Asking directly does not plant the idea. What raises risk is a person who has been thinking about ending their life for weeks, is asked nothing, and concludes that the subject is unspeakable even here. Choose the sentence you would really say at six moments; all four options then open with the technique or the trap named. Then climb the ladder from passive ideation to access to means, repair four pieces of stigmatising chart language, and build a formulation in place of a score.
Six moments
1 of 6
The ladder: what do you ask next?
Mr. Whitlock, 58, emergency department, 21:40. Ideation → method → plan and intent → preparatory behaviour → access to means and reasons for living. Each rung gives you his answer; you choose the next question. Answering a rung opens all three options.
Silence after the question is your friend. Count to five in your head before filling it. If he discloses, respond to the content and not to your own alarm — thank him for telling you, then keep gathering detail. Visible panic in the nurse teaches a patient that this information is too much for professionals to hold, and the next person they tell will be no one.
Your bench
0
Moments worked
0
Therapeutic first choice
0
Ladder rungs matched
0
Findings classified
Ask everywhere, not only in psychiatry. A large proportion of people who die by suicide have contact with a health service in the preceding month — most often primary care or an emergency department, and often for a physical complaint. Chronic pain, a new cancer diagnosis, traumatic brain injury and delirium in an older adult are all contexts where the question belongs.
The tools, and their limits. The C-SSRS forces the specific questions clinicians skip under time pressure — wish to be dead, non-specific active thoughts, method without intent, intent without plan, plan with intent, then lifetime and three-month preparatory behaviour and attempts. ASQ is a four-item screen validated for youth in medical settings. PHQ-9 item nine is case-finding only: a positive item nine mandates a full assessment, it is not itself one. Run any of them as a conversation, and record the person’s own words in quotation marks — “I keep thinking about my father’s gun in the closet” carries clinical information that a checked box destroys.
Repair the chart language
These phrases still appear in records, and they are assessed. Each one below is the labelled before — select it to see what you write instead and why the original does harm.
Formulation, not a score
Mr. Whitlock’s findings. Sort each one as static (historical, unchangeable), acute dynamic (present today and modifiable) or protective. Correctly sorted findings assemble into the formulation below.
Why not a number? Meta-analyses across fifty years show that risk factors predict suicide barely better than chance at the level of the individual. There is no score that tells you who will die. Instruments such as SAD PERSONS were built for teaching and perform poorly as triage — using a low score to justify discharge is indefensible. A paragraph that names chronic vulnerability, acute drivers, protective factors, what is modifiable now and the plan for tonight is defensible care. A number is not.
Two patterns that should raise your attention, not lower it. A person emerging from severe depression may be at higher risk as psychomotor retardation lifts before mood does, restoring the energy to act — antidepressants take roughly two to six weeks for full mood response while energy and volition often return earlier, and there is a boxed warning about increased suicidal thinking and behaviour in people under twenty-five in early treatment and after any dose change. And a person who has been agitated and ambivalent for days who becomes suddenly calm and settled, giving away possessions or tidying affairs, may have made a decision rather than improved.