Suicidal ideation—thinking about, considering, or planning suicide—and the risk for suicide are only loosely linked. Suicidal ideation is considered “active” when a person is experiencing current, specific, suicidal thoughts—when there is a conscious desire to inflict self-harm, and the individual has any level of desire for death to occur. The individual's expectation that their attempt could produce a fatal outcome is the key consideration (Harmer et al., 2022).

Imminent harm means a person is thought to be at immediate risk of self-harm or suicide. When trying to predict the risk of imminent harm or suicide, transitions in care have been shown to be particularly high-risk periods. These transitions include the initial diagnosis with a mental condition, initiation of psychotropic medication, discharge from the hospital, and having a recent life-changing event (Balbuena et al., 2022).

Imminent danger is linked to certain behavioral warning signs. A person in imminent danger requires immediate attention. Presence of one or more of these behaviors is a strong indication referral is acutely needed (DVA, 2023, November 6):

1. Communicating suicidal thought verbally or in writing, especially if this is unusual or related to a personal crisis or loss.
2. Seeking access to lethal means such as firearms or medications.
3. Demonstrating preparatory behaviors such as putting affairs in order.

6.1 Imminent Harm

The 988 Suicide and Crisis Hotline has established policies for callers at imminent risk of suicide, which apply to in-person interactions as well. It begins with active listening and actively engaging the individual at risk in discussion of their thoughts of suicide. Active engagement, cooperation over coercion, and securing a person’s safety are critical, with the use of involuntary methods as a last resort (SAMHSA, 2022).

Active engagement means crisis counselors work to establish an effective connection with an individual seeking support from the Lifeline. Engagement creates a connection and makes it possible to collaborate with, and empower, the individual to secure their own safety, or the safety of the person for whom they are reaching out. The word “active” encourages conscious and intentional engagement in phone- or text-based crisis counseling (SAMHSA, 2022).

6.2 Discussing Lethal Means

Lethal means are the instruments or objects used to carry out a self-destructive act. The risk of imminent harm is strongly linked to the availability of lethal means. If a patient is experiencing significant distress, appears to be at immediate risk of self-harm, or has a recent history of suicidal behavior, directly ask if he or she has access to lethal means that may be used in a suicide attempt.

Firearms are of particular concern and are the most common instrument used in suicides and suicide attempts, especially among men and both male and female veterans. Household firearm ownership rates can be a significant predictor of both homicides and suicides.

When asking about lethal means, be direct and non-judgmental. For example: “What do you have access to once you leave this office that you can use to harm yourself?” Or “While you’re in this dangerous period, can I call your partner or family member, and ask them to remove the guns, poisons, and medications from your house?”

Show concern by saying for example, “I want to let you know I appreciate and am honored that you’ve shared your concerns with me. I’m worried that you may go to a place of despair when you leave here, and I’m concerned for your safety”. Try to establish trust—if you think the person is at risk, there is no reason to cover your concern or to lie.

6.3 Restricting Access to Lethal Means

Means restriction involves techniques, policies, and procedures designed to reduce access or availability to means and methods of deliberate self-harm. Among suicide prevention interventions, reducing access to highly lethal means of suicide has a strong evidence base and is now considered a key strategy to reduce suicide death rates.

Research has shown that the interval between deciding to act and attempting suicide can be as short as 5 or 10 minutes and people tend not to substitute a different method when a highly lethal method is unavailable or difficult to access. Reducing access to lethal means among people at risk and increasing the time interval between deciding to act and the suicide attempt can be lifesaving (CDC, 2022).

Implementation of means restriction is broad and can include:

1. Complete removal of a lethal method.
2. Reducing carbon monoxide content emissions from vehicles.
3. Interfering with physical access.
4. Reducing the appeal of a more lethal method.
5. Limiting children’s access to firearms in the home.

Safe storage of medications, firearms, and other household products can reduce the risk for suicide by separating a person at elevated risk from easy access to lethal means. Safe storage of firearms and other lethal means has been associated with less risk for suicide among adults and youth, and lethal means counseling in emergency departments can affect storage behavior.

Although strategies to restrict access to lethal means have focused on at-risk individuals, evidence for means restriction has come from situations in which a universal approach was applied to the entire population. For example, the detoxification of domestic gas in the United Kingdom and discontinuation of highly toxic pesticides in Sri Lanka were universal measures associated with 30% and 50% reductions in suicide, respectively (HHS, 2012, latest available).

6.4 Counseling on Access to Lethal Means

Counseling on Access to Lethal Means (CALM) is a free, self-paced, online course for healthcare and social service providers. It is designed for those who have training and experience in mental health counseling but is also appropriate for other healthcare providers. CALM emphasizes that restricting access to lethal means should be part of a comprehensive prevention strategy because many suicidal people are ambivalent about wanting to die, and many suicide attempts are made impulsively, during a short-term crisis (Zero Suicide, 2018).