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Suicidal Behavior

By

Christine Moutier

, MD, American Foundation For Suicide Prevention

Last full review/revision Jun 2021| Content last modified Jun 2021
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Suicide is death caused by an intentional act of self-harm that is designed to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors to completed suicide. Suicidal ideation refers to the process of thinking about, considering, or planning suicide.

Advances in science, advocacy, and stigma reduction have led to an evolution in all of the terminology related to suicide, including those concepts already defined above:

  • Suicidal intent: Intention to end one's life through the act of suicidal behavior

  • Suicide attempt: A nonfatal, potentially injurious behavior directed against the self with an intent to die as a result of the behavior

  • Suicide attempt survivors: People with their own personal experience with suicidal thoughts or attempt(s); often important in the advocacy movement of suicide prevention; suicide attempt survivors sometimes join forces with other advocates (eg, Loss Survivors)

  • Suicide loss survivor or suicide bereaved: Family members or friends of a person who died by suicide

Three other important changes in suicide terminology have also made it into the professional lexicon:

  • Died by suicide: This recommended language is preferred over the phrase “committed suicide.” Other plain language is acceptable as well (eg, “killed himself,” “ended her life,” “took his life”).

  • Nonsuicidal self-injury (NSSI) and self-injurious behavior (SIB): These behaviors are defined as deliberately injuring oneself without suicidal intent; self-cutting is the most common form, but burning, scratching, hitting, and intentionally preventing wounds from healing are other forms. While the behavior itself is without suicidal intent, people who have a pattern of NSSI have been found to have a higher risk of suicide in the long term.

  • Suicidality: This term is frequently used in clinical settings between professionals to refer to the spectrum of possible suicidal experiences; it does not specify ideation, attempt, chronic/recurrent, or singular event. In many instances, communication can be more effective and clear if one articulates the actual issue at hand, such as ideation or attempt, and include any relevant details.

Epidemiology of Suicidal Behavior

Statistics on suicidal behavior are based mainly on death certificates and inquest reports and underestimate the true incidence. To provide more reliable information in the United States, the Centers for Disease Control and Prevention (CDC) established a state-based system that collects facts about each violent incident from various sources to provide a clearer understanding of the causes of violent deaths (homicides and suicides), the National Violent Death Reporting System (NVDRS). The NVDRS is now in place in all 50 states, the District of Columbia, and Puerto Rico.

In the United States, suicide is the 10th leading cause of death.

The age group with the highest suicide rate is now people aged 45 to 64 years, resulting from a recent significant increase. Why this rate has increased is unknown; however, the following factors may have contributed:

  • Years ago, as teenagers, this group had a higher rate of depression than older groups, and researchers predicted that their suicide rate would rise as they aged.

  • This rate includes the increased number of suicides among military personnel and veterans (20% of suicides are in that group).

  • This rate may also stem from intersecting influences, including unmet expectations and beliefs of this particular cohort, rise in the availability of lethal means, the opioid crisis, changes in the economy, and the persistent stigma associated with addressing mental health conditions.

The second highest rate of suicide is in people 75 years.

In the 1990s, youth suicide rates decreased after more than a decade of steady increase, only to start climbing again with an alarming increase in suicide deaths by gun.

In all age groups, male deaths by suicide outnumber female deaths 3.5 to 1. The reasons are unclear, but possible explanations include

  • Men are less likely to seek help when they are distressed.

  • Men have a higher prevalence of alcohol and substance use disorders, which leads to suicidal tendencies.

  • Men are more aggressive and use more lethal means when attempting suicide.

  • The number of suicides in men includes suicides among military personnel and veterans, where there is a higher proportion of men to women.

White men account for 7 in every 10 suicides in the United States even though they account for around one third of the population.

In 2019, an estimated 1.4 million American adults made a suicide attempt. About 25 attempts are made for every death that occurs by suicide. Many make repeated attempts. Only 5 to 10% of people who make an attempt eventually die by suicide; however, in older people, 1 in every 4 suicide attempts ends in death. Although more men than women die by suicide, women attempt suicide 2 to 3 times more often than men; among youth and young adults, there may be 100 attempts by girls to every 1 attempt by boys of the same age.

A suicide note is left by about 1 in 6 people who complete suicide. The content may indicate clues regarding the factors that led to the suicide (eg, psychiatric illness, hopelessness, cognitive constriction and narrowing of perceived options for coping, sense of being a burden to others, and sense of isolation). The intersection of these and other life stressors or losses may precipitate suicide.

Suicide contagion refers to a phenomenon in which one suicide seems to beget others in a community, school, or workplace. Highly publicized suicides may have a very wide effect. Affected people are usually those already vulnerable. Humans are social creatures prone to imitation of one another. Youths are more likely to engage in imitation than adults because of their stage of psychologic development and brain development. It is estimated that contagion is a factor in 1 to 5% of all teen suicides.

Contagion can occur by exposure to a peer who attempts or dies by suicide, by widespread media coverage of a celebrity’s suicide, or by graphic and/or sensationalized portrayal of suicide in popular media. Conversely, media coverage with positive messaging about a suicide death can mitigate the risk and/or impact of suicide contagion for vulnerable youth. Positive messaging typically involves portraying mental health struggles as part of life and human health experience with no stigma related to help seeking and treatment. After a suicide has occurred, positive messages in a school or workplace communicate clearly about the tragic loss of a community member and goes on to express support for the grieving community and provides resources for support. In writing or in in-person meetings for debriefing the loss, the language the leader uses to talk about suicide is important. For more detailed information on communication and templates for written communication, please see the After A Suicide Toolkits freely available on the American Foundation for Suicide prevention ( afsp.org ) web site.

Suicide contagion can also spread in schools and workplaces, which are—in some ways—the ideal settings for implementing and following postvention guidelines to prevent future suicides.

Other categories of suicide are extremely rare. These include

  • Group suicides

  • Murder/suicides

  • "Suicide by cop" (situations in which people act in a way, for example, brandishing a weapon, that prompts law enforcement officers to act with deadly force)

Etiology of Suicidal Behavior

The current scientifically informed view of suicide is that, while complex, suicide is a health-related event that involves a set of genetic, environmental, and psychologic/behavioral factors. psychologic autopsy studies clearly show that in each instance of suicide, decedents were experiencing multiple risk factors for suicide. Research has shown that 85 to 95% of people who die by suicide have a diagnosable mental health condition at the time of their death.

One of the most common, potent, and remediable risk factors for suicide is depression.

The amount of time spent in an episode of depression is the strongest predictor of suicide. For patients with depression, suicide risk can increase during periods when depression is more severe, and when several other risk factors converge. Also, suicide appears to be more common when severe anxiety is part of major depression or bipolar depression. Risk of suicidal thoughts and attempts may increase in younger age groups after antidepressant drugs are started (see Treatment of depression and risk of suicide and Suicide risk and antidepressants ). Effectively treating depression with medications and/or some form of psychotherapy is considered an effective way to reduce suicide risk overall.

Other risk factors for suicide include the following:

  • Most other serious mental health conditions

  • Previous suicide attempts

  • Personality disorders (eg, borderline personality disorder)

  • Impulsivity and aggression

  • Traumatic childhood experiences

  • Family history of suicide and/or psychiatric conditions

  • Use of alcohol, drugs of abuse, and prescription analgesics

  • Serious or chronic physical health conditions (eg, chronic pain, traumatic brain injury)

  • Times of loss (eg, death of family or friends)

  • Relationship conflict (eg, divorce)

  • Work disruption (eg, unemployment)

  • Periods of career transition (eg, changing one's military status from active duty to veteran status or retirement)

  • Financial stress (eg, economic downturns, underemployment)

  • Bullying (eg, cyberbullying, social rejection, discrimination, humiliation)

Death by suicide is more common among people with a psychiatric illness than among age- and sex-matched controls. (See table Frequency of Mental Health Disorders in Suicide.)

Table
icon

Frequency of Mental Health Disorders in Suicide*

Mental Health Disorder

Frequency

Major depression

50 to 60%

25%

Psychosis

15%

10%

10%

6 to 10%

Impulse control disorders

* The disorders are listed in order of decreasing prevalence; those that occur at negligible rates do not have exact figures attached. Please note that these disorders often co-occur in cases of suicide risk, therefore, the prevalence rates do not total 100%.

People with schizophrenia die by suicide at a much higher rate compared to the general population, with as many as 10% of patients with schizophrenia dying by suicide. Drivers of suicide risk among people with schizophrenia include early phase illness, depressive episodes, hallucinations, lack of access to or nonadherence to effective treatment, disability, hopelessness, and akathisia. Other well-known psychosocial risk factors for suicide include relationship disruption, unemployment, and loss.

Alcohol and drugs of abuse may increase disinhibition and impulsivity as well as worsen mood—a potentially lethal combination. Between 30% and 40% of people who die by suicide have consumed alcohol before the attempt, and about half of them were intoxicated at the time. Impulsive young men and women are particularly susceptible to alcohol's effects; in them, moderate levels of intoxication can result in their using more lethal suicide methods (1). However, people with an alcohol use disorder are at increased risk of suicide even when they are sober.

Serious physical health conditions, especially those that are chronic and painful, contribute to about 20% of suicides in older patients. Recently diagnosed or new-onset physical health conditions can also increase suicide risk (eg, diabetes, seizure disorder, pain conditions, multiple sclerosis, cancer, infection, HIV/AIDS). These health conditions can directly impact physiologic brain functioning and, thus, increase suicide risk. The psychologic effects of disability, pain, or a new diagnosis of a serious health condition can also increase the risk of suicide.

People with personality disorders are prone to suicide, especially people with borderline or antisocial personality disorder, who likely have problems with stress intolerance and interpersonal reactivity patterns, including self-injurious behavior and aggression.

Traumatic childhood experiences, particularly the stresses of sexual or physical abuse or parental deprivation, are associated with suicide attempts and perhaps completed suicide.

The genetics of suicide risk are an important area of research and appear to influence suicide risk. While suicide risk can run in families, genes appear to account for only a portion of that risk (2). A family history of suicide, suicide attempts, or psychiatric disorders is associated with an increased risk of suicide.

Genes and environment both matter when it comes to suicide risk. It has been proposed that epigenetic changes (eg, DNA methylation) affecting gene expression could increase or decrease risk for suicide by affecting neurophysiology, cognition, or stress regulation. This means that negative experiences such as trauma and conversely positive experiences such as the social support of psychotherapy can actually change gene expression and significantly affect an individual’s resilience and risk for suicide. This is an area of research that is attempting to determine the roles of epigenetics.

Psychologic traits such as a tendency toward impulsivity, cognitive rigidity, interpersonal rejection sensitivity, or severe neuroticism can also increase risk.

Etiology references

Methods

Choice of method for suicide is determined by many things, including cultural factors, availability of means to complete suicide, and the seriousness of intent. (A combination of these factors surely influences the popularity of pesticide poisoning as a common means of suicide in most Asian countries.) Some methods (eg, jumping from heights) make survival virtually impossible, whereas others (eg, drug ingestion) may allow rescue. However, using a method that proves not to be fatal does not necessarily imply that the intent was less serious.

For suicide attempts, drug ingestion is the most common method used. Violent methods, such as shooting and hanging, are uncommon among attempted suicides.

Approximately 50% of completed suicides in the United States are by firearm; men use this method more than women. Women use poisoning more than men. Other methods of suicide include hanging, jumping from a height, drowning, and cutting.

Management of Suicidal Behavior

In 2018, the National Action Alliance for Suicide Prevention (Action Alliance) published guidelines for recommended standards of care for patients at risk for suicide. These include recommendations for screening, suicide risk assessment, and clinical care in primary care, behavioral health, and emergency department settings (1).

It is important to note that suicide risk is dynamic. Acute risk generally lasts only a short period of time (hours to days). In the majority of suicides, patients had been seen in various health care settings during the period of acute risk, but suicide risk was not detected. Any sound public health strategy to reduce suicide would equip clinicians in all health care settings (even those outside of behavioral health) to actively look for and mitigate any and all suicide-related risks. This can be done by having health care providers

  • Employ a caring response

  • Provide brief interventions (eg, safety planning and lethal means counseling)

  • Communicate with family and close friends of the patient

  • Refer the patient for appropriate care

Currently, these steps have the strongest evidence for reducing suicide risk and saving lives.

Certain periods of time are known to be associated with an elevated risk of suicide. The period of days to weeks following discharge from the emergency department or psychiatric hospital for patients admitted for suicidal ideation or a suicide attempt is just such a period and, therefore, a prime point of intervention (2).

A health care practitioner who foresees the imminent likelihood of suicide in a patient is, in most jurisdictions, required to inform an empowered agency to intervene. Failure to do so can result in criminal and civil actions. At-risk patients should not be left alone until they are in a secure environment (often a psychiatric facility). If necessary, those patients should be transported to that secure environment by trained professionals (eg, emergency medical technicians, police officers). Current advocacy efforts in the United States, the United Kingdom, New Zealand, Australia, and elsewhere aim to reform the crisis response system to move toward reliance on a more robust multi-tiered set of mental health resources such as mobile crisis units and comprehensive crisis care and away from their current reliance on emergency departments and law enforcement.

Any suicidal act, regardless of whether it is a gesture or an attempt, must be taken seriously. Every person with a serious self-injury should be evaluated and treated for the physical injury.

If an overdose of a potentially lethal drug is confirmed, immediate steps are taken to administer an antidote and provide supportive treatment (see Poisoning).

Initial assessment can be done by any health care practitioner trained in the assessment and management of suicidal behavior. However, all patients should have a thorough suicide risk assessment—which is usually done by a psychiatrist, psychologist, or other trained mental health care practitioner—as soon as possible. Decisions must be made about whether patients need to be voluntarily admitted or involuntarily committed for treatment, and whether restraint is necessary (see also Behavioral Emergencies). Patients with a psychotic disorder and some with severe depression and an unresolved crisis should be admitted to a psychiatric unit. Patients with manifestations of potentially confounding medical disorders (eg, delirium, seizures, fever) may need to be admitted to a medical unit with appropriate suicide precautions.

After a suicide attempt, the patient may deny any problems because the severe depression that led to the suicidal act may be followed by a short-lived mood elevation. Nonetheless, the risk of later, completed suicide is high unless the patient receives ongoing treatment and psychosocial support.

Suicide risk assessment identifies the key drivers contributing to the individual's current suicide risk and helps the clinician plan appropriate treatment. It consists of the following:

  • Establishing rapport and listening to the patient's narrative

  • Understanding the suicide attempt, its background, the events preceding it, and the circumstances in which it occurred

  • Inquiring about mental health symptoms and any medications or alternative treatments the patient may be taking for treatment of their mental health condition or relief of symptoms

  • Fully assessing the patient’s mental state, with particular emphasis on identifying depression, anxiety, agitation, panic attacks, severe insomnia, other mental disorders, and alcohol or drug use disorders (many of these problems require specific treatment in addition to crisis intervention)

  • Thoroughly understanding personal and family relationships as well as social networks, which are often pertinent to the suicide attempt and follow-up treatment

  • Interviewing close family members and friends

  • Inquiring about the presence of a firearm or other lethal means in the house and providing lethal means counseling (this may involve facilitating the safe storage or disposal of lethal means away from the home)

Mental health management

Safety planning, the first step after assessment, is an essential intervention that is done to help patients identify triggers to suicidal planning and develop plans to deal with suicidal thoughts when they occur (3, 4). Other steps clinicians should take include providing the patient with crisis resources, counseling on removal or storage of lethal means (5, 6), and referrals for appropriate risk-reduction care (eg, cognitive-behavioral therapy, dialectical behavior therapy, collaborative assessment and management of suicidality [CAMS], family therapy; 4, 7–10). Clinicians can also provide the patient with more frequent contact through outpatient visits or various forms of communication, some of which can be provided by other members of the health care team (11).

Management references

  • 1. National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Work Group: Recommended standard care for people with suicide risk: Making health care suicide safe. Washington, DC: Education Development Center, Inc. 2018.

  • 2. Chung DT, Ryan CJ, Hadzi-Pavlovic D, et al: Suicide rates after discharge from psychiatric facilities: A systematic review and meta-analysis. JAMA Psychiatry 4(7):694-702, 2017. doi:10.1001/jamapsychiatry.2017.1044

  • 3. Michel K, Valach L, Gysin-Maillart A: A novel therapy for people who attempt suicide and why we need new models of suicide. Int J Environ Res Public Health 14(3): 243, 2017. doi: doi: 10.3390/ijerph14030243

  • 4. Stanley B, Brown GK: Safety planning intervention: A brief intervention to mitigate suicide risk. Cogn Behav Pract 19:256-264, 2011.

  • 5. Barber CW, Miller MJ: Reducing a suicidal person’s access to lethal means of suicide: A research agenda. Am J Prev Med 47(3Suppl 2):S264-S272. doi: 10.1016/j.amepre.2014.05.028

  • 6. Harvard TH Chan School of Public Health: Lethal Means Counseling. Accessed 5/3/21.

  • 7. Linehan MM, Comtois KA, Murray AM, et al: Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psych 63(7):757-766, 2006. doi: 10.1001/archpsyc.63.7.757

  • 8. Brown GK, Ten Have T, Henriques GR, et al: Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. JAMA 294(5):563-570, 2005. doi: 10.1001/jama.294.5.563

  • 9. Jobes DA: The CAMS approach to suicide risk: Philosophy and clinical procedures. Suicidologi 14(1):1-5, 2019. doi:10.5617/suicidologi.1978

  • 10. Diamond GS, Wintersteen MB, Brown GK, et al: Attachment-based family therapy for adolescents with suicidal ideation: A randomized controlled trial. J Amer Acad Child Adol Psychiatry 49(2):122-131, 2010. doi: 10.1097/00004583-201002000-00006

  • 11. Luxton DD, June JD, Comtois KA: Can postdischarge follow-up contacts prevent suicide and suicidal behavior? A review of the evidence. Crisis 34(1):32-41, 2013. doi: 10.1027/0227-5910/a000158

Prevention of Suicidal Behavior

Prevention of suicide requires identifying at-risk people (see table Risk Factors and Warning Signs for Suicide) and initiating appropriate interventions.

A public health model can be used to scale suicide-prevention strategies. Implementing key strategies across an entire population (universal) can drive down suicide rates. Suicide-prevention efforts are, therefore, critically important at the regional and national levels. These efforts are supplemented by effective health care in reducing suicide risk. Interventions at the community level have also shown promising results for reducing suicide risk.

There are school-based and public health interventions. One example is the Sources of Strength suicide-prevention program, which is delivered by adolescent peer leaders in high schools (1). Studies also show that appropriately training volunteers who staff suicide lifelines helps callers and can thus save lives (2).

Another powerful example of the effectiveness of universal and selective suicide-prevention programming is evidenced by the outcomes associated with Garrett Lee Smith (GLS) Memorial Act grants. These grants have funded youth suicide-prevention activities in the United States since 2004, on college campus as well as in community and tribal settings in many states. Over a 15-year period, a large proportion of counties in the United States received financial funding to engage in youth suicide-prevention initiatives, including the following (3):

  • Establishment of outreach, awareness-raising, and screening programs

  • Provision of “gatekeeper” training (ie, educating people in key front-line roles to recognize suicide risk and intervene accordingly)

  • Development of coalitions (which typically include a number of local groups, eg, local government departments of mental health or suicide prevention, nonprofit organizations focused on suicide prevention, educators, parent groups, faith-based groups, law enforcement, etc)

  • Implementation of policies and/or protocols

  • Establishment and funding of hotlines

Forty percent of GLS grants are awarded in rural areas of the United States, where suicide rates are higher and where resources for programs and clinical treatment tend to be much less available than they are in other areas. In one study, counties with GLS activities were compared with control counties that had not been exposed to GLS programs. All counties were matched for demographic characteristics (race/ethnicity makeup, median household income, unemployment rates, and suicide rates of youth and adults). Significant reductions were found both for short- and longer-term impact on suicidal behaviors and suicide deaths. The positive effect was greatest in rural areas of the United States (3, 4).

Another innovative nationwide initiative in the United States led by the American Foundation for Suicide Prevention (Project 2025) aims to reduce the US suicide rate by 20% by 2025.

In the clinical arena, there is consensus that patients who are admitted to the hospital after a suicide attempt are at greatest risk of death by suicide during the first few days or weeks after discharge, and the risk remains high during the first 6 to 12 months after discharge. After that, the risk waxes and wanes but is always higher than in people who have never been suicidal.

Consequently, before patients are discharged, they—along with family members and/or close friends—should be counseled about the immediate risk of dying by suicide, and an appointment for follow-up care in the first week after discharge should be made. A simple telephone call or two after discharge has been shown to significantly reduce the occurrence of repeat attempts. In addition, the patient and family members or friends should be told the names, doses, and dose frequency of the patient's drugs.

During the first weeks after discharge, family and friends should make sure that

  • The patient is not left alone.

  • The patient's adherence to the prescribed drug regimen is monitored.

  • The patient is asked daily about general state of mind, mood, sleep pattern, and energy (eg, for getting up, dressing, and interacting with others).

The patient's family member or friend should take the patient to follow-up appointments and should inform the health care practitioner of the patient's progress or lack of it. These interventions should be continued for several months after discharge.

Table
icon

Risk Factors and Warning Signs for Suicide

Type

Specific Factors

Demographic data

Male

Age 45–64

Social situation

Personally significant anniversaries

Unemployment or financial difficulties, particularly if they caused a drastic fall in economic status

Recent separation, divorce, or widowhood

Recent arrest or trouble with the law

Social isolation with real or imagined unsympathetic attitude of relatives or friends

History of suicidality

Previous suicide attempt

Making detailed suicide plans, taking steps to implement the plan (obtaining a gun or pills), and taking precautions against being discovered

Family history of suicide or a psychiatric disorder

Clinical features

Depressive illness, especially at onset

Marked motor agitation, restlessness, and anxiety with severe insomnia

Marked feelings of guilt, inadequacy, and hopelessness; perception of being a burden to others (burdensomeness); self-denigration; nihilistic delusion

Delusion or near-delusional conviction of a physical disorder (eg, cancer, a heart disorder, sexually transmitted disease) or other delusions (eg, delusions of poverty)

Command hallucinations

Impulsive, hostile personality

A chronic, painful, or disabling physical disorder, especially in formerly healthy patients

Drug use

Alcohol or substance use disorder (including abuse of prescription drugs), especially if recent use has increased

Use of drugs that may contribute to suicidal behavior (eg, abruptly stopping paroxetine and certain other antidepressants can result in increased depression and anxiety, which in turn increases risk of suicidal behavior)

Although some attempted or completed suicides are met with surprise and shock, even by close relatives and associates, clear warnings may have been given to family members, friends, or health care practitioners. Warnings are often explicit, as when patients actually discuss plans or suddenly write or change a will. However, warnings can be more subtle, as when patients make comments about having nothing to live for or being better off dead.

On average, primary care physicians encounter 6 potentially suicidal people in their practice each year. About 77% of people who die by suicide were seen by a physician within 1 year before killing themselves, and about 32% had been under the care of a mental health care practitioner during the preceding year.

Because severe and painful physical disorders, substance use disorders, and mental disorders (particularly depression) are often a factor in suicide, recognizing these possible factors and initiating appropriate treatment are important contributions a physician can make to suicide prevention.

Each depressed patient should be questioned about thoughts of suicide. The fear that such inquiry may implant the idea of self-destruction is baseless. Inquiry helps the physician obtain a clearer picture of the depth of the depression, encourages constructive discussion, and conveys the physician’s awareness of the patient’s deep despair and hopelessness.

Even people threatening imminent suicide (eg, those who call and declare that they are going to take a lethal dose of a drug or who threaten to jump from a high height) are thought to have some desire to live. The physician or another person to whom they appeal for help must support the desire to live.

Emergency psychiatric aid for suicidal people includes the following:

  • Establishing a relationship and open communication with them

  • Inquiring about current and past psychiatric care and drugs currently being taken

  • Helping sort out the problem that has caused the crisis

  • Offering constructive help with the problem, which includes a written safety plan developed with the patient

  • Beginning treatment of the underlying mental disorder

  • Referring them to an appropriate place for follow-up care as soon as possible

  • Discharging low-risk patients in the company of a loved one or a dedicated and understanding friend

  • Providing these patients with the telephone number for Lifeline—1-800-273-TALK (8255)—or with links to the online Lifeline Crisis Chat, Crisis Text Line (text HOME to 741741), or the American Foundation for Suicide Prevention

  • Providing access to information about suicide prevention

Prevention references

  • 1. Wyman PA, Brown CH, LoMurray M, et al: An outcome evaluation of the Sources of Strength suicide prevention program delivered by adolescent peer leaders in high schools. Am J Public Health 100:1653-1661, 2010. doi: 10.2105/AJPH.2009.190025

  • 2. Gould MS, Cross W, Pisani AR, et al: Impact of applied suicide intervention skills training (ASIST) on national suicide prevention lifeline counselor. Suicide Life Threat Behav 43:676-691, 2013. doi: 10.1111/sltb.12049

  • 3. Garraza LG, Kuiper N, Goldston D, et al: Long-term impact of the Garrett Lee Smith Youth Suicide Prevention Program on youth suicide mortality, 2006–2015. J Child Psychol Psychiatr 60(10):1142-1147, 2019. doi:10.1111/jcpp.13058

  • 4. National Action Alliance for Suicide Prevention: Transforming communities: Key elements for the implementation of comprehensive community-based suicide prevention. Washington, DC: Education Development Center, Inc. Accessed 5/3/21.

Treatment of depression and risk of suicide

The combination of antidepressants and some proven short-term psychotherapy is the ideal treatment for depression.

People with depression have a significant risk of suicide and should be carefully monitored for suicidal behaviors and ideation. Risk of suicide may be increased early in the treatment of depression, when psychomotor retardation and indecisiveness have been ameliorated but the depressed mood is only partially lifted. When antidepressants are started or when doses are increased, a few patients experience agitation, anxiety, and increasing depression, which may increase the likelihood of suicidal thoughts and even behavior in rare instances.

Recent public health warnings about the possible association between use of antidepressants and suicidal thoughts and attempts in children, adolescents, and young adults have led to a significant reduction (> 30%) in antidepressant prescriptions to these populations. However, youth suicide rates increased by 14% during the same period. Thus, by discouraging pharmacologic treatment of depression, these warnings may have temporarily resulted in more, not fewer, deaths by suicide. Together, these findings suggest that the best approach is to encourage treatment, but with appropriate precautions such as

  • Dispensing antidepressants in sublethal amounts

  • Preferentially using antidepressants that are not lethal if taken in overdose

  • Providing more frequent monitoring and visits early in treatment

  • Giving a clear warning to patients and to family members and significant others to be alert for symptoms such as agitation, insomnia, or suicidal ideation

  • Instructing patients, family members, and significant others to immediately call the prescribing clinician or seek care elsewhere if symptoms worsen or suicidal ideation occurs

Several studies have shown that lithium, when given with antidepressants and atypical antipsychotics, reduces the number of deaths by suicide in patients with major depression or bipolar disorder. Lithium, even in low doses, is highly effective as an anti-suicidal drug for recurrent depression. In addition, clozapine reduces suicide risk in patients with schizophrenia.

There are multiple new treatments under investigation for the depressed suicidal patient, including psychologic interventions and medical interventions with intranasal esketamine and drugs used for treatment of alcohol and opioid withdrawal. Intranasal esketamine is now approved for adults with treatment-refractory depression and those with major depressive disorder and suicidal ideation.

Electroconvulsive therapy (ECT) is still effective for the treatment of severe depression and for suicidal depression. ECT and transcranial magnetic stimulation (rTMS) have been approved for treatment-resistant depression and can be considered for patients with severe treatment-refractory depression, psychotic depression, or bipolar disorder. Both of these forms of treatment may also be helpful in reducing suicide risk (1, 2).

Treatment references

  • 1. Kellner CH, Fink M, Knapp R, et al: Relief of expressed suicidal intent by ECT: A consortium for research in ECT study. Am J Psychiatry 162(5):977-982, 2005. doi: 10.1176/appi.ajp.162.5.977 doi:10.1176/appi.ajp.162.5.977

  • 2. George MS, Raman R, Benedek DM, et al: A two-site pilot randomized 3 day trial of high dose left prefrontal repetitive transcranial magnetic stimulation (rTMS) for suicidal inpatients. Brain Stimul 7(3):421-431, 2014. doi: 10.1016/j.brs.2014.03.006

Effect of Suicide

Any suicidal act has a marked emotional effect on all involved. Losing someone to suicide is a particularly painful and complex type of loss. Suicide-related grief differs from other types of loss because of unanswered questions surrounding why someone died by suicide and because many people have limited knowledge about suicide. In an effort to make sense of the inexplicable and shocking event (suicide), people frequently launch an intense search for information and generate a series of hypotheses about why the suicide occurred. This can lead to guilt, blame, and anger directed at themselves and others for not having prevented the suicide, and also anger at the loved one who died. This natural part of suicide grief is generally extremely intense in the initial few months, and often lessens in intensity in the second year and beyond.

A large number of individuals are affected by each suicide death, including family members, friends, colleagues and others. An international meta-analysis of population-based suicide loss studies found 4.3% of community members had experienced another’s suicide in the past year, and 21.8% during their lifetime. In the United States, even higher rates of exposure were found. From a national sample of 1432 adults, 51% had been exposed to suicide and 35% met criteria for suicide bereavement (defined as experiencing moderate to severe emotional distress related to the suicide loss) at some point in their life (1–3).

The physician can provide valuable assistance to patients who are suicide bereaved.

For clinicians who lose a patient to suicide, the experience can be far more distressing than other clinically related deaths. It is often similar to the traumatic and profoundly distressing experience of the death of a physician's family member rather than to the loss of a patient. In one study, half of psychiatrists who lost a patient to suicide had scores on the Impact of an Event Scale comparable to those of a clinical population who had experienced the death of a parent (4). The loss experience for health professionals often has both personal and professional ramifications, which can include anguish, feeling of guilt, self-doubt, complicated grief, and even thoughts of leaving the profession. There are resources available to clinicians for support through several organizations (American Foundation for Suicide Prevention, American Association of Suicidology, Jed Foundation; [5]), and curriculum are also available to teach trainees and prepare them for the experiences of losing a patient to suicide (6).

Effect of suicide references

  • 1. Berman AL: Estimating the population of survivors of suicide: Seeking an evidence base. Suicide Life Threat Behav 41(1):110-116, 2011. doi:10.1111/j.1943-278X.2010.00009.x

  • 2. Andriessen K, Rahman B, Draper B, et al: Prevalence of exposure to suicide: A meta-analysis of population-based studies. J Psychiatr Res88:113-120, 2017. doi: 10.1016/j.jpsychires.2017.01.017

  • 3. Feigelman W, Cerel J, McIntosh JL, et al : Suicide exposures and bereavement among American adults: Evidence from the 2016 General Social Survey. J Affect Disord 227:1-6, 2018. doi: 10.1016/j.jad.2017.09.056

  • 4. Hendin H, Lipschitz A, Maltsberger JT, et al: Therapists' reactions to patients' suicides. Am J Psychiatry 157(12):2022-2027, 2000. doi: 10.1176/appi.ajp.157.12.2022

  • 5. Sung JC: Sample agency practices for responding to client suicide. Forefront: Innovations in Suicide Prevention. 2016. Accessed 5/18/21.

  • 6. Lerner U, Brooks K, McNeil DE, et al: Coping with a patient’s suicide: A curriculum for psychiatry residency training programs. Acad Psychiatry, 36(1):29-33. 2012. doi: 10.1176/appi.ap.10010006

Physician Aid in Dying

Physician aid in dying (formerly, assisted suicide) refers to the assistance given by physicians to people who wish to end their life. It is controversial but legal in 9 US states (California, Colorado, Hawaii, Maine, Montana, New Jersey, Oregon, Vermont, Washington) and the District of Columbia and is under consideration in 17 other states. All states where physician aid in dying is legal have guidelines for participating patients and physicians, such as eligibility and reporting requirements (eg, the patient must be mentally competent and have a terminal illness with a life expectancy of < 6 months). Voluntary euthanasia is legal in the Netherlands, Belgium, Colombia, and Luxembourg. Assisted suicide is legal in Switzerland, Germany, and Canada.

Physician-assisted suicide (or aid in dying) involves making lethal means available to the patient to be used at a time of the patient’s own choosing. In voluntary active euthanasia, the physician takes an active role in carrying out the patient’s request; it usually involves IV administration of a lethal substance.

Despite the limited availability of physician aid in dying, patients with painful, debilitating, and untreatable conditions may initiate a discussion about it with a physician.

Physician aid in dying may pose difficult ethical issues for physicians.

More Information

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.

  • American Association of Suicidology: A developer and provider of professional training programs to mental and physical health providers who may encounter suicidal individuals, the American Association of Suicidology offers accreditation and training opportunities for organizations and individuals. This organization also provides support to clinicians whose patients have died by suicide.

    American Foundation for Suicide Prevention: Empowers those affected by suicide by funding research, educating the public about mental health issues and suicide prevention, supporting suicide survivors and those who have lost a loved one to suicide, and advocating for relevant public health policies.

  • International Association for Suicide Prevention : Publications, activities, and resources for academics, mental health professionals, crisis workers, volunteers, and suicide survivors.

  • Jed Foundation: The Jed Foundation partners with high schools and colleges to strengthen the mental health or teens and young adults and thus prevent suicide. This organization also provides support to clinicians whose patients have died by suicide.

  • National Suicide Prevention Lifeline: Provides 24/7 support for people in distress. Content available in various formats (eg, for the deaf and hard of hearing) and in Spanish.

  • Preventing Suicide: A technical package of policy, programs, and practices: Issued by the National Center for Injury Prevention and Control, this PDF is a compilation of best practices to help communities and states hone their suicide-prevention activities by focusing on interventions at several levels: the level of the individual, their relationships, the community, and society as a whole.

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