SUICIDAL IDEATION

Ask questions 1 and 2. If both are negative, proceed to “Suicidal Behavior” section. If the answer to question 2 is “yes”, ask questions 3, 4 and 5. If the answer to question 1 and/or 2 is “yes”, complete “Intensity of Ideation” section below.

Lifetime:

Time He/She Felt Most Suicidal

Past 1 month

1. Wish to be Dead

Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.

Have you wished you were dead or wished you could go to sleep and not wake up?

If yes, describe:

Yes No

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Yes No

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2. Non-Specific Active Suicidal Thoughts

General non-specific thoughts of wanting to end one’s life/commit suicide (e.g., “I’ve thought about killing myself”) without thoughts of ways to kill oneself/associated methods, intent, or plan during the assessment period.

Have you actually had any thoughts of killing yourself?

If yes, describe:

Yes No

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Yes No

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3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act

Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a specific plan with time, place or method details worked out (e.g., thought of method to kill self but not a specific plan). Includes person who would say, “I thought about taking an overdose but I never made a specific plan as to when, where or how I would actually do it…and I would never go through with it.”

Have you been thinking about how you might do this?

If yes, describe:

Yes No

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Yes No

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4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan

Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as opposed to “I have the thoughts

but I definitely will not do anything about them.”

Have you had these thoughts and had some intention of acting on them?

If yes, describe:

Yes No

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Yes No

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5. Active Suicidal Ideation with Specific Plan and Intent

Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out.

Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

If yes, describe:

Yes No

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Yes No

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INTENSITY OF IDEATION

The following features should be rated with respect to the most severe type of ideation (i.e., 1-5 from above, with 1 being the least severe and 5 being the most severe). Ask about time he/she was feeling the most suicidal.

Lifetime - Most Severe Ideation:

Type # (1-5) Description of Ideation

Recent - Most Severe Ideation:

Type # (1-5) Description of Ideation

Most Severe

Most Severe

Frequency

How many times have you had these thoughts?

(1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times each day

Duration

When you have the thoughts how long do they last?

1. Fleeting - few seconds or minutes (3) 1-4 hours/a lot of time (4) 4-8 hours/most of day

2. Less than 1 hour/some of the time (5) More than 8 hours/persistent or continuous

Controllability

Could/can you stop thinking about killing yourself or wanting to die if you want to?

1. Easily able to control thoughts (4) Can control thoughts with a lot of difficulty

2. Can control thoughts with little difficulty (5) Unable to control thoughts

3. Can control thoughts with some difficulty (0) Does not attempt to control thoughts

Deterrents

Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you from wanting to die or acting on thoughts of

committing suicide?

1. Deterrents definitely stopped you from attempting suicide (4) Deterrents most likely did not stop you

2. Deterrents probably stopped you (5) Deterrents definitely did not stop you

3. Uncertain that deterrents stopped you (0) Does not apply

Reasons for Ideation

What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way you were feeling (in other words you couldn’t go on living with this pain or how you were feeling) or was it to get attention, revenge or a reaction from others? Or both?

1. Completely to get attention, revenge or a reaction from others (4) Mostly to end or stop the pain (you couldn’t go on

2. Mostly to get attention, revenge or a reaction from others living with the pain or how you were feeling)

3. Equally to get attention, revenge or a reaction from others (5) Completely to end or stop the pain (you couldn’t go on

and to end/stop the pain living with the pain or how you were feeling)

(0) Does not apply

SUICIDAL IDEATION

SUICIDAL BEHAVIOR

(Check all that apply, so long as these are separate events; must ask about all types)

Lifetime:

Past 3 months

Actual Attempt:

Yes No

Yes No

A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to

kill oneself. Intent does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an

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actual suicide attempt. There does not have to be any injury or harm, just the potential for injury or harm. If person pulls trigger while

gun is in mouth but gun is broken so no injury results, this is considered an attempt.

Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or circumstances. For

example, a highly lethal act that is clearly not an accident so no other intent but suicide can be inferred (e.g., gunshot to head, jumping

from window of a high floor/story). Also, if someone denies intent to die, but they thought that what they did could be lethal, intent may

Total # of

Total # of

be inferred.

Attempts

Attempts

Have you made a suicide attempt?

Have you done anything to harm yourself?

Have you done anything dangerous where you could have died?

What did you do?

Did you as a way to end your life?

Did you want to die (even a little) when you ?

Were you trying to end your life when you ?

Yes No

Yes No

Or Did you think it was possible you could have died from ?

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Or did you do it purely for other reasons / without ANY intention of killing yourself (like to relieve stress, feel better,

get sympathy, or get something else to happen)? (Self-Injurious Behavior without suicidal intent)

If yes, describe:

Has subject engaged in Non-Suicidal Self-Injurious Behavior?

Interrupted Attempt:

When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, actual attempt would have occurred).

Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an attempt rather than an interrupted attempt. Shooting: Person has gun pointed toward self, gun is taken away by someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the gun fails to fire, it is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. Hanging: Person has noose around neck but has not yet started to hang - is stopped from doing so.

Has there been a time when you started to do something to end your life but someone or something stopped you before you actually did anything?

If yes, describe:

Yes No

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Total # of Interrupted

Yes No

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Total # of Interrupted

Aborted or Self-Interrupted Attempt:

When person begins to take steps toward making a suicide attempt, but stops themselves before they actually have engaged in any self-destructive behavior. Examples are similar to interrupted attempts, except that the individual stops him/herself, instead of being stopped by something else.

Has there been a time when you started to do something to try to end your life but you stopped yourself before you actually did anything?

If yes, describe:

Yes No

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Total # of aborted or self- Interrupted

Yes No

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Total # of aborted or self- Interrupted

Preparatory Acts or Behavior:

Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization or thought, such as assembling a specific method (e.g., buying pills, purchasing a gun) or preparing for one’s death by suicide (e.g., giving things away, writing a suicide note).

Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)?

If yes, describe:

Yes No

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Total # of preparatory acts

Yes No

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Total # of preparatory acts

Most Recent Attempt Date:

Most Lethal Attempt Date:

Initial/First Attempt Date:

Actual Lethality/Medical Damage:

1. No physical damage or very minor physical damage (e.g., surface scratches).

2. Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; sprains).

3. Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-degree burns; bleeding of major vessel).

4. Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g., comatose with reflexes intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures).

5. Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; third- degree burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area).

6. Death

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Potential Lethality: Only Answer if Actual Lethality=0

Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical damage, had potential for very serious lethality: put gun in mouth and pulled the trigger but gun fails to fire so no medical damage; laying on train tracks with oncoming train but pulled away before run over).

0 = Behavior not likely to result in injury

1 = Behavior likely to result in injury but not likely to cause death

2 = Behavior likely to result in death despite available medical care

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