Understanding Why Patients May Not Report Suicidal Ideation at a Health Care Visit Prior to a Suicide Attempt: A Qualitative Study

Richards, Julie E.; Whiteside, Ursula; Ludman, Evette J.; Pabiniak, Chester; Kirlin, Beth; Hidalgo, Rianna; Simon, Greg

doi:10.1176/appi.ps.201800342

Cited by 167Suicide and Self-Harm StudiesMental Health Treatment and AccessOpioid Use Disorder Treatment

Understanding Why Patients May Not Report Suicidal Ideation at a Health Care Visit Prior to a Suicide Attempt: A Qualitative Study

Richards, Julie E., Whiteside, Ursula, Ludman, Evette J., Pabiniak, Chester, Kirlin, Beth, Hidalgo, Rianna, Simon, Greg·2019·Psychiatric Services

DOI 10.1176/appi.ps.201800342

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Abstract

OBJECTIVE: The authors sought to understand why patients may not report suicidal ideation at a health care visit prior to a suicide attempt. METHODS: Electronic health record data from Kaiser Permanente Washington were used to identify patients who reported having no suicidal ideation on question 9 of the nine-item Patient Health Questionnaire and who subsequently made a suicide attempt (≤60 days). Semistructured interviews were audio-recorded, transcribed, and analyzed by using a combination of directed (deductive) and conventional (inductive) content analysis to validate and further explore reasons why patients may not report suicidal ideation prior to a suicide attempt. RESULTS: Of 42 adults sampled, 26 agreed to be interviewed, of whom about half were women (N=15) and a majority was white (N=20), with ages ranging from 18 to 63. Key themes were that patients who attempted suicide after having reported no thoughts of self-harm were either not experiencing suicidal ideation at the time of screening or feared the outcome of disclosure, including stigma, overreaction, and loss of autonomy. An additional theme that emerged from the interviews included reports of heavy episodic drinking at the time of the suicide attempt, particularly when suicide was completely unplanned. Patients also identified important aspects of interactions with health care system providers that may facilitate disclosure about suicidal ideation. CONCLUSIONS: Nonjudgmental listening and expressions of caring without overreaction among providers may help patients overcome fear of reporting suicidal ideation. Screening for heavy episodic drinking may help identify individuals who make unplanned suicide attempts.

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Prior research suggests that nondisclosure is not uncommon and may be related to fear of stigmatization, uncertainty of repercussions, and prioritization of other mental health issues.
“Prior research suggests that nondisclosure is not uncommon—and may be related to fear of stigmatization, uncertainty of repercussions, and prioritization of other mental health issues [45].”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [45]

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Authors: Richards, J. E., Whiteside, U., Ludman, E. J., Pabiniak, C., Kirlin, B., Hidalgo, R., & Simon, G.
Affiliations: Kaiser Permanente Washington Health Research Institute, Seattle (Richards, Ludman, Pabiniak, Kirlin, Simon); Department of Health Services, University of Washington, Seattle (Richards); , Seattle (Whiteside, Hidalgo); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Whiteside); School of Law, University of California, Berkeley (Hidalgo).
Kaiser Permanente Washington Health Research Institute (US)
ORCID: Whiteside, Ursula
Pabiniak, Chester
Hidalgo, Rianna
Venue: Psychiatric Services
Publisher: American Psychiatric Association Publishing
Published: 2019-01-01
Volume: 70
Issue: 1
Pages: 40-45
ISSN: 0022-1597 (ISSN-L)
1075-2730
1557-9700
DOI: 10.1176/appi.ps.201800342
OpenAlex: W2901606415
Cited by: 167
References: 25
Citations by year: 2026: 24 · 2025: 21 · 2024: 28 · 2023: 24 · 2022: 31 · 2021: 22 · 2020: 10 · 2019: 6
FWCI: 11.14
Type: journal article
Language: en
Open access: closed
Locations: Psychiatric Services (publishedVersion)
PubMed (publishedVersion)
Topics: Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
Keywords: suicidal ideation, suicide attempts, underreporting, stigma, Patient Health Questionnaire, suicide risk screening, binge drinking, provider-patient interaction, medical visits
MeSH terms: Suicide Prevention, Adolescent, Adult, Aged, Female, Humans, Interviews as Topic, Male, Middle Aged, Suicide, Attempted, Washington, Qualitative Research, Young Adult, Electronic Health Records, Suicidal Ideation

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Understanding Why Patients May Not Report Suicidal Ideation at a Health Care Visit Prior to a Suicide Attempt: A Qualitative Study

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