A direct question about suicidal thoughts does not increase suicidal ideation or behaviour; this is well established and underpins standard risk assessment. Vague questions such as "you're not thinking of doing anything silly?" invite a reassuring no.
Ask plainly and in steps: hopelessness, then whether life feels worth living, then thoughts of death, then thoughts of suicide, then plans, access to means and what has stopped them so far. Record the answers in the patient's words.
- Use the word suicide; euphemisms make denial easier.
- Move from hopelessness to thoughts, then plans, then means, then protective factors.
- Ask about access to means — pesticides, stored medicines, ropes — and discuss safe storage with family where appropriate.
- Ask again at follow-up; risk changes, and one negative answer is not permanent.
- Include the patient's social context, such as rejection or discrimination, in what you explore.
Why it matters
The fear of causing harm by asking is one of the commonest reasons risk goes unexplored in a short consultation.
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