Suicidal ideations (SI), often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide. There is no universally accepted consistent definition of SI, which leads to ongoing challenges for clinicians, researchers, and educators.[1] [2] For example, in research studies, SI is frequently given different operational definitions. [3]This interferes with the ability to compare findings across studies and is frequently mentioned as a limitation in meta-analyses associated with suicidality. [4] Some SI definitions include suicide planning deliberations, while others consider planning to be a discrete stage.  Beyond the lack of clear nomenclature, there are other concerns. A systematic review of the numerous interprofessional clinical guidelines for suicide yielded no consensus on a clinical gold standard for assessing and managing SI or people at risk of suicide. [1] Although scales to measure depression, SI and risk for suicide exist, none produce a score that is sufficiently reliable or clinically useful in predicting the very small subgroup of suicide ideators whose death by suicide is imminent. [5](The American Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults, 3rd ed. 2016, p. 19). It is evident that suicidal ideations present in a "waxing and waning manner" [6], so the magnitude and characteristics of SI fluctuate dramatically.[7] It is critically important for healthcare professionals to recognize that SI is a heterogeneous phenomenon. It varies in intensity, duration, and character. As there is no "typical" suicide victim, there are no "typical" suicidal thoughts and ideations. Unfortunately, healthcare records often document SI in a binary yes/no fashion, although it encompasses everything from fleeting wishes of falling asleep and never awakening to intensely disturbing preoccupations with self-annihilation fueled by delusions. Therefore, thoroughly assessing and monitoring the pattern, intensity, nature, and impact of SI on the individual and documenting this accordingly is important for all healthcare professionals. It is also important to reassess SI frequently due to its fluctuating pattern. The magnitude of SI fluctuations was studied using an ecological momentary assessment method. Individuals who attempted suicide in the past year plus a sample of suicidal in-patients recorded the intensity of their suicidal thoughts from hour to hour for four weeks. Analysis of these data showed dramatic fluctuations in the intensity of SI by all participants. All participants had SI, which varied in its intensity, either upwards or downwards, by one standard deviation on most days. Many had one standard deviation fluctuations several hours apart within the same day.[7] This knowledge is important for all healthcare professionals to consider and highlights the need to monitor fluctuations and not dismiss the possibility of sudden increases in suicidal urges, even when the current level is mild, and the individual currently has control over them. Additionally, SI is considered a better predictor of lifetime risk for suicide than imminent risk, so assessments should include describing the characteristics and impact of prior SI as well as current.[8] The Center for Behavioral Health Statistics Quality publishes the results of the American nationwide household survey, the National Survey of Drug Use and Health (NSDUH). Piscopo's 2017 publication summarized the results from the 2009-2014 surveys, which show that 6% of 18-25-year-olds respond affirmatively to the survey question, "At any time in the past 12 months, did you seriously think about trying to kill yourself?" In contrast, the lowest rate of SI was 1.6% in those aged 65 years and above. There is no clear association between endorsing SI and attempting suicide. For every 31 Americans with SI, only one individual will attempt suicide. The rates of suicide deaths also vary by gender, age, race, and other demographic variables. Further evidence of the weak association between reported SI and fatal suicides is apparent when comparing the NSDUH results to CDC mortality records. Despite the low prevalence of SI in white males over age 75 years, they have the highest rate of fatality by suicide (approx. 40 per 100,000). Meanwhile, females over 75 years have much lower rates (4 per 100,000). The suicide ideators in the 18-25-year-old group had significantly fewer suicide deaths (approx. 17.5 per 100,000 for males and 4 per 100,000 for females).  Most people have control over SI and do not attempt suicide, even when reporting SI. Psychiatric Association Practice Guidelines for Psychiatric Evaluation of Adults (2016, p. 19) points out that SI is a symptom of another primary psychiatric diagnosis and suggests that 90% of people who end their lives by suicide meet the diagnostic criteria for one or more psychiatric diagnoses. However, data clearly show that numerous medical illnesses are associated with increased odds of suicide, and that suicidal death extends through all demographic groups and includes virtually all psychiatric and medical diagnoses. The CDC's mortality records for 2017 reveal over 50% of deaths by suicide were by people with no known psychiatric illness. Some criticisms have been made that suicidality should be regarded as a distinct psychiatric diagnosis, with its symptoms and unpinning pathological processes.[2][1] Although this is beyond the scope of this paper, this contention is becoming more widespread.[6]  After reviewing all of the existing clinical guidelines, Bernert et al. concluded there is an urgent need for "easily-accessible best practice guidelines, adaptable to diverse fields of medicine and clinical specialties, that may be the first point of contact for risk detection, intervention, and prevention."[1] Although this paper aims to focus primarily on suicidal ideation, it is important to provide context. Therefore, while the intention is not to broaden the focus to suicide, it is impossible to address the significance of SI without also discussing suicidal behaviors and outcomes to some extent. It is estimated by the Center for Disease Control and Prevention (CDC) that in 2017 there were approximately 10 million people in the USA who experienced suicidal thoughts. Fortunately, the majority of ideators in the USA and globally will never attempt suicide, and fewer will use lethal means that result in death. Of the 10 million Americans with SI, it is estimated there were 1.4 million suicide attempts in 2017, but healthcare was only sought by approximately one-third of those who attempted. The degree of suicidal intent and the lethality of means used during attempts vary tremendously.  One-half of the 47,000 suicides that occurred in America during 2017 were caused by firearms. (CDC). Globally, the World Health Organization (WHO) collects mortality data, including the prevalence and means of suicides, for all member nations. Beginning in 2013, after declaring that the rising suicide rates constituted a "global public health crisis," they advocated for evidence-based strategies to prevent suicides globally. In developing nations, where the ingestion of pesticides was the leading cause of fatal attempts, suicide prevention efforts promoted using less toxic pesticides. Evidence exists that reductions in suicides can be achieved by reducing access to lethal means, but this requires a comprehensive systemic approach that includes collaboration between policy-makers, healthcare professionals, and interventions to reduce modifiable risk factors.[1] A recent meta-analysis of 44 studies of healthcare services used by suicide victims showed a chief reliance on primary care professionals in all countries. Only 31% of suicide decedents received inpatient or outpatient mental health services in the year before their death; 57% of the decedents had contact with mental health services at some point during their lifetime.[9] Primary care professionals are more apt to have an established relationship with patients and have a more complete understanding of their health history. Furthermore, due to having a pre-established relationship, when patients experience worsening SI or stressors that may precipitate suicidal behaviors, they are more likely to seek help from primary care professionals. Studies show that 80-90% of suicide decedents increased their contact with primary care professionals in the year and months before their suicide; 44% of those who died by suicide had contact with primary care in their last month of life.[9][10] Although the impetus for increased contacts is undoubtedly variable, it does indicate opportunities exist for healthcare professionals to identify any new risk factors for suicide and offer treatment options to address modifiable factors.  During their final visit with primary care professionals, 90% of successful suicides in a UK study disclosed their SI to primary care providers.[11] These same providers were interviewed about their experience losing a patient in their practice to suicide (n=39). In each case, the primary care physician had referred their patient for psychiatric services, so the physician's communication with both their patient and the psychiatric service professionals (physicians and community psychiatric nurses) could be examined in the study. Twenty percent of the physicians who heard their patients endorsing suicidal thoughts stated they were concerned about their patient's safety during their final appointment.[11] The researchers noted that many of the primary care providers were uncertain about how to interpret the meaning of SI when expressed by their patients. This was particularly evident when the patient had a history of voicing SI. Examples of statements from the primary care physicians include; "Although we put her down as a moderate suicide risk, none of us thought she’d ever do it because she talked about it so much." (p. 263). "He’d done this on numerous occasions. Taken overdoses, not as a suicidal attempt but in an attention-seeking, in a [state of] mental distress, help me, [a] cry for help ... there was never a disorder" [11]  The limited understanding of how to assess and treat people with SI was apparent in some of the interviews in this UK study, although there was substantial variability between physicians. However, similar gaps in knowledge are also evident in other studies involving primary care professionals.  An observational study of primary care providers in the Netherlands showed SI was assessed in only 44% of clinically depressed patients and 66% of new-onset depression patients.[12] The frequent lack of suicide risk prevention policies in primary care practices is also apparent, and even when they do exist, there may be uncertainty regarding what they entail.[13] Julie Goldstein Grumet, director of US Health and Behavioral Health Initiatives for the Suicide Prevention Resource Center and the director of the Zero Suicide Institute, published preliminary research data in the Jan. 2019 Journal of Health Care Compliance. Less than one-third of healthcare providers (n=15,000) who completed an optional self-test for the Zero Suicide initiative in the USA reported feeling knowledgeable about suicide risk warning signs. Similarly, only 1 in 3 knew their organization's procedures for patients at increased risk or felt confident in their ability to respond to a suicidal patient. Although standardized tools, instruments, and rubrics do not provide a clear indication of imminent suicidal risk, the American Psychiatric Association Clinical Guidelines for Evaluating Suicidality suggests these tools can be useful as prompts when interviewing to ensure thoroughness in the questions asked during the risk assessment. Grumet et al. reported that only 35.5% of the providers stated they use any of these available tools when screening or assessing. Furthermore, only one-third of the healthcare professionals responsible for delivering treatment (n = 4,101) indicated they "strongly agreed" when self-rating their level of confidence or comfort in treating patients with elevated suicide risk.  Although additional training is recommended by many to improve the competence of healthcare professionals, the outcomes from an interprofessional course which included how to assess SI produced modest results. Students were taught the importance of SI assessments during an online module and then required to practice completing suicide risk assessments on standardized patients. However, later in the semester, only 55% of the students (65.5% of medical; 54.5% of nursing; 46.4% of pharmacy) completed an SI assessment on the depressed standardized patient during their final objective clinical standardized exam (OSCE).[14] This emphasizes the importance of reinforcing learning in academic settings and monitoring competence and compliance in healthcare organizations. There were additional findings in the study of UK primary care physicians that are pertinent to consider. Multiple barriers with psychiatric services were described by the primary care physicians. The primary care providers commented that they often felt frustrated when they were left to manage suicidal patients alone or when the system created obstacles and referral mazes which made it difficult for them to advocate for what they believed was in their patient's best interests:[11] Examples of statements from the interviews include; "Because the patient did not attend his last psychiatric appointment, the psychiatrist discharged him and sent a letter to us stating this. I disagreed [because the patient needed the psychiatrist's expertise]" p. 264. "Sometimes we feel like we have to manipulate the system [to expedite referrals] just to get a patient assessed ... we, therefore, refer to hospital [emergency department] as patients will get seen and assessed on the day and they do follow-up as their referrals go to the CMHT (Community Mental Health)" p. 265.[11]  Almost all of the physicians (90%) said they knew their deceased patient "well," but this knowledge may have been under-utilized during the subsequent psychiatric treatment planning. One of the physicians was frustrated about being excluded from providing input into the psychiatric treatment plan - a plan he disagreed with and which he suggested may have contributed to the suicide.[11] The issues and conclusions identified in this UK study are consistent with other studies. A review of literature focusing on improving primary practice professionals ability to detect and treat SI and prevent suicide produced four major recommendations: i) educating practitioners on risks for suicidal thoughts and behaviors ii) providing patient screening to identify suicide risk and/or mood disturbances iii) using evidence-based interventions, including collaborative, multi-disciplinary teams, to manage depression iv) assessing for the presence of suicide risk factors and managing suicide risk when symptoms arise.[15] These recommendations are similar to the reaction of the American accreditation agency, the Joint Commission (JC), to address frequent suicides following contact with ED, PCP, and MH services. The Joint Commission’s Sentinel Event database received 1,089 reports of suicides from 2010 to 2014 among patients receiving care in an accredited hospital or within 72 hours of hospital discharge or release from an emergency department. Shortcomings in the patient's psychiatric assessment were the most frequently cited root cause. As of July 1, 2019, the JC requires the use of validated screening tools to assess any patient whose primary reason for seeking treatment or evaluation is for a behavioral health problem. However, universal screening was not mandated, although many organizations may elect to do this. The JC, working with other suicide reduction organizations, has numerous resources on its website to assist members to meet this accreditation requirement. Their stated rationale for new requirement included rising suicide rates, increased empirical knowledge and available risk assessment tools, and the non-compliance of over 21% of accredited behavioral health organizations and 5% of hospitals to meet JC's National Patient Safety Goal (NPSG) 15.01.01 "Element of Performance 1 – Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide" (Joint Commission, NPSG 15.01.01)[16] The JC advised that all accredited organizations should do the following: 1) Review each patient’s personal and family medical history for suicide risk factors. 2) Screen all patients for suicide ideation using a brief, standardized, evidence-based screening tool. 3) Review screening questionnaires before the patient leaves the appointment or is discharged. 4) Take action based on the assessment results to inform the level of interventions needed. (The Joint Commission, 2016, p. 3)[17] "Active" suicidal ideation denotes experiencing current, specific, suicidal thoughts. Active SI is present when there is a conscious desire to inflict self-harming behaviors, and the individual has any level of desire, above zero, for death to occur as a consequence. The probable lethality of their actions, based on the means used for the suicide attempt, is not the focus. Rather, the individual's expectation that their attempt could produce a fatal outcome is the key consideration.[18]  Example of an Active SI assessment item Miller et al. (1991) Modified Suicidal Ideation Scale "Over the past day or two, when you have thought about suicide, did you want to kill yourself? How often? A little? Quite often? A lot? Do you want to kill yourself now?"  "Passive" SI refers to a general wish to die but when there is no plan of inflicting lethal self-harm to kill oneself. Passive SI includes indifference to an accidental demise which would occur if steps are not taken to maintain one's own life. Passive SI receives less attention from clinicians and researchers than active SI. Although most research studies do not distinguish between active and passive SI, few studies focus on passive ideations. One author pointed out the underlying assumption of healthcare professionals is that the desire for death is not typically thought of as a harbinger of more severe suicidal outcomes.[19]  Examples of Passive SI assessment items Beck et al. (1979) Scale for Suicidal Ideation (SSI) was the first to measure "passive suicidal desire": 0 = Would take measures to save [one's own] life. 1 = Would leave life/death to chance. 2 = Would avoid steps necessary to save or maintain life[20]. European Depression Scale item, "In the past month, have you ever wished you were dead?"[21]  Miller et al. (1991) Modified Suicidal Ideation Scale  "Would you deliberately ignore taking care of your health? Do you feel like trying to die by eating too much (too little), drinking too much (too little), or by not taking needed medications?"  Assessing SI is an essential component of suicide risk assessment for individuals extending beyond those with known psychiatric conditions, especially in the older adult populations around the world. Individuals who endorse SI have a higher lifetime risk of future suicide than individuals who have never experienced any SI, although the prediction value is only weak. The value of SI in predicting imminent suicide risk has not been shown but does factor into the overall assessment of protective versus risk factors in short-term, imminent suicide risk.  A common misconception is that passive SI has less clinical importance. Large population-based studies (n>85,000) that compared the odds ratio to predict suicide attempts based on reported passive SI or reported active SI show there is no significant difference.  Including questions to assess both active and passive SI was recommended as the best clinical practice to predict risk.[19]   Compared to younger populations, older adults are more apt to endorse passive SI and less inclined to express active SI or seek mental health care. Also, the majority die on their initial attempt.[22] White males over 85 years have the highest rates, largely due to the use of lethal means like firearms. A systematic review revealed that older adults who died by suicide have very different personality profiles than younger suicide victims. Overall, older suicide victims had less evidence of maladaptive personalities, and the majority did not meet the threshold for psychiatric diagnosis. The only significant association was with a relatively small number of older suicide victims who had obsessive-compulsive and avoidant personality disorders. The researchers suggested these personality traits may have made later-life changes and transitions more difficult. They also noted that older suicide victims were more heterogeneous in both their risk factors and experiences compared to early-life suicide victims.[23]  Overall, there is a paucity of research addressing the nature of SI in older populations, although passive SI is understood to be more associated with older adults. However, when searching the literature using analogous terms like "death ideation," "death wish," "self-chosen death," and "wish to hasten death" (WTHD), it becomes more clear that this terminology has been ascribed to older adults' ideations. Healthcare professionals should bear in mind the social constructs and norms that influence the way suicidality is addressed and indirectly minimized by the use of these terms to describe SI in this age group. Without drifting too far into this literature, several examples of recent studies may help illuminate this relatively well-researched area of study. Death wishes:  A death wish was expressed in 9.5% of a large sample (n= >35,000) of New Zealanders aged 65 and older who were being evaluated for home care services. Depression, poor self-reported health, and loneliness were each independent, predictive variables of death wish.[24]  Self-chosen death:  Interviews with Dutch older adults (n=25) who were 70 years or older (mean age of 82), who wanted to die because they considered their lives complete and no longer worth living. All of these ideators had age-related debilitation, but none had a terminal disease. They considered their death wish to be reasonable and wanted to have the same ability as those with terminal illnesses to chose death based on the Dutch euthanasia laws.[25]. Wish to hasten death: A systematic review of 16 studies examining WTHD in patients with advanced illnesses showed that feeling like a burden contributed and may have triggered the WTHD.[26]. A study of incarcerated prisoners aged 50 years and older (n=124) found past alcohol dependence and self-rating one's health as poor/fair were equally associated with both passive (10%) and active (11%) SI. Compared to inmates who denied any SI, both groups of ideators had significantly higher incidences of previous suicide attempts and/or major depressive episodes.[27] A European study of retired middle-aged and older adults (n >35,000) examined the association between health status and passive suicidal ideations. They found increased odds of passive suicidal ideation when the participant had been diagnosed with a heart attack, diabetes/high blood sugar, chronic lung disease, arthritis, ulcer, and hip/femoral fractures.[28] Other studies show elevated odds ratios for suicide with hepatic disease [29], CVA [30] physical disability [31]). These findings suggest a need for all healthcare professionals to be aware that the lack of adherence to the medication or dietary regime may warrant further exploration concerning possible SI.  Research findings from a community sample of older adults (n=1,226) who participated in the PROSPECT study (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) showed that SI was present in 29% of participants with major depression; 11% with minor depression; and 7% without depression. The findings from this study underscore the need to assess SI in older patients, including those who do not have signs and symptoms of depression.   [32] A systematic review of self-harm in older adults concluded that more research needs to be done better to understand this population's unique characteristics and needs. Suicide attempts in this age group are usually fatal in their first attempt due to the lethality of their means, existing fragility, and lack of desire or opportunity for rescue. Because older adults typically have frequent contact with PCPs, opportunities to detect SI and provide appropriate interventions.[33] The suicide risk assessment (SRA) focuses on identifying the risk factors and protective factors for any given individual. This is followed by the suicide risk formulation (SRF), which assigns a level of imminent suicide risk. The subsequent triage and treatment plans are based on the SRF. One of the concerns discussed in the literature is the emphasis on the patient's communication of suicide ideation.[34] The American Psychiatric Association (2016) Practice Guidelines for the Psychiatric Evaluation of Adults states, "When the clinician is communicating with the patient, it is important to remember that simply asking about suicidal ideas or other elements of the assessment will not ensure that accurate or complete information is received." (p. 21).  Not all ideators are apt to share their SI. Over a dozen research studies have shown that 75% of patients who die by suicide denied SI the final time they were asked by a healthcare professional. Typically, their death by suicide occurred within the month of their last visit [8]. Berman completed chart reviews of 157 patients throughout the USA who died by suicide within 30 days of being evaluated by a healthcare professional. All victims were either receiving in-patient or out-patient mental health care; or were evaluated in an emergency department or by their primary care professional. The Joint Commission requires healthcare professionals in these practice settings to assess SI for anybody at risk of suicide. However, despite being asked, the majority (66%) denied SI. Within two days, 50% of these individuals who had denied SI ended their lives by suicide.[8] Berman noted that the denial of SI provides a basis for patient discharge if the individual was admitted due to SI. While this may be an incentive for a patient to deny SI, particularly if they want to be discharged, caution should be exercised. Berman states that too frequently, clinicians assume that SI must exist for suicide to occur when SI is only a risk factor for suicide. Additionally, SI is a weak predictor of increased lifetime risk, it does not predict imminent risk -- but, then again, nothing does.  Ribet et al. examined the root causes that may have contributed to 141 veteran suicides within a week of their hospital discharge. Flaws in communication were frequently cited. It was also noted that almost half of the suicides occurred following an unplanned discharge.[35]  The Joint Commission released multiple sentinel event warnings over the past decade based on reports of patient deaths in hospitals or shortly after discharge from mental health units or release from emergency departments.  They stated, "there is no typical suicide victim” and cautioned against assuming only certain individuals are at risk based upon their diagnosis or treatment setting.[17]  Beginning July 1, 2019, healthcare professionals are required by the Joint Commission's NPSG 15.01.01 to use a validated tool to assess suicidal risk for all patients whose primary reasons for seeking healthcare is the treatment or evaluation of a behavioral health condition.[17] The ability to accurately triage patients is contingent on the reliability of the instruments and also the clinician's clinical judgments. Much remains to be learned about the risk factors for imminent, short-term, and long-term suicidal behavior and the best way to identify risk.  A recent prospective study in Canada compared the risk of suicide attempt within 6 months for individuals presented in ED with SI but whose presentations differed, as evident in their responses to screening questions (n= 5,655). During ED triage screening, some individuals primarily endorsed SI characterized by an "ambivalence about living" while others expressed active SI. Within 6 months, 3% of the initially screened sample presented again in the ED with a suicide attempt. Individuals who initially identified with "ambivalence about living" had more than double the risk of suicide attempts (odds ratio [OR] = 2.57, 95% CI = 1.64-4.02, P < 0.001). Those with active suicidal ideation had more than triple the risk of an attempt within 6 months compared to non-SI individuals (OR = 3.75, 95% CI = 2.61-5.34, P < 0.001) Both active suicidal ideation and ambivalence about living are concerning presentations associated with risk of attempt within 6 months. Clinicians should be mindful that differentiating between active suicidal ideation and ambivalence about living are presentations that warrant follow-up due to the increased 6-month risk of attempts.[36][37]  Data show that 10% of people who ended their lives by suicide visited an emergency department within two months of inflicting fatal self-harm.[38] People who have psychiatric histories, substance use disorders, or depression were most apt to be assessed for SI, but this negates the significance of many other known socioeconomic factors. Chart reviews of suicide victims who ended their lives within hours to days of being assessed by a healthcare professional showed the pitfalls of relying too much on patients' admissions of SI.  Berman's review of the victims' charts showed strikingly similar profiles between the patients who admitted to SI or denied the presence of SI.  There were no significant differences in their diagnoses, current presentations, or current circumstances. Almost all suicide decedents' charts had documentation showing current anxiety/agitation and sleep problems, current interpersonal problems or job/financial strain, current comorbid diagnoses, current social isolation/withdrawal, plus a history of SI/prior attempts plus many had a family history of a mental disorder. Healthcare professionals should bear in mind that relying on verbalized or reported SI as a gateway to assessing suicide risk may be inadequate, especially when SI is denied. [8]  A 2013 study indicated that 0.6% of emergency department (ED) visits were due to suicidal thoughts, but when screening for SI was done, incidental, occult suicidal ideation was found in over 11% of patients who arrived due to medical complaints. Although SI was identified in medical patients and communicated, no follow-up regarding their SI occurred while on the medical unit.[39] The Joint Commission does not require universal screening of all patients, but some suicide risk reduction programs, professional organizations, and healthcare systems are advocating and implementing policies for universal screening in ED. A recent study of ED nurses and physicians in ED showed that most felt confident completing SI screenings, but only 7% of physicians (residents and attendings) and 37% of nurses reported they did so all of the time or most of the time.[40] Focus group interviews with ED nurses produced skepticism that the risk for suicide can be more reliably assessed with a brief screening tool question, such as 'Do you have thoughts or plans to harm yourself?' compared to a clinician's judgment. The participants described their efforts to improve suicide screening during ED triage required an ongoing iterative process of assessing for SI, which included probing, eliciting, evaluating, and reacting to identify occult SI.[41] Children ages 10-12 years who presented at the ED were screened with the Ask Suicide-Screening Questions (ASQ) and Suicidal Ideation Questionnaire. Positive screen results were present in 54% of patients whose chief complaint was psychiatric, but screening also showed positive results for 7% who presented to the ED with chief medical complaints. The overall rate of SI for these pre-teens was 29%, with 17% reporting engaging in prior suicidal behaviors. Although this sample was small, these findings highlight the potential value of screening children as young as 10 years for SI, including those who present with medical concerns.[42] These findings suggest that a substantial number of individuals who present in ED may have occult SI. The interprofessional ED team should bear in mind that some individuals may express suicidal thoughts differently or deny SI when presented in the form of a screening tool and feel more comfortable disclosing it when approached privately in a supportive, direct manner.  The literature suggests that all healthcare providers in ED will benefit from additional training to increase their knowledge, skills, and confidence.[43] A large meta-analysis (71 studies N= 4,669,303 individuals) included inpatient and non-inpatient adult populations to examine whether expressing SI was associated with subsequent suicides. Only limited sensitivity of SI for suicide was found (41% at 95% Confidence Interval (CI) 35–48), which means approximately 60% of suicide victims did not report experiencing SI. These authors examined whether there was a difference between using a structured instrument to assess SI versus relying on the healthcare professional's clinical judgment. Using structured instruments to assess SI was associated with a non-significantly lower pooled odds ratio (2.38, 95% CI 1.14–4.99) than when SI was clinically defined (OR = 3.72, 95% CI 2.96–4.67), but a great deal of heterogeneity in the studies. An important finding was that having a suicide plan, which was reported in only four studies, did significantly increased eight-fold (OR = 8.51, 95% CI 5.51–13.06). Two studies used an expressed wish to die as their operational definition of SI (OR = 3.01, 95% CI 1.49–6.06). 65 studies did not specify the individual's level of intent or planning when describing SI. There was a moderately strong but highly heterogeneous association between suicidal ideation and later suicide (n = 71, OR = 3.41, 95% CI 2.59-4.49, 95% prediction interval 0.42-28.1, I2 = 89.4, Q-value = 661, d.f.(Q) = 70, P ≤0.001).[44] Chapman's (2015) meta-analysis examined whether expressing SI was related to subsequent suicides for two different groups of individuals -- adults diagnosed with mood disorders (11 studies reporting on 860 suicides) and adults diagnosed with schizophrenia spectrum psychotic disorders (14 studies reporting on 567 suicides).  Results showed that people with schizophrenia spectrum psychosis who expressed SI had over a six-fold increase of suicide [14 studies; Odds ratio (OR) 6.49, 95% confidence interval (CI) 3.82-11.02]. Meanwhile, the association between expressing SI and suicide among patients with mood disorders was not significant (11 studies; OR 1.49, 95% CI 0.92-2.42).[45]  Another meta-analysis used data from 50 longitudinal studies that followed individuals who had experienced psychotic symptoms. These researchers attempted to differentiate between the impact of positive and negative symptoms of psychosis and their association with SI. Findings showed that positive symptoms in psychosis were weakly associated with SI (50 studies; OR = 1.70, 95% CI 1.39-2.08). On the other hand, negative symptoms in psychosis failed to show significance with SI and were found to be protective factors against death by suicide.[46]  A meta-analysis and systematic review of longitudinal studies of individuals in the general population (n > 84.000 representing 12 samples from 23 countries) showed that people who reported having at least one lifetime psychotic experience had double the odds of experiencing SI in the future (5 articles; n = 56,191; OR 2.39, 95% CI,1.62-3.51); triple the odds of a future suicide attempt (8 articles; n = 66,967; OR = 3.15 95% CI, 2.23-4.45), and four times the odds of future suicide death (1 article; n = 15,049; OR= 4.39 95% CI, 1.63-11.78]. The authors concluded these elevated risks exceeded what could be explained by co-occurring psychopathology. suggesting healthcare professionals should be alert to the risk of SI in anybody with a history of psychotic experience.[47] These findings emphasize the need for healthcare professionals to recognize the importance of psychosis as a risk factor for SI and suicidal behaviors.