Suicidal ideation

Suicidal ideation refers to the situation in which a person thinks about ending their own life. The presentation of suicidal ideation can vary from being fleeting and vague to very concrete. Concrete ideation involves method selection, planning and/or intention to complete suicide. A person could act upon ideation, undertaking an action in which they expect to end their own life. Depending on the fatality of the outcome, the action is considered a suicidal attempt or suicide. According to the World Health Organization (WHO, 2019), close to 800 000 people die due to suicide every year. It is a global phenomenon across countries. Yet, suicides are preventable with a comprehensive multi-sectoral prevention strategy.

International first aid, resuscitation, and education guidelines 2020.
https://www.globalfirstaidcentre.org/ Suicidal ideation | 2 The following actions may help people with suicidal ideation: > assessing the risk of suicide and harm > listening non-judgmentally > engaging in the conversation > giving reassurance > encouraging professional support > encouraging other support > ensuring safety.

Context considerations
Consider whether there is any stigma surrounding mental health and suicide within the context and adjust education accordingly, aiming to diminish stigma. Programme designers should consider the local statistics of suicide, (e.g., increased numbers of children or older adults feeling suicidal and completing suicide) and develop programmes specific to the groups with higher risk, being careful not to stereotype.

Learner considerations
Children and young people may focus on recognising unusual behaviour in friends and how to appropriately inform a trusted adult. Often, they will be concerned about confidentiality and breaking 'trust'. Emphasise the importance of getting help. Programme designers should ensure the depth and level of training and the support available are appropriate to the first aid provider. This will vary among different countries and first aid education programmes. Avoiding stigmatising language (e.g. in English 'commit suicide' emphasises criminality). Consider the culture and faith of learners and adapt education appropriately.

Facilitation tips and tools
Distinguish between suicide and self-harm. Create a safe space for learners where they can report if they are affected by this topic and can access any support they may need as a result. Develop ground rules with the group to ensure confidentiality, respect and sensitivity within the group.
Have two facilitators present for sessions so that specific support can be offered to individuals if necessary. Explore and address myths or misconceptions the learners may have. These may include concerns about 'planting thoughts' or the types of at-risk people. Use case studies which explore the behaviours mentioned and risk factors (e.g. a person who has had significant life events). Focus on recognising signs of concern rather than on 'assessment'. Discuss how to have difficult conversations. What things can you say? What to avoid? Practise how to ask difficult questions to understand concerns and fears. Stress the importance of doing so. Use a video of a person's story as people often find it difficult to empathise. Ensuring a human approach is vital. Emphasise that it is the first aid provider's role to get assistance if necessary and that they should take any threat of suicidality seriously.

NOTE
A tool commonly used in psychological first aid is Look, Listen, Link. See Psychological first aid for details of this.

Systematic review
An evidence summary developed by the Centre for Evidence-Based Practice identified 12 studies that looked at communication to people with suicidal ideation (Dockx et al., 2020). Evidence is of low quality and results cannot be considered precise due to the low number of events and large variability of results.

Appraisal of or having a confidant
There is limited evidence with benefit for appraisal of having a confidant (i.e. the perceived availability of someone to talk to about one's problems.). It was shown that appraisal of or having a confidant resulted in a statistically significant decreased risk of suicidality, compared to low appraisal of or not having a confidant.

Staying connected to and befriending
There is limited evidence in favour of staying connected to the person at risk such as through means of sending postcards. In one study, after hospital discharge, postcards were sent every few weeks or months. In these postcards, a doctor asked how the person was doing and whether they wished to drop them a note. It was shown that sending postcards resulted in a statistically significant decrease in suicidal ideation and suicide attempts, compared to not sending any postcards. A statistically significant decrease of suicidal death, when sending postcards compared to not sending postcards, could not be demonstrated.
There is limited evidence in favour of befriending. This involved using a trusting and non-judgmental approach to providing care and opportunities for people to talk about their life events in a calm, relaxing and safe environment. In the study, the people stayed in a respite centre for a time-limited four-night period. It was shown that this method resulted in a statistically significant decrease in psychological distress from pre to post and follow-up measurement.
Psychological first aid intervention principles International first aid, resuscitation, and education guidelines 2020. https://www.globalfirstaidcentre.org/ Suicidal ideation | 5 Psychological first aid is a method of helping people in distress to feel calm and supported in coping with their challenges. It addresses both the emotional and social needs of individuals, with the intention of helping people use their resources, enhance their resilience and make informed decisions. There are a limited number of studies that researched the effectiveness of psychological first aid as a complete programme. Two existing systematic reviews on psychological first aid both concluded that there is a lack of controlled studies to support it (Dieltjes et al., 2014;Fox et al., 2012). However, as it is unlikely to have adequate representation of randomised controlled trials using interventions for traumatic events, interventions need to be informed by good practices and psychological first aid is supported by expert opinion.

Guidelines for suicide developed via Delphi methodology
While randomised controlled trials provide a high quality of research evidence, it is highly infeasible and unethical to conduct such studies in developing guidelines in response to suicidality, and good-quality observational research is currently lacking. The Delphi method is a methodology of reaching expert consensus, and the following guidelines developed using Delphi methods. (Colucci et al., 2011;Kelly et al., 2008;Ross et al., 2014) There are five basic actions when responding to suicide "ALGEE" (Mental Health First Aid Australia, 2014): Assess the risk of suicide and/or harm. Listen non-judgmentally. Give reassurance.
Encourage professional support. Encourage other supports.

Psychological first aid intervention principles
Psychological first aid provided by trained persons is widely supported by expert Suicidal ideation | 6 International first aid, resuscitation, and education guidelines 2020. https://www.globalfirstaidcentre.org/ Suicidal ideation | 6 opinion and rational conjecture as the tool to be provided by trained persons for people who have experienced a traumatic event (Shultz & Forbes, 2014).
Through observation and expert experience there is widespread consensus and support (IASC, 2007) for the five principles that should be used to guide and inform any psychosocial support intervention and prevention efforts at the early to midterm stages of an emergency. These five principles facilitate survivors' short-term adjustment and long-term adaptation to the impact of disasters (Hobfoll et al., 2007) and they involve the promotion of: calm hope connectedness a sense of safety a sense of self and community efficacy.

First aid for mental health problems
In 2019 the Belgian Red Cross-Flanders developed guidelines to provide first aid to people experiencing mental health problems based on a systematic review of scientific evidence (evidence summaries developed by CEBaP, as mentioned above), expert opinion and the preferences of the target population (Dockx et al., 2020). The guidelines include specific recommendations to support people exposed to shocking events.

Signals of suicidal ideation
Many people experiencing suicidal ideation exhibit signals during the suicidal process which could be observed by others. Awareness and attentiveness by the first aid provider for signs of suicidal thoughts and warning signs of suicidal threat could contribute to the person getting the help they need in time.
Warning signs of suicidal threat include (Mental Health First Aid Australia, 2014; IFRC Reference Centre for Psychosocial Support, 2020): Threats of suicide or self-injury.
Suicidal ideation | 7 International first aid, resuscitation, and education guidelines 2020. https://www.globalfirstaidcentre.org/ Suicidal ideation | 7 Planning for suicide (e.g., searching for methods, acquiring means). The risk somebody takes their own life increases if somebody has a clear plan (how, where, when), has the means to execute the plan and or declares the intention to act. Talking, writing, online posting about death or suicide. Previous suicide attempts.
Other possible signals of suicidal ideation include (Mental Health First Aid Australia, 2014; IFRC Reference Centre for Psychosocial Support, 2020): Making arrangements, appearing to 'say goodbye', getting affairs in order. Affective changes such as pronounced negative feelings (e.g., hopelessness; stuck, feeling there is no way out; angry, vengeful; seeing no reason to live; inferior, feeling a burden to others; anxious) or pronounced fluctuations in mood.
Changes in behaviour such as increased risk behaviour (e.g., recklessness, increased consumption of alcohol or other drugs), a sudden display of elation (as a plan has been finalised), sleep problems, or social withdrawal.

Risk and protective factors for suicide
Suicide risk is assessed based on the risk factors, protective factors, and circumstances of the suicide attempt if the person survives after such an attempt. Examples of risk factors for suicide include the following (IFRC Reference Centre for Psychosocial Support, 2020): presence of depression presence of psychosis sex (the risk ratio of male: female is 2:1) age (the older the age, the higher the risk) single, separated, divorced or widowed presence of alcohol or substance misuse previous history of a suicide attempt presence of a suicide plan lack of social support presence of chronic illness (e.g. chronic pain).
International first aid, resuscitation, and education guidelines 2020. https://www.globalfirstaidcentre.org/ Suicidal ideation | 8 Examples of protective factors for suicide involve (IFRC Reference Centre for Psychosocial Support, 2020): strong perceived social support close family relationship good coping and problem-solving skills having a sense of meaning and purpose in life ability and willingness to seek help access to resources.
Circumstances of an unsuccessful suicide attempt that indicate a higher risk: planning in advance precautions to avoid discovery no attempts to obtain help afterwards final acts (e.g. writing a suicide note or making a will, transferring savings to a close relative's account, asking someone to help to take care of small children) dangerous method (e.g., a lethal dose of drugs was used; the use of a violent method). The person's perception of the lethality of the method used should also be considered.
Professional help in the case of suicidal ideation should always be encouraged. A trained healthcare professional should conduct a thorough assessment of suicide risk and for the possibility of an underlying mental illness that can lead to the same.
Supporting a suicidal person can be stressful so first aid providers should guard their personal boundaries and take care of themselves. A first aid provider should do their best for the person they are helping. However, despite best efforts, some people will still die by suicide.