By Ley Linder, MA, M. Ed, BCBA and Craig Escudé, MD, FAAFP, FAADM

This article is part of a co-authored series on behavioral presentations in which a physician and a behavior analyst provide insight into real-life case studies to share their expertise on how behavioral issues can be addressed in an interdisciplinary fashion. Dr. Escudé and Ley are the proud recipients of the 2024 AADMD Excellence in IDD Journalism Award for this ongoing series.

Debra is a 63-year-old woman with a mild intellectual disability who is an effective communicator, expressively and receptively. She lives with three other women of similar functioning ability. She attends a day program where she enjoys “retirement” by engaging in various leisure activities, volunteering, and attending community events. She is an incredibly social woman, active in her church, and seeks out interaction with a variety of people, including staff members, peers, and especially her sister. She has psychiatric diagnoses of depression, anxiety, and schizophrenia, for which she takes olanzapine, escitalopram, and divalproex sodium (plus benztropine for side effects of olanzapine).

It is not uncommon for Debra to have short periods (a day or two) of becoming highly fixated on specific topics, such as her family not liking her, that she is not good at what she is working on, that “nobody likes her,” or “she has no friends.” Historically, these periods are related to negative interpersonal interactions, overcorrection when working, holiday periods, birthdays, or home visits.

Recently, Debra has begun perseverating on death and dying. Debra routinely talks about deceased family members and graveyards and makes comments such as, “I’m okay with being with God” or “I’m ready to go home (to God).” Twice in the last two months, Debra has visited the emergency department after staff members became concerned for her mental health and possible suicidal thoughts.

Medical Discussion

According to the National Institute of Mental Health, suicide is the 11th-leading cause of death overall, with more than 49,000 suicides in 2022 in the U.S.1 From a medical standpoint, studies show chronic pain, heart disease, chronic obstructive pulmonary disease, stroke, cancer, congestive heart failure, and asthma have all been associated with increased risk for suicide. Having multiple co-occurring conditions may be linked to an even greater risk. Hormonal problems, including thyroid and parathyroid problems and changes related to menopause, have been associated with depression.

Some medications are associated with an increase in suicide risk. Examples include opioid painkillers that combine hydrocodone bitartrate and acetaminophen, anti-anxiety drugs alprazolam and diazepam, and prednisone, a corticosteroid. Divalproex sodium and escitalopram, two of Debra’s medications, are medications that have been linked to suicidal thoughts. While many antidepressants carry an FDA warning of a potential increase in suicidal thoughts, they are also often used to treat depression, which, itself, can increase suicidal thoughts.

While it is important to note potential medical causes of suicidal thoughts, the focus should be on addressing these thoughts and Debra’s overall mental health.

“Suicidal ideations and/or actions are always incredibly serious and concerning behaviors. Behaviorally, it is essential to remember that describing the behaviors and providing current and historical context can be valuable information during crisis management – particularly for first responders and medical professionals. ”

Behavioral Discussion

Suicidal ideations and/or actions are always incredibly serious and concerning behaviors. Behaviorally, it is essential to remember that describing the behaviors and providing current and historical context can be valuable information during crisis management – particularly for first responders and medical professionals.

Understanding the context in which a person may engage in these behaviors is essential. Is there an identifiable reason the person is saying and engaging in behaviors that can jeopardize their health and safety? Is the person distraught? Aggressive? Calm? Are they lucid vs. confused? Are they displaying other psychiatric behaviors, such as delusional thoughts or increased impulsivity? Observing and describing the person’s behavior beyond the suicidal comments/actions is often necessary.

It is also always imperative to understand the person’s history of suicidal ideations/actions, as this can provide insight into the behavioral patterns. Has the person said or engaged in these behaviors before? If so, what was the reason? What was the intervention? What was the outcome? Past behaviors can provide valuable insight into current presentations.

Lastly, when describing behaviors to others, it is beneficial to delineate between ideation vs. action and general comments vs a feasible plan. When possible, it is vital to provide insight into whether the person is expressing thoughts or making comments, as opposed to engaging in a dangerous action. For example, suppose a person has engaged in a non-lethal action (e.g., holding their breath or pinching their nose). In that case, the act of “trying” is noteworthy, as it could be indicative of increased impulsivity and willingness to engage in suicidal actions. Additionally, if a person is discussing a thought-out and feasible plan, it indicates a greater level of concern than making generalized comments related to death. All of this information is valuable insight to provide during crisis management but also for long-term psycho-behavioral support.

*Anytime it is believed that a person’s health and safety is in danger, immediately contact 911.

Outcome

Debra has difficulty managing stress, particularly from social situations and environmental events. Debra’s extended period of hyper-focus on death and dying, which is somewhat atypical, was related to multiple factors occurring at the same time. Debra was experiencing stress related to her sister and home visits, in addition to having problems with a housemate. Additionally, Debra attended several funerals in recent months as part of being active in her church, which coincided with the period of her hospital visits and comments of, “I’m okay with being with God” or “I’m ready to go home (to God).”

The context of Debra’s comments was significant in relation to the known behavior patterns of her perseverating or fixating on topics. She had no history of suicidal ideations or actions, and her remarks were generalized with no specific plan of action. On both occasions, the hospital staff determined she was not a threat to herself or others, and she was discharged that day. The interdisciplinary team, including her psychiatrist, met and decided that no medication changes were necessary. Due to the rural location of her residence, Debra did not have access to counseling. Still, the behavior, residential, and day program teams developed robust strategies to provide informal counseling and one-on-one social interaction with highly preferred staff members to provide additional support when she was fixating on any topic.

1. https://www.cdc.gov/suicide/facts/data.html, Accesses 1/8/2025

About the Authors

Unlocking Behaviors: Suicidal Ideations

Inclusive Healthcare Education

FROM THE STACKS