Passive suicidal ideation is the one that catches guys off guard, because it doesn't look like the thing they think they're supposed to be worried about.
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Passive suicidal ideation is the one that catches guys off guard, because it doesn’t look like the thing they think they’re supposed to be worried about. It’s the “I wouldn’t mind if I didn’t wake up” thought. The “if a truck hit me on I-5, honestly, fine” thought. A lot of the patients who eventually mention it have had it kicking around for months or years and never told anyone, because in their head a real suicidal person is the one with a plan, and they don’t have a plan, so they figure they’re basically fine.
They’re not exactly fine. They’re also not in immediate danger, and that distinction is most of what this post is about… because confusing those two situations gets people either sent to an emergency room for something that didn’t need one, or kept silent about something that did.
Passive versus active, in actual English
Passive ideation is wishing you weren’t here. Active ideation is thinking about how to make that happen, with a method, sometimes a plan, sometimes a timeline. Those are not the same situation and they don’t get the same response. Active ideation with a method and access to that method is an emergency tonight, not next Tuesday. Passive ideation that’s been hanging around in the background for a month is a regular appointment with somebody who knows what they’re doing, plus a real conversation about means restriction (which we’ll get to in a minute, and which is the actual save-your-life part of this whole conversation).
The reason this matters for guys specifically is that a lot of them won’t say anything to anyone because they think the second the words come out they’re getting hauled to the ER, losing their guns, losing their CDL (the commercial driver’s license that pays the bills if you drive for work), losing their kids, losing whatever. Most of the time, with passive ideation, none of that is on the table. Most of the time it’s a conversation, maybe a medication tweak, maybe a referral, and you go home. The fear of the consequence is doing more damage than the actual consequence would.
The lethal-means conversation nobody wants to have
The Stanley-Brown safety plan is the worksheet most clinicians use, and it’s basically a piece of paper with six lines on it. Warning signs you can spot in yourself. Things you can do on your own to ride the wave out. People or places that take your attention off it. Friends and family you can call. Professionals you can call. And the means-restriction line, which is the one that matters most and the one nobody wants to talk about.
Means restriction means: if there’s a gun in the house and you’re having these thoughts, the gun goes somewhere else for a while. A buddy’s safe. A range locker. Your brother’s house. Out of the house. This is the line where I lose a lot of guys before I’ve finished the sentence, because the gun feels like a bigger part of their identity than the thoughts do, and asking them to part with it for a stretch feels like surrendering something. It isn’t. It’s the most evidence-backed move in this entire conversation.
Here’s the math, and it’s not subtle. Most suicide attempts are impulsive in the sense that the window between deciding and acting can be very short, sometimes ten or fifteen minutes. The lethality of the method on hand is most of what determines whether you survive, and the numbers on this are not subtle… firearms are something like ninety percent lethal, pills are something like two percent. Putting the gun across town for a couple months doesn’t take away anyone’s Second Amendment rights and it doesn’t mean you’ve been declared anything by anyone, it just means the worst version of a bad night doesn’t have the worst possible instrument in it. The Harvard School of Public Health and a stack of CDC data both keep landing on the same point on this… lethal-means counseling is among the most effective suicide prevention interventions there is. Wait can you say that out loud? Yes, you can, and most clinicians don’t, because they’re worried about the conversation. The conversation is the intervention.
When to call who
988 (the three-digit national suicide and crisis line) is for the in-between. Not in immediate danger but not trusting yourself to make it through the night is the call. If there’s a method, real access, and a real plan in mind for tonight, that’s not 988, that’s the emergency room, or 911 if you can’t get yourself there safely. The threshold isn’t how bad you feel, the threshold is whether you can keep yourself from doing the thing.
For chronic background passive ideation that isn’t acute but isn’t going away either, the right move is making an actual outpatient appointment with somebody who can dig into what’s driving it. Could be unaddressed depression. Could be a marriage that’s been on fire for two years. Could be drinking that’s gotten away from you. Could be three of those things stacked. The point is that it’s something that can actually be worked on once it gets named, which mostly doesn’t happen if you don’t tell anyone it’s there.
The lithium thing nobody mentions
Lithium is an old mood stabilizer most people associate with bipolar disorder, and it has a separate signal on suicide that no other psych medication has. Multiple meta-analyses, including the Cipriani 2013 BMJ paper that’s the most-cited one, show roughly a sixty percent reduction in suicide deaths in patients on long-term lithium. It’s not just that it’s treating the underlying mood disorder either. There’s something specifically anti-impulsive about lithium that the field doesn’t fully understand, and the data has been consistent for forty years.
Which is one of the things that’s nice to hear in a conversation that doesn’t have a lot of nice things in it. There’s an actual medication, dirt cheap, in generic since the 1970s, that has a real and replicated effect on the outcome that matters most. If somebody’s got bipolar-spectrum stuff layered with a history of these thoughts, lithium gets a hard look even if other medications are already doing something on the mood. The catch is that lithium has a narrow therapeutic window… too low does nothing, too high gets dangerous, so it requires periodic blood draws to check the level, plus kidney and thyroid panels every six months or so. A lot of prescribers won’t touch it because of the monitoring, which is one of those professional convenience preferences that quietly costs patients something. If your prescriber is allergic to lithium, that might be worth asking about.
The pattern I keep seeing
The kind of guy who eventually says something has usually been carrying it for months. Sometimes a year or two. He’s been having the “if I didn’t wake up tomorrow that’d be fine” thought a few times a week. No plan. No method specifically in mind, although there’s a gun in the bedroom closet and it has crossed his mind once or twice in passing. He hasn’t told anyone because in his head he isn’t “really” suicidal, and saying it out loud feels like making it more real than it actually is. Sometimes his wife finds a text he sent his brother that said something like “if I drove off the bridge tomorrow would you actually be surprised,” and she’s the reason the appointment happens, because he wasn’t going to make it on his own.
The work after that, the parts that actually move the needle, are pretty unglamorous. You do the safety plan together. The gun goes to the brother’s house, which gets fought, then agreed to once we walk through the impulsivity data slowly enough that it sinks in. You start treating whatever’s underneath… could be lithium if there’s bipolar in the picture, could be an antidepressant plus the boring behavioral work, could be naming the marriage problem the depression is wrapped around. Six months later the thoughts are mostly gone, the gun is still at the brother’s, and the patient says some version of “I hadn’t realized how loud the background noise was until it got quiet.” Which is also basically the only metric that matters for whether this stuff is working.
Most suicide attempts are impulsive in the sense that the window between deciding and acting can be ten or fifteen minutes, and the lethality of what’s on hand is most of what determines whether you survive.
The thing about not making a thing of it
The biggest single reason guys with passive ideation stay quiet is that they don’t want to “make a thing of it.” They tell themselves the thought is just a venting valve, just a way the brain has of complaining when life is annoying, and that bringing it up to a doctor or a wife or a buddy will turn it into a bigger deal than it is. Sometimes that’s even partly true… not every passive ideation needs an intervention.
The trap is that the only way to know which kind you’ve got is to actually run it past somebody who can tell the difference. A primary care doc can do this. Most psychiatrists or PMHNPs (psychiatric mental health nurse practitioners, the prescriber type a lot of you already see) can do this. A decent therapist can do this, though if it’s escalating they’ll usually loop in a prescriber. The conversation goes faster than you think and it doesn’t end with handcuffs or a hospital bracelet ninety-five times out of a hundred. The other five times it does, and those are the times the conversation saved somebody’s life, and afterwards they will tell you they’re glad someone made them go. That’s also nice to hear, though it isn’t said often enough.
Where people actually land
The patients who do say something usually end up with some combination of: a safety plan with a real means-restriction step, an outpatient prescriber working on whatever’s underneath, a few months of therapy if they’re open to it, and a couple of friends or family who know enough to ask how they’re doing on a real schedule. Not all of that has to happen. Most of it does in the patients who get the best outcomes.
The patients who don’t say anything sometimes get away with it. Sometimes they don’t. The math on which group somebody ends up in isn’t visible from the inside, which is the whole reason this is a topic worth a post and not just a private worry. If you’ve been quietly hauling this around for months because you didn’t want to make a thing of it, that’s specifically the situation where making a thing of it is what changes the outcome. The conversation isn’t the dramatic part. The conversation is the boring part that prevents the dramatic part.
Bottom line, such as there is one
Passive ideation is common, treatable, and almost never an ER trip. Active ideation with a method on hand is. Means restriction is the single most evidence-backed step in this entire conversation, and the gun across town for a couple months is the version that saves the most lives. Lithium has a separate signal on suicide and is underused because it’s annoying to monitor. And the part where you don’t want to “make a thing of it” is the part the data wants you to push past.
If you’ve been reading this and your face moved at any of it, the appointment you’ve been putting off is the appointment to make. Most of the bad outcomes in this space are people who waited until they had a plan to ask for help. The good outcomes are people who asked while it was still passive.
Sources
- Cipriani A, Hawton K, Stockton S, Geddes JR. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ. 2013;346:f3646. PMID 23814104.
- Stanley B, Brown GK. Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cogn Behav Pract. 2012;19(2):256-264.
- Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med. 2014;160(2):101-110. PMID 24592495.
