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Suicide- What is it and what are the signs?

What are the risk factors and protective factors for suicide?
Ethnically, the highest suicide rates in the United States occur in non-Hispanic whites and in Native Americans. The lowest rates are in non-Hispanic blacks, Asians, Pacific Islanders, and Hispanics. Former Eastern Bloc countries currently have the highest suicide rates worldwide, while South America has the lowest. Geographical patterns of suicides are such that individuals who live in a rural area versus urban area and the western United States versus the eastern United States are at higher risk for killing themselves. The majority of suicide completions take place during the spring.

In most countries, women continue to attempt suicide more often, but men tend to complete suicide more often. Although the frequency of suicides for young adults has been increasing in recent years, elderly Caucasian males continue to have the highest rate of suicide completion. Other risk factors for taking one's life include poor access to mental-health care, single marital status, unemployment, low income, mental illness, a history of being physically or sexually abused, a personal history of suicidal thoughts, threats or behaviors, or a family history of attempting suicide. A lack of access to mental-health care has also been identified as increasing the likelihood of suicide. The means of attempting suicide can have particular risk factors as well. For example, individuals who attempt suicide by jumping from a height like a bridge may be more likely to be single, unemployed, and psychotic, while those who use firearms may more often have a history of legal issues, alcoholism, and certain personality disorders.

Data regarding mental illnesses as risk factors indicate that depression, manic depression, schizophrenia, substance abuse, eating disorders, and severe anxiety increase the probability of suicide attempts and completions. Nine out of 10 people who commit suicide have a diagnosable mental-health problem and up to three out of four individuals who take their own life had a physical illness when they committed suicide. Behaviors that tend to be linked with suicide attempts and completions include impulsivity, violence against others, and self-mutilation, like slitting one's wrists or other body parts, or burning oneself.

Risk factors for adults who commit murder-suicide include male gender, older caregiver, access to firearms, separation or divorce, depression, and drug abuse or addiction. In children and adolescents, bullying and being bullied seem to be associated with an increased risk of suicidal behaviors. Specifically regarding male teens who ultimately commit murder-suicide by school shootings, being bullied may play a significant role in putting them at risk for this outcome. Another risk factor that renders children and teens more at risk for suicide compared to adults is having someone they know commit suicide, which is called contagion or cluster formation.

Generally, the absence of mental illness and substance abuse, as well as the presence of a strong social support system, decrease the likelihood that a person will kill him- or herself. Having children who are younger than 18 years of age also tends to be a protective factor against mothers committing suicide.

What are the signs and symptoms for suicidal behavior?
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Warning signs that an individual is imminently planning to kill themselves may include the person making a will, otherwise getting his or her affairs in order, suddenly visiting friends or family members (one last time), buying instruments of suicide like a gun, hose, rope, pills, or other forms of medications, a sudden and significant decline or improvement in mood, or writing a suicide note. Contrary to popular belief, many people who complete suicide do not tell their therapist or any other mental-health professional they plan to kill themselves in the months before they do so. If they communicate their plan to anyone, it is more likely to be someone with whom they are personally close, like a friend or family member.

Individuals who take their lives tend to suffer from severe anxiety or depression, symptoms of which may include moderate alcohol abuse, insomnia, severe agitation, loss of interest in activities they used to enjoy (anhedonia), hopelessness, and persistent thoughts about the possibility of something bad happening. Since suicidal behaviors are often quite impulsive, removing guns, medications, knives, and other instruments people often use to kill themselves from the immediate environment can allow the individual time to think more clearly and perhaps choose a more rational way of coping with their pain. It can also allow the person's caregivers or loved ones time to intervene.

How are suicidal thoughts and behaviors assessed?
The risk assessment for suicidal thoughts and behaviors performed by mental-health professionals often involves an evaluation of the presence, frequency, severity, and duration of suicidal feelings in the individuals they treat as part of a comprehensive evaluation of the person's mental health. Therefore, in addition to asking questions about family mental-health history and about the symptoms of a variety of emotional problems (for example, anxiety, depression, mood swings, bizarre thoughts, substance abuse, eating disorders, and any history of being traumatized), practitioners frequently ask the people they evaluate about any past or present suicidal thoughts (ideations), dreams, intent, and plans. If the individual has ever attempted suicide, information about the circumstances surrounding the attempt, as well as the level of dangerousness of the method and the outcome of the attempt, may be explored. Any other history of violent behavior might be evaluated. The person's current circumstances, like recent stressors (for example, end of a relationship, family problems), sources of support, and accessibility of weapons are often probed. What treatment the person may be receiving and how he or she has responded to treatment recently and in the past, are other issues mental-health professionals tend to explore during an evaluation.

Sometimes professionals assess suicide risk by using an assessment scale. One such scale is called the SAD PERSONS Scale, which identifies risk factors for suicide as follows:

Sex (male)
Age younger than 19 or older than 45 years of age
Depression (severe enough to be considered clinically significant)
Previous suicide attempt or received mental-health services of any kind
Excessive alcohol or other drug use
Rational thinking lost
Separated, divorced, or widowed (or other ending of significant relationship)
Organized suicide plan or serious attempt
No or little social support
Sickness or chronic medical illness

What is the treatment for suicidal thoughts and behaviors? What types of specialists treat people who are suicidal?
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Those who treat people who attempt suicide tend to adapt immediate treatment to the person's individual needs. Those who have a responsive and intact family, good friendships, generally good social supports, and who have a history of being hopeful and have a desire to resolve conflicts may need only a brief crisis-oriented intervention. However, those who have made previous suicide attempts, have shown a high degree of intent to kill themselves, seem to be suffering from either severe depression or other mental illness, are abusing alcohol or other drugs, have trouble controlling their impulses, or have families who are unable or unwilling to commit to counseling are at higher risk and may need psychiatric hospitalization to prevent a repeat attempt in the days following the most recent attempt by providing close monitoring (for example, suicide watch) and long-term outpatient mental-health services to achieve recovery from their suicidal thoughts or actions.

Talk therapy (psychotherapy) that focuses on helping the person understand how their thoughts and behaviors affect each other (cognitive behavioral therapy) has been found to be an effective treatment for many people who struggle with thoughts of harming themselves. School intervention programs in which teens are given support and educated about the risk factors, symptoms, and ways to manage suicidal thoughts in themselves and how to engage adults when they or a peer expresses suicidal thinking have been found to decrease the number of times adolescents report attempting suicide.

Although concerns have been raised about the possibility that antidepressant medications increase the frequency of suicide attempts, mental-health professionals try to put those concerns in the context of the need to treat the severe emotional problems that are usually associated with attempting suicide and the fact that the number of suicides that are completed by mentally ill individuals seems to decrease with treatment. The effectiveness of medication treatment for depression in teens is supported by research, particularly when medication is combined with psychotherapy. In fact, concern has been expressed that the reduction of antidepressant prescribing since the U.S. Food and Drug Administration required that warning labels be placed on these medications may be related to the 18.2% increase in U.S. youth suicides from 2003-2004 after a decade of steady decrease. While the use of specific antidepressants has been associated with lower suicide rates in adolescents over the long term, uncommon short-term side effects of serotonergic antidepressants (for example, fluoxetine [Prozac], sertraline [Zoloft], paroxetine [Paxil], escitalopram [Lexapro], or vortioxetine [Trintellix]) may include an increase in suicide. Therefore, most practitioners consider antidepressant medication an important part of treating depression while closely monitoring their patients' progress to prevent suicide.

Mood-stabilizing medications like lithium (Lithobid) -- as well as medications that address bizarre thinking and/or severe anxiety, like clozapine (Clozaril), risperidone (Risperdal), and aripiprazole (Abilify) -- have also been found to decrease the likelihood of individuals killing themselves.

How can people cope with suicidal thoughts?
In the effort to cope with suicidal thoughts, silence is the enemy. Suggestions for helping people survive suicidal thinking include engaging the help of a doctor or other health professional, a spiritual advisor, or by immediately calling a suicide hotline or going to the closest emergency room or mental-health crisis center. In order to prevent acting on thoughts of suicide, it is often suggested that individuals who have experienced suicidal thinking keep a written or mental list of people to call in the event that suicidal thoughts come back. Other strategies include having someone hold all medications to prevent overdose, removing knives, guns, and other weapons from the home, scheduling stress-relieving activities every day, getting together with others to prevent isolation, writing down feelings, including positive ones, and avoiding the use of alcohol or other drugs.

How can people cope with the suicide of a loved one?
Grief that is associated with the death of a loved one from suicide presents intense and unique challenges. In addition to the already significant pain endured by anyone who loses a loved one, suicide survivors may feel guilty about having not been able to prevent their loved one from killing themselves and the myriad conflicting emotions already discussed. Friends and family may be more likely to experience regret about whatever problems they had in their relationship with the deceased, and they may even feel guilty about living while their loved one is not. Therefore, individuals who lose a loved one from suicide are more at risk for becoming preoccupied with the reason for the suicide while perhaps wanting to deny or hide the cause of death, wondering if they could have prevented it, feeling blamed for the problems that preceded the suicide, feeling rejected by their loved one and stigmatized by others.

Some self-help techniques for coping with the stress associated with the suicide of a loved one include avoiding isolation by staying involved with others, sharing the experience by joining a support group or keeping a journal, thinking of ways to handle it when other life experiences trigger painful memories about the loss, understanding that getting better involves feeling better some days and worse on other days, resisting pressure to get over the loss, and the suicide survivor's doing what is right for them in their efforts to recover. Many people, particularly parents of children who commit suicide, take some comfort in being able to use this terrible experience as a way to establish a memorial to their loved one. That can take the form of everything from writing a poem, planting a tree, or painting a mural in honor of the departed to establishing a scholarship fund in their loved one's name to teaching others about how to survive a child's suicide. Generally, coping tips for grieving a death through suicide are nearly as different and numerous as there are bereaved individuals. The bereaved person's caring for him- or herself through continuing nutritious and regular eating habits and getting extra, although not excessive, rest can help strengthen their ability to endure this very difficult event.

Quite valuable tips for journaling as an effective way of managing bereavement rather than just stirring up painful feelings are provided by the Center for Journal Therapy. While encouraging those who choose to write a journal to apply no strict rules to the process as part of suicide recovery, some of the ideas encouraged include limiting the time journaling to 15 minutes per day or less to decrease the likelihood of worsening grief, writing how one imagines his or her life will be a year from the date of the suicide, and clearly identifying feelings to allow for easier tracking of the individual's grief process.

To help children and adolescents cope emotionally with the suicide of a friend or family member, it is important to ensure they receive consistent caretaking and frequent interaction with supportive adults. All children and teens can benefit from being reassured they did not cause their loved one to kill themselves, going a long way toward lessening the developmentally appropriate tendency children and adolescents have for blaming themselves and any angry feelings they may have harbored against their lost loved one for the suicide. For school-aged and older children, appropriate participation in school, social, and extracurricular activities is necessary to a successful resolution of grief. For adolescents, maintaining positive relationships with peers becomes important in helping teens figure out how to deal with a loved one's suicide. Depending on the adolescent, they even may find interactions with peers and family more helpful than formal sources of support like their school counselor.

Is it possible to prevent a suicide attempt?
For the population at large, suicide-prevention strategies include increasing access to health care, promoting mental health, avoidance of drug use, and restricting access to means to complete suicide. Responsible media reporting to raise mental-health and suicide awareness, as well as how to report suicides and other violence that occurs are other suicide-prevention strategies that are often used in general populations.

Suicide-prevention measures for individuals who have a mental-health history following a psychiatric hospitalization usually involve mental-health professionals trying to implement a comprehensive outpatient treatment plan prior to the individual being discharged. This is all the more important since many people fail to comply with outpatient therapy after leaving the hospital. It is often recommended that all firearms and other weapons be removed from the home, because the individual may still find access to guns and other dangerous objects stored in their home, even if locked. It is further often recommended that sharp objects and potentially lethal medications be locked up as a result of the attempt.

Vigorous treatment of the underlying psychiatric disorder is important in decreasing short-term and long-term risk. Contracting with the person against suicide has not been shown to be especially effective in preventing suicidal behavior, but the technique may still be helpful in assessing risk, since hesitation or refusal to agree to refrain from harming oneself or to fail to agree to tell a specified person may indicate an intent to harm oneself. Contracting might also help the individual identify sources of support he or she can call upon in the event that suicidal thoughts recur.

What is the prognosis for someone who has made a suicide attempt or threat?
While most people who attempt suicide do not ultimately die by suicide, those who have tried to kill themselves are at much higher risk of completing suicide compared to those who have never attempted to do so. People who attempt suicide have been found to be at risk for developing symptoms of posttraumatic stress disorder (PTSD), with the suicide attempt being the traumatic event. This has been found to be more likely the more serious the suicide attempt and the more steps the person took in an effort to avoid detection before their demise. Given the potentially fatal prognosis of attempting suicide, the need for treatment is all the more important.

Where can people get help for suicidal thoughts?
American Association of Suicidology

American Foundation for Suicide Prevention


Jason Foundation


National Suicide Prevention Hotline
800-SUICIDE (784-2433)

National Suicide Prevention Lifeline
800-273-TALK (8255)

Society for the Prevention of Teen Suicide


Substance Abuse and Mental Health Services Administration (SAMHSA)

Suicide Prevention Advocacy Network (SPAN)

Yellow Ribbon Suicide Prevention Program

The future

How to best assess the risk of someone committing suicide continues to be an elusive challenge for health professionals, so this is an appropriate goal for future research. The best way to achieve the balance between using psychiatric medication to treat any underlying conditions that may result in suicidal thoughts and the potential side effects of those medications is an ongoing issue in suicide prevention.



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