation

Few hours of EMT and paramedic programs are spent learning how to respond to mental health emergencies, yet this type of call—from the “emotionally disturbed person” to those with explicit suicidal ideation—is common in many systems. This article offers some assessment, response, and patient care suggestions for these types of calls, specifically patients who have attempted suicide or are showing suicidal ideation. 

Suicidal ideation is broken down into two forms: active and passive. Active suicidal ideation involves an existing wish to die accompanied by a plan to carry it out. Passive suicidal ideation involves a desire to die but without a specific plan for carrying it out. While both are mental health emergencies, the former is typically where EMS is called.

Per the World Health Organization, about 800,000 people die from suicide every year—one person every 40 seconds.¹ For every adult who dies by suicide, 20 or more may attempt it. In 2016 suicide accounted for 1.4% of all deaths worldwide.

Warning Signs

Suicidal ideation can present in a variety of ways. While some behaviors might be obvious—attempts to harm oneself, overt threats, or obtaining lethal means like a weapon—others are less so. Subtler signs can include talking about the subject, as well as writing, texting, and posting on social media about it. Mood swings are common, as are anger, sleeplessness, anxiety, extreme sadness, and irritability. Persons considering suicide might also engage in uncharacteristically reckless behaviors or start or increase alcohol or drug use. They may also start giving away possessions or saying good-bye to friends and loved ones.

All these signs, especially threats, need to be taken seriously by EMS providers, even if the person says they were joking. 

Assessing the Patient

Scene safety and situational awareness should take precedence on every call but especially if you suspect a mental health emergency. In many systems law enforcement is first on scene of dispatched mental health emergencies, and EMS will be dispatched either concurrently or upon police request. Work with law enforcement to make sure the scene is safe, including a scan for weapons. 

Once you can proceed, complete a physical assessment as you normally would and add a suicide risk assessment. The National Council for Behavioral Health suggests using the acronym ALGEE:²  

Assess for risk of suicide or harm—Begin by asking the patient if they are considering harming themselves. Some people mistakenly think asking this will give the patient the idea or make the situation worse—it won’t. Instead, direct conversation and plain talk will help determine the urgency of the situation and help the patient feel less alone. Ask the following questions:

• Are you having thoughts of suicide?
• Do you have a plan to kill yourself?
• Have you decided when you’d do it?
• Do you have everything you need to carry out your plan?

Just because they don’t have a plan or don’t share it doesn’t mean everything is fine. This can help you understand the level of immediacy or distress the person is in.

Listen without judgement—Encourage your patient to share their story. Remember that in crisis patients are scared, and you need to build trust. Remain calm, talk in an even voice, and acknowledge their feelings without judgement. Feelings aren’t wrong, and you can listen and respond with additional questions to find out more. You are trying to listen but not to “fix” things. Don’t say things like, “I know how you feel,” because you probably don’t. Instead you can thank them for sharing their thoughts and remind them you are there to help. Honesty throughout the encounter will help build trust.

Give reassurance and information—Let your patient know that in addition to your help, there is more help available from other professionals. Share that while thoughts of suicide can be common, they need not be acted on. Normalizing mental health concerns may help anxious or embarrassed patients admit symptoms. Say something like, “Sometimes when people are feeling sad or hopeless, they’ll notice they drink more than usual or take drugs to feel better. Has that been happening to you?” or “People have told me that when they feel really sad, they find themselves crying, or at least feeling like crying, often. Have you noticed anything like that?”

Encourage appropriate professional help; encourage self-help and other support strategies—Tell these patients they are doing the right thing by getting help. Tell them it makes them brave and feeling better is possible. Ask them to think about support systems that have existed for them in the past, like family, friends, and religious or other groups. Encourage them to accept transport to an appropriate facility and connection with additional caregivers.

Creating Comfort

How do you address the patient?—Suicide expert Shawn Shea, MD, says how you address the patient can set the stage for a good or bad encounter.³ “One should never assume a first-name basis without asking first,” he advises. “Some [patients] find a first name threatening or a ‘put-down,’ especially if the patient is much younger or older than the clinician.” He suggests you ask the patient what they wish to be called. 

Uncovering patient concerns—Jane Skolnick, a licensed clinical social worker, likes to tell patients, “I want to make sure you feel comfortable. Perhaps a good place to start is for you to share your understanding of why we’re here right now and what’s going to happen.” This statement allows the EMS provider to uncover the patient’s primary concerns and gives the patient a chance to ask questions or air their fears about what’s happening, why EMS is there, and what will happen to them. It is also a great opportunity to let patients know they are not in trouble, and everyone is there to help.

EMS is often ill-equipped—EMS can lack training on this subject, which can leave us unprepared to handle suicidal ideation calls as effectively as we would like. Training and understanding go a long way for someone in a suicidal/mental health crisis. The most critical component of intervention is to create a human connection. New Jersey psychologist Steven Myers, PhD, described one of his first days working with patients with suicidal ideation in an emergency room in New Jersey: 

“I can still remember nearly 20 years ago, my first day working at the hospital and meeting patients in the inpatient unit. My gut was that these people were not like me, and fear became a barrier to my connection. After relating with them and understanding their stories, I was better able to develop that connection. In a suicidal crisis we need to walk in and do that work much faster, so it really requires that we drop our preconceived notions and stigma that surrounds mental health and approach the situation without judgement or shame.”

In doing so, Myers says, it is essential a responder “acts like they’ve been there before,” so to speak, as well as shedding any stereotypes. Speak with confidence, assurance, humility, and an eagerness to understand—just like anything in EMS, experience breeds comfort. 

Final Thoughts

Calls involving mental health emergencies, especially suicidal ideation calls, are challenging for EMS. While EMS is trained to assess and treat illness, there is little we can physically do for these patients beyond assessment and transport to a facility that handles mental health emergencies. While this may frustrate some providers, it also poses a great opportunity to provide reassurance, encouragement, and support for patients having suicidal ideation both on the scene and during transport by using effective listening skills and engagement strategies.  

Sidebar: The COVID Effect on Suicide

A recent study out of Detroit found that surprisingly, despite the COVID pandemic and accompanying anxiety many expected others to have, there was not an uptick in suicide and attempted suicide calls to EMS during the pandemic.⁴ While the study was limited, it noted that “while the results…did not find an increase in 9-1-1 [suicide attempt] calls for service during the height of the COVID-19 pandemic, [agencies] should not assume that all is well in their communities. In fact, the opposite may be true, given the heightened levels of unemployment, anxiety, isolation, and depression that many citizens report.”

References

1. World Health Organization. Mental Health and Substance Use: Suicide Data, www.who.int/teams/mental-health-and-substance-use/suicide-data.

2. National Council for Behavioral Health. What is ALGEE? www.thenationalcouncil.org/wp-content/uploads/2013/10/NC-Mag-MHFA-Origami-Insert.pdf?daf=375ateTbd56.

3. Training Institute for Suicide Assessment & Clinical Interviewing. Archive for the Resources Category, https://suicideassessment.com/resources/.

4. Lersch KM. COVID-19 and Mental Health: An Examination of 911 Calls for Service. Policing, 2020 Dec; 14(4): 1,112–26; https://academic.oup.com/policing/article/14/4/1112/5881455.

Barry Bachenheimer, EdD, NREMT/FF, has more than 35 years in EMS and fire as a provider and instructor. He is a frequent contributor to EMS World.