Suicidal Behavior

About one in six people who kill themselves leaves a suicide note, which sometimes provides clues as to why. Reasons given include mental illness, feelings of hopelessness, feeling like a burden to others, and inability to cope with various life stresses.

Research has shown that many people who completed suicide were experiencing multiple risk factors at the time of death. About 85 to 95% of people who die by suicide have a diagnosable mental health condition at the time of their death.

The most common factor that contributes to suicidal behavior is

Depression, including the depression that is part of bipolar disorder, Bipolar Disorder In bipolar disorder (formerly called manic-depressive illness), episodes of depression alternate with episodes of mania or a less severe form of mania called hypomania. Mania is characterized... read more is involved in over 50% of attempted suicides and an even higher percentage of completed suicides. Depression can occur out of the blue, be triggered by a recent loss or other distressing event, or result from a combination of factors. In people with depression, marital problems, recent arrest or trouble with the law, unhappy or ended love affairs, disputes with parents or bullying (among adolescents), or the recent loss of a loved one (particularly among older people) may trigger a suicide attempt. The risk of suicide is higher if people with depression also have significant anxiety. Overview of Anxiety Disorders Anxiety is a feeling of nervousness, worry, or unease that is a normal human experience. It is also present in a wide range of psychiatric disorders, including generalized anxiety disorder,... read more

Medical disorders, especially those that are painful and chronic, contribute to about 20% of suicides in older people. Recently diagnosed medical disorders, such as diabetes, multiple sclerosis, Multiple Sclerosis (MS) In multiple sclerosis, patches of myelin (the substance that covers most nerve fibers) and underlying nerve fibers in the brain, optic nerves, and spinal cord are damaged or destroyed. The cause... read more cancer, and infection, can also increase suicide risk. Some health conditions such as AIDS, Acquired immunodeficiency syndrome (AIDS) Human immunodeficiency virus (HIV) infection is a viral infection that progressively destroys certain white blood cells and is treated with antiretroviral medications. If untreated, it can cause... read more temporal lobe epilepsy, Focal-onset seizures and head injuries Overview of Head Injuries Head injuries that involve the brain are particularly concerning. Common causes of head injuries include falls, motor vehicle crashes, assaults, and mishaps during sports and recreational activities... read more can directly affect people's brain functioning and, thus, increase suicide risk.

Traumatic childhood experiences, particularly including physical and sexual abuse, increase the risk of attempted suicide.

Use of alcohol may intensify depression, which, in turn, makes suicidal behavior more likely. Alcohol also reduces self-control and increases impulsivity. About 30% of people who attempt suicide drink alcohol before the attempt, and about half of them are intoxicated at the time. Because alcohol use, particularly binge drinking, often causes deep feelings of remorse during dry periods, people who engage in unhealthy alcohol use are at higher risk of suicide.

Almost all other mental health conditions also put people at higher risk of suicide.

People with schizophrenia Schizophrenia Schizophrenia is a mental disorder characterized by loss of contact with reality (psychosis), hallucinations (usually, hearing voices), firmly held false beliefs (delusions), abnormal thinking... read more or other psychotic disorders may have delusions (fixed false beliefs) that they find impossible to cope with, or they may hear voices (auditory hallucinations) commanding them to kill themselves. Also, people with schizophrenia are prone to depression. As a result, they die by suicide at a much higher rate (10%) than the general population.

People with borderline personality disorder Borderline Personality Disorder (BPD) Borderline personality disorder is characterized by a pervasive pattern of instability in relationships, self-image, moods, and behavior and hypersensitivity to possible rejection and abandonment... read more or antisocial personality disorder, Antisocial Personality Disorder Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. People with antisocial personality disorder go after what... read more especially those with a history of impulsivity, aggression or violent behavior, are also at higher risk of suicide. People with these personality disorders tend to have decreased frustration tolerance and tend to react to stress impetuously, sometimes leading to self-harm or aggressive behavior.

Isolation increases the risk of suicidal behavior. People who have been separated, divorced, or widowed are more likely to complete suicide. Suicide is less common among people who are in a secure relationship than among single people.

The choice of method is often influenced by cultural factors and availability of lethal means (for example, firearms). It may or may not reflect the seriousness of intent. Some methods (such as jumping from a tall building) make survival less likely, whereas other methods (such as overdosing on drugs) make rescue more possible. However, even if a person uses a method that proves not to be fatal, the intent may have been just as serious as that of a person whose method was fatal.

Suicide attempts most often involve drug overdose and self-poisoning. Violent methods, such as shooting and hanging, are uncommon among suicide attempts because they usually result in death.

About 50% of completed suicides in the United States involve guns. Men use this method more than women. Other methods include hanging, poisoning, jumping from a height, and cutting.

Worldwide, poisoning with pesticides accounts for a significant portion of suicides, particularly in Asia, where dangerous pesticides are widely available.

Although some attempted or completed suicides come as a shock to family members and friends, many people give warnings. Signs of distress or suicidal thoughts to look for include any change in the person's usual behavior pattern, such as changes in mood, behavior, sleep, or energy. Because most suicidal people often do not speak directly about their thoughts and distress, it is important to note when things people say suggest they may be feeling hopeless, overwhelmed, trapped, or that they are a burden to others. Changes in behavior include withdrawal from usual activities, agitation, anger outbursts, irritability, drinking or using drugs more than usual, or other odd behaviors such as saying goodbyes or giving away possessions. Any mention of suicidal thoughts even in the form of a joke and certainly any suicide attempt must be taken seriously. If it is ignored, a life may be lost.

If a person is imminently in the process of attempting suicide or has already attempted suicide, the authorities should be contacted immediately (in the United States by calling 911) so that emergency services can arrive as soon as possible. Until help arrives, stay with the person and speak in a calm, nonjudgmental, supportive manner.

A doctor may hospitalize people who have threatened or attempted suicide. Most states allow doctors to hospitalize people against their wishes if the doctors believe that those people are at high risk of harming themselves or others.

Newer comprehensive public health policies for preventing suicides use multiple methods, including suicide prevention training and trained peer counselors in schools and workplaces. Improvement in access to mental health care includes providing suicide risk–reducing clinical interventions in mental health care settings as well as in primary care offices and emergency departments. Recently, the development of artificial intelligence on social media platforms has helped to identify at-risk individuals and provide timely assistance. Public health policies that make lethal means less accessible are also prevention measures.

Health care professionals take any suicidal act seriously, but the plan for safety and treatment is customized to the person's situation.

If people seriously injure themselves, doctors evaluate and treat the injury and typically admit the person to the hospital. If people have taken an overdose of a potentially lethal drug, doctors immediately take steps to prevent absorption of the drug and speed its elimination from the body. People are also given any available antidote and provided with supportive care, such as a breathing tube.

After the initial evaluation, people who have attempted suicide are referred to a psychiatrist, who tries to identify problems that contributed to the attempt and plan appropriate treatment.

To identify problems, psychiatrists do the following:

Because depression increases the risk of suicidal behavior, doctors carefully monitor people with depression for suicidal behavior and thoughts. For people with depression, Depression A short discussion of prolonged grief disorder. Depression is a feeling of sadness and/or a decreased interest or pleasure in activities that becomes a disorder when it is intense enough to... read more suicide risk can increase during periods when depression is more severe, as well as when several other risk factors are also present. Doctors may be able to treat depression effectively with drugs and/or psychotherapy, Psychotherapy Extraordinary advances have been made in the treatment of mental illness. As a result, many mental health disorders can now be treated nearly as successfully as physical disorders. Most treatment... read more and thereby reduce suicide risk overall.

Some evidence suggests that using lithium, antidepressants, and newer antipsychotics to treat mood disorders in people who are at risk of suicide may reduce the number of completed suicides. Treating schizophrenia with clozapine reduces the risk of suicide.

The risk of suicide changes over time, with the most serious acute risk lasting from hours to days. Yet, according to a 2018 report of suicide risk, in a majority of suicides, people had been assessed in a variety of health care settings before their suicide, but their suicide risk was not detected. These findings highlight the importance of adopting public health strategies to reduce the risk of suicide in these people. For example, doctors should do the following:

Because of the increased risk of suicide following a person's discharge from an emergency department (ED) or psychiatric facility, current advocacy efforts in some countries are aimed at reforming the crisis-response system to create a wider, more robust safety net that does not rely on return visits to the ED or the intervention of law enforcement officers. Some helpful steps doctors can take to assist in this new crisis-response model, either during hospitalization and/or at discharge, include

There are strategies that health systems can employ to reduce suicide among the highest-risk patients. One such framework is called Zero Suicide, which advocates for universal training in suicide screening for all health system staff, the use of the electronic health record to help facilitate better patient care, and the use of the above brief interventions (safety planning, lethal means counseling, strong communication with the patient and family when possible, and appropriate referrals and follow-up).

Newer evidence-based interventions can reduce suicide risk in high-risk individuals. These include cognitive behavioral therapy Behavioral therapy Extraordinary advances have been made in the treatment of mental illness. As a result, many mental health disorders can now be treated nearly as successfully as physical disorders. Most treatment... read more (CBT), dialectical behavior therapy Treatment (DBT), and some forms of family therapy such as attachment-based family therapy. People who are identified to be at risk for suicide should be encouraged to pursue one of these types of therapy and to consider taking drugs individualized to their needs. As with any health condition, adjusting treatment when needed and providing follow-up care are important ways to optimize treatment.

Death by suicide has a marked emotional effect on all involved. Family, friends, and doctors may feel guilt, shame, and remorse at not having prevented the suicide. They may also feel anger toward the person. Eventually, they may work through these complicated grief experiences and cope with the loss.

Sometimes a grief counselor or a support group can help family and friends deal with their feelings of guilt and sorrow. The primary care doctor or local mental health service (for example, at the county or state level) can often help locate these resources. In addition, national organizations, such as the American Foundation for Suicide Prevention, maintain directories of local suicide loss survivor support groups. Resources are also available on the internet.

The effect of attempted suicide is similar. However, family members and friends have the opportunity to resolve their feelings by learning more about suicide, mental health treatment, and ways to be supportive and responsive to the individual.

Physician aid in dying refers to the assistance given by physicians to people who wish to end their lives. It is very controversial because it reverses the doctor's usual goal, which is to preserve life. However, physician aid in dying is legal in 10 U.S. states (California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and Washington) and the District of Columbia. It is also now under consideration in more than 15 other states. In the rest of the United States, doctors can provide treatment to minimize physical and emotional suffering, but they cannot intentionally hasten death.

Physician-assisted suicide is also legal in Switzerland, Belgium, Germany, and Canada, as well as in some other countries.

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.