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The Nature Of Suicide
Defining Suicide
Suicide Warning Signs
Suicide: A Reactive Action
How Do You Know Your Level Of Suicide Risk?
Why Does Suicide Seem Like A Solution To Your Problem(s)?
How Did You Get To This Suicidal Place?
Coping With Suicidality
Suicide Prevention And Societal Measures
Becoming Suicidal: Biological Contributions
Becoming Suicidal: Sociocultural Contributions
Tying It All Together: Why Does Someone Become Suicidal?
Suicide Triggers
Suicide Triggers Continued
Other Factors Contributing To Suicide Risk
Suicide: What Will Happen To You When You Ask For Help?
Suicide: What Do You Do Now?
Outpatient Suicide Treatment-Finding A Psychotherapist
Community And On-line Self-Help Resources For Major Depression
Fill out a Safetry Plan and keep it handy. I'm talking to you
Find a mental health provider
Suicide Statistics
Related topics: Are you feeling suicidal? Attempts, Crisis Text Line, Crisis Trends, Contagion/Clustering, Depression, Emergency Phone/Chat/Text Numbers, Euthanasia, Facebook Live , Guns, How to Help, How to talk with your kids about suicide, Mental Illness, Need to Talk?, Online Depression Screening Test , Oregon Suicides 1990 to date, Prevention, Religion, Safety Plan, Secrets No More, 741741, Semicolon Campaign, Stigma, Struggling Teen, Suicide, Suicide Internationally, Suicide Notes, Suicide Resources, Suicide 10-14 Year-Olds, Teen Depression, Teen Suicide, 3-Day Rule, 13 Reasons Why', Veterans, Warning Signs

The Nature Of Suicide

This introductory document discusses suicide; the taking of one's own life. It is intended to educate readers about the nature of suicide.

Research indicates that the risk for suicidal behavior or suicidal tendencies is elevated due to substance use disorders, particularly alcohol abuse. If you are abusing alcohol or other illicit substances, please read about treatment here.

However, if you are seriously considering committing suicide right now, you don't need education about the nature of suicide.

  • You need immediate support from caring people who can help you get through this crisis and rediscover meaning in your life.
  • You need to stop everything else and get help as soon as possible, no matter how badly you feel, because otherwise, you may kill yourself in short order.

If you are seriously suicidal right now - if you know that you will harm yourself unless something happens very shortly to stop you from doing so - PLEASE take the following steps right now:

  • Go to the nearest emergency room (or have a friend or family member take you there) and tell the admitting staff there that you are "acutely suicidal".
  • If you cannot get yourself safely to the emergency room, call the emergency operator (911 in the United States) and ask for assistance. Again, tell the operator that you are acutely suicidal and require immediate help.

"Acutely" Suicidal

Your use of the term "acute" tells the people you're speaking with that you are in immediate danger of committing suicide right now, and that they need to act quickly to help keep you safe.

If you are still reading (and not on the phone with an emergency operator, or already on the way to the hospital), we'll take it as a sign that you are not acutely suicidal right now.

Though you may not be in crisis this moment, you may be experiencing a great deal of emotional pain nevertheless, and seeking information about how to best deal with that pain.

If that is the case, feel free to skip over this introductory article and go right to our article discussing practical tips and suggestions for coping with and managing suicidal feelings and thoughts.

If you are a friend or family member seeking practical information about how to deal with another person who is suicidal, we have another article written specifically for you. We hope you will find this practical information to be useful.

If you are still reading, we'll take that as a sign that you have a few minutes to spend learning about suicide (rather than just reacting to it). It's useful to learn about the nature of suicide, because knowing this information can help you to keep your suicidal feelings (or the suicidal feelings of a loved one) in perspective, and can thus make you more able to manage those feelings, rather than be managed by them. In this article:

  • We lay the foundation for our discussion of suicide by first defining the types of behaviors and thoughts that fit the definition of "suicidal".
  • We then share important information concerning the number of people who commit suicide each year, and their typical characteristics and issues.
  • We also discuss why someone might commit suicide. We end our discussion with a some societal recommendations for the prevention of suicide.

Keep in mind that you always have the option of picking up the phone or text and calling or texting for help should you become overwhelmed by suicidal feelings while reading this article.

  • Call the emergency operator (911 in the United States) or take yourself to the emergency room at the local hospital.
  • Call a suicide hotline. The National Suicide Prevention Lifeline phone number is: 1 (800) 273-8255. For the National Crisis Text Line text SOS to 741741 on your cell phone.
  • Find and review the Safety Plan that you made while waiting for help to arrive.
  • Taking these actions will help keep you safe.
  • Maybe not entirely comfortable; maybe embarrassed; maybe even ashamed; but safe, nevertheless.


Defining Suicide

The term suicide describes the act of taking one's own life. There are various kinds of suicide, so our first task is to clarify our use of the term. Within this article, we are referring to suicide in the conventional sense, in which someone plans out or acts upon self-destructive thoughts and feelings, often while they are experiencing overwhelming stress. “Assisted suicide” occurs when a physician helps a terminally ill person to die, avoiding an imminent, inevitable and potentially painful decline. Our current discussion of suicide does not address assisted suicide.

The intent of suicidal behavior, whether consciously or unconsciously motivated, is to permanently end one's life. Truly suicidal acts (or, as they are sometimes called, "gestures") need to be distinguished from other self-harming, self-injurious, or parasuicidal acts and gestures which are also deliberate, but not intended to cause death. Typical self-injurious acts include cutting or burning oneself. The intention behind these behaviors is to cause intense sensation, pain and damage, but not to end one's life. Self-injurious behaviors may lead to accidental suicide if they are taken too far, but their initial intent and goal are not suicidal.

Though self-injurious behavior is not suicidal behavior, it isn't exactly healthy behavior, either. If you engage in or have the urge to engage in self-injurious behavior it is also important that you seek mental health care. Dialectical Behavior Therapy (or DBT, as it is commonly known) is an effective and now widely available form of psychotherapy that helps people who injure themselves learn and practice alternative and safe means of coping with life stresses, and, by doing so, reduces their self-harming tendencies. Various medications, prescribed by a psychiatrist, can also be helpful in reducing the need to act out self-harming impulses.

Suicidal feelings and impulses sometimes co-occur with homicidal (i.e., murderous) feelings and impulses. Some people who feel that life is not worth living also come to feel that others' lives should not continue either. Such people may then decide to end the lives of other people prior to (or in conjunction with) killing themselves. Motivations behind suicide-homicide events can include a desire to punish some person (or people), or gain revenge over a those who have caused intolerable pain to the suicidal individual. Such events may also be motivated by religious beliefs or by military orders. Some examples of suicide-homicide include: suicide bombings, joint suicide, cult suicide, school or workplace massacres followed by suicide (such as the 2007 Virginia Tech shootings), or situations where people kill their families and then kill themselves. We aren't going to talk further about suicide-homicide events in this document. However, if you are experiencing both suicidal and homicidal impulses, for the safety of yourself and others around you, it is important that you get help for yourself as soon as possible so that these impulses can be properly and safely addressed.

Suicidal Ideation

Suicidal ideation is a term used by mental health professions to describe suicidal thoughts and feelings (without suicidal actions). For example, people experiencing suicidal ideation commonly report that they feel worthless, that life is not worth living, and that the world would be better off without them. The presence of suicidal ideation, occurring alone in the absence of any plans to act out actual suicide, anchors the low/less-dangerous end of the suicide risk continuum. The potential for someone engaging in suicide is still there, but the risk is not acute (i.e., immediate).

Even though suicidal ideation is considered less serious than actual suicide attempts, it can be a real cause for concern. The fact that suicidal ideation is occurring at all suggests a very real possibility that suicide could occur should circumstances become worse and stress levels mount. Anyone who has suicidal ideation is at some risk of becoming actively suicidal.

A further problem is that once suicidal ideation has become established, it can become a "cognitive habit"; something that reappears periodically and spontaneously during times of stress as an automatic and habitually negative, dysfunctional style of thinking. Such dysfunctional automatic thinking styles are especially common in people who are currently depressed or who are recovering from a previous period of depression. The continuing presence of such styles of thinking in a person who has recovered from depression can be a risk factor for further depression and for suicidal gestures.

Suicidal Gestures

Suicidal ideation is only dangerous to the extent that it motivates suicidal planning and actions. Moving from thinking about suicide to considering a specific suicidal plan represents an increase in the level of suicide-danger risk, no matter whether the plans made are concrete or vague; organized, or haphazard. When suicidal actions occur, the level of suicide-danger risk increases.

Actual attempts to kill yourself are labeled "suicidal gestures" or "suicide attempts" by mental health professionals, no matter how ineffective those attempts may ultimately be. Suicidal gestures may be acted out with full lethal intent, or they may be acted out half-heartedly, more as a means of communicating the depths of your pain to others around you than an actual effort to end your life. Regardless of the intent and degree of seriousness that motivates them, suicidal gestures are often dangerous events. Even ambivalent, half-hearted suicidal gestures can result in a completed suicide.

Suicide Warning Signs

Having suicidal thoughts is the most important and most common warning sign for suicidality. If you regularly focus on themes of suicide or death in conversation (e.g., talking about giving up on life, or how others would be better off without you), thinking, writing, music or artwork, you may be at risk. Even though not all suicidal thoughts represent an emergency, such ideation is a signal, and should be taken seriously. You should seek help from trained mental health professionals as soon as possible. Don't let suicidal thoughts continue unchecked and potentially become worse. This type of thinking may also be a symptom of an ongoing mental health problem (such as depression) which can often be successfully treated.

In addition to suicidal ideation, there are other potential danger signals that suggest increased suicide risk. These signs may occur in isolation, or in pairs and combinations. The presence of any of these warning signs may also indicate that you are experiencing a mental or physical disorder in addition to being suicidal; so, make sure to investigate the cause of any unusual or worrisome changes.

Additional warning signs of suicide can include:

  • decreased performance in school or work
  • an unusual desire for social isolation
  • a decrease in self-esteem
  • increased emotionality (anger, agitation, anxiety, hopelessness, sadness, etc.)
  • a sudden decrease in emotionality; particularly, a movement from depression or agitation to remarkable and uncharacteristic calm
  • uncharacteristic behaviors or emotions
  • uncharacteristic carelessness concerning personal safety
  • increased drug and/or alcohol use
  • an urge to tie up lose ends (e.g., giving away personal items, making a will)

If you have a history of depression, or are recently recovering from a depressive episode, you may also be at risk. It seems weird to think that because you are getting better, you might be more suicidal. However, an increased level of energy coming off a depression may be just the boost you needed to propel you to plan and act upon your suicidal feelings.

As mentioned above, your level of risk has increased if you have moved beyond just thinking about killing yourself to a process of planning how suicide can be accomplished. Suicidal people will often start assembling their "suicide kit" (e.g., those tools and ingredients they will need to end their life according to their chosen method). For instance, someone who has decided to overdose herself on pills may start stockpiling medicines. Someone who has decided to shoot himself may purchase a gun or ammunition. Attempts to obtain tools that might be used for suicide can thus also be a warning sign of suicide-risk.

If your suicidality has progressed to the point where you are presently engaged in assembling the means of your suicide, you are in acute, immediate and substantial danger of harming yourself.

Suicide: A Reactive Action

Suicidal acts seldom occur spontaneously. Rather, they are typically planned and premeditated events triggered by a chain of stressful internal and external circumstances. In other words, most suicide occurs as a reaction to stressful events. Since suicidal impulses are reactive, such urges typically fade as stressful events subside. It is not inevitable that you will continue to feel the urge to commit suicide just because the idea enters your head. If you can find a different, more effective way to cope with or think about the stressful events that have caused you to think in a suicidal direction, your suicidal thoughts and the impulse to act upon them will usually decrease.

As suggested above, suicidality is often described as occurring along a continuum of potential lethality and intent. Lethality has to do with how likely some action is to cause death. Intent has to do with how determined you are to succeed. The more you are determined to kill yourself, and the more lethal the methods you choose to end your life with, the more dangerous is your situation.

Your moment-to-moment level of risk is influenced by multiple factors, including: whether you have a specific and defined plan for committing suicide, easy access to the tools you need to carry out your plan, and a history of past suicidal gestures. All of these things increase your present risk of committing suicide.

Your psychological state is, of course, a vital component in determining your risk. If you are in a good place in life, your risk is lower than if you are experiencing a stressful life crisis. Further, if you are able to cope and manage the degree of stress you are currently experiencing, your risk is lower than if you are feeling overwhelmed by circumstance. We will discuss other factors that contribute to your suicide risk in a later section of this document. Right now, it's important to understand that people often move backwards and forwards across this spectrum of suicide-danger-risk as the circumstances that trouble them change and their related emotions wax and wane.

The Suicide Crisis

Suicidal ideation is relatively common and is not necessarily associated with a crisis situation. Instead, it may be a symptom of an ongoing problem that is difficult to address without outside assistance (such as depression). In contrast, suicidal gestures typically occur in the context of crisis periods, or periods that are associated with overwhelming stress, seemingly unbearable and unendurable emotional and/or physical pain, and which seem to have no possible solution other than suicide.

The stresses endured by people in a suicidal crisis are undoubtedly severe and overwhelming, but they are not typically unsolvable or permanent. They seem that way to people who are experiencing the crisis, however, because their strong emotions overwhelm, interfere with and degrade their ability to think rationally and to place their problems in perspective.

The thinking of people who are experiencing a suicidal crisis is typically clouded and negatively biased, intensely self-focused, and highly emotional. As discussed previously, homicidal feelings may intermingle with suicidal feelings if there is a sense that someone else has deliberately caused harm. Feelings of loneliness, isolation, alienation, anger and rage are common, as well as the following kinds of thoughts:

  • Hopelessness:
  • A sense that things will never get better
  • A feeling of inability or lack of motivation to change the situation
  • A belief that your emotional pain is permanent or too much to bear
  • A sense of personal worthlessness, self-hatred or self-loathing
  • A sense that all meaning has been removed from life
  • A sense that suicide is the only way to make the stressors stop (founded upon the utter sense of hopelessness described above).

Even though it is very hard to believe it in the moment of crisis, the following statements are almost always true:

  • Suicidal crises are temporary conditions.
  • The intensity and urgency associated with suicidal crises tends to disappear or diminish with time.
  • People CAN be helped through suicidal crises if they are open to accepting appropriate help and treatment.


How Do You Know Your Level Of Suicide Risk?

Mental health professionals tend to think about suicidal feelings and thoughts on a continuum or spectrum, with high risk and imminent danger on one end, and low risk and little imminent danger on the other. As a general rule, the level of danger suicidal people present to their own lives increases dramatically as they progress along the steps towards suicide. This is to say, people's risk goes up as they move from 1) thinking about suicide (e.g., suicidal ideation), to 2) planning their suicide, to 3) collecting the necessary equipment, and then finally 4) actually trying to commit suicide. The earlier in this progression suicidal people can be identified and helped, the better.

It is very difficult to accurately predict suicide risk and suicide outcomes, even your own! The best guide when trying to predict suicide is a history of past suicidal behavior. Therefore, if you have a history of past serious suicide attempts you should assume that your present day suicide crises are just as significant and serious as your past ones, if not more so.

People who go on to attempt suicide often, but not always, show some warning signs before engaging in this behavior. If you can recognize your own warning signs before you attempt suicide, you can potentially save yourself. You'd think that recognizing your own warning signs would be easy, but it isn't always the case. Warning signs for suicide can be obvious or subtle. They may build up gradually or come on suddenly. There isn't always a specific "red light" thought in your head that suicide is where you're going.

You should be concerned if you notice yourself starting to think in suicidal ways. We suggest that if you start to think about suicide as a good idea, this is an indication that you could benefit from professional mental help. On the other hand, it is also true that many more people exhibit suicide warning signs than go on to actually attempt suicide. Though it is possible that your suicide warning signs may be a false alarm, you should take them seriously anyway, just in case.

Why Does Suicide Seem Like A Solution To Your Problem(s)?

  • You may not be aware (or you may be forgetting) that there are other means you might bring to bear in solving your problems and coping with your stressors. Examples of coping mechanisms you might not be taking full advantage of include but are not limited to: psychotherapy, medication, various forms of social, occupational and educational assistance, and the support of other people who get where you are coming from.
  • You may be confusing thoughts that feel true for thoughts which are true. There is a difference! Just because you feel hopeless doesn't mean that life and your situation are truly hopeless. In most cases, a variety of thinking errors (called cognitive biases) conspire to make situations seem more dire than they really are.
  • You may be assuming that your current feelings and situation will never change for the better. This is not likely. Suicidal feelings and thoughts tend to decrease over time. Suicidal feelings are NOT a permanent state in most cases. Your mental state will change with time, your pursuit of treatment, and your active efforts to alter the things in the environment that are bothering you. It is very likely that if you kill yourself, you will have confused the temporary for the permanent.
  • You may not be thinking about the other people you will harm. Suicide will affect your entire family as well as your close friends. All of the people who are close to you will be very wounded by your death, and the ones who care about you the most, or need you the most, will be the most affected. If there is even one person in your family (or one friend, even) that you care about, your suicide will carve a permanent hole into that person's heart that will never quite successfully heal. Life will go on, of course, but living with a permanent grief is never a good state of affairs.
  • You may be thinking that this is an effective way to punish or communicate pain to people who have previously hurt you. You may be thinking "I will show them all", that you'll prove something, or get someone to to listen to you or take you seriously. Your decision to commit suicide won't prove anything. Plus, if you're gone, how people react to you or think about you doesn't matter anyway. There is nothing you can do, ultimately, to force other people to change, or to care about you. However, you can change your responses and reactions to them. Also, if you can learn to care about yourself, you will find that various people notice that, and will start to care about you. It's not a paradox, but it may seem like one at first.
  • You may have a mental illness that is contributing to your suicidal thoughts. Alternatively, you may have become suicidal in response to having to cope with a chronic physical or mental illness. Feeling suicidal is pretty common when you're moderately or seriously depressed. If you are depressed, things that used to feel good to you will lose their motivating capability. It is common to feel worthless and helpless and to start thinking in negative and extreme ways when you are depressed. . For example, it's common for depressed people to start taking responsibility for all the negative things that have ever happened to them, while simultaneously discounting their role in helping to create the good things that have happened. You may rewrite history so it seems that things have always been terrible/horrible/awful when this isn't really entirely the case. In general, the brain starts doing a sort of attentional narrowing and filtering such that everything is seen through the excrement-colored glasses of depression. Your perspective and your vision narrows until everything looks depressing and there is no apparent way out. Once this negative thinking style sets in your judgment becomes compromised and it is rather easy to look to suicide as the "only way out" and as an appropriate and well deserved fate. In depression, even though these sorts of thoughts occur frequently, they are NOT TRUE! Fortunately, cognitive behavioral therapy for depression, and various anti-depressant medications can help clear up these negative thought biases. For more information about how depression can affect your thinking, please click here.
  • You may also have forgotten to thoroughly think through the ramifications of committing suicide. Some people have impulsive personalities, or are sensation seekers that like to "live life on the edge." If you fit into either of these categories, take a moment right now to stop and think carefully about what you are considering. It may even be helpful to make a list of the pros and cons of engaging in self-destructive behavior. If you are unable to think clearly, find a trusted friend, family member, or mental health professional to help you sort through everything. You may need ongoing help from a mental health professional in order to "reign in" your tendency to act without careful deliberation. There are other ways to achieve the "high" or "alive" feeling you desire that don't involve harming yourself.

Are you the only person that feels this way?

Absolutely not!!! You're in good company, in fact. Estimates suggest that approximately 800,000 Americans attempt suicide per year. This number most probably underestimates the true magnitude of the issue, but there is no way to tell for sure. According to official statistics, suicide was the 11th leading cause of death in the US in 2001.

We don't present these numbers in order to lead you to think that suicide is the best way to handle your situation. Just to show you that a lot of people come to see suicide as attractive in any given year. Use this statistic to remind yourself that you are not alone, and that mental health professionals have tons of experience helping people who have been through experiences that are similar to what you are going through now

How Did You Get To This Suicidal Place?

Suicide can be thought of as an extreme method of coping that some people choose when faced with circumstances that are overwhelming their ability to function. It may seem odd to characterize suicide as a coping method. Coping is usually thought of as an adaptive behavior that provides a positive outcome. Technically speaking, though, coping is simply a collection of potential behaviors that can be used to reduce stress. The specific behaviors we choose are not necessarily positive, and can actually cause harm. For instance, drinking excessively, working too much, and ignoring our problems are all ways to (at least temporarily) distract ourselves from stress, and are therefore "coping" behaviors. However, they are not healthy or adaptive in the long run. Suicide is an extreme example of harmful coping behavior.

As a coping mechanism, suicide is generally a method of last resort. Suicidal people have come to believe (often mistakenly, but firmly nevertheless) that suicide represents their only hope of escape from an overwhelming, chronic and negative situation. Suicidal people choose death because they cannot or do not appreciate, or do not know about (i.e., never learned) alternative coping methods. Suicide can thus be prevented, to some extent, when suicidal people can be helped to expand and enhance their coping repertoire. Suicidal people cannot do this work on their own because, by definition, they have already concluded that suicide is the only means of relief currently available to them. Instead, assistance from other people is often necessary: first to interrupt and disarm any active suicide attempts and defuse the danger of the immediate suicidal crisis, and second, to help expand the suicidal person's perspective and access to coping resources through teaching. If you are feeling acutely suicidal, the smartest and best thing you can do is to seek help from mental health or health professionals.

The circumstances that have led you to feel suicidal are probably a combination of several different factors. We review risk factors and potential suicide triggers in our introductory article (click here for more information). For right now, know that there is no one reason why someone becomes suicidal. It's probably a combination of biology and genetics (e.g., you may have inherited a tendency to develop a mental illness and/or a tendency to react poorly to stress), psychological factors (e.g., you tend to think about yourself and your surroundings in a negative way), and social factors (e.g., you may have experienced a traumatic event, or you simply cannot deal with a stressful event (a stressor) or series of stressors that have pushed you to the breaking point).

Because people are different, they are affected differently by stress. So, what is stressful to one person may not bother another. What is most important right now is that something (or multiple somethings) is/are stressful to YOU. Obviously, these issues are very important to you personally if they have pushed you to feel suicidal.

Here is yet another good reason to seek help from a mental health professional for your suicidal feelings and thoughts. This article that you are reading has tips for dealing with your thoughts and feelings, but they are not designed to fit you personally. A trained clinician can work with you to create a tailored, or customized plan you can use to help combat the unique set of stressors that have triggered your suicidal crisis.

The most frequent stressful event leading up to suicide in the US today is mental illness, which is estimated to account for about 90% of all suicides. Depression is the most common mental illness in people who commit suicide. The great news is that depression and most other forms of mental illness are treatable conditions. We now have a wonderful array of psychotherapies and medications available to help you if you are dealing with depression or other forms of mental illness. These treatments are not really something that can be done in a self-help mode, however. They require the assistance of one or more trained mental health clinicians to implement, which is yet another reason why it is a good idea for suicidal people to seek professional help.

Coping With Suicidality

First Things First: Get Effective Help RIGHT NOW If You're Suicidal

Our coverage of suicide, the taking of one's own life, is divided into three articles. The first article is intended to educate readers about the nature of suicide, the number of people who commit suicide each year, their typical characteristics and issues, and some societal recommendations for the prevention of suicide (if this is the type of information you are looking for please click here). The third article is designed for friends and family members who are interested in helping someone that they love (if you are interested in reading this information now, please click here). The article you are reading now is designed for people who are currently dealing with their own suicidal feelings and thoughts or who have done so in the past. While this article contains a number of tips and strategies for dealing with suicidal thoughts and feelings, it is NOT a substitute for the caring, compassionate, assistance you can get from talking to a live person who is trained to help you. Right now, if you are seriously suicidal - if you know that you will harm yourself unless something happens very shortly to stop you from doing so - PLEASE:

  • Go to the nearest emergency room and tell the admitting staff there that you are "acutely suicidal". Your use of the term "acute" tells the people you're speaking with that you are in danger of killing yourself right now, and that they need to act immediately to help keep you safe.
  • If you cannot get yourself safely to the emergency room by any other method, call the emergency operator (911 in the United States) and ask for assistance. Again, tell the operator that you are acutely suicidal and require immediate help. Stay on the phone with the operator, no matter how long it takes, until help arrives.
    Please get help right now. Even though suicide may seem like an option to deal with your pain or cope with whatever is going on that is stressful, it's actually a terrible idea. You are not thinking clearly right now. Suicide is not an effective way to reduce pain or cope with issues that are stressful. Killing yourself is not simply ending your pain or ending's ending your life. It is debatable whether ending your life will end your personal pain. However, it is not debatable that your suicide will have a negative effect on those you leave behind. Your family and friends will almost certainly suffer your loss, and the closer and more dependent they are upon you, the more deeply and permanently will be their suffering. Why not give yourself the chance to try some ways that we know can help to decrease pain and stress and stick around to see what that feels like?

    A likely outcome of reaching out for help is that you will be brought into the hospital as a psychiatric patient for a few days, until your immediate crisis passes. Few people find the idea of going into the hospital to be an entirely pleasant prospect, but that is always the case for whatever condition you might find yourself with, isn't it? You go to the hospital when you are sick - at risk of dying. If you are really acutely suicidal and have no other reliable means of keeping yourself safe, getting yourself to the hospital before you act can mean the difference between living and dying.

    Remember, mental health professionals are specifically trained to help keep suicidal people safe. They will not think you are weird for having these types of thoughts and feelings. With their help, finding ways to live a satisfying life and avoiding the tragedy of suicide can become real posibilities for you again - even if you can't see how this can be possible right now.

    If you are still reading (and not on the phone with an emergency operator), we'll take it as a sign that you are not acutely suicidal right now. Though you may not be in crisis this moment, you may be in significant emotional pain nevertheless, and seeking information about how to best deal with that pain. Please continue reading; we hope that the strategies we describe are helpful to you.

This article may bring up additional concerns and questions for you. If you are not acutely suicidal, but still need and want someone to discuss your feelings and thoughts with, please call 1-800-SUICIDE (1-800-784-2433) or 1-800-273-TALK (1-800-273-8255) or text SOS to the national crisis text line 741741. If, while reading this article, you notice that your suicidal feelings and thoughts become more intense, and that you are no longer able to keep yourself safe, please (as we discussed above) go the nearest emergency room or call 911 immediately.

Suicide Prevention And Societal Measures

We discuss the prevention of suicide at the level of what can be done to help individual suicidal people in our other chapters. Though this is very important information, it is only half of the equation. While there is truth to the idea that people become suicidal in part due to personal difficulties they have in coping with circumstances, it is also true that social issues influence suicide rates. These issues could be addressed and at least partially remediated if there were effective policies and institutions in place to address those issues (and enough money to fund them). Proper health policy changes and cultural attitude shifts could very likely prevent more suicides from occuring than an army of dedicated psychotherapists or a sea of hospital beds.

The best, most wide-reaching suicide prevention techniques exert their effects by helping to make our country, communities, organizations and families as physically and mentally healthy as possible. Sane policy to accomplish such a health-motivated agenda would contain effective and reasonably-funded measures to:

  • Combat stigma. The stigma surrounding suicidal thoughts and behavior, and other treatable factors linked to suicide risk (e.g., mental illness, subtance abuse, domestic violence, and child/elder abuse) creates several negative outcomes, resulting in diminished opportunities for employment and social relationships; lowered self-esteem; and a reluctance to seek help and/or treatment. Education about these issues is important to combat stigma as well as to promote knowledge of risk factors and treatment options.
  • Address necessary changes in our mental health care system. Untreated mental illness increases suicide risk. Approximately 50% of people who were mentally ill and committed suicide were not receiving treatment prior to their deaths. People who do receive mental health services are often undertreated, "lost" in the system (i.e., not followed across time as they move from different levels of care such as being discharged from an inpatient hospital setting to an outpatient clinic), and/or do not follow treatment recommendations. Many individuals do not have access to appropriate mental health care because the current system is disjointed and disorganized, and/or because they lack adequate insurance (or have no insurance at all).
    Mental health services should be delivered in an integrated fashion. In addition, insurance companies should be required to treat mental illnesses similarly to physical illnesses (often referred to as "mental health parity"). For instance, insurance companies should reimburse providers adequately, and maintain reasonable co-payments and eligibility for mental health services for patients. Laws and policies mandating mental health parity are necessary. Similarly, uninsured adults and children must be provided with appropriate mental health care services.
  • Adequately train current and new health care providers. Most people who complete suicide saw a health care professional within a year of their death; and 40% saw a clinician within a month of their death. Screening for depression, suicidality, and substance abuse is not routine in primary care settings. Primary care clinicians should be trained to recognize and screen for signs of depression, suicide, alcohol and substance abuse. However, we shouldn't simply add this task onto the other activities that these doctors must accomplish in 15-20 minutes without compensating them accordingly and allowing extra time for patient visits. At the very least, if primary care doctors are unable and/or unwilling to take on this additional role, we should have mental health "screeners" working in primary care offices.
    Most people receive medications intended to treat psychological conditions from primary care doctors. Many of these doctors have not received adequate training in prescribing and monitoring these types of medications. If we are going to continue to operate with this method of prescribing (i.e., obtaining psychiatric medications from primary care clincians rather than psychatrists), we need to require that primary care doctors are appropriately trained. Primary care offices should also establish linkages with nearby mental health clinicians who can offer assistance with complex cases, provide psychotherapy services, and allow more structured follow-up (symptom monitoring). Professional evidence-based guidelines for suicide risk screening, assessment, and referral need to be developed and used in primary health care settings.
  • Educate and Collaborate with the Media. Media professionals should be educated about their role in imitation/copycat and cluster suicides. Mental health and media professionals should work together to find appropriate ways to provide coverage of suicides (particularly regarding celebrities) across all media venues. In addition, this partnership could be used to develop (and study the effectiveness of) long-term public education campaigns about suicide, risk factors, and treatment options.
  • Limit Access to Methods. Access to guns should be reduced and more tightly regulated, especially for those who are mentally ill and at high risk of suicide. Family members of potentially suicidal young people often do not follow instructions about removing or securing firearms, or removing other means of suicide from the environment. Health care providers should be educated about how to better encourage families to cooperate with these guidelines.
  • Bolster Social Support Networks. Community-based groups and government programs need to work together to address the most prevalent needs for groups at risk of suicide, especially since the more natural supports of extended families, highly involved neighbors, and religious groups are either not intact or not equipped to do it all. Partnering mental health professionals with culturally relevant providers (including spiritual leaders) in easily accessible locations (and at convenient times) could increase access to and utilization of mental health services.
    Certain populations face additional barriers to treatment that increase their vulnerability to suicide. For instance, older adults and young children often have difficulty with transportation to and from treatment sites. Individuals from minority groups may face discrimination and/or health care providers who are ignorant and/or insensitive to their needs and style of handling mental illness and suicidality. Again, tailoring services to the needs of particular communities is vital.
    School-based programs can enhance social support, self-efficacy, and self-esteem, and may reduce depression, substance abuse, and suicidality in children. These programs should provide skills training for staff, teachers and administrators, include designated "gatekeepers" who are responsible for addressing these issues on a schoolwide basis, develop crisis response plans, and mechanisms for screening students. Longer-term approaches that include teaching, appropriate follow-through, and a coherent service plan are more effective than short-term educational seminars (i.e., having someone from the community come in and give a presentation).
  • Enhance Research on Suicide Statistics and Prevention. Suicidal individuals have been largely excluded from tightly controlled research studies investigating the effectiveness of medications, psychotherapy, and a combination of both due to liability concerns (from funding agencies; Institutional Review Boards, the committees that govern research with human subjects; and from individual researchers). As a result, we don't have very much or very good information about what treatment strategies are effective in reducing suicide. Large, interconnected research centers are studying other psychological conditions (e.g., bipolar disorder) and should also be used to investigate suicidality with long-term studies. Adequate funding should be provided for centers and researchers focused on investigating this issue.


Becoming Suicidal: Biological Contributions

Suicidal behavior can be viewed as a poor response to stress. Our reaction to stress is not only dependent on psychological variables, but our physiology (body makeup) also determines, in part, how we cope with stressful situations.

Specific Temperament Types Have an Increased Risk of Suicide

Personality is the relatively stable set of characteristics (called traits) that people display over time and across situations. Personality is composed of learned characteristics and genetically-based individual differences in attention, arousal, and reactivity to new or novel situations (called temperament).

Research suggests that suicidal adults and adolescents tend to display characteristic temperaments. The first is referred to as "depressive/withdrawn", "negativistic/avoidant", or "high in neuroticism". Individuals with the negativistic/avoidant temperament type show high levels of negative mood, have difficulty controlling their moods (particularly negative ones) and tend to "overreact" to daily stressors. As a result, these individuals are more likely to develop depression and anxiety disorders, and often commit suicide as a result. In addition, people with this temperament type often have histories of being abused or developing inadequate relationships with caregivers.

Other people who commit suicide have an "impulsive/aggressive" (sometimes called the "negativistic/avoidant/antisocial") temperament. These individuals also have difficulty controlling their emotions, particularly anger, and are more likely than the individuals described above to commit suicide in the absence of a mood disorder like depression or anxiety. People with this temperament type are often diagnosed with antisocial personality disorder (a long-standing pattern of a disregard for other people's rights, breaking laws, deceitfulness, irritability and aggressiveness, reckless disregard for safety of self or others, consistent irresponsibility), or show some antisocial behaviors. "Impulsive/aggressive" people are sensation seekers, so they often engage in risky behavior, make poor and/or snap judgments, and abuse alcohol and/or other substances. Children with this temperament type often have histories of abuse (particularly sexual abuse).

Research suggests that someone's temperament type is related to genes that control the regulation of the neurotransmitters (chemical messengers in the brain and nervous system) norepinephrine and serotonin (substances that influence mood regulation). Temperament is also influenced by the environment and can affect someone's ability to cope with stress (so, for example, individuals with the temperament types described above would likely have poor coping skills and subsequent ability to deal with stress). In addition, very early on, someone's temperament influences the responses they receive from their caregivers. Difficult and highly irritable infants are not fun to be around, and they often trigger negative responses from caregivers. Difficult children may also experience negative reactions from peers, which then increases their risk for developing mental disorders. In turn, youth with psychological problems or psychiatric disorders have a greater risk of being exposed to stressful events related to these disorders, which then influences personality development and so on.

An Individual's Genetic Makeup Can Influence Suicide Risk

Research suggests that genetic factors are highly related to a particular person's risk for committing suicide. Suicide "runs " in families; the offspring of suicide attempters and completers are much more likely to engage suicidal behavior themselves. In addition, there are high suicide rates among adopted children whose biological families have elevated rates of suicide. Research with twins also supports a genetic link to suicide; if a monozygotic (i.e., genetically identical) twin attempted suicide, his/her co-twin has a 17.5-fold increased risk of having made an attempt as well. Genetic data about suicide has also been collected on concordance rates (i.e., the presence of the same trait in both members of a pair of twins). There is a higher concordance rate for suicide among monozygotic than dizygotic twins (11.3% vs. 1.8%). In other words, if an identical twin commits suicide, the co-twin has an 11.3-fold increased risk of committing suicide as well.

It is not exactly clear which genes are related to suicide. However, many researchers suggest that there is not a specific gene (or set of genes) that are increasing someone's suicide risk per se. Instead, what is being transmitted is a likelihood of developing specific types of mental illness that increase the risk of committing suicide (e.g., depression), or a specific personality type (e.g., impulsive/aggressive temperament). Others suggest that the genetic transmission of problems in the body's stress response systems (e.g., the HPA axis described below) or problems in the ability to control mood and impulsive behavior are likely culprits.

Neurological and Neurochemical Differences Increase Suicide Risk

The hypothalamic-pituitary-adrenal (HPA) axis (a system tying together the hypothalamus and the pituitary gland in the brain with the adrenal glands near the kidneys) controls our body's responses to actual, anticipated, or perceived harm. In addition, the HPA axis regulates our ability to adapt to stressors over time. Dysregulation of the HPA axis, which, in susceptible people, can develop following traumatic events or chronic stress, has been linked to severe depression, severe anxiety disorders (particularly PTSD), and suicidal behavior.

In response to stress, the HPA axis produces glucose, cortisol, and steroids. Each of these chemicals prepares our body for the famous "fight (i.e., confronting a stressor) or flight" (i.e., running away from a stressor) response by increasing blood and oxygen flow to the muscles, increasing heart rate, dilating pupils, enhancing the immune response, and increasing alertness. However, the body response initiated by the HPA axis cannot be sustained for long periods of time without leading to illness. Autopsy studies show that people who committed suicide have elevated cortisol levels and enlarged adrenal glands, suggesting that their bodies were experiencing extreme stress.

Exactly how the HPA axis influences suicidal behavior is not yet clear. Some researchers suggest that increased cortisol levels affect the mood-regulating neurotransmitter serotonin, making it difficult for serotonin to get to brain and nervous system receptors (i.e., neurochemical "catchers" that, when stimulated, can create a response). Both suicide attemptors and individuals who died from suicide have shown low serotonin levels (or poor ability to receive serotonin) in the brain stem and cerebrospinal fluid. In addition to regulating mood, serotonin seems to help inhibit impulsive behvaiors. Someone with a malfunctioning serotonin system may be more likely to engage in suicidal and other potentially harmful impulsive acts.

Suicidal people also seem to have lower levels of norepinephrine (also called epinephrine or adrenaline) in the part of the brain called the locus ceruleus. Norepinephrine is a chemical messenger that affects the central nervous system and the bloodstream. When you are confronted with danger, epinephrine is released into the bloodstream, increasing your heart rate and blood pressure, readying you for action.

Becoming Suicidal: Sociocultural Contributions

The sociocultural factors that affect suicide rates operate at many different levels. The degree to which someone's surroundings exert a positive or negative influence depends on individual factors (e.g., demographic characteristics, life stressors, coping skills, and the biological dimensions linked to suicide described earlier) as well as whether an individual's family, community and country are supportive or stressful.

Sociocultural factors are impacted by psychological and biological factors. A person with a dysregulated HPA axis and an impulsive/aggressive temperament may look for confirming evidence that their community and life is completely negative (a cognitive distortion). They may begin acting in aggressive and self-destructive ways, and alienate friends, family, and colleagues who otherwise might help them through difficult times. Or, a person who is repeatedly subjected to family and community stress (e.g., a child who is abused and ill-served by the nearby social service agency) may sustain changes in their neurotransmitter systems and/or develop poor coping skills.

Social Support

No person is an island. Rather, identity is an inherently social thing. A social network of family, friend and colleague relationships is an important component of and foundation for many people's sense of self-esteem and self-efficacy. Those who enjoy close relationships with others also cope better with stressors and have better overall psychological and physical health. Social networks provide opportunity for emotional release and feeling connected to others. Isolation, on the other hand, can lead to feelings of alienation and depression that may ultimately lead to suicidal thoughts and behaviors. In addition, research has shown that social support can help prevent someone moving from suicidal ideation to suicide attempts.

Group Membership

Social and cultural groups can be supportive, creating feelings of belonging, love, and comfort, as well serving as a "safety net" to catch individuals who are experiencing problems or stressors. In these cases, individuals who feel suicidal can turn to friends, family members, or other acquaintances for emotional, financial, and practical (e.g., childcare, transportation) assistance. Being a member of a group that is tightly bound (i.e., highly integrated ) often serves as a suicide deterrent.

However, group membership can come with a price. Groups sometimes require stress-inducing obligations and high levels of commitment; and they may lead us to adopt behavioral and attitudinal norms (rather than thinking for ourselves). These types of groups can feel repressive and stifling and may actually contribute to suicidal thoughts and feelings. In extreme cases, groups can even demand that someone sacrifice him or herself for the "greater good."

Social Norms

A norm is a rule that is socially enforced. A particular group, community, or nation promotes norms regarding a range of attitudes and behaviors. For instance, there are norms with regard to how someone should act in a church or synagogue. Social norms regarding suicide can influence its meaning (i.e., whether it is stigmatized) as well as its frequency. Many societies and religious traditions ban suicide and view it as a sin or taboo behavior. Others portray suicide as a legitimate behavior in certain circumstances. For instance, some Islamic groups promote suicide as a means of martyrdom in a war against an enemy. Among Buddhist monks, self-sacrifice for religious reasons can be viewed as an honorable act. In India, it is acceptable for a widow to burn herself on her husband's funeral pyre. The Hindu code of conduct condones suicide for incurable diseases or as a response to great misfortune.

Social Change

Societies that are experiencing upheaval and unrest have higher rates of suicide. For instance, political violence can increase suicide rates- a long-standing civil war in Sri Lanka has been linked to a higher rate of suicide. Social change brought about by modernization, globalization, economic turmoil, and/or new political systems (particularly when they result in the breakdown of a culture's traditional values and cultures) can also be accompanied by a rise in suicide rates. Since the fall of the Soviet Union, many Eastern European countries are dealing with increased rates of alcohol and drug abuse, and some of the highest suicide rates in the world today.

Young People and Suicide

Although most people know that adolescents have a relatively high rate of suicidal behavior; it is a myth that very young people do not kill themselves. In 2003, suicide was the 12th leading cause of death in children ages 12 and under.

Depression, antisocial personality disorder (APD, a long-standing pattern of a disregard for other people's rights, breaking laws, deceitfulness, irritability and aggressiveness, reckless disregard for safety of self or others, and consistent irresponsibility), conduct disorder (essentially APD in children younger than 18), alcohol/ substance use disorders, and impulsivity/sensation-seeking are all strong risk factors for suicidal behavior in adolescents and youth. Hopelessness is also associated with suicidality in adolescents.

Tying It All Together: Why Does Someone Become Suicidal?

We have already discussed risk factors/vulnerabilities and triggers that may lead someone to commit suicide. Researchers have tried to weave these risk factors and triggers into a coherent picture of the reasons why someone who attempts or commits suicide. Suicide is not a simple behavior, therefore, the explanations are complex and composed of different layers of factors. Most researchers and clinicians agree that suicide is the result of the interplay between psychological, biological, and sociological factors. Each these factors does not occur in isolation, but interacts with and influences the others. Some research suggests that there may even be subtle differences between people who attempt suicide and those who complete it.

Psychological Contributions

Psychodynamic Explanations

Traditional psychodynamic theories are based on the idea that mental illness and problems result from internal, unconscious conflicts. Freud (the originator of psychodynamic theories) thought that suicidal and homicidal behavior were two sides of a similar coin. He suggested that we have two basic drives; one oriented toward love and life (called Eros), and one oriented toward death (Thanatos). Freud suggested that people who function adaptively are able to balance and integrate these drives. So, for instance, a healthy person would be able to engage in loving relationships and wide array of stimulating and growth-oriented activities, yet pull back from the world (and other people) when it is necessary to conserve physical and psychic (mental) energy. In contrast, if these drives are unbalanced, a person's destructive impulses may surface, resulting in violence against others (i.e., homicide) or violence against oneself (i.e., suicide).

Object relations theorists (one of the contemporary psychodynamic theories) suggest that people can become suicidal or homicidal as a result of a difficult early relationship with a caregiver object (another person (e.g., a parent) as represented in memory). The inappropriate relationship leads to a fear of engulfment (i.e., being completely overtaken by the object) or abandonment (i.e., being completely abandoned or rejected by the object). This fear leads to an internal conflict that can become so intense that people seek a method to relieve it. Sometimes, this release is achieved by harming someone else, or themselves.

Cognitive-Behavioral Explanations

Cognitive-behavioral theories suggest that people become suicidal because they have learned to think and behave in characteristic and unhelpful ways that make suicide seem like an appropriate choice and/or coping strategy. According to these theories, how suicidal people think about stressful situations (rather than the stressors themselves) will predict how they will react to them. Both maladaptive thought patterns (called cognitive distortions) and inappropriate behavior (or a lack of skills/behavior) can propel someone toward harming themselves. It's a "chicken and egg question" in terms of which comes first. For some people, a characteristic thinking style, present very early on (see our discussion below on temperament), leads to unhelpful behavior. For others, specific behaviors and the resulting feedback (or consequences) leads to maladaptive thoughts.

Cognitive distortions that can potentially lead to suicide include:

  • Dichotomous thinking - portraying oneself and the world in black and white (e.g., thinking "my life is completely horrible", rather than "I, like everyone else, have good and not so good aspects of my life/situation/self").
  • Overgeneralization - assuming that one bad event means that the whole day (week, year, etc.) will be bad.
  • Minimization - the "flip side" of overgeneralization; assuming that a good trait or event is unimportant or "a fluke" (e.g., I did well on that presentation, but it's only because no one was paying attention to me).
  • Selective Attention - focusing only on negative information or information that confirms other negative or unhelpful thoughts (e.g., thinking "I can't do anything right" and then reviewing your week for only those things that you messed up on, rather than also considering the things you did well).

As discussed previously, one particular way of thinking raises a serious red flag with regards to suicidal behavior. People may become (or are currently) suicidal if they feel hopeless- or that things will never get better.

Behavior that can potentially lead to suicide includes skill deficits and maladaptive coping styles. For example, people who have never learned to be appropriately assertive (a skill deficit) may repeatedly be taken advantage of or lose out on important opportunities such as job promotions, meeting new friends, etc. These behaviors may lead to one of the cognitive distortions described above (e.g., dichotomous thinking; such as thinking "I am a total loser because I can't make friends").

Research also suggests that suicidal individuals often have not learned appropriate coping styles. Coping styles/skills describe how well someone can manage a stressful situation, as well as regulate their emotional, physiological, behavioral, and cognitive reactions to stressors. Active coping styles include planning/problem solving, seeking and utilizing social support, and reinterpreting (i.e., finding meaning and benefit from adverse events). Suicidal individuals use fewer active coping strategies and more avoidant (passive) coping styles such as suppression (i.e., avoiding or denying the stressor) and blaming oneself for the cause of events. In addition, those suicidal people who try to be more active in solving problems tend to rely on an impulsive method than a more logical and methodical process.

Unhelpful behaviors and thoughts often intertwine in a particularly maladaptive state referred to as "learned helplessness." Individuals in this state have a style of thinking referred to as an "internal locus of control." People with this pattern of viewing the world tend to think that negative life events are caused by internal (i.e., from me), stable (i.e., not changeable), and pervasive causes. In other words, bad things happen, they are completely my fault, and I can't change them or prevent them from happening. People who show learned helplessness "give up trying" and use passive coping skills, believing that they can't impact negative outcomes or control their moods. An internal locus of control and learned helplessness can lead to pervasive feelings of hopelessness; which again, is often a trigger for suicidality.

Suicide Triggers

In overly simplistic terms, suicidal thoughts and behaviors start when vulnerable individuals encounter stressful events, become overwhelmed, and conclude that suicide is the only reasonable way (given their very likely biased way of thinking) to stop the pain they are experiencing. Determining what makes events stressful is difficult because of the highly individual nature of human coping abilities and perspectives. What may seem relatively trivial to one person may seem devastating or insurmountable to another.

Both negative and positive events can be sources of significant stress. Examples of events that cause positive stress include marriage, moving (when it is a desired move), having a child, and changing jobs (when that is desired). Examples of negatively stressful events include losses related to health, significant relationships and jobs, debts, peer pressure to be thin and beautiful, and similar difficult situations. Some suicidal individuals never quite developed the skills necessary to successfully cope with stressful situations and have personalities that are vulnerable to becoming overwhelmed by negative circumstance. Other suicidal individuals may have reasonable coping skills in place at one point, but find themselves worn down by circumstance to the point where they can no longer manage.

The most frequent stressful event leading up to suicide (what is often called a precipitating event) in the US today is mental illness, which is estimated to account for about 90 percent of all suicides. As we discussed earlier, a newly diagnosed and/or poorly treated mental illness can trigger a suicide in some cases. In addition, a change in someone's existing mental illness (for the worse or better) can function as a precipitating event for suicide. Most people incorrectly assume that only deteriorating conditions should be monitored. However, as was previously discussed, people who have been severely depressed and are now starting to regain their energy may suddenly find themselves with enough energy to carry out suicide plans.

Depression is the most common mental illness in people who commit suicide, so we will briefly detour from the topic of suicide to discuss this common disorder, which is discussed in significant detail in our Depression topic center. According to the DSM-IV-TR (the latest version of the manual used by clinicians to diagnose mental disorders) you must meet the following criteria in order to qualify for a diagnosis of Major Depression:

At least five of the following symptoms are present during the same period. At least (1) depressed mood or (2) loss of interest or pleasure must be present. Symptoms are present most of the day, nearly daily for at least 2 weeks.

1. Depressed mood (sometimes irritability in children and adolescents) most of the day, nearly every day.

2. Markedly diminished interest or pleasure in almost all activities most of the day, nearly every day (as indicated by either subjective account or observation by others of apathy most of the time)

3. Significant weight loss/gain.

4. Insomnia/hypersomnia (Impaired sleeping or sleeping too much).

5. Psychomotor agitation/retardation (restlessness or reduced movement).

6. Fatigue (loss of energy).

7. Feelings of worthlessness (guilt).

8. Impaired concentration or indecisiveness.

9. Recurrent thoughts of death or suicide.

It's helpful to know the criteria that professionals use to diagnose depression, but it is not a good idea to attempt to diagnose yourself. One reason why this is true is that the consequences of getting the diagnosis wrong can be quite negative. Though depression is a serious condition that is associated with significant suicide risk and does thereby end up being a lethal disorder sometimes, it is also a very treatable disease which can be addressed by either medical or psychological means (or both). If you wrongly conclude that you are not depressed when you are, you might very well miss out on treatment opportunities that a diagnosing clinician could offer you.

Don't assume that you must feel sad and depressed in order to qualify for a diagnosis of major depression, as this is not the case. You may experience irritability during the required two week period of symptoms. Or, you may experience your depression as physical pain. If you even meet one of the symptoms listed above (particularly the suicide symptom), it would be a very reasonable idea to consult with a mental health professional. Of course, if you have several symptoms, you definitely should schedule an appointment.

In addition to major depression, depressive symptoms may also be caused by bipolar disorder, or may co-occur with another disorder. Bipolar disorder is typically characterized by alternations of mood and energy levels occurring over months, weeks or days. Symptoms may include periods of hyperactivity, fast speech, expansive sexuality, lack of need for sleep and feelings of inflated-well being; and corresponding periods of depression where some or all of the symptoms listed above are present.

Suicide Triggers Continued

Anxiety Disorders

The term "anxiety disorders" covers a range of conditions that impairs someone's ability to function, ranging from Simple Phobias (intense fear of a particular item or situation such as spiders or bridges), Panic Disorder (described below), Generalized Anxiety Disorder (a intense, all encompassing sense of worry), Obsessive-Compulsive Disorder (a person experiences obsessions, or repeated unwanted and intrusive thoughts and engages in compulsions, or repetitive and ritualistic anxiety-reducing behaviors), PTSD (described below), and Social Phobia (intense anxiety created by social or public situations). Even though these disorders have very different symptoms, they all share a cardinal feature: intense, extreme, and disabling anxiety that appears in anticipation of or in response to situations which does not subside over time.

Individuals with anxiety disorders may feel overwhelmed, ashamed, or frustrated that they are unable to control their symptoms. Many individuals with severe anxiety symptoms also become socially isolated and/or try to relieve their feelings by using alcohol and/or other substances. These features of anxiety disorders can lead someone to attempt or commit suicide.

Post-Traumatic Stress Disorder

As mentioned several times in this document, PTSD is an extreme reaction to a traumatic event characterized by flashbacks (traumatic memories), trauma-themed nightmares, extreme jumpiness, and difficulties managing emotions. Individuals with PTSD have the highest rate of suicide when compared to all other anxiety disorders.

Panic Disorder

People with panic disorder experience recurrent and unexpected panic attacks (bouts of intense anxiety characterized by unpleasant physical symptoms such as nausea, racing heartbeat, dizziness, etc.). They are extremely anxious about having future panic attacks as well as very worried about what might happen as a result of these attacks (e.g., they worry about being trapped and unable to get help, or driving and wrecking). Approximately 20% of suicide deaths are due to panic disorder (a rate that is below major depression and PTSD, but still relatively high). People with comorbid (co-occurring) panic disorder and depression are particularly at risk.


Schizophrenia is a disorder characterized by odd and often highly irrational or disorganized behavior, disorganized thinking, and a loss of touch with reality. Four to 10% of people with schizophrenic disorders commit suicide. Suicide attempts among this group of people are more likely to be moderately to severely lethal with high levels of intent. In other words, individuals with schizophrenia who attempt suicide frequently do not survive.

Personality Disorders

Personality disorders are enduring patterns of behavior and ways of thinking that significantly impede functioning. Between 4 and 8% of people with a personality disorder complete suicide, and approximately 40 to 90% have attempted suicide.

Antisocial personality disorder is a long-standing pattern of a disregard for other people's rights, breaking laws, deceitfulness, irritability and aggressiveness, reckless disregard for safety of self or others, and consistent irresponsibility. People with antisocial personality disorder are often highly impulsive, which, as we discussed before, can lead someone to engage in self-destructive behavior as a means of obtaining intense stimulation and gain attention, without thinking through the possible outcome and ramifications of their actions.

Borderline personality disorder (BPD) is characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This disorder affects approximately 2% of adults, mostly young women. Individuals with BPD have a high rate of self-injurious behavior, suicide attempts, and completed suicide. Often, suicidal behaviors in BPD occur when the person is not showing any signs of depression, so some clinicians suggest that suicide in this population is more of an impulse control problem than some of the other mental illnesses discussed previously

Even though it's important to understand the link between mental illness and suicide it is also important to remember that not everyone who attempts or completes suicide has a mental illness, and not all people with mental illness attempt or complete suicide. As we discussed before, it's likely a combination of factors that propel someone toward engaging in suicidal behavior.

At this point, if you are confused about the difference between risk factors, vulnerabilities, and triggers, don't worry. These are not "cut and dried" categories, and the distinctions between them are often blurry. The important message we're trying to communicate here is that you can and should be alert to circumstances that cause people to become suicidal, ask for help if you find yourself encountering such circumstances, and be concerned enough to reach out to others you know who encounter such circumstances and need assistance.

Other Factors Contributing To Suicide Risk

The following risk factors (sometimes called "vulnerabilities") are also related to suicide risk.

  • Sixty percent of all suicides are committed by people with mood disorders. Mood disorders are a broad category of mental illness that includes major depression and bipolar disorder (an illness characterized by shifts between low levels of mood and energy to high levels of mood and energy), and other conditions including dysthymia (a long-term, low-grade level of depression), cyclothymia (a milder form of bipolar disorder) and schizoaffective disorder (an illness with a combination of psychotic thinking and mood problems).
    People who are just emerging from a prolonged depressive episode are particularly at risk of committing suicide. There is little energy to plan and implement a suicide in the depths of depression. However, as depressive symptoms begin to wane, more energy is available for such planning. In addition, physical symptoms of depression (e.g., fatigue) frequently resolve faster than cognitive symptoms (e.g., suicidal ideation), so a person may have more energy to carry out self-destructive thoughts. Adding alcohol to the equation (which may also cloud thinking) significantly increases the suicide risk of people with mood disorders.
  • Approximately 30% of suicides are committed by people who have psychiatric disorders other than mood disorders. This number includes individuals with post traumatic stress disorder (PTSD, described later), schizophrenia, personality disorders, sleep disorders, eating disorders (particularly anorexia nervosa), and many other conditions. In total, some 90% of people who commit suicide have one or more diagnosable mental illnesses. People with psychiatric "co-morbidity" (i.e., individuals who have two diagnosable mental disorders occurring at the same time) are particularly at risk for suicide.
    Psychiatric disorders are associated with a range of symptoms that can trigger suicidal ideation, planning and gestures. For example, psychotic disorders such as schizophrenia can be accompanied by auditory hallucinations (e.g., voices) that may direct people to kill themselves. Other mental disorders can cause poor impulse control and a lack of judgment and perspective. Some patients turn to suicide as an escape from their seemingly unending symptoms, while others may turn to suicidal behavior in an effort to get and hold other people's attention, or to punish other people.
  • There is a significantly higher rate of suicide among people who abuse alcohol and/or drugs. Alcohol is involved in an estimated 30% of suicides. Alcohol causes depressed mood, lowers inhibitions, and impairs judgment, any or all of which may set up vulnerable people to act on suicidal plans. These same factors (lowered inhibition and impaired judgment) are also associated with domestic violence and abuse, another factor that increases the likelihood that suicide will occur.
  • Some suicides are the result of the side effects of prescription drugs, or combinations of prescription and recreational drugs. Certain drugs cannot be mixed safely, and many drugs do not mix safely with alcohol. A bad combination of drugs/medications or over-dose can be lethal. Knowing these possibilities, some people purposefully use combinations of drugs and medications against prescribed advice as a means of committing suicide. Others accidentally kill themselves by way of the same method.
  • People who have access to firearms are more likely to commit suicide. Firearms were the most common method of suicide for both men and women, accounting for an estimated 55% - 56% of all suicides. In addition, almost 2/3 of completed teenage suicides were by firearm.
  • Emotional insults, such as rejection, public humiliation or shame, may be experienced as painful enough by some people to push them towards suicide. Perceived social rejection often leads to social isolation, which also increases suicidality. In addition, a combination of poor coping skills or other suicide vulnerability factors and an emotional insult can be particularly devastating. In the late 1980s, some research suggested a link between homosexuality, social rejection, and teen suicide, particularly in young males. Current research suggests that young homosexual or bisexual males are at greater risk than heterosexuals for suicide attempts, but findings are less clear regarding suicide completion.
  • Survivor guilt caused by witnessing or experiencing torture, abuse, war/combat, genocide or other violence appears to be a cause of suicide in some cases. Survivor guilt occurs when someone survives an atrocity, violent accident or combat situation, and is later overcome by feelings of guilt over the fact that they survived while others died or were maimed. Survivors may become unable to forgive themselves for feeling relieved that they lived while others died. They may also start to think that they did not deserve to live while others perished. Intense shame and guilt emotions can lead to suicidal ideation, gestures, or to self-injurious/parasuicidal behaviors. Survivor guilt and associated emotions can co-occur with PTSD, a condition characterized by flashbacks (traumatic memories), trauma-themed nightmares, extreme jumpiness, and difficulties managing emotions.
  • People who are terminally ill or have long-term, serious chronic illnesses, paralysis, disfigurement or loss of limbs sometimes commit suicide. People experiencing these conditions may commit suicide because of pain or discomfort related to their condition or its treatment, or due to grief surrounding the loss of functioning or appearance. Suicide may also be a method for avoiding the potential long-term emotional pain of slowly deteriorating or seeing loved ones struggle to cope with the dying process. Some people use suicide as an attempt to regain some control concerning when and how they will die, rather than feeling like the passive victim of an incurable medical condition. Others may commit suicide to avoid what they believe would be a complete, or near complete, lack of quality of life as a terminal condition progresses.
  • Significant grief and loss can also be associated with suicidality. Losing an important person, (e.g., a spouse, child, parent, friend or other significant relationship), a job, a treasured social role or status, financial assets, health, or something else of significance usually results in grief. Grief feelings are most always painful. They can easily become overwhelming, particularly in the short term when they are fresh, and then later on during anniversaries of the loss. People who've undergone significant loss may feel emotionally devastated and completely alone in the world. They may also feel like they do not have the emotional resources, coping skills, or social supports necessary to cope with grief. Significant loss can trigger an existential crisis state in which the grieving person cannot see any reason to continue living. Such feelings can be fairly common when passionate love affairs end abruptly. They can also occur when losses are more about social status and economic means rather than intimate affairs. For example, some people committed suicide during the U.S. stock market crash of 1929 in the wake of significant financial losses.
    Grieving is a universal reaction, but there is great individual variability in how it is experienced. If you find yourself in a grief situation (and if you live long enough, it is certain that you will), give yourself the permission to grieve in the manner that you find most natural. More information about the grief process may be found in our
    Grief and Bereavement Topic Center.
  • People with a family history of suicidal behavior are more likely to attempt or commit suicide. Children learn how to cope through a process known as modeling. In essence, children are watching their parents and caregivers cope, and imitating what they see. Modeling is a powerful teaching tool, and the parent-child relationship is usually the most significant teaching-learning relationship experienced in a lifetime. A parent who attempts or completes suicide ends up unwittingly modeling for their children that suicide is an acceptable method for coping with emotional pain or stressful situations. Such childhood lessons about suicide can be replayed even when someone becomes an adult. Depending on people's pre-existing vulnerabilities and the importance they place upon a particular relationship, suicide by another family member, school teacher, coach or mentor may also set people up for suicide themselves.
  • People who commit or attempt suicide are sometimes copying an idol or famous case of suicide. In a copy-cat suicide, a person with identity issues who has become over-identified with an appealing or admired (sometimes famous) individual re-enacts his or her suicide. Sometimes, just finding out about a suicide (e.g., the method used or the circumstances) initiates copycat behavior in a vulnerable individual, because the individual was already feeling suicidal to begin with. Suddenly, the vulnerable individual is provided with a viable suicide method and becomes convinced that he or she can follow through with the act. Repeated media coverage of the suicides of political/religious figures or celebrities may also initiate copycat suicides. Research suggests that youth are more likely to be influenced by media presentations of suicide and to die in cluster suicides (groups of suicides occurring in close proximity in terms of time and/or place) than other age groups.
  • People who are highly impulsive sometimes commit suicide. Some people are more impulsive than others, which is to say, they are more willing to act spontaneously and before they have had occasion to carefully think through the ramifications of their actions. Impulsive people are highly driven by rewards, but are less concerned with the punishing or negative consequences of their behavior. Cautious people, on the other hand, are more punishment-sensitive and less motivated by rewards. Because of their reward sensitivity, impulsive people are more willing than cautious people to engage in risky behavior; especially when that risky behavior has intense short-term rewards associated with it. Examples of such risky behavior might include unprotected, promiscuous sex, taking drugs, picking unnecessary fights, gambling, driving too fast, playing "chicken" with trains and "Russian Roulette" with loaded guns.
    Impulsivity is a normal dimension of personality on which everyone varies. (see our discussion below on temperament). Some people are born being more impulsive than other people. However, impulsivity can also be caused by psychiatric disorders, brain injuries, and drugs and medications like Valium and alcohol.
    Impulsivity may seem attractive in a person who is carefree, unpredictable, and full of fun and life. However, impulsivity can also lead people to make rash decisions, such as acting on suicidal impulses, without first carefully weighing the risks and benefits of those actions. Some highly impulsive people have histories of parasuicidal, violent, homicidal, or otherwise dangerous behavior which may also be associated with alcohol or drug use. However, it's often not until such a person completes a suicide or makes a significant suicide gesture that these behaviors come to be correctly viewed as warning signs.
  • People who've made other suicide attempts, gestures, or who have harmed themselves physically in other ways in the past are at higher risk of completing suicide than are other people who haven't done these things. Some people who survive an initial suicide attempt go on to make additional suicide attempts. People who have made prior suicide attempts are some 38x more likely to attempt suicide again in the future.
  • People who were abused or neglected as children have a higher risk of suicide than others. These children are sent lots of unhelpful messages that impair their sense of self-worth and ability to trust as adults. Victims of abuse or neglect may also fail to develop methods to cope with daily stresses or may develop a sense of hopelessness or helplessness to improve their lot in life. Still others may develop PTSD, a condition characterized by flashbacks (traumatic memories), trauma-themed nightmares, extreme jumpiness, and difficulties managing emotions.
  • Victims of domestic violence are at higher risk of suicide than people who have not had this experience. As is the case for childhood abuse and neglect, domestic violence may result in PTSD, emotional distress, and impaired coping skills. Many people in abusive relationships feel desperate and trapped - some enough so to attempt or commit suicide.
  • People involved in, or arrested for, committing crimes are at higher risk of committing suicide than other people. Most suicide victims in jails of all types and sizes (e.g., rural and urban county jails, city jails, and prisons) are young white males arrested for nonviolent offenses, intoxicated upon arrest, who subsequently hang themselves. It is difficult to know exactly why this is the case, as there are many variables that come into play. Though people with criminal records are more likely to commit suicide, they are also more likely to have personal histories including child abuse, and alcohol or substance abuse. Suicide may seem like a means of escaping punishment when the sentence for criminal behavior is lengthy, or involves significant prison time. Some inmates may also turn to suicide as a means of escaping rape at the hands of other prisoners. Many prison facilities have policies in place to try and prevent inmate suicidal behavior.
    Having reviewed the significant risk factors and vulnerabilities that are linked to suicidal behavior, we now turn to discuss the contribution of stressful events and life circumstances that act to trigger suicidal ideation and behavior.



Suicide: What Will Happen To You When You Ask For Help?

The Triage Process

Whether you end up at the ER or the office of a mental health professional, you can expect to be interviewed in order to establish the acuteness and lethality of your present suicide risk. In a hospital environment this entrance interview is typically known as triage. If your risk of harming yourself is judged to be severe, you will likely be asked to enter the hospital as a psychiatric patient on an inpatient unit. If your suicide risk is judged to be lower than severe, you will likely be given some names of local mental health professionals and sent home.

You can expect a similar introductory interview to be part of your first interactions with any psychiatrists or psychotherapists you may work with on an outpatient basis. Those professionals also must establish your level of suicide risk and the type of care necessary to reasonably ensure your safety. See the section below concerning the Initial Treatment Interview, for a list of some of the questions you may be asked that help professionals to understand your current level of suicide risk. Even if you start off in a clinician's office, if you are judged to be acutely suicidal, you may be asked to enter the hospital for a while. If you are not judged to be an acute risk, you will likely be offered psychiatric and/or psychotherapeutic care consistent with your presenting symptoms, and your suicidality risk will be monitored on an ongoing basis.

Please be as open and honest as you can during this triage process. Try to let go of any shame you may experience at feeling suicidal and focus on describing what you are thinking and feeling as accurately as possible. Suicidality is often a response to overwhelming stress; it does not mean you are "crazy". Many people feel at least vaguely suicidal at some point in their lives, and a substantial minority of them will experience a true suicidal crisis. Most of those people recover, and recovery is a strong possibility for you as well if you allow helpers to know what is happening so that they can respond appropriately.

Inpatient Treatment

If the doctor or therapist performing triage on you determines that you are not safe to return home, he or she will discuss more intensive levels of help that might benefit you, including voluntary and involuntary forms of hospitalization.

Voluntary psychiatric or substance abuse hospitalization (or similar crisis treatment facilities) are often recommended if you are judged to be at high risk for suicide and are willing to be admitted for treatment. If you are judged to be a high risk for suicide and refuse your therapist's recommendation for voluntary hospitalization, or if you are intoxicated, you may be lawfully hospitalized against your will for several days. In many states, involuntary substance abuse and psychiatric systems are separate, so whether you are intoxicated will determine which type of involuntary hospitalization will be used.

Voluntary and involuntary hospitalization processes differ from state to state (sometimes even within states). Someone's need for involuntary hospitalization is usually determined by two court-appointed medical specialists. As a result, you may be interviewed multiple times; first by a triage doctor, and then later by one or more mental health professionals who will determine whether you require commitment (as the process of involuntary hospitalization is commonly known).

Be as open and honest and as accurate as you can be when discussing your condition with such specialist doctors. It may be annoying and irritating to have to repeat yourself multiple times, but this repetition is actually for your benefit so that you are not railroaded into an unnecessary hospitalization. The process is typically designed such that separate doctors must speak with you directly and arrive independently at the same opinion that hospitalization is necessary to keep you safe before you can be restrained against your will.

Many people fear involuntary commitment and are resistant to the idea of seeking help for their suicidal feelings purely on the basis of this fear. In addition to fears of being restrained (in a locked hospital unit), many people fear that they may be hospitalized indefinitely. While you might indeed be admitted to a locked unit for a few days, any fears you have of indefinite hospitalization should be put to rest now. In today's modern world, you probably would not be hospitalized indefinitely even if you really needed it. It's too expensive to keep people in the hospital for long periods of time. Financial and other societal factors work together to minimize the duration of all hospital stays.

A typical involuntary hospitalization scenario in the U.S. works like this. Your initial commitment period lasts at most three days, after which it must be reviewed by two court-appointed mental health specialists (typically psychiatrists) who can re-certify it for perhaps an additional three days. All the while, insurance companies (and the courts) are reviewing your progress closely with an eye to ordering your discharge as soon as possible so that their costs are kept to a minimum. It is the rare and very ill patient who is kept hospitalized on an indefinite basis these days. In fact, in many cases today, patients are discharged before they feel they are ready to go home, while they are still feeling somewhat overwhelmed and suicidal.

If you enter the hospital on a voluntary basis, you are typically free to leave the hospital once your level of suicidality has decreased. However, if it seems to your doctors that you continue to be an acute risk for suicide and you decide to leave the hospital against medical advice, your doctors may be allowed by law to ask for involuntary commitment at that point (i.e., you started off as a voluntary patient, but then become an involuntary one). Involuntary hospitalization may also be extended while your suicide risk remains high, but such extensions require additional assessment procedures and certification by a court or a mental health court, depending on the laws in your area.

Unfortunately, there may not be any available hospital beds in your area at the particular time you need one. In such a case, the mental health professional who is in charge of the triage procedure will work to find another crisis facility that you can go to. If a suitable placement cannot be found for you when you need it, do what you can do to set up a circumstance for yourself that will help keep you safe. Call your psychotherapist (if you have one), local crisis lines and supportive friends and family as necessary. Ask a reliable family member or friend to stay with you until you are feeling safer.

Regardless of the circumstances of your hospitalization, it is okay to ask questions about the nature of your treatment. Questions such as how long you will be hospitalized, and what you can expect to occur while you're hospitalized are very reasonable and should be answered by hospital staff to the best of their abilities.

While in the hospital, you will likely be interviewed at least once by a psychiatrist, who may prescribe various medications. You will also generally be asked to participate in individual and group therapy sessions. The more you cooperate with your treatment recommendations and requirements, the better you are likely to feel.

If you believe that your care plan is not helpful or appropriate, it is okay to say so. Offering alternative treatment ideas may prove more successful than simply expressing dissatisfaction. You can also ask for help from your psychotherapist, a family member, a friend, a legal advocate or an advocacy organization such a local NAMI (National Association for the Mentally Ill) chapter. It is best to discuss your objections and ideas in as calm and rational a manner as possible, so as to best be listened to and taken seriously. Hospital staff members must maintain an orderly environment for all patients under their care, and they may restrain patients who throw fits or temper tantrums in order to keep the general peace. Restraint techniques used by hospital staff members are designed and regulated so as to be as non-harmful as possible for the individuals being restrained, but they still suck. It is always best to avoid the need for restraint in the first place.

Suicide: What Do You Do Now?

If you are presently assembling the means of your own death, the time to go to the hospital so as to prevent yourself from killing yourself is now. As mentioned several times already in this article, you require immediate psychiatric care if you are feeling acutely suicidal. You need a safe environment to be in for a while where you can be protected from acting upon suicidal urges. You may also benefit from medication to calm you, help you sleep or to serve as an anti-depressant. Most acute suicidal urges pass, or at least decrease in urgency, after a period of time has gone by. If you can hold out and not act, there is a very good likelihood that you will shortly feel better. It is much easier to hold out and not attempt suicide if you are hospitalized in an environment designed to keep you safe, than if you are out and about in your normal environment.

Unless you have pre-existing arrangements set up already with a therapist or doctor, the only surefire way to get the care and safe environment you need is to go to a local Emergency Room (ER). Please go to the hospital immediately if you are acutely suicidal. Recruit a friend to take you to the hospital if you cannot get yourself there safely. As a last resort, you should call the emergency operator who can dispatch an ambulance or police officers to your location. This can be a rather expensive way to go, but if it is the only reasonable way to get yourself to the hospital, then don't let the expense get in your way.

It may cross your mind to call an emergency telephone crisis line such as those mentioned below. This is a good idea if you are just feeling vaguely suicidal and want human contact with someone who can help you work through your thoughts. If you are acutely and dangerously suicidal, however, calling a crisis line is not the best thing to do, as it will distract you from getting the hands-on assistance you need. In such a case, you really need the safe environment that only a hospital can provide. Get yourself to the emergency room, or if there is no cheaper alternative, call the emergency operator (911 in the United States) for assistance.

If you are confident that you are not an immediate suicide risk; you may not require hospitalization. Nevertheless, you should still seek out professional mental health care for your condition, which is still life-threatening and rather serious. There is a good chance that you are depressed, or may have some other psychiatric disorder that would benefit from proper treatment. You will almost certainly benefit from having a mental health professional with whom you can confide, who can provide you with a more objective third-party perspective on your difficulties, who can help monitor your ongoing suicide risk, and who can help teach you better coping methods than you are presently able to use in addressing your concerns.

You can search for referrals to mental health professionals in your area here.

Even if you start calling for appointments today, it can take time to be seen by psychiatrists and psychotherapists. Appointment schedules may be full for weeks in advance. If this is the case, ask the receptionist if you can have the next available appointment, and to call you if any cancellations occur. It is also a good idea to stress the urgent nature of your need. While you are waiting for an appointment (and between appointments as you require) you can reach out to the various telephone crisis lines such as the ones that are listed on The Samaritans website ( In the United States you may also call toll-free 1-800-273-TALK or 1-800-SUICIDE. Teenagers may also call Covenant House's NineLine at 1-800-999-9999 or text SOS to 741741. Participating in online support group communities may also be a good idea.

Community And On-line Self-Help Resources For Major Depression

Self-help need not be a solitary pursuit. Instead, it can be very helpful to gather together with other people experiencing similar problems for purposes of mutual support. Community-based support groups like Alcoholics Anonymous and Weight Watchers fall outside of the psychotherapy realm. Such groups are not conducted by a therapist, but by a nonprofessional leader, group member, or by the group as a whole. Though not professionally led, these support groups do offer many of the same social support, identity, and belonging benefits that make group therapy effective. Participation in support groups is sometimes recommended in addition to participation in psychotherapy or in professionally-led group therapy. Participation in a self-help support group after formal psychotherapy has ended may be a useful strategy to ward off future episodes of depression.

One of the nicer aspects of living during the Internet era is that virtual support groups are available on-line all the time and are accessible from any Internet connection. People from all over the world gather together in these on-line communities for mutual support. On-line communities are a particularly good and important resource during the disabling phases of depression when people are not able to motivate themselves to leave their homes.

There are numerous websites that offer on-line support for depressed individuals. A few useful community links are provided below:

Undoubtedly, more and more groups are being formed all the time. A simple search on the Internet will yield numerous options for those looking for on-line help. For more information on self-help methods and how to develop an effective self-help plan, please consult our Psychological Self-Tools Online Self-Help eBook

Outpatient Suicide Treatment-Finding A Psychotherapist

If your need for acute care is not urgent and/or if you are being discharged from the hospital, you need to find a psychotherapist who can work with you (and perhaps a psychiatrist also). Hopefully, you will be provided with a list of potential therapists if you are leaving the hospital. However, it is your responsibility to follow up with this list to determine who can best meet your needs (e.g., are they on your insurance provider panel? Are they close by? Are their hours convenient for you? etc). It is particularly important for you to connect with a clinician as soon as possible if you are leaving a hospital, as research suggests that your risk of suicide is much higher in the first month after being discharged from the hospital than in subsequent months.

You may wonder about the different terms you encounter when you search for or start contacting clinicians. The first distinction you need to know about revolves around the type of treatments different clinicians are able to offer you.

• Medicine. Psychiatrists are trained and licensed to practice medicine, and to prescribe medications. Certain other professionals may also be able to offer you appropriate medical treatment, including nurse practitioners, psychiatric nurses, and in a few states, psychologists.

• Psychotherapy. Psychotherapists are trained (and should be licensed as well) to assist people in learning to mange problems in living that affect their moods, thoughts and behaviors. Be careful, though. The term "psychotherapist" is not regulated! Just because people call themselves psychotherapists doesn't necessarily mean that they have proper training and expertise necessary to help you. Be sure to ask about your therapist's training and background, as well as any licenses he or she might hold.

Psychotherapists are a diverse bunch, and this diversity has ramifications for how they approach the task of counseling. Psychiatrists, psychologists, nurses, social workers and various professional counselors may all fit under the umbrella of a psychotherapist. These clinicians may approach therapy from various and different points of view. Psychodynamic, cognitive-behavioral, humanistic, family systems, and "eclectic" (a combination of several different theories) orientations are terms you may come across to describe these points of view. Most therapists cannot prescribe medication. However, psychiatrists who are also psychotherapists may prescribe medication.

Despite the complexity of approaches to psychotherapy, at the end of the day, there are two important things to look for in a therapist. First, the therapist should come across as caring, genuine and professional. If a therapist you talk to sounds distant or intimidating, or otherwise leaves you feeling uncomfortable, don't start up a relationship with him or her unless there is no other good choice available to you. You should select an experienced psychotherapist with whom you feel comfortable and who has worked with suicidal people before.

Second, and of slightly less importance than the genuineness factor above, the therapist ought to be able to offer you a therapy that is scientifically established to help fix the problem you are having. Not all therapies have been subjected to scientific testing, and sometimes it is not important that your therapist can offer you a scientifically proven therapy (e.g., the science doesn't make the therapy good - it just establishes that it works). All things considered, however, if you have the choice to go with a scientifically proven therapy, you're probably better off doing so. Scientifically proven therapies are sometimes called EV therapies (EV stands for "empirically validated"). Examples include cognitive behavioral therapy, rational emotive behavioral therapy, and interpersonal therapy

Often, the best way to find a psychotherapist is by referral from someone you trust who has personal experience with that therapist. If a personal referral is not available to you, you can obtain quality referrals from local mental health centers, health insurance providers, primary care physicians, school counselors, health clinics, the yellow pages of your phone book (look under counselors, therapists, psychotherapists, psychologists, or psychiatrists), therapy referral services, and through websites, such as Mental Help Net. The search engine on Mental Help Net will show you therapists who can treat suicidality and related conditions in your local area (as defined by your zip or postal code).

When you call a psychotherapist for an appointment, you may be asked about the nature of your issue and why you desire an appointment. This is a time to be truthful. If you have had any suicidal thoughts, say so. If you don't make the urgency of your situation clear, and the psychotherapist has a busy schedule (which is likely), it may be some time before you are able to have your first appointment. If the therapist you call cannot give you an appointment soon enough to suit your needs, call another therapist or two until you get a timely appointment. Ask therapists for further referrals if they cannot accommodate your needs; they will almost surely know of other experienced therapists practicing in your area whom they can recommend.

Alert the person answering the phone if you are in an acute suicidal crisis when you call for your appointment. She or he will likely direct you to a crisis service that can provide assistance until your appointment can occur.

The Initial Suicide Treatment Interview

You will likely be asked many probing questions during your first visit to a psychotherapist's or psychiatrist's office. Common questions are designed to help the interviewer (often the doctor or therapist who will be treating you, but sometimes not) to understand your background and history, and presenting symptoms. These questions may include:

•Why you are seeking help at this time?

•What is your understanding of the nature of your problems?

•What are your symptoms? (headaches, sleep and eating disturbances, etc.)

•How your problems have affected your life?

•Demographic information (your age, educational background, etc.)

•Social information (marital and relationship status, occupational status, legal history)

•Past history of mental and physical health conditions and treatments

•Past and present substance abuse history and treatments

•Past and present history of abuse or neglect, and/or exposure to trauma

•History of past suicide attempts and treatment history (and history of past suicides/ suicide attempts and mental illness in your family)

•Information on recent life changes and stressful events


The interviewer should spontaneously ask you specific and detailed questions concerning your suicidality, but sometimes this important question gets overlooked. If this happens, be sure to volunteer that you are feeling suicidal. Please do not be ashamed about feeling suicidal. Having suicidal feelings does not make you a "loser" or any other negative name you might come up with as a label for yourself. Many people feel suicidal and many people come close to acting on their suicidal urges. Your interviewer has talked with numerous patients who are coping with suicidal urges before hearing your story, and will very likely continue to hear similar stories long after you are feeling better. Your information is unlikely to shock or surprise the interviewer, or cause him or her to think less of you.

Assessment of Suicide Risk

Assuming you've been honest regarding your suicidal ideation, the interviewer will shift to assessing your current level of suicide and self-harm risk. If you do not presently have a specific plan or easy access to a method for committing suicide, the interviewer may conclude that your present risk for suicide is not high. Just because you have been classified as lower suicide risk does not mean that your pain is not real or that your condition is not serious. The psychotherapist is simply determining your risk level in order to determine the most effective and safest course of treatment to offer you. As mentioned before, high risk patients are typically asked to enter the hospital because they are likely to be a danger to themselves if they are not temporarily confined to a safe environment. Lower risk patients are offered outpatient help.

During the risk assessment phase of your interview, the interviewer is likely to touch upon the following questions:

  • Why are you thinking about suicide now?
  • Do you have a specific plan?
  • If so, how and when will this occur?
  • What are some options for coping besides suicide?
  • Have you ever felt this way before? If so, what did you do avoid suicide?
  • Do you hear voices telling you to harm or kill yourself?
  • Are you depressed, or have you been depressed until recently?
  • Have you been giving away personal possessions?
  • Is the anniversary of a loss (e.g., death of someone) or any other significant date (birthday, holiday) approaching?
  • Have you been avoiding or withdrawing from others?
  • Have you recently made a will or other arrangements for your death?
  • Have you recently experienced any significant losses (such as losing a job, home, significant person to death or divorce, or financial investment)?
  • Are you terminally or chronically ill?
  • Are you currently under the influence of alcohol or other substances? Do you use alcohol and/or other substances on a frequent basis?
  • Have you ever been told that you take too many risks or are impulsive?

Even if you are not currently suicidal, but you have had previous suicidal thoughts or attempts, the interviewer may still ask the above questions to determine your level of risk. You may expect to hear these questions repeated during later therapy visits as a way of monitoring your risk level over time.


Ordinarily, the information you share with a doctor concerning your health, both physical and mental, is kept confidential and secret. However, this is typically not the case when it comes to suicide. By law, if you are an acute suicide risk, your therapist or doctor must "break confidentiality" and share information concerning your condition with other professionals (and possibly with the police and court system) so as to keep you safe. If you express clear suicide intent, and describe a specific plan of high potential lethality (e.g., using a gun, jumping from a high place, cutting your wrists or drinking poison), and you have access to the means by which to act on your plan your psychotherapist or doctor may:

  • Remove the planned means of suicide.
  • Help you generate possible alternative coping strategies other than suicide.
  • Consult with your psychiatrist (if you have one), their supervisor (if they work in an agency), a crisis worker (in person or by telephone, chat or text) or a colleague to help keep you safe.
  • Help you to develop a crisis safety plan.
  • Stay with you until your crisis has subsided.
  • Facilitate your hospitalization or other residential crisis placement.

No therapist or doctor wants to hospitalize their patients. Rather, it is their goal, in general, to want to help patients remain in as high functioning a circumstance as possible. Your therapist will hospitalize you only if that seems necessary. Otherwise, if you are judged safe to return home, he or she will likely help you develop a suicide safety plan, or a plan for keeping yourself safe. This plan may be written or verbal, and will likely include things you can do to help ensure your safety if you start feeling suicidal again. Here's an example of information included in such a plan:

  • a list of your strengths and skills for dealing with stressors
  • examples of common triggers for suicidal thoughts (i.e., a list of events that often make you feel overwhelmed by suicidal feelings) and some options for dealing with those specific triggers
  • other suggestions for how to deal effectively with suicidal feelings (e.g., "if I start thinking about killing myself again, I will listen to some good music, or call my best friend, or go jogging so as to distract myself and help myself feel better. If I still feel suicidal, I will call a crisis number {provided by the therapist - either the therapist's emergency number, or the number for another crisis service} or I will go to the nearest hospital emergency room").

As part of this plan, a therapist may also ask you to sign a no-suicide contract, which is your written statement promising not to attempt suicide before the next office visit on a specified date. This type of strategy was recommended as a best-practice to therapists not all that long ago. However, more recent research suggests that boiler-plate (i.e., non specific) no-suicide statements are not particularly effective in keeping people safe. The newer recommendation to therapists dealing with suicidal patients is that they develop a detailed safety plan (as described above) that is personalized for each patient.

Keep copies of your suicide safety plan (and, if relevant, your no-suicide contract) on your person (in your purse or wallet) so that you can refer to them if you find yourself starting to feel suicidal again. It is nice when copies of your plan are shared with the other therapists and doctors you are working with, so that all of your professional helpers can be on the same page with regard to your care. However, these days, communication between doctors is often scarce. For practical and confidentiality reasons, do not assume that one doctor knows what your other doctors know. If you call for further crisis assistance, and are helped by someone new or someone who doesn't know about the work you've already done, be sure to bring them up to date.

During the initial treatment (and subsequent meetings), you will also be asked other questions about your mood, behavior, and ability to function in daily life. These questions are necessary to determine whether your suicidal thoughts and feelings are connected to a mental disorder. Based on your responses, you may be given a diagnosis of a specific mental disorder (or, you may have been given a diagnosis if you were hospitalized for your suicidality). Although you may feel embarrassed or angry at being labeled, an accurate diagnosis is an important part of understanding the nature of your problems and how they may best be treated. For example, as mentioned previously, depression is a frequent trigger of suicidal thoughts. If a clinician knows that you are depressed, he or she can tailor your treatment to actively decrease your depression. Exactly how your diagnosis is treated will depend on your particular circumstances, characteristics, strengths and preferences, and on the methods that your therapist and doctor have been trained to use for your condition.

Suicide Statistics

Now that we have defined suicidal behavior, we can discuss its prevalence. Suicide prevalence has to do with the number of people who commit suicide in a given time period, such as within a year. We know that throughout recent history, suicide has been one of the leading causes of death in the USA. However, the accuracy of our statistics is not clear since there are methodological (data collection) problems with existing studies that complicate how accurately suicide attempts and completions are measured.

Attempted suicides resulting in emergency room visits are typically "counted" in studies, but researchers really don't know how many other people attempt suicide and do not end up at the hospital. Some scientists have simply asked groups of people whether or not they have ever attempted suicide and extrapolated from those percentages, but it is unclear whether respondents are entirely honest in answering this sort of question. As a result, there are no entirely reliable national statistics for the numbers of suicide attempts. Estimates suggest that approximately 800,000 Americans attempt suicide per year. This number most probably underestimates the true magnitude of the issue, but there is no way to tell for sure.

We have a clearer picture of the number of completed suicides, although some accidents may still be mistakenly considered suicides and vice versa. According to official statistics, suicide was the 11th leading cause of death in the US in 2001. Even though we typically think of suicide as a teenage problem, other age groups also commit suicide. Older Caucasian males (85 years or older) committed suicide at the highest rate of any age group.

Demographic Contributions To Suicide Risk

Some factors that can help predict whether someone is at risk of committing suicide have to do with their demographics or how they fit into the various segments of the population. Certain groups of people tend to be more at risk for completing suicide than others. For instance, as we just noted, older Caucasian males are at a greater risk for completing suicide than other groups.

While it is certainly useful to know this demographic information, it is important to keep in mind that the predictive power that this knowledge confers is rather weak. Even within high risk groups, actual suicide is a low frequency event. Many more people will show signs of possible suicidality (such as suicidal ideation) than will ever actually commit suicide. Predicting who will commit suicide on the basis of demographics alone is impossible. Combining knowledge of those demographic risks and other life circumstances/triggering factors that cause someone to commit suicide can provide greater (but still quite imprecise) insight into the true risks.

Here are some of the demographic (social group membership) characteristics that have been associated with recent suicides in the United States:

  • Suicide is the third leading cause of death for adolescents and young adults from age 15-24. Between 1970 and 1990, suicide rates for adolescents (ages 15 through 19) nearly doubled. Since 1990, the overall suicide rate for this age group has stabilized at approximately 11 deaths per 100,000. Younger people are more likely to attempt and less likely to complete a suicide than older people.
  • Increased alcohol and substance use, the increased availability of firearms, and the fact that many mental disorders (such as depression and schizophrenia) begin or worsen during these ages all contribute to these statistics. Suicide victims under the age of 30 are also more likely to have dual diagnoses (a combination of a mental illness and a substance abuse disorder), impulsive and/or aggressive behavior disorders, and legal problems than people over 30 who commit suicide. However, the challenges of adolescence alone are enough for some teens to commit or attempt suicide.
  • As mentioned previously, older Caucasian males commit suicide at the highest rate of any population group. Older men are more likely to use lethal methods (e.g., firearms) than older women and people of other ages. Older individuals in general make fewer suicide attempts per completed suicide than other age groups, and have often spent a fair amount of time planning their suicide. However, although many older adults who kill themselves give indirect warnings (saying things like "there is nothing left for me anymore", or tying up lose ends with wills, etc.), they are less likely to directly communicate their intent to die. Widowhood, serious medical illness, and social isolation are particularly common risk factors for this demographic group.
  • Whites and Native Americans (especially adolescents) have the highest suicide rates than any other ethnic group in the US. In addition, the rate of suicide among young African American males has been steadily increasing.
  • Men are more likely to commit suicide than women. Researchers suggest that men suffering from depression are more likely to go unrecognized and untreated than women suffering from depression, in part because men may avoid seeking help (viewing it as a weakness). Men who are depressed are also more likely to have co-occurring alcohol and substance use disorders than women.
  • Men are more likely than women to use highly lethal methods to commit suicide. Men are more likely than women to use a gun, carbon monoxide, to hang themselves, or to jump from a height to commit suicide. In addition, men who are intoxicated and suicidal are more likely to use a gun than females who are intoxicated and suicidal.
  • Women are more likely than men to attempt suicide. In terms of method, women tend to overdose or to cut their wrists.
  • Marital status is associated with suicide risk. Living alone and being single both increase the risk of suicide. Marriage is associated with lower overall suicide rates; and divorced, separated and widowed people are more likely to commit suicide. Gender seems to affect this relationship; divorced and widowed men are more likely than divorced and widowed women to commit suicide.
  • Being a parent, particularly for mothers, appears to decrease the risk of suicide. Even pregnant women have a lower risk of suicide than women of childbearing age who are not pregnant.
  • The Rocky Mountain and Western states have the highest rates of suicide in the U.S. Interestingly, this statistic isn't weather-related (it's a myth that cold, rainy, snowy and/or cloudy weather results in a higher rate of suicide; most suicides occur in the springtime), but is related to the concentration of people in these states. Even though there are certainly large cities in these states, overall, the population is more "spread out" than in other parts of the country. See the next bullet point.
  • Suicide rates are higher in rural areas. People in rural ares are more likely to attempt suicide with a firearm. Because people who use a firearm are more likely to die (than others who choose a less lethal method), more people in rural areas die from suicide.
  • Industrialized countries generally have higher rates of suicide than non-industrialized countries. Among industrialized countries, the U.S. has a moderate rate of suicide.

There may be some suicide rate differences between groups of people employed in certain careers or occupations, but there isn't enough evidence to know for sure. Dentists, psychiatrists, police officers, and other groups have all claimed to have the highest rates of suicide, but since no nationwide data has been collected and many of the studies that have been conducted are substantially flawed, no one really knows whether this is true.

Religiosity seems to have a protective effect against suicide. Exactly which religion(s), during what ages/developmental periods, and among which ethnicities remain unanswered questions. Many of the studies of the relationship between religion and suicide have been too small, contradictory, or flawed to make overall conclusions. However, research suggests that in the United States, areas with higher percentages of individuals without religious affiliation have correspondingly higher suicide rates. Involvement with a religion may provide a social support system, a direct way to cope with stressors, a sense of purpose and/or hope, and may lead to a stronger belief that suicide is wrong. Religiosity also seems to be related to other demographic factors; religious North Americans are much less likely than nonreligious people to abuse drugs/alcohol and to divorce (which are both associated with increased suicide risk).

Economic status has not been found to be a predictor in the simple way that social scientists once thought. Early suicide researchers theorized that poverty was a significant risk factor for suicide. The theory was that being poor could make one feel depressed, desperate or ashamed at times. This isn't entirely wrong, but research has shown that both the lowest-low and the highest-high incomes are more strongly associated with rates of suicide than other income levels. In other words, it's the extremes of either poverty or wealth that are associated with higher suicide rates.

Unemployment is associated with increased rates of suicide. Obviously, people who are unemployed often experience financial stress. In addition, alcohol consumption and marital discord can increase with financial difficulties, which can also increase someone's risk of suicide.