Suicide Attempt History: Getting It Right Without Losing the Relationship
This is Part 8 in our series on Past Psychiatric History.
Read Part 7: Medication History – How to Identify Treatment Resistance and Avoid Repeating Failed Trials for the previous component.
Having explored pharmacologic interventions that shape recovery, we now turn to the most critical dimension of safety: understanding the patient’s relationship with death itself. Suicide history sits at the crossroads of safety and understanding. Each attempt represents a moment when distress overwhelmed all coping, when death seemed like the only escape. Understanding these moments is both a safety imperative and a window into the patient’s internal world.
Assessing suicide attempt history is one of the most critical components of any psychiatric evaluation. It enables risk stratification, lethality assessment, pattern identification, and safety planning. Beyond protecting the patient, asking compassionately about suicide strengthens rather than damages the therapeutic relationship. Your approach determines whether patients will be honest about the most vulnerable moments of their lives.
Learning Objectives
After reading this section, you should be able to:
- Identify key chart sources for prior suicide attempt documentation
- Gather structured data about method, timing, intent, and medical outcome for each attempt
- Differentiate lethality from intent and recognize protective factors
- Identify patterns across multiple attempts that inform prevention strategies
- Document suicide attempt history with clinical clarity and compassion
Start With Chart Review
Before interviewing the patient, review available documentation for suicide attempt history:
Emergency department records – Look for chief complaints like “overdose,” “self-harm,” “suicidal ideation,” or medical codes for intentional self-harm. Note method, medical treatment provided, and disposition.
Inpatient psychiatric records – Admission notes often detail the precipitating attempt, including circumstances, method, intent, and patient’s description of the event.
Discharge summaries – Document treatment course, risk assessment at discharge, safety planning, and follow-up recommendations after suicide attempts.
Prior psychiatric evaluations – Often include comprehensive suicide history with dates, methods, and outcomes of previous attempts.
Medical records from intensive care or trauma services – Reveal medical severity of attempts requiring advanced interventions (intubation, dialysis, surgical repair).
Safety plans and crisis response documents – Show what interventions were tried after previous attempts and what worked or didn’t work.
Collateral documentation – Family reports, case manager notes, or crisis team documentation may describe attempts the patient doesn’t remember or minimizes.
💡 Clinical Pearl: Chart review reveals objective severity data the patient may not recall or may minimize. A patient who says they “took some pills” may have required ICU admission for life-threatening overdose. Understanding medical facts before the interview helps calibrate your assessment and frame questions appropriately. This review ensures that when you speak with the patient, you begin informed rather than reactive.
Interview the Patient
After chart review, explore suicide attempt history directly with the patient. This conversation requires particular sensitivity, as many patients fear judgment, hospitalization, or loss of autonomy.
Creating Safety to Disclose
Many patients fear being honest about suicidal thoughts and behaviors. They worry about involuntary hospitalization, being judged, losing custody of children, losing jobs, or being seen as weak or manipulative. Your approach determines whether patients feel safe enough to be honest.
Frame questions with empathy and normalization:
- “Have there been times when things felt so overwhelming that you thought about ending your life?”
- “Many people who struggle with depression have thoughts about suicide. Has that been true for you?”
- “Have you ever done anything to try to end your life?”
Provide reassurance about confidentiality with honest limits:
- “I want you to feel comfortable being honest with me. Everything we discuss is confidential, with some important exceptions – if I’m concerned about immediate safety, we may need to make a plan together to keep you safe.”
Acknowledge the courage it takes to discuss this:
- “I appreciate you being willing to talk about this with me. I know these are difficult things to discuss.”
Opening Questions
Start with broad screening questions:
- “Have you ever tried to hurt yourself or end your life?”
- “Have there been times you’ve acted on thoughts of suicide?”
- “Tell me about times you’ve done something to try to die.”
Essential Information to Gather for Each Attempt
For every suicide attempt, explore these dimensions systematically:
Timing
- When did this happen? (Date or approximate timeframe)
- How old were you?
- How long ago was this?
Method
- What did you do?
- Can you walk me through exactly what happened?
- What did you use? (Medication name and amount, weapon type, height of fall, etc.)
Intent and Planning
- Did you plan this or was it impulsive? How long had you been thinking about it?
- Did you expect to die?
- Did you take steps to avoid being found? (Locked doors, chose isolated location, timed it when alone)
- Did you tell anyone beforehand or leave a note?
- How did you feel when you survived? (Relieved, disappointed, ambivalent)
Context and Precipitants
- What was happening in your life at that time?
- What made you feel like you couldn’t go on?
- Had you been using alcohol or drugs at the time?
- Were you in psychiatric treatment? Taking medications?
- Had anything changed recently? (Relationship loss, job loss, trauma, medication change)
Medical Severity
- What happened after? Who found you?
- Did you require medical treatment?
- Were you hospitalized? For how long?
- How serious were the injuries? (ICU admission, intubation, surgery, dialysis)
Aftermath and Reflection
- What happened after you were medically stable?
- Did you receive psychiatric treatment? (Inpatient, partial hospitalization, outpatient)
- How do you feel about it now, looking back?
- What kept you alive or helped you recover?
- What would you do differently if you felt that way again?
💡 Clinical Pearl: The ratio of intent to medical lethality is crucial for risk assessment. A patient who took 10 aspirin fully expecting to die demonstrates high suicidal intent despite low medical lethality. Conversely, a patient who impulsively took 50 pills “just to sleep” but didn’t want to die shows low intent despite high lethality. Both high intent and high lethality are concerning, but they require different prevention approaches. High intent with low lethality may reflect poor knowledge about lethality but serious wish to die. High lethality with low intent may reflect impulsivity, intoxication, or ambivalence.
Assessing Lethality and Intent
Understanding both the medical dangerousness of the method and the psychological intent to die provides a complete risk picture.
High-Lethality Methods
- Firearms
- Hanging or suffocation
- Jumping from significant height
- Severe overdoses (tricyclic antidepressants, opioids, acetaminophen in large quantities)
- Carbon monoxide poisoning
- Drowning in isolated locations
Lower-Lethality Methods
- Superficial cutting to arms or legs
- Small overdoses of over-the-counter medications (few pills)
- Low-dose overdoses of less dangerous medications
High Intent Indicators
- Detailed planning over days or weeks
- Final arrangements (wills, goodbye letters, giving away possessions)
- Efforts to avoid discovery (timing when alone, remote locations, locked doors)
- Disappointment or anger at survival
- Belief the method would be lethal
Low Intent Indicators
- Impulsive action with minimal planning
- Ambivalence about dying
- Relief at survival
- Actions taken in view of others or with high likelihood of discovery
- Recognition the method was unlikely to be lethal
🚩 Important Note: Never assume low-lethality methods indicate low risk. Patients may simply lack knowledge about lethality. A patient who takes 20 acetaminophen tablets thinking it won’t kill them may still have high suicidal intent. Similarly, superficial cutting can escalate to more lethal methods. Always assess intent separately from method.
Patterns Across Attempts
When patients have multiple suicide attempts, patterns often emerge that inform both formulation and prevention strategies.
Escalating Lethality
Multiple attempts with progressively more dangerous methods suggest increasing desperation and treatment resistance. This pattern requires urgent intervention and consideration of intensive treatment modalities.
Consistent Method
Repeated use of the same method may indicate strong method preference shaped by access, cultural factors, or perceived effectiveness. This pattern is critical for safety planning – restricting access to the preferred method becomes paramount.
Impulsive Attempts During Intoxication
Attempts that occur exclusively or primarily when intoxicated suggest substance use is a major risk factor. This pattern indicates need for substance use treatment as a suicide prevention strategy.
Attempts During Specific Triggers
Some patients attempt suicide consistently in response to particular triggers – relationship conflicts, anniversary dates, seasonal patterns, or medication changes. Identifying these triggers allows for targeted prevention during high-risk periods.
Attempts with Similar Precipitants
When attempts consistently follow certain life events (rejection, loss, humiliation), this reveals core psychological vulnerabilities. Treatment can then address these underlying sensitivities.
🎯 What Patterns Reveal: Multiple attempts don’t simply add up – they reveal qualitative patterns about coping capacity, impulsivity, substance use, and relationship with death. A patient with five impulsive attempts during intoxication has a fundamentally different clinical picture than someone with five carefully planned attempts while sober. The former needs addiction treatment and impulsivity management; the latter needs intensive psychiatric intervention for treatment-resistant illness and unremitting suicidal ideation. Identifying these themes transforms data points into insight for formulation and prevention.
Aborted and Interrupted Attempts
Not all suicide attempts are completed. Two types of near-attempts provide important risk information:
Aborted Attempts
The patient prepared to act but changed their mind at the last moment:
- “I had the gun in my hand but put it down.”
- “I stood at the edge of the bridge but stepped back.”
- “I had the pills in my hand but didn’t take them.”
Clinical significance: Aborted attempts indicate high risk (preparation occurred) but also reveal protective factors (something stopped the patient). Understanding what changed their mind provides crucial information for safety planning.
Interrupted Attempts
The patient began to act but someone or something intervened:
- “I was about to jump but someone walked by.”
- “I had started taking pills but my roommate came home.”
- “I was tying the rope but got a phone call.”
Clinical significance: Interrupted attempts show the patient was actively attempting suicide. The intervention was external, not an internal decision. This may indicate higher risk than aborted attempts because internal protective factors didn’t engage.
How to Ask About Near-Attempts
- “Have there been times you were planning or preparing to kill yourself but didn’t go through with it?”
- “Have there been times you were about to act but changed your mind or were stopped?”
- “What stopped you or changed your mind?”
These questions often reveal suicidal crises the patient doesn’t count as “real attempts” but which represent significant risk periods and protective factor information.
Special Considerations
Attempts in Childhood or Adolescence
Early suicide attempts shape adult relationship with suicide and treatment:
- Assess developmental context – what was happening in family, school, peer relationships
- Determine if attempt was understood as potentially lethal at the time
- Explore how family responded – supportive treatment vs. punishment vs. minimization
- Consider how early attempts influence current help-seeking and disclosure
Early attempts, especially in context of trauma or family dysfunction, may predict chronic suicidal ideation and repeated attempts across lifespan.
Non-Suicidal Self-Injury (NSSI)
Distinguish suicide attempts from self-injury without intent to die:
- NSSI typically involves superficial cutting for emotional regulation, not death
- Patients usually distinguish clearly: “I cut to feel better, not to die”
- However, NSSI increases suicide risk and can transition to attempts
- Document separately but recognize NSSI as important risk factor
Cultural and Religious Context
Cultural beliefs about suicide shape how patients describe and understand attempts:
- Some cultures stigmatize suicide heavily, affecting disclosure
- Religious beliefs about afterlife may influence attempt methods or interpretation
- Family shame may lead patients to minimize or conceal attempts
- Understanding cultural context helps interpret patient’s narrative
What to Document
Your documentation should capture both objective facts and the patient’s subjective experience, balancing clinical precision with compassionate language.
| Documentation Level | What to Include | Example | When to Use This Level |
|---|---|---|---|
| Minimal | Number of attempts; most recent method and timing; current safety status | “Patient reports two prior suicide attempts, most recent 3 years ago by overdose.” | Routine follow-up visit; remote history; no current concerns; patient engaged in treatment |
| Standard | Minimal + Methods and dates for each attempt; basic intent and outcome information; precipitants; psychiatric treatment received afterward | “Patient reports two prior suicide attempts. First at age 16 (10 years ago) by overdose of mother’s pain medications after parents’ divorce; required brief medical hospitalization, then outpatient therapy. Second at age 22 (4 years ago) by cutting wrists after relationship breakup; required ER suturing, admitted to psychiatric unit for 5 days, started on sertraline. Reports both attempts were impulsive during acute distress. Has been stable on medication since.” | Initial evaluations; multiple attempts; need to establish pattern; guiding treatment planning; moderate complexity |
| Detailed | Standard + Intent assessment for each attempt; lethality vs. intent analysis; detailed precipitants and context; pattern recognition; protective factors identified; connection to current presentation and formulation | “Patient has complex suicide attempt history with four attempts between ages 19 to 25, pattern suggesting escalating lethality in context of untreated bipolar disorder. First attempt age 19: impulsive overdose (20 ibuprofen tablets) during depressive episode after academic failure; low lethality, moderate intent (hoped to die but ambivalent); required ER evaluation only, no psychiatric follow-up. Second attempt age 21: planned overdose (50 acetaminophen tablets) during severe depression; high lethality, high intent (left note, timed when roommate away); required ICU admission for liver failure, then 2-week psychiatric hospitalization; started fluoxetine but became manic and discontinued treatment. Third attempt age 23: hanging attempt interrupted by partner returning home; very high lethality, high intent (detailed planning, goodbye texts); psychiatric hospitalization, started mood stabilizer. Fourth attempt age 25: firearm attempt (gun misfired) during mixed episode after medication nonadherence; highest lethality method, unambiguous intent to die; hospitalized 3 weeks, finally received bipolar diagnosis and lithium. Now age 28, has been stable on lithium for 3 years with excellent medication adherence. Pattern reveals attempts occurred exclusively during untreated mood episodes, particularly mixed states. No attempts since mood stabilization achieved. “ | Complex histories requiring detailed formulation; treatment-resistant presentations; high-risk patients; forensic or disability evaluations; consultation requests; teaching presentations |
Why This Information Matters
Suicide attempt history is far more than a safety checklist. It reveals the patient’s relationship with death, their capacity to tolerate distress, the severity of their illness, and the effectiveness of their coping strategies. This information serves multiple essential clinical functions that directly shape care.
Risk Stratification and Safety Planning: Past suicide attempts are the single strongest predictor of future attempts and completed suicide. Understanding the number, timing, methods, and circumstances of previous attempts allows evidence-based risk assessment. A patient with multiple recent high-lethality attempts requires more intensive intervention than someone with a single remote low-lethality attempt. This history determines appropriate level of care, need for hospitalization, frequency of outpatient monitoring, and intensity of safety planning. Knowing a patient’s preferred method allows targeted means restriction – removing firearms, limiting medication quantities, addressing access to heights or bridges.
Pattern Recognition for Prevention: Patterns across attempts reveal modifiable risk factors. Attempts that occur exclusively when intoxicated indicate substance treatment is suicide prevention. Attempts following relationship conflicts suggest need for interpersonal skills or couples therapy. Attempts during mixed episodes point to need for mood stabilization. Attempts after medication changes warrant careful monitoring during future adjustments. Understanding these patterns allows clinicians to intervene preventively rather than reactively during the patient’s highest-risk moments.
Diagnostic Clarity: Suicide attempt history often clarifies diagnosis. Multiple impulsive attempts may suggest borderline personality disorder rather than recurrent depression. Attempts during distinct mood episodes support bipolar diagnosis. Psychotic content surrounding attempts points to schizophrenia spectrum illness. Command hallucinations prompting self-harm indicate need for antipsychotic treatment. The relationship between symptoms and suicidal behavior helps refine the diagnostic formulation.
Understanding Intent and Ambivalence: The distinction between intent and lethality reveals critical psychological information. High intent with low lethality may reflect poor knowledge about methods but genuine wish to die, warranting intensive psychiatric intervention. High lethality with low intent may indicate impulsivity, intoxication, or a “cry for help” that accidentally became medically serious. Some patients remain profoundly ambivalent about living, demonstrated by rescue behaviors (calling 911 after overdose) or survival actions (calling out for help while attempting). This ambivalence is a therapeutic foothold – something within the patient wants to live. Identifying and strengthening that part becomes central to treatment.
Identifying Protective Factors: Understanding what stopped aborted attempts or what helped recovery after attempts reveals protective factors to strengthen. Did religious beliefs intervene? Thoughts of family? Fear of pain? Therapeutic relationship? Future plans? These factors become anchors in safety planning and reasons for living to revisit during crises. A patient who aborted an attempt because “I thought about my daughter” needs treatment that strengthens that relationship and explores parenthood as meaning.
Strengthening Therapeutic Alliance: Asking about suicide attempts with genuine curiosity and compassion rather than fear or judgment communicates that the patient’s most desperate moments matter and can be understood. Patients often expect clinicians to be uncomfortable with suicide discussion or to respond punitively with hospitalization. When clinicians instead explore attempts with empathy, seeking to understand rather than control, trust deepens. This allows ongoing honest communication about suicidal thoughts, which is itself protective. Patients who believe they can tell their therapist about suicidal ideation without automatic hospitalization are more likely to disclose – and disclosure allows intervention.
Suicide attempt history transforms from a crisis-focused safety screening into a window on the patient’s suffering, coping capacity, illness trajectory, and potential for recovery. Gathering this history with depth and compassion transforms moments of crisis into opportunities for understanding and prevention.
Next in this series: Part 9 – Self-Harm History: Understanding the Distinction from Suicidal Behavior
Previous post: Part 7 – Medication History: How to Identify Treatment Resistance and Avoid Repeating Failed Trials
