Beyond Magic: How Do We Detect Suicidal Thoughts?

No objective test exists for suicidal thoughts – no X-ray to detect broken hope, no CAT scan to reveal intolerable emotional pain, no blood test to expose toxic intentions.

This reality is disappointing, even devastating. People understandably want professionals to predict and prevent suicide. For example, after a pilot intentionally slammed a Germanwings plane into a mountain in the Alps in 2015, killing 149 people plus the pilot, some people called for airlines to screen pilots for suicidal thoughts.

There’s a hope that screening people for suicidal thoughts would automatically reveal who longs to die. Unfortunately, it’s not that simple.

The Benefits of Suicide Screening

Screening people for mental illness and suicidal thoughts undoubtedly identifies many people whose suicidal thoughts would otherwise remain hidden. Suicide screening tools are used in primary care physicians’ offices, schools, the military, and more.

Asking everyone about suicidal thoughts, whether or not they show symptoms of distress, might save lives. The suicide rate in the U.S. Air Force went down dramatically after the military began screening all Air Force personnel for mental health problems and suicidal thoughts – and, not incidentally, increased access to mental health services.

The Limits of Suicide Screening

First, millions of adolescents and adults in the U.S. seriously consider suicide in any given year, and the vast majority – roughly 99.7% – do not die by suicide. This means that suicidal thoughts alone do not convey whether someone’s at high risk for suicide.

As Dr. Seena Fazel, professor of forensic psychiatry at University of Oxford, explained to NBC News:

“…If you apply a reasonably good [suicide] screen to 100,000 persons, for whom you expect 10 to die from suicide (based on population averages), this suicide screening tool would lead to eight correct screens, two missed suicides, but importantly nearly 30,000 persons who would be identified at high risk but would not die from suicide.”

And those are the people who reveal suicidal thoughts. Even when asked directly if they’re thinking of suicide, many others don’t answer truthfully. Research indicates that 50% of people who consider suicide – including those who go on to kill themselves – deny thinking of suicide when asked.

Why Do People Hide Suicidal Thoughts?

Many forces conspire against the honest disclosure of suicidal thoughts, some of which this article discusses, and others of which I’ve observed in my clinical practice:

There is embarrassment, as if suicidal thoughts signify a weakness of character or will.

There is fear of others’ reactions; someone might be judgmental or overreact or give poor advice or feel burdened or call the police. There is fear, too, of loss – loss of one’s job, loss of one’s identity, and loss of one’s freedom, too, if hospitalized.

There is hopelessness, a conviction that telling others of suicidal thoughts will do no good These feelings and fears often aren’t actually true — you know, don’t believe everything you think — but they feel true to many people.

And then, most dangerous of all, some people simply are determined to not be stopped from dying by suicide. So, why tell?

What Can We Do, Then, to Identify Suicidal Thoughts?

To uncover hidden suicidal thoughts in a specific person, professionals need to skillfully ask questions, often posing the same question in different ways. As I explain in a different post, there are techniques for drawing out this kind of sensitive information.

Professionals can also look at situational crises, recent developments, risk factors and warning signs to form an opinion about whether a person is at high risk for suicide. Again, obtaining this information depends on skillfully asking questions, as well as looking at medical records and talking to people who know the person well.

The professional’s opinion might well be wrong. One study found that clinicians’ ability to predict whether a patient would attempt suicide was little better than chance.

If we want someone to open up about their suicidal thoughts, we also must provide an environment where it is safe to get help, safe to share what is terrifying to share, safe to make oneself vulnerable in a world with too much stigma, judgment, and hate.

What We Should Not Do

The reaction to the crash of the Germanwings flight, in particular the reaction to reports of the pilot’s apparent history of depression, creates the opposite environment of one that would help suicidal people feel safe to disclose their thoughts.

Some people question why pilots with depression would be allowed to fly. Yet a ban on flying would assure that pilots who have depression and who want to keep their jobs would not disclose their depression to others. Such pilots almost certainly would be less willing to seek professional help if a doctor or therapist had to report the results to the pilots’ employer.

And then what would we have? We would have pilots with depression flying planes carrying hundreds of passengers while feeling even more desperate and trapped than ever, unable to get help without tremendous loss to their career, professional identity, and income. This is a recipe that certainly will not improve passenger safety.

A Plan Beyond Magical Thinking

To help people from endangering others with their suicidal plans, we as a society must make it OK to ask for help.

We must be careful not to brand people with depression and suicidal thoughts as potential murderers, as if one suicidal pilot’s mass murder speaks for all people with depression. (In reality, many millions of people in the U.S. alone experience major depression every year. Among people who receive mental health services for depression, only 2% ultimately die by suicide, and roughly the same amount do physical harm to others.)

We must remain vigilant for suffering and despair, and ask with compassion and concern about the welfare, feelings, and thoughts of those who are hurting.

We must stop stigmatizing mental illness and mental health treatment.

Coaxing out suicidal thoughts, by skillfully asking questions and creating an environment in which it is safe to answer honestly, is hardly an objective test to detect whether someone is thinking of suicide. But presently, in the absence of magic or medical advances, it is the best we can do.

© Copyright 2015 Stacey Freedenthal, PhD, LCSW, All Rights Reserved. Written for Speaking of Suicide.

Updated August 31, 2022