Assessing imminent suicide risk: What about future planning?

A patient who has the ability to plan for their future can be reassuring for a clinician who is conducting an imminent suicide risk evaluation. However, that patient may report future plans even as they are contemplating suicide. Therefore, this variable should not be simplified categorically to the mere presence or absence of future plans. Such plans, and the process by which they are produced, should be examined more closely. In this article, we explore the relationship between a patient’s intent to die by suicide in the near future and their ability to maintain future planning. We also use case examples to highlight certain characteristics that may allow future planning to be integrated more reliably into the assessment of imminent risk of suicide.

An inherent challenge

Suicide risk assessment can be challenging due to the numerous factors that can contribute to a patient’s suicidal intent.¹ Some individuals don’t seek help when they develop suicidal thoughts, and even among those who do, recognizing who may be at greater risk is not an easy task. Sometimes, this leads to inadequate interventions and a subsequent failure to ensure safety, or to an overreaction and unnecessary hospitalization.

A common difficulty is a patient’s unwillingness to cooperate with the examination.² Some patients do not present voluntarily, while others may seek help but then conceal suicidal intent. In a sample of 66 psychotherapy patients who reported concealing suicidal ideation from their therapist and provided short essay responses explaining their motives for doing so, approximately 70% said fear of involuntary hospitalization was their motive to hide those thoughts from their doctor.³ Other reasons for concealment are shame, stigma, embarrassment, fear of rejection, and loss of autonomy.^3-5 Moreover, higher levels of suicidal ideation are associated with treatment avoidance.⁶ Therefore, it is important to improve suicide predictability independent of the patient report. In a survey of 1,150 emergency physicians in Australasia, Canada, the United Kingdom, and the United States, the need for evidence-based guidelines on when to hospitalize a patient at risk for suicide was ranked as the 7th-highest priority.⁷ There are limitations to using suicide risk assessment scales,^8,9 because scales designed to have high sensitivity are less specific, and those with high specificity fail to identify individuals at high risk.^9,10 Most of the research conducted in this area has focused on the risk of suicide in 2 to 6 months, and not on imminent risk.¹¹

What is ‘imminent’ risk?

There is no specific time definition for “imminent risk,” but the Lifeline Standards, Trainings, and Practices Subcommittee, a group of national and international experts in suicide prevention, defines imminent risk of suicide as the belief that there is a “close temporal connection between the person’s current risk status and actions that could lead to his/her suicide.”¹² Practically, suicide could be considered imminent when it occurs within a few days of the evaluation. However, suicide may take place within a few days of an evaluation due to new life events or impulsive actions, which may explain why imminent risk of suicide can be difficult to define and predict. In clinical practice, there is little evidence-based knowledge about estimating imminent risk. Recent studies have explored certain aspects of a patient’s history in the attempt to improve imminent risk predictability.¹³ In light of the complexity of this matter and the lack of widely validated tools, clinicians are encouraged to share their experience with other clinicians while the efforts to advance evidence-based knowledge and tools continue.

The function of future planning

Future planning is a mental process embedded in several crucial executive functions. It operates on a daily basis to organize, prioritize, and carry out tasks to achieve day-to-day and more distant future goals. Some research has found that a decreased ability to generate positive future thoughts is linked to increased suicide risk in the long term.^14-17 Positive future planning can be affected by even minor fluctuations in mood because the additional processing capacity needed during these mood changes may limit one’s ability to generate positive future thoughts.¹⁸ Patients experiencing mood episodes are known to experience cognitive dysfunctions.^19-21 However, additional measurable cognitive changes have been detected in patients who are suicidal. For example, in a small study (N = 33) of patients with depression, those who were experiencing suicidal thoughts underperformed on several measures of executive functioning compared to patients with no suicidal ideation.²²

However, when addressing imminent rather than future suicide risk, even neutral future plans—such as day-to-day plans or those addressing barriers to treatment—can be a meaningful indicator of the investment in one’s future beyond a potential near-term suicide, and therefore can be explored to further inform the risk evaluation. Significant mental resources can be consumed due to the level of distress associated with contemplating suicide, and therefore patients may have a reduced capacity for day-to-day planning. Thus, serious suicide contemplation is less likely in the presence of typical future planning.

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