Understanding Suicide Intervention and IS PATH WARM

Suicide is the leading cause of death around the world for people between the ages of 15 and 24. However, predicting and evaluating the warning signs of suicide is complicated. For decades, mental health professionals have used acronyms such as IS PATH WARM as mnemonic devices to help counselors and the public recognize the warning signs of suicide.

IS PATH WARM: What Is It?

Every day, around 120 people die by suicide in the U.S., according to the Centers for Disease Control. For every 25 suicide attempts, one person will succeed. Anticipating suicidal behavior is a challenging task for mental health and medical professionals. IS PATH WARM is an evidenced-based set of signs and signals of immediate suicide intent or risk. Each letter in the acronym stands for a symptom researchers and treatment professionals have discovered and connected with evidence of suicide risk through the years.I = IdeationS = Substance AbuseP = PurposelessnessA = AnxietyT = TrappedH = HopelessnessW = WithdrawalA = AngerR = RecklessnessM = Mood Change

Assessing Suicide Risk Using IS PATH WARM

Mental health professionals determine a client’s risk of suicide as either acute or chronic. They also assess whether the risk is low, moderate, or high. Acute risk means that the client could die or permanently injure themselves within 24 hours. Chronic situations allow the professional more time for intervention. Mental health guidelines call for multiple assessments to make the determination. IS PATH WARM is one of the most common techniques for assessing the client’s level of risk.

The History of IS PATH WARM

The American Association of Suicidology, a nonprofit organization that advocates for suicide prevention, created the IS PATH WARM mnemonic device in 2003. They brought together a group of suicidologists who examined the existing research on suicide intent and risk. Over the years, the acronym has become a common method in the prediction of suicidal behavior. However, researchers and mental health professionals alike are quick to point out that practitioners should use a variety of tools to anticipate suicidal behavior.

The Difficulties of Identifying Suicidal Behavior

The causes of suicide are complex and unpredictable. The list of warning factors for suicide contains hundreds of potential predictors. Mental health professionals know that depression is an important and relevant sign. About 2 percent of those who receive a diagnosis of severe depression eventually die due to suicide. But depression is only a part of the puzzle. To increase the accuracy of predicting whether or not an individual is in danger of suicide, researchers use large amounts of data to create more consistent methods of predicting suicide attempts. This data comes from analyzing health records, hospital visit patterns, medication prescriptions, demographics, and mental health diagnoses.

The Cases Against IS PATH WARM

A 2011 study showed researchers found the IS PATH WARM mnemonic was limited in its scope and inaccurately predicted suicidal behavior. Another study stated that none of the ten signs in the acronym can accurately predict completed suicides. Mental health experts say that the acronym focuses on “near-term” risks such as substance abuse, aggressive behavior, anxiety, and dramatic mood changes. It does not take into account long-term risk factors, such as family history, impulsive behaviors, and history of trauma, abuse, and self-harm behaviors. Additionally, IS PATH WARM is based on lifelong risk factors and, therefore, some experts do not consider it valuable for predicting suicidal behavior in children. Many mental health professionals and researchers agree that it is more effective in predicting suicidal thoughts or planning than actionable suicidal behavior.

Suicide Notes and IS PATH WARM

Another 2011 study combined suicide notes written by people who attempted suicide with those written by people considering suicide who did not ultimately attempt it. The researchers used the IS PATH WARM mnemonic to analyze whether the notes led to suicide attempts. They found no evidence that the IS PATH WARM tool identified any difference between genuine suicide notes and those of individuals simulating a suicidal crisis. The researchers were also unable to find clues based on IS PATH WARM that might indicate which notes resulted in death and which did not.

Evaluation By Nonprofessionals

Mental health professionals are usually not the first to notice the intial signs of suicidal behavior. Family members, friends, and co-workers often observe early symptoms of mental health issues, along with changes in the individual’s day-to-day demeanor. The IS PATH WARM mnemonic is a simple way for nonprofessionals to observe behaviors that could potentially lead to suicide or self-harm. The person observing the changes can start a conversation with the individual and evaluate their behavior based on the signs outlined in the acronym. Or, if they feel the individual is likely to act on their suicidal thoughts, they can report the behavior to emergency services.

Partner Strategies for Evaluating Suicidal Behaviors

IS PATH WARM is just one suicide risk assessment tool. Mental health professionals use other interview techniques instead of IS PATH WARM —or alongside it — to assess imminent risk.

• SIMPLE STEPS is similar to IS PATH WARM but adds specifics such as Protective Factors, Earlier (Suicide) Attempts, Stressors, and Loss.
• The CASE Method encourages the clinician to discover their own way of assessing suicidal ideation and to increase the client’s sense of safety
• Positive and Negative Suicide Ideation Inventory (PANSI) is a self-reported measurement of suicide-related vulnerability
• Sad Persons Scale is another mnemonic device, but recent studies suggest it has little or no clinical value due to low sensitivity.
• The Hamilton Rating Scale for Depression measures a client’s level of depression before, during, and after treatment.
• Collaborative Assessment and Management of Suicide (CAMS) is a flexible approach for suicide evaluation using high interaction between clinician and the client.

The Importance of Suicide Risk Assessment

Mental health professionals must assess whether or not their clients require immediate intervention. People who have a low and chronic risk might benefit from frequent therapy sessions in a community health setting instead. However, those who have attempted suicide in the past are at a much higher risk of attempting suicide again. The loss of a family member to suicide or a past hospitalization due to an acute suicidal risk also place an individual at a higher risk of self-harm. By combining IS PATH WARM techniques with other assessment tools, clinicians are better able to accurately evaluate suicide risk and determine effective treatment.

When Patients Deny Suicidal Thoughts

Accurate suicide risk assessment is crucial to identifying clients who are having suicidal thoughts. One study found that about 25% of suicidal patients deny suicidal ideation. Many of these clients may view their counselor as an enemy who is getting in the way of their intent. Interview techniques such as IS PATH WARM offer a way for mental health professionals to ask additional questions and to further evaluate client responses. Most experts say the denial of suicidal ideation should be the beginning of assessment using various interview techniques. Many agree that assessments requiring the clinician to check off boxes are insufficient. Continued observation and narrative assessment should be part of the suicide risk assessment process throughout the client’s treatment, to observe changes in behavior or risk.